Int J Angiol 2020; 29(03): 168-174
DOI: 10.1055/s-0040-1713769
Review Article

Acute Lower Limb Ischemia—Etiology, Pathology, and Management

Balaji Natarajan*
1   Department of Cardiology, University of California Riverside, School of Medicine, Riverside, California
Prashant Patel*
1   Department of Cardiology, University of California Riverside, School of Medicine, Riverside, California
Ashis Mukherjee
1   Department of Cardiology, University of California Riverside, School of Medicine, Riverside, California
› Author Affiliations


Acute limb ischemia (ALI) is a vascular emergency associated with a high risk for limb loss and death. Most cases result from in situ thrombosis in patients with preexisting peripheral arterial disease or those who have undergone vascular procedures including stenting and bypass grafts. The other common source is cardioembolic. The incidence has decreased in recent times due to better anticoagulation strategies. Patients with suspected ALI should be evaluated promptly by a vascular specialist and consideration should be given for transfer to a higher level of care if such expertise is not available locally. Initial assessment should focus on staging severity of ischemic injury and potential for limb salvage. Neurological deficits can occur early and are an important poor prognostic sign. Duplex ultrasound and computed tomography angiography help plan intervention in patients with a still-viable limb and prompt catheter-based angiography is mandated in patients with an immediately threatened limb. Further investigations need to be pursued to differentiate embolic from thrombotic cause for acute occlusion as this can change management. Options include intravascular interventions, surgical bypass, or a hybrid approach. In this article, the authors discuss the common etiologies, clinical evaluation, and management of patients presenting with acute limb ischemia.


None of the authors have any disclosures relevant to the content of this manuscript.

* Both authors contributed equally to the manuscript.

Publication History

Article published online:
27 June 2020

© 2020. Thieme. All rights reserved.

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  • References

  • 1 Lau JF, Weinberg MD, Olin JW. Peripheral artery disease. Part 1: clinical evaluation and noninvasive diagnosis. Nat Rev Cardiol 2011; 8 (07) 405-418
  • 2 Hess CN, Huang Z, Patel MR. , et al. Acute limb ischemia in peripheral artery disease. Circulation 2019; 140 (07) 556-565
  • 3 Creager MA, Kaufman JA, Conte MS. Clinical practice. Acute limb ischemia. N Engl J Med 2012; 366 (23) 2198-2206
  • 4 Hess CN, Rogers RK, Wang TY. , et al. Major adverse limb events and 1-year outcomes after peripheral artery revascularization. J Am Coll Cardiol 2018; 72 (09) 999-1011
  • 5 O'Connell JB, Quiñones-Baldrich WJ. Proper evaluation and management of acute embolic versus thrombotic limb ischemia. Semin Vasc Surg 2009; 22 (01) 10-16
  • 6 Santistevan JR. Acute limb ischemia: an emergency medicine approach. Emerg Med Clin North Am 2017; 35 (04) 889-909
  • 7 Callum K, Bradbury A. ABC of arterial and venous disease: Acute limb ischaemia. BMJ 2000; 320 (7237): 764-767
  • 8 Gerhard-Herman MD, Gornik HL, Barrett C. , et al. 2016 AHA/ACC Guideline on the management of patients with lower extremity peripheral artery disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2017; 135 (12) e686-e725
  • 9 Olinic D-M, Stanek A, Tătaru D-A, Homorodean C, Olinic M. Acute Limb Ischemia: An Update on Diagnosis and Management. J Clin Med 2019; 8 (08) 1215
  • 10 Dieter R, Dieter III RA, Dieter III RA, Nanjundappa A. , eds. Critical Limb Ischemia Acute and Chronic. Switzerland: Springer International Publishing; 2017
  • 11 Aboyans V, Ricco J-B, Bartelink MEL. , et al; ESC Scientific Document Group. 2017 ESC Guidelines on the diagnosis and treatment of peripheral arterial diseases, in collaboration with the European Society for Vascular Surgery (ESVS): document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries endorsed by: the European Stroke Organization (ESO)The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS). Eur Heart J 2018; 39 (09) 763-816
  • 12 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
  • 13 Comerota AJ, Weaver FA, Hosking JD. , et al. Results of a prospective, randomized trial of surgery versus thrombolysis for occluded lower extremity bypass grafts. Am J Surg 1996; 172 (02) 105-112
  • 14 Fogarty TJ, Cranley JJ, Krause RJ, Strasser ES, Hafner CD. A method for extraction of arterial emboli and thrombi. Surg Gynecol Obstet 1963; 116: 241-244
  • 15 Ansel GM, Botti Jr CF, Silver MJ. Treatment of acute limb ischemia with a percutaneous mechanical thrombectomy-based endovascular approach: 5-year limb salvage and survival results from a single center series. Catheter Cardiovasc Interv 2008; 72 (03) 325-330
  • 16 Gupta R, Hennebry TA. Percutaneous isolated pharmaco-mechanical thrombolysis-thrombectomy system for the management of acute arterial limb ischemia: 30-day results from a single-center experience. Catheter Cardiovasc Interv 2012; 80 (04) 636-643
  • 17 Schrijver AM, van Leersum M, Fioole B. , et al. Dutch randomized trial comparing standard catheter-directed thrombolysis and ultrasound-accelerated thrombolysis for arterial thromboembolic infrainguinal disease (DUET). J Endovasc Ther 2015; 22 (01) 87-95
  • 18 Gandini R, Merolla S, Chegai F, Del Giudice C, Stefanini M, Pampana E. Foot embolization during limb salvage procedures in critical limb ischemia patients successfully managed with mechanical thromboaspiration: a technical note. J Endovasc Ther 2015; 22 (04) 558-563
  • 19 Acar RD, Sahin M, Kirma C. One of the most urgent vascular circumstances: Acute limb ischemia. SAGE Open Med 2013; 1: 2050312113516110
  • 20 Ouriel K, Shortell CK, DeWeese JA. , et al. A comparison of thrombolytic therapy with operative revascularization in the initial treatment of acute peripheral arterial ischemia. J Vasc Surg 1994; 19 (06) 1021-1030
  • 21 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
  • 22 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
  • 23 Earnshaw JJ, Whitman B, Foy C. National Audit of Thrombolysis for Acute Leg Ischemia (NATALI): clinical factors associated with early outcome. J Vasc Surg 2004; 39 (05) 1018-1025
  • 24 Taha AG, Byrne RM, Avgerinos ED, Marone LK, Makaroun MS, Chaer RA. Comparative effectiveness of endovascular versus surgical revascularization for acute lower extremity ischemia. J Vasc Surg 2015; 61 (01) 147-154
  • 25 Howard DP, Banerjee A, Fairhead JF, Hands L, Silver LE, Rothwell PM. Oxford Vascular Study. Population-based study of incidence, risk factors, outcome, and prognosis of ischemic peripheral arterial events: implications for prevention. Circulation 2015; 132 (19) 1805-1815
  • 26 Bonaca MP, Gutierrez JA, Creager MA. , et al. Acute limb ischemia and outcomes with vorapaxar in patients with peripheral artery disease: results from the trial to assess the effects of vorapaxar in preventing heart attack and stroke in patients with atherosclerosis-thrombolysis in myocardial infarction 50 (TRA2°P-TIMI 50). Circulation 2016; 133 (10) 997-1005
  • 27 Rushing AM, Donnarumma E, Polhemus DJ. , et al. Effects of a novel hydrogen sulfide prodrug in a porcine model of acute limb ischemia. J Vasc Surg 2019; 69 (06) 1924-1935
  • 28 Wang JC, Kim AH, Kashyap VS. Open surgical or endovascular revascularization for acute limb ischemia. J Vasc Surg 2016; 63 (01) 270-278