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Acute limb ischemia: contemporary approach

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Abstract

Acute limb ischemia is a critical condition with high mortality and morbidity even after surgical or endovascular intervention. Early recognition is important, but a delayed presentation is not uncommon. Viability of the limb is assessed by motor and sensory function and with interrogating Doppler flow signals in pedal arteries and popliteal veins as categorized by Rutherford. Category IIa indicates mild-to-moderate threat to limb salvage over a time frame without revascularization. Limb ischemia is critical without prompt revascularization in category IIb. Because the risk of reperfusion injury is high in this group of patients, perioperative management is important. In category III, reperfusion is not indicated except for embolism within several hours of onset. Intimal injury should be avoided by careful tactile control of a balloon with a smaller size catheter and under radiographic monitoring. Adjunctive treatment with catheter-directed thrombolysis or bypass surgery is sometimes necessary. Endovascular treatment is a promising option for thrombotic occlusion of an atherosclerotic artery. Ischemia-reperfusion injury is a serious problem. Controlled reperfusion with low-pressure perfusion at a reduced temperature and use of a leukocyte filter should be considered. The initial reperfusate is hyperosmolar, hypocalcemic, slightly alkaline, and contains free radical scavengers such as allopurinol. Immediate hemodialysis is necessary for acute renal injury caused by myoglobinemia. Compartment syndrome should be managed with assessment of intra-compartment pressure and fasciotomy.

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Acknowledgments

A part of this review was presented at the Postgraduate Course of the 67th Annual Meeting of the Japanese Association for Thoracic Surgery.

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Authors and Affiliations

  1. Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan

    Ikuo Fukuda, Mari Chiyoya, Satoshi Taniguchi & Wakako Fukuda

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  1. Ikuo Fukuda
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  2. Mari Chiyoya
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  3. Satoshi Taniguchi
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  4. Wakako Fukuda
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Correspondence to Ikuo Fukuda.

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This review was submitted at the invitation of the editorial committee.

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Fukuda, I., Chiyoya, M., Taniguchi, S. et al. Acute limb ischemia: contemporary approach. Gen Thorac Cardiovasc Surg 63, 540–548 (2015). https://doi.org/10.1007/s11748-015-0574-3

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  • DOI: https://doi.org/10.1007/s11748-015-0574-3

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