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.

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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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