This document summarizes the key differences and management recommendations for acute limb ischemia (ALI) and critical limb ischemia (CLI). It defines ALI as an acute condition lasting less than 2 weeks characterized by severe limb hypoperfusion, while CLI is a chronic condition lasting over 2 weeks characterized by rest pain and non-healing wounds. For ALI, the recommended treatments include heparin, oxygen, analgesia, and emergent revascularization via catheter-directed thrombolysis or surgical embolectomy. For CLI, the recommendations include physiological testing, imaging to guide revascularization, and endovascular or open surgical procedures based on the lesion location. Revascularization aims to improve tissue perfusion and prevent amputation for

1. ACUTE LIMB ISCHEMIA VS
CRITICAL LIMB ISCHEMIA :
CLINICAL PRACTICE
By
F1 Parach Sirisriro
22 Feb 2018

2. OUTLINE
• Definition
• Clinical presentation
• Diagnosis
• Management and recommendation for ALI
• Management and recommendation for CLI

3. REFERENCE
- 2016 AHA/ACC Lower Extremity PAD Guideline
- 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral
Arterial Diseases, in collaboration with the European Society for Vascular
Surgery (ESVS)
- Cronenwett, Jack L.; Johnston, K. Wayne. Rutherford's Vascular
Surgery 8th edition , Chapter 161 - 162
- Creager, M. A., et al. (2012). "Acute limb ischemia." New England
Journal of Medicine 366(23): 2198-2206.
- Rutherford, R. B. (2009). Clinical staging of acute limb ischemia as the
basis for choice of revascularization method: when and how to
intervene. Seminars in vascular surgery, Elsevier.
- A.J. Comerota and R. Sidhu. (2009. Can Intraoperative Thrombolytic
Therapy assist with the Management of Acute Limb Ischemia? Seminars
in Vascular Surgery

4. DIFFERENTIATE BETWEEN ACUTE AND
CHRONIC ISCHEMIA

5. DEFINITION
Acute Limb Ischemia (ALI) Critical limb ischemia
• Acute (<2 wk), severe
hypoperfusion of the limb
characterized by these
features
• Pain
• Pallor
• Pulselessness
• Poikilothermia(cold)
• Paraesthesias, and
• Paralysis
A condition characterized by
chronic (>2 wk) ischemic rest pain,
nonhealing wound/ulcers, or
gangrene in 1 or both legs
attributable to objectively proven
arterial occlusive disease.
Cronenwett, Jack L.; Johnston, K. Wayne. Rutherford's Vascular Surgery 8th edition , Chapter 161 - 162

6. SIGN AND SYMPTOMS
ALI CLI
History
- Leg symptoms in ALI relate to pain or
function.
- Duration and intensity of the pain and
presence of motor or sensory changes.
- Previous Hx of claudication, heart
disease or aneurysm, and atherosclerotic
risk factor
History
- Claudication
- Other non–joint-related exertional
lower extremity symptoms (not typical of
claudication)
- Impaired walking function
- Ischemic rest pain
Physical Examination
- Rule of Ps—pain, pallor, paresis,
pulse deficit,paresthesia, and
poikilothermia
- Marblewhite skin
- Muscle tenderness, particularly in
the
calf
- Proximity strong pulse (water-
hammer effect )
Physical Examination
- Abnormal lower extremity pulse
examination
- Vascular bruit
- Nonhealing lower extremity wound
- Lower extremity gangrene
- Other suggestive lower extremity
physical findings (e.g., elevation
pallor/dependent rubor)
Cronenwett, Jack L.; Johnston, K. Wayne. Rutherford's Vascular Surgery 8th edition , Chapter 161 - 162

7. ALI : HOW WILL YOU DIFFERENTIATE BETWEEN
EMBOLUS AND THROMBUS?
Cronenwett, Jack L.; Johnston, K. Wayne. Rutherford's Vascular Surgery 8th edition , Chapter 161 - 162

8. MANAGEMENT OF ACUTE LIMB ISCHEMIA:
RECOMMENDATIONS
- 2016 AHA/ACC LOWER EXTREMITY PAD GUIDELINE
- 2017 ESC GUIDELINES ON THE DIAGNOSIS AND
TREATMENT OF PERIPHERAL ARTERIAL DISEASES,
IN COLL ABORATION WITH THE EUROPEAN SOCIETY
FOR VASCUL AR SURGERY (ESVS)

9. SEVERITY OF ALI
2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery

10. MANAGEMENT OF ACUTE LIMB ISCHEMIA:
RECOMMENDATIONS
2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery

11.  Oxygen delivered by facemask
 Correct dehydration  IV fluid resuscitation
 IV heparin
 Prevents clot propagation + maintains collateral
vessel
 Dose: bolus 80 mg/kg then drip 18 mg/kg/hr
 Keep aPTT ratio 2-3
 Adequate analgesia (PCA is a good alternative)
MANAGEMENT OF ACUTE LIMB ISCHEMIA:
RECOMMENDATIONS
-Creager, M. A., et al. (2012). "Acute limb ischemia." New England Journal of Medicine 366(23): 2198-2206.

13. MANAGEMENT OF ACUTE LIMB ISCHEMIA:
RECOMMENDATIONS
Nonviable limb : Condition of extremity (or portion of extremity) in
which loss of motor function, neurological function, and tissue integrity
cannot be restored with treatment.
Salvageable limb : Condition of extremity with potential to
secure viability and preserve motor function to the weight-bearing portion
of the foot if treated
2016 AHA/ACC Lower Extremity PAD Guideline

15. NON VIABLE LIMB
An area of fixed cyanosis
surrounded by reversible mottling
Major Tissue loss
And Rigor muscle

16. REVASCULARIZATION FOR ALI:
RECOMMENDATIONS
1 local resources and patient factors (e.g., etiology
and degree of ischemia)
2. Emergently vs urgent depend on severity
3. Catheter-directed thrombolysis vs surgical
thromboembolectomy
Main target : RAPID RESTORATION of arterial flow with
least risk to patient
2016 AHA/ACC Lower Extremity PAD Guideline

17. 1. For marginally or immediately threatened limbs
(Category IIa and IIb ALI), revascularization should be
performed emergently (within 6 hours).
2. For viable limbs (Category I ALI), revascularization
should be performed an on urgent basis (within 6 to 24
hours).
MANAGEMENT OF ACUTE LIMB ISCHEMIA:
RECOMMENDATIONS
2016 AHA/ACC Lower Extremity PAD Guideline

18. TREATMENT ACUTE LIMB ISCHEMIA

19. Pros
 Rapid revascularization
 Can be done via low tech instrument
 Transfemoral approach can be done via local anesthesia
Cons
 Vessel injury
 Reperfusion syndrome
 Low success rate if ischemia >24 hour
 Adjunct by “Intraoperative thrombolysis”
SURGICAL EMBOLECTOMY
Cronenwett, Jack L.; Johnston, K. Wayne. Rutherford's Vascular Surgery 8th edition , Chapter 161 - 162

20. 4F Red
0.75 ml (fluid)
9 mm
5F White
1.5 ml (fluid)
11 mm
6F Blue
2 ml (fluid)
13 mm
7F Yellow
2.5 ml (fluid)
14 mm
Tibial vesselsEIA, SFA, PACIA, EIA
Aortic femoral graft
Saddle aortic embolus
3F Green
0.2 ml (fluid)
5 mm
Cronenwett, Jack L.; Johnston, K. Wayne. Rutherford's Vascular Surgery 8th edition , Chapter 161 - 162
Embolectomy catheter / arterial /
balloon

21. SURGICAL
EMBOLECTOMY
Cronenwett, Jack L.; Johnston, K. Wayne. Rutherford's Vascular Surgery 8th edition , Chapter 161 - 162

22. Pros
 Adjunct to surgical thromboembolectomy  Clear residual thrombus in
the small arteries and arteriole
 Minimal risk of bleeding
Cons
 May be inadequate in some patients with extensive distal and small
vessel thrombosis
A.J. Comerota and R. Sidhu. (2009. Can Intraoperative Thrombolytic Therapy assist with the Management of Acute Limb Ischemia?
Seminars in Vascular Surgery
INTRA-OP THROMBOLYSIS

23. A.J. Comerota and R. Sidhu. (2009). Can Intraoperative Thrombolytic Therapy assist with the Management of Acute Limb Ischemia?
Seminars in Vascular Surgery
Operative thromboembolectomy
Complete/Near complete
thrombus extraction
Extensive residual thrombus,
Multi-vessel distal occlusion
Bolus intra-arterial lytic Rx
into distal and proximal
arterial segment during
arterial occlusion
Incomplete thrombus
extraction with small volume
residual thrombus
Bolus intra-arterial lytic Rx
during arterial occlusion
(+repeat dose)
-or-
20-30 minutes infusion
intra-arterial lytic Rx after
arterial infusion is
restored
High dose isolated limb
perfusion
(Manual infusion or Partial
bypass with pump
oxygenator)
INTRA-OP THROMBOLYSIS

24. A.J. Comerota and R. Sidhu. (2009). Can Intraoperative Thrombolytic Therapy assist with the Management of Acute Limb Ischemia?
Seminars in Vascular Surgery
High dose isolated limb perfusion
INTRA-OP THROMBOLYSIS

25. Pros
 Direct delivery of the drug into existing thrombus
 ↓ Thrombolytic drug dosages
 ↓ Systemic bleeding complications
 Lyses clot in both large and small vessels
 Lower reperfusion syndrome than embolectomy
 Done via percutaneous approach with local anesthesia
Cons
 Usually takes 12 - 24 hours to be effective
 Still increased bleeding risk
 ICH: 0-2.5%
 Major bleeding: 1-20%
CATHETER DIRECTED THROMBOLYSIS
Cronenwett, Jack L.; Johnston, K. Wayne. Rutherford's Vascular Surgery 8th edition , Chapter 161 - 162

26. Catheter-based thrombolysis
effective for patients with ALI and a salvageable
(viable or marginally threatened) limb
Particularly in setting of
1. recent occlusion,
2. thrombosis of synthetic grafts
3. stent thrombosis
MANAGEMENT OF ACUTE LIMB ISCHEMIA:
RECOMMENDATIONS
2016 AHA/ACC Lower Extremity PAD Guideline

27. Contralateral approach Ipsilateral approach
CATHETER DIRECTED THROMBOLYSIS
Cronenwett, Jack L.; Johnston, K. Wayne. Rutherford's Vascular Surgery 8th edition , Chapter 161 - 162

28. Cronenwett, Jack L.; Johnston, K. Wayne. Rutherford's Vascular Surgery 8th edition , Chapter 161 - 162

29. Percutaneous mechanical thrombectomy (PMT)
as adjunctive therapy to thrombolysis (pharmacologic therapy)
Pros
 Disrupts the thrombus Allows better penetration of the clot by a
thrombolytic agent
 ↓ Thrombolytic dosing
 ↓ Therapy time  Increasingly being used in “class IIb”
 Done via percutaneous approach with local anesthesia
 Less vessel injury
Cons
 Can be used only large vessel
 Expensive device
MECHANICAL THROMBECTOMY
Cronenwett, Jack L.; Johnston, K. Wayne. Rutherford's Vascular Surgery 8th edition , Chapter 161 - 162

30. Trellis device (Mechanical mixing
device)
insert the wire for mechanical
thrombus fragmentation
MECHANICAL THROMBECTOMY
AngioJet®
 Using a high-velocity saline
jet to extract the thrombus in
an isovolumic manner
“Venturi effect”
Cronenwett, Jack L.; Johnston, K. Wayne. Rutherford's Vascular Surgery 8th edition , Chapter 161 - 162

31. Pros
 Use in patient that…
 Failed other procedures  Our last resort!!!
 Severe tissue injury
 Peripheral vascular disease
 Main treatment for thrombosed popliteal artery aneurysm
Cons
 High surgical risk
ARTERIAL BYPASS SURGERY
Cronenwett, Jack L.; Johnston, K. Wayne. Rutherford's Vascular Surgery 8th edition , Chapter 161 - 162

32. • Amputation* :
• Performed as the first(index) procedure in
• A nonsalvageable (class III) limb
• Low potential of limb salvage
• Risk of reperfusion syndrome and associated MOF
*may be deferred if pain under control and no
infection and meets with patients goals
MANAGEMENT OF ACUTE LIMB ISCHEMIA:
RECOMMENDATIONS
2016 AHA/ACC Lower Extremity PAD Guideline

33. • Monitored and treated (e.g., fasciotomy) for compartment
syndrome after revascularization (due to reperfusion causing
edema)
• Indications
1. Raised intra compartment pressure (> 30 mmHg) – not always
easily accessible
2. Clinical: increased pain, tense muscle, or nerve injury
3. Category IIb ischemia for whom time to revascularization is > 4
hours
MANAGEMENT OF ACUTE LIMB ISCHEMIA:
RECOMMENDATIONS
2016 AHA/ACC Lower Extremity PAD Guideline

34. MANAGEMENT OF CRITICAL LIMB ISCHEMIA:
RECOMMENDATIONS
- 2016 AHA/ACC LOWER EXTREMITY PAD GUIDELINE
- 2017 ESC GUIDELINES ON THE DIAGNOSIS AND
TREATMENT OF PERIPHERAL ARTERIAL DISEASES,
IN COLL ABORATION WITH THE EUROPEAN SOCIETY
FOR VASCUL AR SURGERY (ESVS)

35. RECOMMENDATIONS FOR
PHYSIOLOGICAL TESTING
2016 AHA/ACC Lower Extremity PAD Guideline

36. BMT

37. SEVERITY OF CLI
Cronenwett, Jack L.; Johnston, K. Wayne. Rutherford's Vascular Surgery 8th edition , Chapter 161 - 162

38. CLI RECOMMENDATIONS FOR
IMAGING
2016 AHA/ACC Lower Extremity PAD Guideline

39. MANAGEMENT OF CRITICAL LIMB ISCHEMIA:
RECOMMENDATIONS
2016 AHA/ACC Lower Extremity PAD Guideline

40. MANAGEMENT OF CRITICAL LIMB ISCHEMIA:
RECOMMENDATIONS
2016 AHA/ACC Lower Extremity PAD Guideline

41. MANAGEMENT OF CRITICAL LIMB ISCHEMIA:
RECOMMENDATIONS REVASCULARIZATION
OPTIONS: GENERAL ASPECTS
2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery

42. MANAGEMENT OF CRITICAL LIMB ISCHEMIA:
REVASCULARIZATION OPTIONS: GENERAL
ASPECTS
2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery

43. REVASCULARIZATION OPTIONS:
AORTO-ILIAC LESION
2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery

44. REVASCULARIZATION OPTIONS:
FEMORO-POPLITEAL LESION
2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery

45. REVASCULARIZATION OPTIONS:
INFRA-POPLITEAL OCCLUSIVE LESION
2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery

46. MANAGEMENT OF CRITICAL LIMB ISCHEMIA:
REVASCULARIZATION OPTIONS: GENERAL
ASPECTS
2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery

47. THE WIFI CLASSIFICATION
The target population for
• Ischaemic rest pain with objectively confirmed
haemodynamic studies
ABI <0.40
Ankle pressure <50mmHg
Toe pressure <30mmHg
TcPO2 <30mmHg
• Diabetic foot ulcer,
• Non-healing lower limb or foot ulceration >_2 weeks
duration
• Gangrene involving any portion of the foot or lower limb.
2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery

48. THE WIFI CLASSIFICATION
2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery

49. THE WIFI CLASSIFICATION

50. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery

51. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery

52. MANAGEMENT OF CRITICAL LIMB ISCHEMIA:
RECOMMENDATIONS
2016 AHA/ACC Lower Extremity PAD Guideline

53. MANAGEMENT OF CRITICAL LIMB ISCHEMIA:
RECOMMENDATIONS
2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery

54. THANK YOU