Treatment of acute lower limb ischaemia

Abstract

Summary: Acute lower limb ischaemia poses a major threat to limb survival. For many years surgical thromboembolectomy was the mainstay of treatment. Recent years have brought an endovascular revolution in the management of acute lower limb ischaemia. A wide range of endovascular procedures can nowadays be employed, providing results at least as good as the traditional surgical approach. This paper is an overview of currently utilised endovascular options as well as recent modifi cations of standard surgical techniques.

Current Treatment Options in Acute Limb Ischemia

“…The CDT approach is recommended in Category-IIa ALI with a short duration of symptomatology (< 14 days) where the thrombus is still fresh and there is adequate time for the thrombolytic agent to perform its intended function. In the literature, information about dosing and duration of thrombolytic therapy differs extensively and can range between 2.5 and 48 hours in the exemplary case of alteplase [12,29]. The following protocols are recommended: 1. weight-adapted administration of alteplase with 0.001-0.02 mg/kg/h or 2.…”

“…On the other hand, an elevated risk of distal embolization may be associated with high-dose, short-duration thrombolytic infusions. The infusion of the thrombolytic agent may be continuous, pulse-spray, or initial pulse-spray with subsequent continuous infusion, the idea behind the latter being to more rapidly penetrate and induce fragmentation of the thrombus [12,29]. To date, there is no standardization of the therapeutic protocol in regard to dosing and duration of the thrombolytic agent or monitoring of the patient.…”

“…There are different generations of thrombolytic agents, with each generation achieving increased specificity for fibrin-bound plasminogen. First-generation thrombolytics (streptokinase, urokinase) are no longer used due to the increased risk of hemorrhagic complications; second-generation agents (alteplase) act practically solely on fibrin-bound plasminogen; third-generation agents have less affinity for free circulating plasminogen (reteplase) or better resistance to endogenous inactivating factors in the plasma (tenecteplase) [12,29]. Alfimeprase, a novel recombinant variant of fibrolase (direct fibrinolytic enzyme with no effect of plasminogen), first showed promising results in preclinical and pilot studies with regard to duration of therapy and risk of bleeding.…”

“…Percutaneous thrombus aspiration (PAT) via large lumen catheters (6-to 8-French) was the first method of endovascular arterial thrombus extraction, which gained acceptance as a cheap method offering quick recanalization, especially in below-the-knee arteries [29]. Typically, it is utilized as a sole or an adjunctive procedure in patients with thromboembolic complications after endovascular procedures [40].…”

Access and closure management of large bore femoral arterial access

“…An aorto‐iliac angiogram is performed by contrast injection through the large‐bore sheath's side arm or by using selective catheter engagement into the ipsilateral iliac artery from an additional arterial access. The extremities are able to tolerate low perfusion state for short periods of time (less than 30 min) . However, when limb perfusion is compromised it may be necessary to establish flow distally by ex‐vivo ipsilateral bypass using antegrade access technique.…”