Current Treatment Options in Acute Limb Ischemia

Abstract

Background Acute limb ischemia represents a clinical emergency with eventual limb loss and life-threatening consequences. It is characterized by a sudden decrease in limb perfusion. Acute ischemia is defined as a duration of symptoms for less than 14 days. Aging of the population increases the prevalence of acute limb ischemia. The two principal etiologies are arterial embolism and in situ thrombosis of an atherosclerotic artery. Immediate diagnosis, accurate assessment and urgent intervention when needed are crucial to save the limb and to prevent a major amputation. Delay in diagnosis and therapy may lead to irreversible ischemic damage.

Method To assess the current treatment options in acute limb ischemia, this review is based on a selective literature search in PubMed representing the current state of research.

Results and Conclusion Patients with acute limb ischemia should receive immediate anticoagulation. Treatment depends on the classification based on the degree of ischemia and limb viability. Especially acute (< 14 days symptom duration) Rutherford Categories IIa and IIb with marginally and immediately threatened limbs require definitive therapeutic intervention and are salvageable, if promptly revascularized. The current literature suggests that open surgical revascularization is more time effective then catheter-directed thrombolysis. However, with the advent of thrombolytic delivery systems and mechanical thrombectomy devices, treatment time can be minimized and successful utilization in patients with Category IIb (Rutherford Classification for Acute Limb Ischemia) has been reported with promising limb-salvage and survival rates. Large randomized studies are still missing, and guidelines suggest choosing the method of revascularization depending on anatomic location, etiology, and local practice patterns, with the time to restore the blood flow being an important factor to consider.

Key points: 

• Acute limb ischemia is an interdisciplinary emergency. It can lead to limb loss with life-threatening consequences.

• Immediate diagnosis and treatment are crucial to prevent irreversible damage.

• An endovascular approach should be considered in acute limb ischemia Category IIa and IIb of the Rutherford Classification for Acute Limb Ischemia (< 14 days), on a case-based decision and local capabilities. Especially elderly, multimorbid patients with high perioperative risk (may probably) benefit from these minimally invasive procedures.

Citation Format

• Fluck F, Augustin A, Bley T et al. Current Treatment Options in Acute Limb Ischemia. Fortschr Röntgenstr 2020; 192: 319 – 326

Zusammenfassung

Hintergrund Die akute Ischämie der unteren Extremität stellt einen klinischen Notfall mit möglichem Extremitätenverlust und lebensgefährlichen Folgen dar. Sie ist durch eine plötzliche Minderdurchblutung der Extremität gekennzeichnet. Definitionsgemäß weist die akute Ischämie eine Symptomdauer bis zu 14 Tagen auf. Die Prävalenz der akuten Extremitätenischämie ist durch die zunehmende Lebenserwartung in den letzten Jahren gestiegen. Die Thrombembolie und Lokalthrombose sind die häufigsten ätiologischen Faktoren. Ausschlaggebend für den Extremitätenerhalt ist die sofortige Diagnosestellung und Initiierung des therapeutischen Prozederes. Eine Verzögerung von Diagnose und Therapie kann zu irreversiblen ischämischen Schäden führen.

Methoden Diese Übersichtsarbeit basiert auf einer selektiven Literaturrecherche in PubMed, die den aktuellen Forschungsstand repräsentiert.

Ergebnisse und Schlussfolgerungen Patienten mit akuter Ischämie der unteren Extremität sollten umgehend antikoaguliert werden. Das weitere diagnostische und therapeutische Prozedere ist abhängig vom Schweregrad der Ischämie. Insbesondere die akuten (< 14 Tage Symptomdauer) Rutherford-Kategorien IIa und IIb mit marginaler und unmittelbarer Gefährdung der Extremitäten erfordern eine definitive therapeutische Intervention und sind im Falle einer prompten Revaskularisation beinerhaltend angehbar. Bislang galt die offen chirurgische Revaskularisation als zeiteffektiver im Vergleich zur lokalen Thrombolyse. Durch die Entwicklung neuer perkutaner mechanischer Katheterthrombektomie-Systeme ist die Behandlungszeit verkürzt und erfolgsversprechende Ergebnisse bezüglich Extremitätenerhalt und Überlebensraten wurden berichtet. Es fehlen randomisierte Studien und die Leitlinien empfehlen, die Methode der schnellstmöglichen Revaskularisation in Abhängigkeit von Lokalisation, Ätiologie und persönlicher Expertise zu wählen.

Kernaussagen: 

• Die akute Ischämie der unteren Extremität ist ein interdisziplinärer Notfall. Er kann zum Extremitätenverlust führen und lebensbedrohliche Folgen haben.

• Sofortige Diagnosestellung und Therapieeinleitung sind entscheidend, um irreversible Schäden zu vermeiden.

• Der endovaskuläre Behandlungsansatz sollte in den Kategorien IIa und IIb nach der Rutherford-Klassifikation für akute Extremitätenischämie (< 14 Tage) erfolgen. Insbesondere ältere, multimorbide Patienten mit hohem perioperativem Risiko profitieren (mutmaßlich) von der minimalen Invasivität.

Key words

ischemia/infarction - thrombolysis - embolism/thrombosis - extremities - interventional procedures - acute

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