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Semin intervent Radiol 2018; 35(05): 453-460
DOI: 10.1055/s-0038-1676321
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Acute Limb Ischemia Therapies: When and How to Treat Endovascularly

Anthony N. Hage   *
1   Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
,
Joseph L. McDevitt   *
2   Department of Radiology, University of Texas-Southwestern Medical Center, Dallas, Texas
,
Jeffrey Forris Beecham Chick
3   Department of Cardiovascular and Interventional Radiology, Inova Alexandria Hospital, Alexandria, Virginia
,
Venu Vadlamudi
3   Department of Cardiovascular and Interventional Radiology, Inova Alexandria Hospital, Alexandria, Virginia
› Author Affiliations
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Publication History

Publication Date:
05 February 2019 (online)

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Abstract

Acute limb ischemia is an emergent limb and life-threatening condition with high morbidity and mortality. An understanding of the presentation, clinical evaluation, and initial workup, including noninvasive imaging evaluation, is critical to determine an appropriate management strategy. Modern series have shown endovascular revascularization for acute limb ischemia to be safe and effective with success rates approaching surgical series and with similar, or even decreased, perioperative morbidity and mortality. A thorough understanding of endovascular techniques, associated pharmacology, and perioperative care is paramount to the endovascular management of patients presenting with acute limb ischemia. This article discusses the diagnosis and strategies for endovascular treatment of acute limb ischemia.

Keywords

acute limb ischemia - endovascular - thrombolysis - thrombectomy - interventional radiology

* Drs. Hage and McDevitt contributed equally and share first authorship for this manuscript.


 

  • References

  • 1 Creager MA, Kaufman JA, Conte MS. Clinical practice. Acute limb ischemia. N Engl J Med 2012; 366 (23) 2198-2206
    CrossrefPubMedGoogle Scholar
  • 2 Gilliland C, Shah J, Martin JG, Miller Jr MJ. Acute limb ischemia. Tech Vasc Interv Radiol 2017; 20 (04) 274-280
    CrossrefPubMedGoogle Scholar
  • 3 Patel NH, Krishnamurthy VN, Kim S. , et al; CIRSE and SIR Standards of Practice Committees. Quality improvement guidelines for percutaneous management of acute lower-extremity ischemia. J Vasc Interv Radiol 2013; 24 (01) 3-15
    CrossrefPubMedGoogle Scholar
  • 4 Lukasiewicz A, Lichota W, Thews M. Outcomes of accelerated catheter-directed thrombolysis in patients with acute arterial thrombosis. Vasc Med 2016; 21 (05) 453-458
    CrossrefPubMedGoogle Scholar
  • 5 Baril DT, Ghosh K, Rosen AB. Trends in the incidence, treatment, and outcomes of acute lower extremity ischemia in the United States Medicare population. J Vasc Surg 2014; 60 (03) 669-77.e2
    CrossrefPubMedGoogle Scholar
  • 6 Falluji N, Mukherjee D. Critical and acute limb ischemia: an overview. Angiology 2014; 65 (02) 137-146
    CrossrefPubMedGoogle Scholar
  • 7 Rutherford RB, Baker JD, Ernst C. , et al. Recommended standards for reports dealing with lower extremity ischemia: revised version. J Vasc Surg 1997; 26 (03) 517-538
    CrossrefPubMedGoogle Scholar
  • 8 Morrison HL. Catheter-directed thrombolysis for acute limb ischemia. Semin Intervent Radiol 2006; 23 (03) 258-269
    Article in Thieme ConnectPubMedGoogle Scholar
  • 9 Lukasiewicz A. Treatment of acute lower limb ischaemia. Vasa 2016; 45 (03) 213-221
    CrossrefPubMedGoogle Scholar
  • 10 Sedghi Y, Collins TJ, White CJ. Endovascular management of acute limb ischemia. Vasc Med 2013; 18 (05) 307-313
    CrossrefPubMedGoogle Scholar
  • 11 Smeds MR, Sandhu HK, Leake SS, Miller CC, Charlton-Ouw KM. Patterns in the management of acute limb ischemia: a VESS survey. Ann Vasc Surg 2017; 38: 164-171
    CrossrefPubMedGoogle Scholar
  • 12 Valle JA, Waldo SW. Current endovascular management of acute limb ischemia. Interv Cardiol Clin 2017; 6 (02) 189-196
    PubMedGoogle Scholar
  • 13 Grip O, Wanhainen A, Michaëlsson K, Lindhagen L, Björck M. Open or endovascular revascularization in the treatment of acute lower limb ischaemia. Br J Surg 2018; 105 (12) 1598-1606
    CrossrefPubMedGoogle Scholar
  • 14 Gillani S, Cao J, Suzuki T, Hak DJ. The effect of ischemia reperfusion injury on skeletal muscle. Injury 2012; 43 (06) 670-675
    CrossrefPubMedGoogle Scholar
  • 15 Blaisdell FW. The Pathophysiology of Skeletal Muscle Ischemia and the Reperfusion Syndrome: A Review. 2016. Available at: http://dx.doi.org/101177/096721090201000620 . Accessed November 15, 2018
    CrossrefPubMedGoogle Scholar
  • 16 Berridge DC, Kessel DO, Robertson I. Surgery versus thrombolysis for initial management of acute limb ischaemia. (Review) Cochrane Database Syst Rev 2013; (06) CD002784
    PubMedGoogle Scholar
  • 17 Funaki B. Thrombolysis for acute limb-threatening ischemia: a practical approach. Semin Intervent Radiol 2012; 29 (03) 201-203
    Article in Thieme ConnectPubMedGoogle Scholar
  • 18 McNamara TO, Fischer JR. Thrombolysis of peripheral arterial and graft occlusions: improved results using high-dose urokinase. AJR Am J Roentgenol 1985; 144 (04) 769-775
    CrossrefPubMedGoogle Scholar
  • 19 Kwok CHR, Fleming S, Chan KKC. , et al. Aspiration thrombectomy versus conventional catheter-directed thrombolysis as first-line treatment for noniatrogenic acute lower limb ischemia. J Vasc Interv Radiol 2018; 29 (05) 607-613
    CrossrefPubMedGoogle Scholar
  • 20 Heller S, Lubanda JC, Varejka P. , et al. Percutaneous mechanical thrombectomy using Rotarex® S device in acute limb ischemia in infrainguinal occlusions. BioMed Res Int 2017; 2017: 2362769
    PubMedGoogle Scholar
  • 21 Leung DA, Blitz LR, Nelson T. , et al. Rheolytic pharmacomechanical thrombectomy for the management of acute limb ischemia: results from the PEARL registry. J Endovasc Ther 2015; 22 (04) 546-557
    CrossrefPubMedGoogle Scholar
  • 22 Baumann F, Sharpe III E, Peña C, Samuels S, Benenati JF. Technical results of vacuum-assisted thrombectomy for arterial clot removal in patients with acute limb ischemia. J Vasc Interv Radiol 2016; 27 (03) 330-335
    CrossrefPubMedGoogle Scholar
  • 23 Davis FM, Albright J, Gallagher KA. , et al. Early outcomes following endovascular, open surgical, and hybrid revascularization for lower extremity acute limb ischemia. Ann Vasc Surg 2018; 51: 106-112
    CrossrefPubMedGoogle Scholar
  • 24 Nehler MR, Mueller RJ, McLafferty RB. , et al. Outcome of catheter-directed thrombolysis for lower extremity arterial bypass occlusion. J Vasc Surg 2003; 37 (01) 72-78
    CrossrefPubMedGoogle Scholar
  • 25 Raabe RD. Ultrasound-accelerated thrombolysis in arterial and venous peripheral occlusions: fibrinogen level effects. J Vasc Interv Radiol 2010; 21 (08) 1165-1172
    CrossrefPubMedGoogle Scholar
  • 26 Saxon RR, Benenati JF, Teigen C, Adams GL, Sewall LE. ; PRISM Trialists. Utility of a power aspiration-based extraction technique as an initial and secondary approach in the treatment of peripheral arterial thromboembolism: results of the multicenter PRISM trial. J Vasc Interv Radiol 2018; 29 (01) 92-100
    CrossrefPubMedGoogle Scholar
  • 27 Grip O, Kuoppala M, Acosta S, Wanhainen A, Åkeson J, Björck M. Outcome and complications after intra-arterial thrombolysis for lower limb ischaemia with or without continuous heparin infusion. Br J Surg 2014; 101 (09) 1105-1112
    CrossrefPubMedGoogle Scholar
  • 28 Acosta S, Kuoppala M. Update on intra-arterial thrombolysis in patients with lower limb ischemia. J Cardiovasc Surg (Torino) 2015; 56 (02) 317-324
    PubMedGoogle Scholar
  • 29 Robertson I, Kessel DO, Berridge DC. Fibrinolytic agents for peripheral arterial occlusion. Cochrane Database Syst Rev 2013; (12) CD001099
    PubMedGoogle Scholar
  • 30 Razavi MK, Wong H, Kee ST, Sze DY, Semba CP, Dake MD. Initial clinical results of tenecteplase (TNK) in catheter-directed thrombolytic therapy. J Endovasc Ther 2002; 9 (05) 593-598
    CrossrefPubMedGoogle Scholar
  • 31 Qureshi AI, Pande RU, Kim SH, Hanel RA, Kirmani JF, Yahia AM. Third generation thrombolytics for the treatment of ischemic stroke. Curr Opin Investig Drugs 2002; 3 (12) 1729-1732
    PubMedGoogle Scholar
  • 32 Verstraete M. Third-generation thrombolytic drugs. Am J Med 2000; 109 (01) 52-58
    CrossrefPubMedGoogle Scholar
  • 33 Theodoridis PG, Davos CH, Dodos I. , et al. Thrombolysis in acute lower limb ischemia: review of the current literature. Ann Vasc Surg 2018; 52: 255-262
    CrossrefPubMedGoogle Scholar
  • 34 Laroia S, Alexander S, Morales SA, Miller NG, Laroia A. Making the best out of the lab values; correlation of fibrinogen level with rate of thrombus resolution during tissue plasminogen (TPA) therapy. J Vasc Interv Radiol 2015; 26: S159-S160
    PubMedGoogle Scholar
  • 35 Poorthuis MHF, Brand EC, Hazenberg CEVB. , et al. Plasma fibrinogen level as a potential predictor of hemorrhagic complications after catheter-directed thrombolysis for peripheral arterial occlusions. J Vasc Surg 2017; 65 (05) 1519-1527.e26
    CrossrefPubMedGoogle Scholar
  • 36 Lee K, Istl A, Dubois L. , et al. Fibrinogen level and bleeding risk during catheter-directed thrombolysis using tissue plasminogen activator. Vasc Endovascular Surg 2015; 49 (07) 175-179
    PubMedGoogle Scholar
  • 37 Skeik N, Gits CC, Ehrenwald E, Cragg AH. Fibrinogen level as a surrogate for the outcome of thrombolytic therapy using tissue plasminogen activator for acute lower extremity intravascular thrombosis. Vasc Endovascular Surg 2013; 47 (07) 519-523
    CrossrefPubMedGoogle Scholar
  • 38 Ouriel K, Kandarpa K, Schuerr DM, Hultquist M, Hodkinson G, Wallin B. Prourokinase versus urokinase for recanalization of peripheral occlusions, safety and efficacy: the PURPOSE trial. J Vasc Interv Radiol 1999; 10 (08) 1083-1091
    CrossrefPubMedGoogle Scholar
  • 39 Ouriel K, Veith FJ, Sasahara AA. ; Thrombolysis or Peripheral Arterial Surgery (TOPAS) Investigators. A comparison of recombinant urokinase with vascular surgery as initial treatment for acute arterial occlusion of the legs. N Engl J Med 1998; 338 (16) 1105-1111
    CrossrefPubMedGoogle Scholar
  • 40 Results of a prospective randomized trial evaluating surgery versus thrombolysis for ischemia of the lower extremity. The STILE trial. Ann Surg 1994; 220 (03) 251-266 , discussion 266–268
    CrossrefPubMedGoogle Scholar
  • 41 Darwood R, Berridge DC, Kessel DO, Robertson I, Forster R. Surgery versus thrombolysis for initial management of acute limb ischaemia. Cochrane Database Syst Rev 2018; 8: CD002784
    PubMedGoogle Scholar
  • 42 Byrne RM, Taha AG, Avgerinos E, Marone LK, Makaroun MS, Chaer RA. Contemporary outcomes of endovascular interventions for acute limb ischemia. J Vasc Surg 2014; 59 (04) 988-995
    CrossrefPubMedGoogle Scholar
  • 43 Urbak L, de la Motte L, Rørdam P, Siddiqi A, Sillesen H. Catheter-directed thrombolysis in the treatment of acute ischemia in lower extremities is safe and effective, especially with concomitant endovascular treatment. Ann Vasc Dis 2017; 10 (02) 125-131
    CrossrefPubMedGoogle Scholar
  • 44 Tisi PV, Callam MJ. Treatment for femoral pseudoaneurysms. Cochrane Database Syst Rev 2013; (11) CD004981
    PubMedGoogle Scholar
  • 45 Gillani S, Cao J, Suzuki T, Hak DJ. The effect of ischemia reperfusion injury on skeletal muscle. Injury 2012; 43 (06) 670-675
    CrossrefPubMedGoogle Scholar
  • 46 Watson JD, Gifford SM, Clouse WD. Biochemical markers of acute limb ischemia, rhabdomyolysis, and impact on limb salvage. Semin Vasc Surg 2014; 27 (3-4): 176-181
    CrossrefPubMedGoogle Scholar
  • 47 Petejova N, Martinek A. Acute kidney injury due to rhabdomyolysis and renal replacement therapy: a critical review. Crit Care 2014; 18 (03) 224
    CrossrefPubMedGoogle Scholar
  • 48 Aycock RD, Westafer LM, Boxen JL, Majlesi N, Schoenfeld EM, Bannuru RR. Acute kidney injury after computed tomography: a meta-analysis. Ann Emerg Med 2018; 71 (01) 44-53.e4
    CrossrefPubMedGoogle Scholar
  • 49 Lambert MA, Belch JJF. Medical management of critical limb ischaemia: where do we stand today?. J Intern Med 2013; 274 (04) 295-307
    CrossrefPubMedGoogle Scholar
  • 50 Anand SS, Bosch J, Eikelboom JW. , et al. Rivaroxaban with or without aspirin in patients with stable peripheral or carotid artery disease: an international, randomised, double-blind, placebo-controlled trial. Lancet 2018; 20 ;391(10117): 219-229
    PubMedGoogle Scholar