This document summarizes the 2020 European Society for Vascular Surgery guidelines for the treatment of acute limb ischemia. It defines acute limb ischemia as a sudden decrease in arterial blood flow to the limb that threatens limb survival, requiring urgent evaluation and management within 2 weeks. The guidelines discuss the common causes of acute limb ischemia, diagnostic criteria including the 6 Ps signs, imaging options, classification systems for severity, and treatment approaches including open revascularization, thrombolysis, endovascular techniques, and postoperative management. Complications like compartment syndrome and reperfusion injury are also covered.
2. ACUTE LIMB ISCHEMIA – 2020 ESVS GUIDELINES
• definition:
• Sudden decrease in arterial perfusion of the limb
• Potential threat to the survival of the limb
• Requiring urgent evaluation and management
• Duration: < 2 weeks
• Common causes
• Embolism
• Thrombosis of native arteries or reconstructions
• Peripheral arterial aneurysm
• Dissection
• Traumatic arterial injury
• Diagnosis
• Medical emergency
• 6Ps: late signs pain, pallor, pulselessness,
poikilothermia, paresthesia, paralysis
• ABI < 0.7 is critical
• Look for signs of visceral ischemia, neurosigns,
and DVT
• Cardiac exam to look for cardiac cause: AF
• Imaging: DSA, duplex US, CE-MRA, and CTA (first
line, most often used
• Classification for severity: Rutherford
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3. • Treatment
• Initial
• Oxygen therapy
• UFH: 5000 U or 70-100 U/kg IV and monitor + adjust
APTT ratio (aim: to reduce further embolism or clot
propagation and provide anti-inflammatory effect
• Adequate analgesia
• Rehydration
• Decision making
• Open revascularization VS thrombolysis VS hybrid
ACUTE LIMB ISCHEMIA – 2020 ESVS GUIDELINES
• Open revascularization techniques
• Thrombo-embolectomy
• Using fogarty balloon
• Under LA
• Transverse arteriotomy if no plan to bypass
• Surgical bypass
• Used if intravascular recanalization not
achieved
• Used in acute on chronic ischemia
• Vein graft VS prosthetic graft
• Completion angiogram after surgery or
embolectomy: recommend
• If residual is found, intraarterial rtPA 4 – 10 mg
directly into artery downstream
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4. • Thrombolysis
• Systemic: not recommend
• Catheter directed thrombolysis (CDT)
• Equivalent results to surgery
• Initially used in IIA
• Systematic review showed it may be
used in Rutherford IIB
• Access: femoral artery under US guide
• Drugs: urokinase and rtPA (0.02 – 0.1
mg/kg/h)
• Complications:
• bleeding and access site
• Distal embolization
• Other endovascular techniques
• Thrombus aspiration
• Endovascular mechanical thrombectomy
• Ultrasound accelerated thrombolysis
ACUTE LIMB ISCHEMIA – 2020 ESVS GUIDELINES
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5. COMPLICATIONS OF RESTORATION TO ISCHEMIC
TISSUE: COMPARTMENT SYNDROME AND
REPERFUSION INJURY
• Tissue swelling in fascial compartment
• Late diagnosis results in irreversible muscle necrosis
and ischemic nerve damage
• Dx: based on clinical symptoms and signs
severely pain but can be minimal if nerve injury
• Results: muscle damage myoglobin and CK
leakage into circulation AKI
• Compartment pressure: little consensus on
threshold
• Risk factors: duration > 6h, young, previous Hx of
ALI, hypotension, high CK, severity, inadequate
intraop backflow, positive fluid balance
• Treatment: fasciotomy
• Prevention: prophylactic fasciotomy after
revascularisation
• Postoperative treatment and follow up
• Most common cause is AF and intracardiac thrombus
prevention of recurrent embolization echo and
CTA whole aorta if no cardiac source
• For native arterial thrombosis
• Look for concomitant malignancy or
thrombophilia
• Smoking cessation
• Antithrombotic and statin recommend to
decrease cardiac complication and to prevent
atherosclerotic disease progression
• Imaging: duplex US is modality of choice during
follow up
ACUTE LIMB ISCHEMIA – 2020 ESVS GUIDELINES
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