Early Outcomes Following Alternative Treatment Strategies in the Management of the Acutely Ischemic Limb

Abstract

The modem emergency management of the acutely ischemic limb has evolved considerably with the introduction of catheter-directed thrombolysis. Following preservation of life, the next goal of intervention in these emergency cases, whether with surgery or thrombolysis, is limb salvage. We report our own experience with both approaches in the early outcome of the emergency management of the acutely ischemic limb. This is a retrospective review of a tertiary-level vascular unit’s experience. The inclusion criteria consisted of acute limb ischemia as defined by the guidelines of the Vascular Surgical Society of Great Britain and Ireland. Data acquisition used the hospital’s inpatient enquiry system, and its operative and radiology databases. Analysis used the χ² test and the Yates correction factor (p < 0.05). Patients: N = 84. Events: 103. Median age: females, 82 yrs; males, 71 yrs. 17–91 yrs. Females vs. males > 70 years: χ² = 5.4, d.f. = 1, 0.01 < p, 0.02) (χ²: p= 0.05). Seventy-one patients underwent preoperative angiography. Successful limb salvage was achieved in 75% of cases. Overall, the amputation and mortality rates were 16.5% and 13.1%, respectively. We initially treated 62% of events with surgery and 38% with thrombolysis. In those patients who underwent thrombolysis there, 31% went on to have reconstructive surgery. Thrombolytic treatment resulted in a limb salvage rate of 69%. Thrombolysis was discontinued in six cases due to complications. Significant differences in outcome were not demonstrable between the two treatment groups (χ² = 1.1, d.f. = 1, 0.5 < p < 0.1). Acute limb ischemia has significant morbidity and mortality rates. The use of catheter-directed thrombolysis offers the surgeon an alternative to emergency surgery. This approach does not demonstrate any increase in the rate of limb loss.