ESC Guidelines on the diagnosis and treatment of peripheral artery ...

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Page 36 of 56 Rest pains Pain control (morphine) Feasible Endovascular revascularization Clinical and non-invasive assessment of haemodynamic result (Table 8 ) Favourable Control CVD risk factors, debridement, shoe adaptation (removal of weight-bearing stress to lesion), surveillance Management of critical limb ischaemia Urgent revascularization Technical failure, endovascular revascularization unsuitable Surgical revascularization Unfavourable Control CVD risk factors, pain control (morphine), wound care Prostaglandins, consider spinal cord stimulation Figure 4 Management of critical limb ischaemia. CVD ¼ cardiovascular disease. Ischaemic lesion, gangrene Pain control (morphine), wound care, treatment of infection (antibiotics) Unfeasible re-do procedure (endovascular or surgical) Amputation, rehabilitation <strong>ESC</strong> <strong>Guidelines</strong>
<strong>ESC</strong> <strong>Guidelines</strong> Page 37 of 56 vessel closure devices are the potential causes of ALI. The viability of the limb is mostly threatened in this context. Quick and proper management is needed for limb salvage. Once the clinical diagnosis is established, treatment with unfractionated heparin should be given. 6,342 Analgesic treatment is often necessary. The level of emergency and the choice of therapeutic strategy depend on the clinical presentation, mainly the presence of neurological deficiencies, and the thrombotic vs. embolic cause. The clinical categories are presented in Table 8. An irreversible or unsalvageable extremity may require amputation before deterioration of the patient’s clinical condition, although attempts are usually made to save the limb, or at least to limit the level of amputation. A viable limb mandates urgent imaging as well as the assessment of major co-morbidities. In the case of severely deteriorated renal function, detailed DUS imaging may replace angiography. In some cases, a clear cardiac embolization in potentially normal arteries can be treated by surgical embolectomy without previous angiographic imaging. Otherwise, given the emergency level of care, angiography can be performed with no previous vascular ultrasound to avoid therapeutic delays. Different revascularization modalities can be applied (Figure 5). The options for quick revascularization consist of percutaneous catheterdirected thrombolytic therapy, percutaneous mechanical thrombus extraction or thromboaspiration (with or without thrombolytic therapy), and surgical thrombectomy, bypass, and/or arterial repair. The therapeutic strategy will depend on the type of occlusion (thrombus or embolus) and its location, duration of ischaemia, co-morbidities, type of conduit (artery or graft), and therapy-related risks and outcomes. Owing to reduced morbidity and mortality compared with open surgery, endovascular therapy is the initial treatment of choice, especially in patients with severe co-morbidities, if the degree of severity allows time for revascularization, and pending local availability of an emergency interventional team. Treatment results are best with an ALI duration ,14 days. 6 Intra-arterial thrombolysis is the classic endovascular technique for thrombus removal. Various techniques and different thrombolytic agents are currently Table 8 Clinical categories of acute limb ischaemia Grade Category Sensory loss Motor deficit Prognosis I Viable None None No immediate threat IIA Marginally threatened IIB Immediately threatened None or minimal (toes) More than toes III Irreversible Profound, anaesthetic None Salvageable if promptly treated Mild/ moderate Profound, paralysis (rigor) Adapted from Rutherford et al., with permission. 328 Salvageable if promptly revascularized Major tissue loss Amputation. Permanent nerve damage inevitable used. 6 Intrathrombotic delivery of the thrombolytic agent is more effective than non-selective catheter-directed infusion. Different devices aiming at mechanical removal of the clot have been developed and are commonly used alone or in combination with thrombolysis, with the main advantage of decreasing delay to reperfusion. The modern concept of the combination of intra-arterial thrombolysis and catheter-based clot removal is associated with 6-month amputation rates ,10%. 6 Systemic thrombolysis has no role in the treatment of patients with ALI. Based on the results of old randomized trials, 343 –345 there is no clear superiority of thrombolysis vs. surgery on 30-day mortality or limb salvage. Thrombolysis offers better results when applied within the first 14 days after the onset of symptoms. Thrombectomy devices have been proposed to treat ALI, but the benefits are not well documented. After thrombus removal, the pre-existing arterial lesion should be treated by endovascular methods or open surgery. Based on clinical presentation and availability of an emergency centre, surgical revascularization should be preferred when limb ischaemia is highly threatening and catheter-based treatment attempts may delay revascularization. Lower extremity fourcompartment fasciotomies are sometimes performed to prevent a post-reperfusion compartment syndrome, especially in the setting of class IIb and III ischaemia with surgical revascularization. In cases of viable limb, open or endovascular revascularization may not be possible, especially in the case of absent distal arteries, even after primary in situ thrombolysis; the only option then is to stabilize the ischaemic status with medical therapy (anticoagulation, prostanoids). Recommendations for acute limb ischaemia Recommendations Class a Level b Ref c Urgent revascularization is indicated for ALI with threatened viability (stage II). In the case of urgent endovascular therapy, catheter-based thrombolysis in combination with mechanical clot removal is indicated to decrease the time to reperfusion. Surgery is indicated in ALI patients with motor or severe sensory deficit (stage IIB). In all patients with ALI, heparin treatment should be instituted as soon as possible. Endovascular therapy should be considered for ALI patients with symptom onset
Page 1 and 2: European Heart Journal doi:10.1093/
Page 3 and 4: ESC Guidel
Page 35: ESC Guidel

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