What are the guideline sources, guidelines and references for Acute limb ischemia ?
Guideline sources The following summarized guidelines for the evaluation and management of acute limb ischemia are prepared by our editorial team based on guidelines from the Society for Vascular Surgery (SVS 2022), the European Society for Vascular Surgery (ESVS 2020), the American Heart Association (AHA/ACC 2017; 2006), and the American College of Chest Physicians (ACCP 2012). 1 2 3 4 5 Guidelines 1. Classification and risk stratification Severity assessment: Use the Rutherford classification for clinical evaluation of patients presenting with acute limb ischemia: https://web.pathway.md/diseases/recFMC5Qu0dpvOiCu 1/7 6/23/23, 1:58 AM Acute limb ischemia Pathway Situation Guidance Asymptomatic Grade 0, Category 0 Mild claudication Grade I, Category 1 Moderate claudication Grade I, Category 2 Severe claudication Grade I, Category 3 Ischemic rest pain Grade II, Category 4 Ischemic ulcers (minor tissue loss) Grade III, Category 5 Severe ischemic ulcers or gangrene (major tissue loss). B Grade IV, Category 6 2. Diagnostic investigations Clinical assessment: As per ESVS 2020 guidelines, obtain urgent clinical assessment, performed by a vascular specialist responsible for planning further investigation and management, in patients presenting with a possible diagnosis of acute limb ischemia. B As per AHA 2017 guidelines: Obtain a rapid, non-imaging assessment of limb viability and potential for salvage in patients with suspected acute limb ischemia. B Ensure that patients with acute limb ischemia are evaluated emergently by a clinician with sufficient experience to assess limb viability and implement appropriate therapy. B Diagnostic imaging: obtain diagnostic imaging to guide treatment in patients presenting with acute limb ischemia, provided it does not delay treatment, or if the need for primary amputation is obvious. B Show 2 more Laboratory testing: do not use results of myoglobin and CK on admission to decide between revascularization and primary amputation in patients presenting with acute limb ischemia. D Evaluation for underlying causes: Elicit a comprehensive history to determine the cause of thrombosis and/or embolization in patients with acute limb ischemia. B Consider evaluating patients with a history of acute limb ischemia for a cardiovascular cause of thromboembolism. C 3. Respiratory support https://web.pathway.md/diseases/recFMC5Qu0dpvOiCu 2/7 6/23/23, 1:58 AM Acute limb ischemia Pathway Supplemental oxygen: administer supplemental oxygen in patients with acute limb ischemia awaiting revascularization. B 4. Medical management Setting of care: Transfer patients diagnosed with acute limb ischemia in a non-vascular center to a vascular center offering the full range of open and endovascular interventions with an urgency depending on the severity of the ischemia. B Ensure that patients with acute limb ischemia have access to treatment in a hybrid theater or operating theater with C-arm equipment and by a clinical team able to offer a full range of open or endovascular interventions during a single procedure. B Anticoagulant therapy: As per ESVS 2020 guidelines: Initiate heparin in patients with acute limb ischemia awaiting revascularization. B Do not continue heparin administration in patients with acute limb ischemia undergoing thrombolysis. D As per AHA 2017 guidelines, initiate systemic anticoagulation with heparin in patients with acute limb ischemia unless contraindicated. B As per ACCP 2012 guidelines, consider administering immediate systemic anticoagulation with UFH in patients with acute limb ischemia secondary to arterial emboli or thrombosis. C Intravenous thrombolysis: do not use IV thrombolysis in patients with acute limb ischemia. D Pain management: provide adequate analgesia in patients with acute limb ischemia awaiting revascularization. B Rehydration: administer IV rehydration in patients with acute limb ischemia awaiting revascularization. B 5. Therapeutic procedures Catheter-directed thrombolysis, indications: As per ESVS 2020 guidelines, do not perform catheter-directed thrombolysis in patients with acute onset, non-limb-threatening claudication (Rutherford grade I). D Show 2 more As per ACC/AHA 2017 guidelines, perform catheter-based thrombolysis in patients with acute limb ischemia and a salvageable limb. A Catheter-directed thrombolysis, imaging guidance: As per ESVS 2020 guidelines, use ultrasound guidance for arterial access in patients undergoing endovascular therapy. A https://web.pathway.md/diseases/recFMC5Qu0dpvOiCu 3/7 6/23/23, 1:58 AM Acute limb ischemia Pathway As per ACC/AHA 2017 guidelines, insufficient evidence regarding the usefulness of ultrasound- accelerated catheter-based thrombolysis in patients with acute limb ischemia and a salvageable limb. I Catheter-directed thrombolysis (intraprocedural heparin): do not administer heparin during catheter-directed thrombolysis. D Catheter-directed thrombolysis, fibrinolytic agents: As per ESVS 2020 guidelines, administer rtPA or urokinase for thrombolysis. A As per ACCP 2012 guidelines, consider administering rtPA or urokinase over streptokinase in patients undergoing intra-arterial thrombolysis. C Catheter-directed thrombolysis (fibrinogen monitoring): do not obtain routine monitoring of plasma fibrinogen in patients undergoing thrombolytic therapy for acute limb ischemia. D Catheter-directed thrombolysis (monitoring for complications): monitor vital signs, the condition of the limb and for access site complications in patients undergoing thrombolytic treatment. B Show 2 more Mechanical thrombectomy: As per ESVS 2020 guidelines, consider performing aspiration and mechanical thrombectomy in patients with acute limb ischemia. C As per AHA 2017 guidelines, consider performing percutaneous mechanical thrombectomy as an adjunct to thrombolysis in patients with acute limb ischemia and a salvageable limb. C 6. Perioperative care Perioperative prostacyclin analogs: consider administering prostacyclin analogs during and after open surgical revascularization of patients with acute limb ischemia. C Intraoperative completion imaging: obtain completion angiography in patients undergoing open or endovascular surgery for acute limb ischemia. B 7. Surgical interventions Surgical thromboembolectomy, indications: As per ACC/AHA 2017 guidelines: Determine the revascularization strategy in patients with acute limb ischemia depending on the local resources and patient factors (such as etiology and degree of ischemia). B Consider performing surgical thromboembolectomy in patients with acute limb ischemia secondary to embolism and a salvageable limb. C As per ACCP 2012 guidelines, prefer surgery over intra-arterial thrombolysis in patients undergoing reperfusion therapy. B https://web.pathway.md/diseases/recFMC5Qu0dpvOiCu 4/7 6/23/23, 1:58 AM Acute limb ischemia Pathway Surgical thromboembolectomy (anesthesia): consider administering regional or local anesthesia in patients with acute limb ischemia undergoing surgical thromboembolectomy. C Surgical thromboembolectomy (embolectomy catheters): consider using over-the-wire embolectomy catheters under fluoroscopic control for surgical thromboembolectomy. C Surgical thromboembolectomy (infrainguinal bypass): consider using a vein graft in patients requiring an infrainguinal bypass procedure for acute limb ischemia. C Surgical thromboembolectomy (intraoperative local thrombolysis): consider administering intraoperative local thrombolysis in patients with residual thrombus after open surgery. C Hybrid technique: consider performing simultaneous endovascular treatment addressing inflow or outflow stenosis after open revascularization for acute limb ischemia. C Prophylactic fasciotomy: Do not perform routine prophylactic fasciotomy in patients undergone revascularization for acute limb ischemia as it is associated with prolonged hospital stay, local infection, and development of late deep venous insufficiency. D Consider performing prophylactic 4-compartment fasciotomy if ischemia before revascularization has been profound or prolonged. C Amputation: perform surgical amputation as the first procedure of choice in patients with acute limb ischemia and an unsalvageable limb. B 8. Specific circumstances Pediatric patients: initiate heparin as initial conservative management of infants and pediatric patients < 2 years of age with acute limb ischemia. B Show 3 more Patients with malignancy: consider performing active revascularization in selected patients with acute limb ischemia and underlying malignant disease as the immediate postoperative outcome is comparable to patients without malignancy. C Patients with popliteal aneurysm thrombosis: As per SVS 2022 guidelines, decide on the intervention for thrombotic and/or embolic complications of popliteal artery aneurysm depending on the severity of acute limb ischemia at presentation. B Show 3 more As per ESVS 2020 guidelines, consider repairing the popliteal artery aneurysm with a saphenous vein bypass in patients with acute limb ischemia secondary to thrombosis of the popliteal artery aneurysm. C Show 5 more As per ACC 2006 guidelines, consider performing catheter-directed thrombolysis or mechanical thrombectomy (or both) to restore distal runoff and resolve emboli in patients with acute ischemia and popliteal artery aneurysms and absent runoff. C https://web.pathway.md/diseases/recFMC5Qu0dpvOiCu 5/7 6/23/23, 1:58 AM Acute limb ischemia Pathway Patients with acute aortic occlusion: Perform urgent revascularization in patients with acute limb ischemia secondary to acute aortic occlusion. B Ensure close collaboration with anesthesiologists and intensivists to reduce complications of ischemia-reperfusion injury after revascularization for acute limb ischemia secondary to acute aortic occlusion. B Patient with acute graft occlusion: Identify and treat the cause of graft occlusion in patients with acute limb ischemia caused by graft occlusion. B Consider initiating long-term anticoagulation after thrombectomy or endovascular treatment of a prosthetic bypass graft occlusion. C Patients with acute upper limb ischemia: Obtain preoperative imaging in patients with acute ischemia of the upper limb unless embolic occlusion is obvious, the limb is immediately threatened and axillary or proximal brachial pulses are palpable. B Do not offer conservative treatment with anticoagulation alone in patients with acute ischemia of the upper limb if the arm is threatened or if limb function is important to quality of life. D 9. Patient education General counseling: take into account the best interests of the patient before deciding on treatment, obtain informed consent to management if at all possible, and clearly record decisions. B 10. Follow-up and surveillance Post-revascularization monitoring: consider monitoring patients after revascularization, including cardiovascular condition and functional status of the limb. C Show 3 more Post-revascularization anticoagulation: initiate long-term anticoagulation after revascularization of acute limb ischemia caused by an embolus secondary to AF or intracardiac thrombus. B Show 2 more Management of post-reperfusion compartment syndrome: As per ESVS 2020 guidelines, perform emergency 4-compartment fasciotomy for the treatment of post-ischemic compartment syndrome. B Show 2 more As per AHA 2017 guidelines, monitor for and treat compartment syndrome after revascularization. B https://web.pathway.md/diseases/recFMC5Qu0dpvOiCu 6/7 6/23/23, 1:58 AM Acute limb ischemia Pathway 11. Quality improvement Vascular registries: monitor outcomes after treatment of acute limb ischemia in vascular registries using variables developed specifically for this group of patients. B References 1. Martin Bj rck, Jonothan J Earnshaw, Stefan Acosta et al. Editor's Choice European Society for Vascular Surgery ESVS 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia. Eur J Vasc Endovasc Surg. 2020 Feb;59 2 173 218. Open 2. Marie D Gerhard-Herman, Heather L Gornik, Coletta Barrett 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 Mar 21;135 12):e686-e725. Open 3. Pablo Alonso-Coello, Sergi Bellmunt, Catherine McGorrian et al. Antithrombotic therapy in peripheral artery disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141 2 Suppl):e669S-e690S. Open 4. Alan T Hirsch, Ziv J Haskal, Norman R Hertzer et al. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation. 2006 Mar 21;113 11):e463 654. Open 5. Alik Farber, Niren Angle, Efthymios Avgerinos et al. The Society for Vascular Surgery clinical practice guidelines on popliteal artery aneurysms. J Vasc Surg. 2022 Jan;75 1S 109S 120S. Open https://web.pathway.md/diseases/recFMC5Qu0dpvOiCu 7/7