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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3751_Библиотеки_им_академика_М_И_Перельмана
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FIGURE15.2 IVUS(intravascularultrasound)imageoftruelumenfromPioneerPlusCatheter.
III.OutbackRe-EntryCatheter
TheLuMend(RedwoodCity,CA)OutbackcatheterwasthefirstreentrydevicetogainFoodandDrug
Administration approval in 2001. In 2005, Cordis Corporation (Warren, NJ) purchased LuMend and
released the second-generationOutback LTD reentry catheter. The current product is marketed as the
OutbackElitereentrycatheter.Thiscatheteris6Frandusesanextendable22Gnitinolneedlethatexitsa
fenestrationthat is demarcatedby radiopaquemarkers onthe catheter.The true lumen is aligned using
orthogonalviewsunderfluoroscopicguidance,andthenitinolhypotubeisdeployed,19allowingan0.014
″wiretobeadvancedintothetruelumen(Fig.15.3).TheOutbackdevicehasbeenusedsuccessfullyin
femoropopliteal lesions and external iliac disease.20 The reported procedural success rate with the
Outback catheter has ranged from 65 to >95%,
20–22
and the primary reasons for failure are failure to
recannalizethetruelumenandinabilitytocrosstheiliacbifurcation.22Thecatheter lengthis 80 cm or
120cmwhichlimitsusebelowtheknee.
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FIGURE15.3 A,FluoroscopicimageoftheCordisOutbackLTDreentrycatheterwith0.014″wireenteringthetrue
lumenofthesuperficialfemoralartery(SFA)andradiopaque“L”marker.B,CordisOutbackElitereentrycatheter
withneedleextended.
A,From
SchneiderPA,Cap sM T,NelkenN.Re-entryintothetruelumenfromthesubintimalsp ace.JVascSurg.2013;58(2):529-534
.B,CourtesyofCordis,aCardinalHealthCompany.
IV.BostonScientificOffroadReentryCatheterSystem
The Boston Scientific (Marlborough, MA) Offroad reentry catheter system uses a positioning balloon
catheterwithasemicompliant5.4mmconicalballoonthatpositionswithanoutlettowardthetruelumen
of the vessel. Theoretically, the media and adventitia provide greater resistance to balloon inflation
allowing the catheter to orient toward the softer initima of the true lumen. A 20 mm lancet-tipped
microcatheteristheninsertedthroughtheballooncatheterandusedtocrosstheintimalplaneintothetrue
lumen,allowingpassageofanoncoated0.014″wire(Fig.15.4).Theballooncatheteris5Frbutrequires
a 6Fr guiding sheath. This device was studied inthe multicenter Re-ROUTE trial which enrolled 92
patients in Europeancenters withCTO lesions between1 and30 cm (average length 17.5 mm). The
technical success rate was 85% with a major adverse event rate of 3.3% rate due to thrombus
embolization.23 This device has been available since 2013, and thecatheter shaft lengthis 70 cm or
100cm.
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FIGURE15.4 BostonScientificOffroadsystemwith5Frover-the-wireballooncatheterandinnerlancet-tipped
microcatheter.
ImageprovidedcourtesyofBostonScientific.©2019BostonScientificCorporationoritsaffiliates.Allrightsreserved.
V.MantarayBalloonCatheter
BridgePoint Medical (Minneapolis, MN)developed the Mantarayballooncatheter andreceived FDA
approvalin2011.Anexclusivelicensingagreementwasreached withCovidienandthedeviceis now
marketedastheEnteerreentrysystem.ThisplatformissimilartotheStingraycoronaryCTOdevice.A
flat,noncompliantballoonisadvancedintosubintimalspaceandexpanded,orientingaporttowardthe
intimaandtruelumen.Astiff0.014″guidewirecanthenbeadvancedthroughtheporttogaintruelumen
entry(Fig.15.5). Unlike the three previouslydiscussed systems that use sharp needles or lancets, the
Enteer relies on the ability for a stiff guidewire to penetrate the intima. Technical success has been
reported from 82% to 86% in two studies, including the Peripheral Facilitated Antegrade Steering
TechniqueinChronicTotalOcclusions(PFAST-CTO)trial.24Thisdevicecanbeusedin5Frsheathsand
isavailablein135cmand150cmcathetershaftlengths,makingitusefulforinfrapoplitealdisease.
FIGURE15.5 CovidienEnteerreentrysystemwith5Frshaft,flatnoncompliantballoon,andoffsetportfor
guidewireexitintotheintimalplane.
UsedwithpermissionbyMedtronic©2019.
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VI.Conclusion
TruelumenreentryisapivotalaspectofendovascularCTOintervention,andthesereentrydeviceshave
beendemonstratedtoimproveratesofsuccessandreduceproceduretime.Devicecostsaresignificant
andcanrange from over $1500 togreater than $3000,17 and use of a reentry device is not currently
reimbursedbypayersources.However,this added expense may be offsetbyhigheroverallprocedural
success.Theriskstothe patientofreentrydeviceuseinclude vesselinjuryorperforationfrom needle,
lancet, or wire trauma. In outcome analyses for each device the rates of major adverse events are
typically less than 5% and rarely related to device use.
17,18,20–22,24
Use of a specific reentry device
requiresoperatorfamiliaritywiththedevicecharacteristics(sheathsize,cathetershaftlength,guidewire
requirements), IVUS or fluoroscopic landmarks, and maneuvers for troubleshooting device failure or
malfunction. There are no randomized trials comparing one device against another,so operators must
choosethe equipmentthatis bestsuitedfor a particular situation.In summary, specialized true lumen
reentry devices are a major technological advancement in the field of peripheral intervention and
subintimalangioplasty,andthesedeviceshavebecomeanessentialtoolforcomplexCTOintervention.
References
1.MahmudE,CavendishJJ,SalamiA.Currenttreatmentofperipheralarterialdisease:roleofpercutaneousinterventionaltherapies.JAm
CollCardiol.2007;50(6):473-490.
2.SethiS,MohammadA,AhmedSH,etal.RecanalizationofpoplitealandinfrapoplitealchronictotalocclusionsusingVianceand
CrossBosscrossingcatheters:amulticenterexperiencefromtheXLPADRegistry.JInvasiveCardiol.2015;27(1):2-7.
3.BanerjeeS,PershwitzG,SarodeK,etal.Stentandnon-stentbasedoutcomesofinfrainguinalperipheralarteryinterventionsfromthe
multicenterXLPADregistry.JInvasiveCardiol.2015;27(1):14-18.
4.BanerjeeS,SarodeK,PatelA,etal.Comparativeassessmentofguidewireandmicrocathetervsacrossingdevice-basedstrategyto
traverseinfrainguinalperipheralarterychronictotalocclusions.JEndovascTher.2015;22(4):525-534.
5.RoyT,DueckAD,WrightGA.Peripheralendovascularinterventionsintheeraofprecisionmedicine:tyingwire,drug,anddevice
selectiontoplaquemorphology.JEndovascTher.2016;23(5):751-761.
6.SafianRD.CTOoftheSFA:whatisthebestapproach?CatheterCardiovascInterv.2013;82(3):493-494.
7.GallagherKA,MeltzerAJ,RavinRA,etal.Endovascularmanagementasfirsttherapyforchronictotalocclusionofthelowerextremity
arteries:comparisonofballoonangioplasty,stenting,anddirectionalatherectomy.JEndovascTher.2011;18(5):624-637.
8.BoliaA,MilesKA,BrennanJ,BellPR.Percutaneoustransluminalangioplastyofocclusionsofthefemoralandpoplitealarteriesby
subintimaldissection.CardiovascInterventRadiol.1990;13(6):357-363.
9.BanerjeeS,ThomasR,SarodeK,etal.Crossingofinfrainguinalperipheralarterialchronictotalocclusionwithabluntmicrodissection
catheter.JInvasiveCardiol.2014;26(8):363-369.
10.JacobsDL,MotaganahalliRL,CoxDE,WittgenCM,PetersonGJ.Truelumenre-entrydevicesfacilitatesubintimalangioplastyand
stentingoftotalchronicocclusions:Initialreport.JVascSurg.2006;43(6):1291-1296.
11.LondonNJ,SrinivasanR,NaylorAR,etal.Subintimalangioplastyoffemoropoplitealarteryocclusions:thelong-termresults.EurJVasc
Surg.1994;8(2):148-155.
12.KrishnamurthyVN,EliasonJL,HenkePK,RectenwaldJE.Intravascularultrasound-guidedtruelumenreentrydeviceforrecanalization
ofunilateralchronictotalocclusionofiliacarteries:techniqueandfollow-up.AnnVascSurg.2010;24(4):487-497.
13.SaketRR,RazaviMK,PadidarA,KeeST,SzeDY,DakeMD.Novelintravascularultrasound-guidedmethodtocreatetransintimal
arterialcommunications:initialexperienceinperipheralocclusivediseaseandaorticdissection.JEndovascTher.2004;11(3):274-280.
14.FoodandDrugAdministrationODE.Class2DeviceRecallPioneerPlusCatheterPPlus120.RecallNumberZ-0864–2011
[Internet].2011.Availablefrom:https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfRES/res.cfm?id=91085
15.RezqA,AprileA,SangiorgiG.Pioneerre-entrydeviceforiliacchronictotalocclusion:trulyaparadigmshift.CatheterCardiovasc
Interv.2013;82(3):495-499.
16.Al-AmeriH,ShinV,MayedaGS,etal.Peripheralchronictotalocclusionstreatedwithsubintimalangioplastyandatruelumenre-entry
device.JInvasiveCardiol.2009;21(9):468-472.
17.SmithM,PappyR,HennebryTA.Re-entrydevicesinthetreatmentofperipheralchronicocclusions.TexHeartInstJ.2011;38(4):392-
397.
18.SaketkhooRR,RazaviMK,PadidarA,KeeST,SzeDY,DakeMD.Percutaneousbypass:subintimalrecanalizationofperipheral
occlusivediseasewithIVUSguidedluminalre-entry.TechVascIntervRadiol.2004;7(1):23-27.
19.SchneiderPA,CapsMT,NelkenN.Re-entryintothetruelumenfromthesubintimalspace.JVascSurg.2013;58(2):529-534.
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20.AslamMS,AllaqabandS,HaddadianB,MoriN,BajwaT,MewissenM.Subintimalangioplastywithatruereentrydevicefor
treatmentofchronictotalocclusionofthearteriesofthelowerextremity.CatheterCardiovascInterv.2013;82(5):701-706.
21.GandiniR,FabianoS,SpanoS,etal.RandomizedcontrolstudyoftheoutbackLTDreentrycatheterversusmanualreentryforthe
treatmentofchronictotalocclusionsinthesuperficialfemoralartery.CatheterCardiovascInterv.2013;82(3):485-492.
22.ShinSH,BarilD,ChaerR,RheeR,MakarounM,MaroneL.LimitationsoftheoutbackLTDre-entrydeviceinfemoropopliteal
chronictotalocclusions.JVascSurg.2011;53(5):1260-1264.
23.SchmidtA,KeirseK,BlessingE,LanghoffR,Diaz-CartelleJ,EuropeanStudyG.Offroadre-entrycathetersystemforsubintimal
recanalizationofchronictotalocclusionsinfemoropoplitealarteries:primarysafetyandeffectivenessresultsofthere-routetrial.J
CardiovascSurg(Torino).2014;55(4):551-558.
24.WosikJ,ShorrockD,ChristopoulosG,etal.Systematicreviewofthebridgepointsystemforcrossingcoronaryandperipheralchronic
totalocclusions.JInvasiveCardiol.2015;27(6):269-276.
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C H A P T E R 1 6
AcuteLimbIschemia:Thrombectomyand
Thrombolysis
S.ElissaAltinMD
SenthilrajGaneshanMD
I.Introduction
II.Epidemiology
A.PeripheralArterialDisease
B.Thrombosis
III.Etiology
A.MechanismsofALI
B.Origin
IV.ClinicalPresentation
A.Presentation
B.PhysicalExamination
C.RutherfordClassificationofAcuteLimbIschemia
V.DiagnosticEvaluation
A.DifferentialDiagnosis
B.Imaging
VI.Treatment
A.Anticoagulation
B.Thrombolysis
C.MechanismofActionandDosingofThrombolyticAgent
D.ContraindicationstoThrombolysis
E.TOPAS(ThrombolysisorPeripheralArterialSurgery)
F.STILE(SurgeryvsThrombolysisforIschemiaoftheLowerExtremity)Trial
G.PercutaneousMechanicalThrombectomy
H.PercutaneousAspirationThrombectomy
I.PercuataneousUltrasonography-AssistedFibrinolysis
VII.SurgicalRevascularization
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VIII.ReperfusionInjury
IX.Summary
KeyPoints
■Acute limb ischemia is a vascular emergency when viability of limb is threatened, and
revascularizationisrecommendedwithin3-6hoursforacutepresentations.
■Clinical symptoms and signs include the 6 P’s: pain out of proportion to examination,
diminishedpulses,pallor,poikilothermia,paresthesias,andparalysis.
■Limblossat30daysisreportedtobeashighas30%-50%.
■Endovascular revascularization with catheter-directed thrombolysis, rheolytic
thrombectomy,andaspirationthrombectomyarecommontreatmentoptions.
■Surgicalembolectomyandbypassaremoreinvasivetreatmentmethods.
I.Introduction
Acutelimbischemia(ALI)isavascularemergencythatoccurswhentheviabilityofanextremityandthe
lifeoftheaffectedindividualarethreatenedowingtoasuddeninterruptioninarterialperfusiontoalimb.
It is most commonlythe result of thromboembolic pathology.1 Many patients who develop ALI have
occlusiveperipheralarterialdisease,butintheabsenceofpreexistingatherosclerosis,ALIcanstilloccur
from embolic sources. Patients may present with profound symptoms, including disabling pain in the
settingofacutevascularandneurologicdeficits.2Thesystemic releaseofinflammatorymediatorsasa
result of ischemic injury may result in multiorgan dysfunction, which can become life-threatening.
3
PatientswithALIareathighriskofamputationanddeath,makingitcrucialthatpractitionersestablishthe
diagnosisearly.AlthoughmortalityduetoALIhasdecreased,itisstillestimatedat15%withinthe30dayperiodfromdiagnosis.
4,5
Bydefinition,patientswithALIhaveadecreaseinlimbperfusionforless
than14 days.The Rutherford classificationhas assigned clinical categories usefulfor determining the
severityofthethreattoviability,urgencytorevascularize,andtheoptimalapproachtomanagement.
6
II.Epidemiology
A.PeripheralArterialDisease
1.Despitethesubstantialclinicalburden,therearelimiteddataevaluatingtheepidemiologyofALIina
given population of patients with peripheral arterial disease (PAD). A population-based prospective
cohortstudyofapproximately93,000 peopleintheUnitedKingdomrecentlydescribed anincidenceof
ALI events in 10 per 100,000 per year, which is consistent with the findings of a prior large scale
Swedishregistrydataset.
7,8
Importantly,thisstudypopulationwaspredominantlywhite(94%),makingit
difficulttousethefindingstopredictoutcomesforotherethnicgroups.Overallsurvivalat30dayswas
75.3%and55.9%at5years.Amputation-freesurvivalwas 59.1%at3months,andfuturelimblossat
1yearwas7.5%.AmongpatientswithALI,41.9%hadpriorPADand69%hadahistoryofoneormore
forms ofatheroscleroticcardiovasculardisease.Theinvestigators alsofoundthatwhencomparedwith
the prospective registry datatheycollected over a10-year period, routine hospital episode and death
codingdatamissedapproximatelyhalfofallacuteischemicepisodes(combinationofALI,chroniclimb
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ischemia,andacutevisceralischemia) and,inothercases,incorrectlylabeled aneventasanischemic
episodeindicatingthattheincidenceandprevalenceratesderivedfromcodingdatamaybeinaccurate.
8
2.Accordingtothe2007Trans-AtlanticInter-SocietyConsensus(TASC),30-dayamputationrateshave
beenreportedtobe10%-30%,despiteuseofmodernendovascularmethodsandmortalityratesforALI
rangingfrom15%-20%.Thecauseofdeathisnotreportedinmoststudies.9IntheTOPAStrial,1-year
mortalitywas13.3%aftercatheter-directedthrombolysisand15.7%aftersurgicalrevascularization.
10
B.Thrombosis
Importantly, over the past few decades, rates of thrombosis have risen while rates of embolism have
declinedwithout any significant change in theoverallincidenceofALI.
7,11,12
It is possible that this is
partlyduetoimprovementsinthetreatmentofconditionsresponsibleforembolicphenomena,including
atrialfibrillationandvalvularheartdisease.Withanagingpopulationandanincreaseintheprevalence
ofthemetabolicsyndrome,peripheralarterialdiseaseisanexpandingepidemic,andacontinuedrisein
therateofthrombosisandtheoverall incidence ofALIcanbe anticipatedowingtoincreasingdisease
burdenandasacomplicationofendovascularandsurgicaltreatmentofthedisease.
III.Etiology
A.MechanismsofALI
Thrombosisandembolismarethe two majormechanismsofALI.In-situthrombosisoccursinpatients
withunderlyingPADorpriorbypassgrafting.13Acutethrombosisofalimbarteryoftenoccursatsitesof
priorstenosisowingtoatheroscleroticdisease,butcanalsooccuratarterialaneurysms.Venousbypass
grafts oftendevelop anastomotic thrombosis, whereas prosthetic grafts maythromboseanywherealong
thelengthoftheconduit.
13
B.Origin
Anestimated85%ofacuteembolismsareofcardiacorigin.RiskfactorsforembolicALIincludeatrial
fibrillation,apicalmyocardialinfarctionwithsubsequentventricularthrombusformation,prostheticheart
valves,patentforamenovaleinassociationwithparadoxicalembolism,andthrombophilias.Extracardiac
emboli arise from sources including aneurysms, atherosclerotic plaque debris, and venous
thromboembolismswhichenterthearterialsystemthroughintracardiacshunting.Aneurysmwalls,dueto
abnormalorslowflow,oftencontainthrombuswhichcanembolizedistally.Inparticular,aneurysmsof
the aorta and popliteal artery are the most common sources of embolic ALI. Hematologic and
thrombophilic conditions can additionally predispose to arterial thrombosis, including the
antiphospholipidsyndromeandheparin-inducedthrombocytopenia.9Atheroscleroticplaquedebrisdueto
dislodgementisamajorsourceofembolismduringcatheterization,aswellasproceduralcatheterbased
thromboembolism.9Embolimostcommonlylodgeatthebifurcationofthefemoralartery,trifurcationof
thepopliteal,andaorticbifurcation.
IV.ClinicalPresentation
A.Presentation
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1.AclassicpresentationofALIincludesaconstellationofsignsandsymptomsdescribedastheclassic
six“P’s”: acute onsetofpainout of proportiontoexamination, diminishedpulses, early skin mottling
(pallor),coolnesstotouch(poikilothermia),distalparesthesias,andparalysis.However,therearemany
factors which can alter the clinical presentation, including the location and duration of the arterial
occlusion, the degree of collateral circulation, the extent of preexisting arterial disease (presence of
collaterals),andthemetabolicconsequencesoftissueischemia.
13
2. Patients are often easilyable torecall the precise timing ofthe onset of pain, especially for those
whose ALI is due to an embolization. Painis usually severe but over time can relent because nerve
damageensuesasischemiaprogresses.PatientswithPADwhohavearterialthrombosiscanpresentwith
a more gradual or stuttering presentation,as the severity ofclinical ischemia is reduced owing tothe
formationof collaterals. Pallor or paleness below the level ofobstruction occurs, and pulses maybe
absent or diminished when compared with the contralateral side. Temperature dysregulation occurs,
causingthe limb to be cool (poikilothermia), as thetransfer of heatto theextremity is interrupted by
inadequate blood flow. Most commonly these findings are located one joint distal to the level of
occlusion. Late symptoms include paresthesias and paralysis which occur secondary to neural and
muscularischemia anddeath,respectively.Livedoreticularismaybe seenifthe embolizationis tothe
moredistalvessels.
B.PhysicalExamination
1.AthoroughphysicalexaminationisnecessaryinthediagnosisofALIanddeterminationofitsseverity
andthepatient’sprognosis.Theinitialevaluationshouldincludevitalsigns,theexternalappearanceof
thepatient,thetemperatureoftheskin,adetailedvascularexaminationincludingpalpationofpulsesin
thefemoral,popliteal,dorsalispedis,andposteriortibialarteriesoftheaffectedandcontralaterallimb,
anda neuromotorevaluationforsensationandmusclestrength.ADopplerinstrumentshouldbeusedto
establishifflowispresentindistalarterieswhenapalpablepulseisabsent.
2.Intheeventofanormalvascularexaminationonthecontralaterallimb,anembolicetiologyofALIis
likely.Ina patientpresentingwith symptoms consistent with thrombosis butnoknownhistoryofPAD,
physical findings to suggest underlying PAD include diminished extremity pulses, scant hair growth,
atrophicskin,hypertrophiednails,andischemiculcers.
C.RutherfordClassificationofAcuteLimbIschemia
Patients shouldbe categorizedinto aRutherford stage ofALI based on their clinical presentationand
physicalfindingswhichcanguidedecisionsontheirimmediatemanagement.StageIincludesthosewith
typicalpresentingsymptoms,audiblearterial andvenous Dopplersignals,andpreservedsensationand
musclestrengthonexamination.PatientscategorizedasstageIhavenoimmediatethreattolimbviability.
Stage II indicates that limb viability is threatened. In stage IIa the threat is marginal, with the limb
consideredsalvageableifpromptlytreated.Thesepatientshaveminimalsensorylossusuallyinvolving
thetoes,andthearterialDopplersignalisfrequentlyinaudible.InstageIIb,thereisanimmediatethreat
tolimbviability,andthelimbmaybesalvageablewithimmediaterevascularization.Sensorylossismore
extensiveandspreadsproximallyalongthefeet,muscleweaknessisalsopresentatamildormoderate
severity,andthearterialDopplersignalisusuallyabsent.InstageIII,thelimbisconsideredirreversibly
damaged with major tissue loss or permanent nerve damage. Sensory loss is profound, paralysis is
present,andarterialaswellasvenousDopplersignalsareabsent.
6
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V.DiagnosticEvaluation
A.DifferentialDiagnosis
The differential diagnosis for ALI includes direct arterial trauma, vasospasm, extrinsic compression,
decreased systemic perfusion, acute neurologic syndromes, deep venous thrombosis, vasculitis, and
chroniclimbischemia.Thehistoryandphysicalexaminationaretypicallysufficienttoarriveataleading
diagnosisofALI.Onceconditionsmimickingacutelimbischemiahavebeenexcluded,nonatherosclerotic
causesofacutelimbischemiashouldbeevaluated.Inmostcases,withtheexceptionofarterialtrauma,
dissection,andcompartmentsyndrome,theinitialmanagementisoftenunchanged.
B.Imaging
1.Noninvasivediagnosticimagingavailabletodeterminethenatureandextentoftheocclusionincludes
duplex ultrasonography, computed tomographic (CT) angiography, and magnetic resonance (MR)
angiography. The role of these imaging modalities in patients with Rutherford IIb ALI is limited as
revascularizationisrequiredwithin3-6hoursforlimbsalvage14;althoughCTorMRangiographymay
delineatevascular anatomyandassistintreatmentplanning,itisimportantthatthesetestsdonotdelay
intervention.
2. Duplex ultrasound is a useful testto perform preprocedurally on most patients, as it can be done
quicklyandentailslittlerisktothepatient.Inpatientsplannedtoundergosurgery,CTorMRangiography
is useful toensure an accuratediagnosis anddetermine theextent ofarterial occlusion.
15,16
In patients
whoareplanned to receiveendovasculartherapies, digitalsubtraction arteriography can beperformed
immediatelybeforetheproceduretoprovidetheinformationnecessarytoplantheintervention.
17
VI.Treatment
Treatmentstrategiesforacutelimbischemiaaredirectedatclotremovalandtreatmentofanyunderlying
vessel lesiontoincludeatheroscleroticdisease, dissection,aneurysm, thrombosis, intimalhyperplasia,
and other predisposing factors. These include medical therapy with anticoagulation, endovascular
treatment with catheter-directed thrombolysis and mechanical thrombectomy, and surgery for
embolectomyor bypass. Thedecisionregarding whichtreatment strategy topursuedepends on patient
characteristics aswellas classification of the threatened limb,includingcandidacyforanticoagulation
and thrombolysis based on clinical history and suitability for surgery based on careful medical
assessmentofcardiacandrespiratoryrisk.Itisimportanttounderstandbeforechoosingtherapywhether
the patientcan toleratethe type and lengthof treatment and whetherthe thrombusis accessible by the
modality chosen and to perform an assessment of the risk-benefit profile of anticoagulation and
thrombolysis.
A.Anticoagulation
Systemic unfractionated heparin (or low-molecular-weight heparin) should be administered at first
presentationwithALIoncediagnosisismadeforgoalaPTT1/5-2xcontrol.18Earlydatafromsurgical
literaturesuggestthatearlyfirst-linehigh-doseheparintreatmentresultsinasignificantdecreaseinthe
mortalityratewithoutanincreaseintheamputationrate.Thisnotonlypreventspropagationofthrombus
distallyinducedbystasisbutalsoproximallyinducedbyturbulenceofincomingbloodabuttingthrombus.
Inadditiontobeneficialeffectsonstallingclotpropagation,heparinhelpstopreventcatheterthrombosis
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