/

Table of contents

Expand All Topics

Acute limb ischemia

What's new

Updated 2024 ESC guidelines for the diagnosis and management of acute limb ischemia .

Background

Overview

Definition
Acute limb ischemia is defined as a sudden decrease in limb blood flow that can lead to potential tissue damage if not promptly treated.
1
Pathophysiology
The pathophysiology of acute limb ischemia primarily involves three main causes: embolism, thrombosis, and arterial dissection. Embolism and thrombosis can lead to blockage of blood flow, while arterial dissection can cause a tear in the artery wall, leading to compromised blood flow.
2
Epidemiology
The incidence of acute limb ischemia in the United Kingdom is estimated at 10 per 100,000 person-years.
3
Disease course
Acute limb ischemia presents with a set of clinical manifestations often referred to as the "5 P's": Pain, Pallor, Pulselessness, Paresthesia, and Paralysis. These symptoms are a result of the sudden decrease in blood flow to the affected limb.
4
Prognosis and risk of recurrence
The prognosis of acute limb ischemia is influenced by several factors. Early diagnosis and prompt treatment are crucial in preventing severe complications such as limb loss. The prognosis is also influenced by the underlying cause of ischemia and the patient's overall health status.
5

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of acute limb ischemia are prepared by our editorial team based on guidelines from the European Society of Cardiology (ESC 2024), the Vascular and Endovascular Surgery Society (VESS/SCAI/ABC/SVM/SVN/SVS/AHA/AACVPR/ACC/APMA/SIR 2024), the American College of Radiology (ACR 2023), the Society for Vascular Surgery (SVS 2022), the European Society for Vascular Surgery (ESVS 2020), ...
Show more

Classification and risk stratification

Severity assessment: as per ESVS 2020 guidelines, use the Rutherford classification for clinical evaluation of patients presenting with acute limb ischemia:
Situation
Guidance
Grade 0, Category 0
Asymptomatic
Grade I, Category 1
Mild claudication
Grade I, Category 2
Moderate claudication
Grade I, Category 3
Severe claudication
Grade II, Category 4
Ischemic rest pain
Grade III, Category 5
Ischemic ulcers (minor tissue loss)
Grade IV, Category 6
Severe ischemic ulcers or gangrene (major tissue loss)
B
Create free account

Diagnostic investigations

Clinical assessment
As per ESC 2024 guidelines:
Obtain an urgent evaluation by a vascular clinician with sufficient experience to assess limb viability and implement appropriate therapy in patients with acute limb ischemia.
B
Elicit a comprehensive medical history and determine the cause of thrombosis and/or embolization in patients with acute limb ischemia.
B
Create free account

More topics in this section

  • Diagnostic imaging

  • Laboratory testing

  • Evaluation for underlying causes

Respiratory support

Supplemental oxygen: as per ESVS 2020 guidelines, administer supplemental oxygen in patients with acute limb ischemia awaiting revascularization.
B
Create free account

Medical management

Setting of care
As per ESVS 2020 guidelines:
Transfer patients diagnosed with acute limb ischemia in a non-vascular center to a vascular center offering the full range of open and endovascular interventions with an urgency depending on the severity of the ischemia.
B
Ensure that patients with acute limb ischemia have access to treatment in a hybrid theater or operating theater with C-arm equipment and by a clinical team able to offer a full range of open or endovascular interventions during a single procedure.
B
Create free account

More topics in this section

  • Anticoagulant therapy

  • Intravenous thrombolysis

  • Pain management

  • Rehydration

Therapeutic procedures

Indications for revascularization
As per ESC 2024 guidelines:
Perform urgent revascularization in cases of neurological deficit. Obtain diagnostic imaging to guide treatment if it does not delay treatment or if the need for primary amputation is obvious.
B
Perform revascularization within hours of initial imaging in a case-by-case decision in the absence of severe neurological deficit.
B
Create free account

More topics in this section

  • Catheter-directed thrombolysis (indications)

  • Catheter-directed thrombolysis (imaging guidance)

  • Catheter-directed thrombolysis (intraprocedural heparin)

  • Catheter-directed thrombolysis (fibrinolytic agents)

  • Catheter-directed thrombolysis (fibrinogen monitoring)

  • Catheter-directed thrombolysis (monitoring for complications)

  • Mechanical thrombectomy

Perioperative care

Perioperative prostacyclin analogs: as per ESVS 2020 guidelines, consider administering prostacyclin analogs during and after open surgical revascularization of patients with acute limb ischemia.
C
Create free account

More topics in this section

  • Intraoperative completion imaging

Surgical interventions

Surgical thromboembolectomy: as per ESVS 2020 guidelines, consider administering regional or local anesthesia in patients with acute limb ischemia undergoing surgical thromboembolectomy.
C
Show 4 more
Create free account

More topics in this section

  • Prophylactic fasciotomy

  • Amputation

Specific circumstances

Pediatric patients: as per ESVS 2020 guidelines, initiate heparin as initial conservative management of infants and pediatric patients < 2 years of age with acute limb ischemia.
B
Show 3 more
Create free account

More topics in this section

  • Patients with malignancy

  • Patients with popliteal aneurysm thrombosis

  • Patients with acute aortic occlusion

  • Patients with acute graft occlusion

  • Patients with acute upper limb ischemia

Patient education

General counseling: as per ESVS 2020 guidelines, take into account the best interests of the patient before deciding on treatment, obtain informed consent to management if at all possible, and clearly record decisions.
B
Create free account

Follow-up and surveillance

Post-revascularization monitoring: as per ESC 2024 guidelines, assess clinical and hemodynamic success after revascularization.
B
Create free account

More topics in this section

  • Post-revascularization anticoagulation

  • Management of post-reperfusion compartment syndrome

Quality improvement

Vascular registries: as per ESVS 2020 guidelines, monitor outcomes after treatment of acute limb ischemia in vascular registries using variables developed specifically for this group of patients.
B
Create free account