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short and long term outcomes of CDT for patients with not immediately threatening
limb ischaemia. Thirty-nine studies were included, comprising 1861 patients who
received CDT for not immediately threatening ALI.Funnel plots showed an indication of publication bias, and heterogeneity was substantial. Data from 5 to 13 studies were included in the meta-analysis. The pooled treatment duration was 2days,
with an angiographic success rate of 80% and a 30day freedom of amputation rate
of 98%. The major bleeding rate was 5%, with a 30day mortality rate of 3%. The
amputation free survival rate was 71% at the 1year and 63% at the 3year follow up.
Long term patency rates were retrieved from four studies: 48% at 1year. Although
CDT in the treatment of not immediately threatening ALI showed high angiographic
success, the long term outcomes were relatively poor, with low patency and a substantial risk of major amputation. Further research is required to interpret the outcome of CDT in the context of potential confounders such as age and
comorbidities.
13.3.1.2 Ultrasound-Accelerated Thrombolysis
Araujo etal. [5] assessed the safety and effectiveness of percutaneous thrombectomy or ultrasound-accelerated thrombolysis (USAT) for the initial management of
ALI in adults. They included one RCT in this Cochrane review. This study had a
total of 60 participants and compared USAT with standard treatment catheterdirected thrombolysis (CDT). There was insufcient evidence to assess the safety
and effectiveness of USAT versus CDT alone for ALI for the evaluated outcomes:
amputation rate, major bleeding, clinical success, and adverse effects.
13.3.1.3 Infusion Techniques forPeripheral Arterial Thrombolysis
The effects of infusion techniques during peripheral arterial thrombolysis for treatment of patients with ALI were compared by Broderick and Patel [6] in a Cochrane
Review (9 studies/671 patients).Trials were grouped according to types of techniques assessed (e.g. intravenous and intra-arterial delivery of the agent, ‘high-’ and
‘low-dose’ regimens of the agent, continuous infusion and ‘forced infusion’ of the
agent, use of adjunctive antiplatelet agents). There was insufcient evidence to
show that any thrombolytic regimen provides a benet over any other in terms of
amputation-free survival, amputation, or 30-day mortality. The rate of cerebrovascular accident or major bleeding requiring surgery or blood transfusion did not
clearly differ between regimens but may occur more frequently in high dose and IV
regimens. This evidence was limited and of very low certainty. Minor bleeding may
be more common with high-dose and IV regimens. In this context, thrombolysis
may be an acceptable therapy for patients with marginally threatened limbs
(Rutherford grade IIa) compared with surgery. Caution is advised for patients who
do not have limb-threatening ischaemia (Rutherford grade I) because of risks of
major haemorrhage, cerebrovascular accident, and death from thrombolysis.
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13 Acute Limb Ischemia
13.3.1.4 Endovascular andSurgical Revascularization Techniques
Veenstra etal. [7] compared the safety and effectiveness of catheter-driven thrombolysis (CDT) with surgical revascularization and evaluated the various brinolytic
agents, endovascular, and pharmacochemical approaches that aim for thrombectomy. Twenty-ve studies, investigating a total of 4689 patients, were included for
meta-analysis. No differences were found in limb salvage between thrombectomy
and thrombolysis. More major vascular events were seen in the thrombolysis group
(6.5% compared with 4.4% in the surgically treated group; P= .02). Comparable
limb salvage was found for high- and low-dose recombinant tissue plasminogen
activator (r-tPA). No signicant differences were found in major vascular event
between low r-tPA (14%) and high r-tPA (10.5%; P=.13). The 30-day limb salvage
rate was 79.7% for r-tPA treatment and 60.4% for streptokinase (OR, 3.14; P=.01).
AngioJet showed more limb salvage at 6months compared with r-tPa (OR, 2.21;
P=.01). Both CDT and surgery have comparable limb salvage rates in patients with
ALI; however, CDT is associated with a higher risk of hemorrhagic complications.
No conclusions can be drawn regarding the risk of hemorrhagic complications
regarding thrombolytic therapy by means of r-tPA, streptokinase, or urokinase.
Insufcient data are available to conclude the preference of using a hybrid approach,
ultrasound-accelerated CDT, heated r-tPA. or novel endovascular (rheolytical)
thrombectomy systems.
13.3.1.5 Outcomes after Acute Limb Ischemia inPatients withCancer
Cancer results in a hypercoagulable state that is associated with both venous and
arterial thromboses. In a systematic review and meta-analysis, Govsyeyev etal. [8]
analyzed the available clinical data on cancer and its association with ALI and evaluated the outcomes in these patients after a diagnosis of ALI.Seven studies with
2899 patients were included in this review. 1195 (41%) had had a diagnosis of ALI
before their cancer diagnosis, and 1704 (59%) had presented with ALI after a cancer
diagnosis. Nearly three quarters of ALI events were among patients with cancer of
the skin and soft tissue (19%), genitourinary (18%), lung (17%), and gastrointestinal (16%) systems. Major amputation was more likely in patients with a diagnosis
of ALI after a cancer diagnosis (7.4% vs 4.6%; P<.01). The incidence of mortality
at 1year was signicantly greater for patients with established cancer who had presented with ALI compared with the patients who had presented with ALI before a
cancer diagnosis (50.6% vs 29.9%; P<.01). The occurrence of ALI in patients with
cancer results in high mortality, regardless of whether it precedes or follows a cancer diagnosis. Because the occurrence of ALI could be a paraneoplastic phenomenon of a clinically silent cancer, an underlying cancer should be considered in
otherwise healthy patients presenting with ALI, and a cancer risk assessment should
be performed.
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13.3.2 Studies/Registries
13.3.2.1 Acute Limb Ischemia among Patients withCOVID-19 Infection
The aim of a review presented by Galyfos etal. [9] was to evaluate pooled data on
patients with COVID-19 infection and ALI.In total, 34 studies (19 case reports and
15 case series/cohort studies) were found. These studies evaluated a total of 540
patients, out of which 199 were eligible for this analysis. Mean age of patients was
61.6years and 78.4% of patients were male. Medical treatment was selected as rst-
line treatment for 41.8% of cases. Pooled mortality rate among 34 studies reached
31.4%. Pooled amputation rate among 34 studies reached 23.2%. Pooled clinical
improvement rate among 28 studies reached 66.6%. Pooled reoperation rate among
29 studies reached 10.5%. Medical treatment was associated with a higher death
risk compared with any intervention (odds ratio, 4.04; P=.045) although amputation risk was not different between the two strategies (odds ratio, 0.977; P=.986)
(data from 31 studies). The message was that SARS-CoV-2 infection is associated
with a high risk for thrombotic complications including ALI.COVID-19 associated
ALI occurred in patients with a low incidence of comorbidities and was associated
with high mortality and amputation risk. Conservative therapy seemed to have a
higher mortality risk than any intervention.
Bellosta etal. [10] evaluated the data from 20 patients with ALI who were posi-
tive for COVID-19. Operative treatment was performed in 17 patients (85%).
Revascularization was successful in 12 of the 17 (70.6%). Of the 20 patients, eight
(40%) had died in the hospital. The patients who had died were signicantly older
(81±10years vs 71±5years; P=.008). Although successful revascularization was
not signicantly associated with the postoperative use of intravenous heparin
(64.7% vs 83.3%; P = .622), no patient who had received intravenous heparin
required reintervention. The use of continuous postoperative systemic heparin infusion was signicantly associated with survival (0% vs 57.1%; P=.042).
Lou etal. [11] assessed endovascular and open surgical lower-extremity revascu-
larization and amputation procedural volumes and outcomes before, during, and
after the rst North American COVID-19 pandemic surge, using data from the
Society for Vascular Surgery Vascular Quality Initiative (VQI). The nal cohort
comprised 57,181 patients from 147 US and Canadian sites. Overall procedure volumes fell 35.2% during and 19.8% following the surge, compared with presurge
months. Procedure volumes fell 71.1% for claudication (p<0.001) and 15.9% for
CLTI (p<0.001) but remained unchanged for ALI when comparing surge to presurge months. Adjusted mortality was signicantly higher among those with claudication (0.5% vs 0.1%; p=0.01) and ALI (6.4% vs 4.4%; p=0.003) when comparing
postsurge with presurge period.
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13 Acute Limb Ischemia
13.3.2.2 Endovascular-First Approach toAcute Limb Ischemia
Poursina et al. [12] performed a single-center, single-arm, retrospective cohort
study of 60 consecutive patients with ALI from 2015 to 2018. The Rutherford class
was I in 15 patients (25%), IIa in 23 (38%), IIb in 13 (22%), and III in 9 patients
(15%).The endovascular-rst approach procedures included catheter-directed
thrombolysis only (n = 19; 32%), catheter-directed thrombolysis plus aspiration
and/or rheolytic thrombectomy (n = 19; 32%), and aspiration and/or rheolytic
thrombectomy (n=16; 26%). Six patients (10%) underwent covered stent placement only. Technical success was achieved in 58 patients (97%), with open conversion required in two patients (3%). At 30days postoperatively, 52 patients (87%)
survived, and 53 (88%) had successful limb salvage. Five patients (8%) had required
four-compartment fasciotomy. At 1year, the Kaplan-Meier estimates were as follows: amputation-free survival 58%, limb salvage 74.3% and survival 73.3%. The
current endovascular approaches to ALI have high technical success rates. Survival,
limb salvage, perioperative complications, and length of stay were similar to those
from previous reports of historical open cohorts.
Tsujimura etal. [13] compared the outcomes of endovascular therapy in 2398
cases of ALI with those in 74,171 patients with CLTI using data from a national
Japanese registry of EVT between January 2015 and December 2018. Patients with
ALI were older and had a higher prevalence of female sex, impaired mobility, and
history of cerebrovascular disease, but a lower prevalence of cardiovascular risk
factors and history of coronary artery disease. The proportion of in-hospital EVTrelated complications in ALI was 6.1% and was signicantly higher compared with
those in chronic symptomatic PAD patients (2.0%, P<0.001). Bedridden status,
history of coronary artery disease, and a suprapopliteal lesion were identied as
independent risk factors for in-hospital complications.
13.3.2.3 Open Surgical Intervention forALI
Using the NSQIP database from 2012–2017, Gupta etal. [14] assessed the rate of
reintervention for ALI after open surgical intervention. A total of 2878 ALI patients
underwent open revascularization; 35.7% were transfers from another acute care
hospital. A total of 13.8% required reoperation and 7.9% required readmission
within 30 days. A total of 32% of reoperations were recurrent revascularization,
representing 4.4% of all ALI patients. The 30-day all-cause mortality was 9.24%.
2135 (74.2%) patients underwent lower extremity revascularization and 707
(24.6%) underwent upper extremity revascularization. Patients with lower extremity ALI had signicantly higher mortality rate (10.1% vs. 6.6%, P=0.03), readmission rate (9.1% vs. 4.4%, P < 0.01), and reintervention rate (15.0% vs. 10.1%,
P<0.01) respectively, compared to upper extremity patients.
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13.3.2.4 Endovascular Versus Surgical Revascularization forALI
Kolte etal. [15] used the 2010 to 2014 National Inpatient Sample databases to identify hospitalizations with a primary diagnosis of ALI.Patients were propensityscore matched on the likelihood of undergoing endovascular versus surgical
revascularization using a logistic regression model. The primary outcome was inhospital mortality. Of 10,484 hospitalizations for ALI, endovascular revascularization was performed in 5008 (47.8%) and surgical revascularization in 5476 (52.2%).
In the propensity-score matched cohort (n=7746; 3873 per group), patients who
underwent endovascular revascularization had signicantly lower in-hospital mortality (2.8% versus 4.0%; P=0.002), myocardial infarction, composite of death/
myocardial infarction/stroke, acute kidney injury, fasciotomy, major bleeding, and
transfusion, but higher vascular complications, compared with those undergoing
surgical revascularization. Rates of any amputation were similar between the 2
groups. Median length of stay was shorter and hospital costs higher with endovascular versus surgical revascularization (Table13.2). In patients with ALI, endovascular revascularization was associated with better in-hospital clinical outcomes
compared with surgical revascularization.
In the National Inpatient Sample databases from 2005 to 2014, Holscher etal.
[16] found a total of 116,451 admissions for ALI. 40,982 (35.2%) patients had an
endovascular rst approach. There was an increase in the proportion of ALI admissions treated by an endovascular-rst approach over time, starting from 25.7% in
2005 and increasing to 41.6% in 2014 (per year: odds ratio, 1.07; P < .001).
Independent predictors of endovascular-rst management included younger age,
male sex, renal insufciency, and more recent calendar year of admission (P≤.02),
whereas patients who underwent fasciotomy, those with Medicaid, and those admitted on a weekend were more likely to undergo open-rst management (P≤ .02).
Table 13.2 In-hospital outcomes of endovascular vs surgical revascularization for acute limb
ischemia. Propensity score matched analysis. Data from the National Inpatient Sample databases
2010 to 2014 (according to [15])
Outcome Endovascular n=3873 Surgical n=3873 P
Death, n (%) 108 (2.8) 156 (4.0) 0.003
Myocardial infarction, n (%) 74 (1.9) 104 (2.7) 0.023
Stroke, n (%) 56 (1.4) 73 (1.9) 0.13
Death/Myocardial infarction/Stroke, n (%) 202 (5.2) 292 (7.5) <0.001
Any amputation, n (%) 182 (4.7) 197 (5.1) 0.43
Fasciotomy, n (%) 74 (1.9) 315 (8.9) <0.001
Acute kidney injury, n (%) 406 (10.5) 462 (11.9) 0.044
Major bleeding, n (%) 648 (16.7) 812 (21.0) <0.001
Intracranial haemorrhage, n (%) 27 (0.7) 13 (0.3) 0.030
Transfusion, n (%) 400 (10.3) 716 (18.5) <0.001
Vascular complications, n (%) 53 (1.4) 26 (0.7) 0.003
Length of stay, days 4.0 (2.0 bis 7.0) 5.0 (3.0 bis 8.0) <0.001
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13 Acute Limb Ischemia
Endovascular-rst management had higher mean hospital costs than open-rst management ($29,719 vs $26,193; P < .001). The risk-adjusted odds of in-hospital
major amputation was similar in both groups (adjusted odds ratio, 0.99; 95% CI,
0.85–1.15; P=.88). ALI patients treated with an endovascular-rst approach had
lower crude in-hospital mortality than those with an open-rst approach (3.9% vs
6.4%; P<.001). After adjustment for patient, hospital, and admission factors, an
endovascular-rst approach was associated with 32% lower odds of in-hospital
mortality compared with an open-rst approach.
Yang etal. [17] compared the safety, feasibility, and outcomes of ALI after surgi-
cal embolectomy or catheter-directed therapy (CDT). Data from the Taiwan’s
National Health Insurance Database (NHID) between the years 2000 and 2015 were
used. There was no signicant difference in mortality risk between CDT (n=905)
and surgical intervention (n=4559; 9.5% vs 10.68%). The risk of amputation was
also comparable between the two groups. (13.59% vs 14.81%). Age (p<0.001) and
liver disease (p= 0.01) were associated with higher mortality risks. Heart failure
(p= 0.03) and chronic or end-stage renal disease (p=0.03) were associated with
higher amputation risks. Prior antithrombotic agent use (p= 0.03) was associated
with a reduced risk of amputation. Both surgical intervention and CDT were effective and feasible procedures for patients with ALI in Taiwan.
13.3.2.5 Thrombolytic Therapy forALI
Acosta etal. [18] compared the effects of thrombolysis, complications, and outcomes of pharmaco-mechanical thrombolysis (PMT) rst versus catheter-directed
thrombolysis (CDT) rst in a large cohort of patients with ALI.In this monocenter
study, all consecutive endovascular thrombolytic/ thrombectomy events in patients
with ALI performed between January rst, 2009, and December 31st, 2018 (n=347)
were included. Presentation of Rutherford IIb ALI was more common in the PMT
rst group (36.2% vs. 22.5%, respectively, P = 0.027). Among the 58 patients
receiving PMT rst, 36 (62.1%) were terminated within a single session of therapy
without need of CDT.The median duration of thrombolysis was shorter (P<0.001)
for the PMT rst group (n=58) compared to the CDT rst group (n=289) (4.0 vs.
23.0h, respectively). There was no signicant difference in amount of tissue plas-
minogen activator given, successful thrombolysis/thrombectomy (86.2% and
84.8%), major bleeding (15.5% and 18.7%), distal embolization (25.9% and 16.6%),
major amputation or mortality at 30-days (13.8% and 7.7%) in the PMT rst compared to the CDT rst group, respectively. The proportion of new onset of renal
impairment was higher in the PMT rst compared to the CDT rst group (10.3% vs.
3.8%, respectively), and the increased odds (odds ratio 3.57, 95% condence inter-
val 1.22–10.41) were maintained in the adjusted model. In conclusion, both PMT
rst and CDT rst have high technical success rates, and PMT rst appears to be a
good treatment alternative in Rutherford IIb ALI.The found renal function deterioration in the PMT rst group needs to be evaluated in a prospective, preferably
randomized trial.
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Doelare etal. [19] determined the relationship between deviating blood clotting
tests, APTT and brinogen, and major bleeding, as well as its impact on patient
relevant clinical outcomes after CDT.All consecutive patients treated with CDT for
ALI in two Dutch hospitals between January 2004 and April 2021 were analysed
retrospectively. Patients were treated with two dosing regimens (low dose:
50,000IU/h; high dose: 100,000IU/h) of urokinase and, after 2018, with a single
low dose regimen of alteplase (rtPA) due to urokinase manufacturing problems. Of
the 443 included cases, 277 underwent CDT with urokinase and 166 with rtPA.The
incidence of major bleeding in the whole cohort was 7%. Patients with a brinogen
levels <1.0g/L developed more major bleeding than those in whom the brinogen
level did not drop below 1.0g/L (15% vs. 6%; p=.041). Systemic heparinisation
during CDT or high (> 80seconds) APTT were not signicantly associated with
major bleeding. Angiographic success (47% vs. 72%; p=.003) and 30day amputation free survival (53% vs. 82%; p<.001) were lower for cases with major bleeding.
Older age, cardiac history, high dose regimens (≥75,000IU/hour urokinase), and
brinogen values <1.0g/L were independent predictors for major bleeding during
CDT. In conclusion, high dose thrombolytic regimens and brinogen levels of
≤1.0g/L were associated with more major bleeding during thrombolytic therapy.
Major bleeding signicantly worsened the clinical outcome.
Bath etal. [20] analyzed the trends, outcomes, and complications of thrombolytic
therapy for ALI in the United States using the Nationwide Inpatient Sample
(2003–2013). A total of 162,240 patients with acute limb ischemia were estimated:
33,615 patients (20.7%) underwent thrombolysis as the initial treatment. The utilization of thrombolysis increased signicantly during the study period (16.8–24.2%,
p<0.0001). The most common group was thrombolysis and endovascular procedure
(40.7%), followed by thrombolysis alone (34.1%), and thrombolysis and open surgery, T+OPEN (25.2%). Overall mortality was 4.9%; thrombolysis and endovascular procedure compared to thrombolysis alone and T + OPEN had a lower mortality
rate (3.2% vs. 6.1% and 5.9%, p<0001). The overall stroke rate was 1.9%; thrombolysis alone had the highest stroke rate (3.0%, p<0.0001) with thrombolysis and
endovascular procedure the lowest (1.2%) and T+OPEN 1.7%. The highest amputation rate was T+OPEN (11.6%, p<0.001) compared to thrombolysis and endovascular procedure (5.1%) and thrombolysis alone (5.3%). T+OPEN had the highest
incidence of cardiac (5.5%), respiratory (7.3%) and renal complications (12.5%),
pneumonia (4.0%), and fasciotomy (16.8%) (all p<0.0001). Thrombolysis remains
an effective treatment for acute limb ischemia with increased utilization over time.
Using a Swedish database, Grip etal. [21] reported long-term outcomes after
thrombolysis in 590 patients (689 limbs) with ALI.The aetiology of ischaemia was
graft/stent/stent graft occlusion in 39.8%, arterial thrombosis in 27.7%, embolus in
25.1% and popliteal aneurysm in 7.4%. The mean follow-up was 59.4months, dur-
ing which 32.9% needed further re-interventions, 16.4% underwent amputation
without re-intervention, and 50.7% had no re-intervention. The need for reintervention during follow-up was 48.0% in the graft/stent occlusions group, 34.0%
of the popliteal aneurysm group, 25.4% in the thrombosis group, and 16.3% in the
embolus group (p<.001). The amputation rate was lower in the embolic group at 1
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Table 13.3 Long-term outcome after thrombolysis for acute lower limb ischaemia. (According
to [21])
Popliteal
Variable Thrombosis Embolus
Patients, n (%) 191 (27.7) 173
(25.1)
Age, years 72.6 76.6 70.1 69.1
Successful thrombolysis, % 73.4 86.7 78.4 85.8
Adjuvant revascularisation
procedure, %
–Endovascular, % 84.4 87.1 33.3 77.1
–Open, % 7,1 4.3 54.8 9.0
–Hybrid, % 8.4 8.6 11.9 13.9
Major bleeding complications, % 13.7 8.7 21.6 15.0
Major amputation <30days, % 13.6 4.1 25.5 10.9
Survival <30days, % 93.7 93.6 98.0 97.4
Primary patency after 1year, % 67.3 85.7 59.1 62.6
Amputation after 1year, % 19.9 8.1 27.1 20.4
Survival after 1year, % 83.2 81.5 96.1 85.8
Primary patency after 5years, % 55.1 83.3 37.9 43.3
Amputation after 5years, % 22.3 11.1 30.6 40.1
Survival after 5years, % 54.1 49.6 83.3 50.5
Note: Signicant differences highlighted
80.6 67.1 82.4 81.4
aneurysm
51 (7.4) 274 (39.8)
13 Acute Limb Ischemia
Graft/stent
occlusion
and 5years (8.1% and 11.1%, respectively, p = .001). Survival was higher in the
group with occluded popliteal aneurysms at 5years (83.3%, p=0.004). Amputation
free survival was 72.1% and 45.2% at 1 and 5years; lower in the occluded graft/
stent group at 5years (37.9%, p=.007). In conclusion, intra-arterial thrombolytic
therapy achieves good medium and long-term clinical outcome, reducing the need
of open surgical treatment in most patients (Table13.3).
Ascher etal. [22] created a fast-track thrombolysis protocol for arteries (FTTP-A).
The goal of the protocol is to re-establish patency during the rst session of thrombolysis, thus decreasing costs and complications associated with prolonged periods
of thrombolytic exposure. FTTP-A includes periadventitial lidocaine injection at
the arterial puncture site under ultrasound guidance, contrast arteriography of the
entire targeted segment, pharmacomechanical rheolytic thrombectomy of the
occluded arterial segment, tissue plasminogen activator infusion along the occluded
segment, balloon maceration of the thrombus, and (if deemed necessary) placement
of a stent in an area of signicant (≥30%) stenosis that is refractory to balloon
angioplasty and thrombolysis. Primary FTTP-A (50 total interventions) was performed in 42 patients. The mean operative time was 148.9 ± 62.9 min (range,
83–313minutes), and the mean volume of tissue plasminogen activator infused was
9.7±4.0mg (range, 2–20mg). Of 42 patients with acute limb ischemia (ALI) who
underwent FTTP-A, 34 (81%) patients had complete thrombus resolution in a single
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session, with no intensive care unit stays, decreased use of tissue plasminogen activator, and decreased costs compared with procedures that required overnight thrombolytic infusion. There was no limb loss or mortality at 5years.
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13.3.3 Special Issues
13.3.3.1 ALI after Cardiac Surgery
In a retrospective analysis of single center prospectively collected registry data,
Folkert etal. [23] investigated the outcomes of patients who suffered from ALI after
open cardiac and thoracic aortic surgery. Between 2002 and 2012, there were 11,343
patients who underwent major open cardiac surgery, with 156 cases of ALI for an
incidence of 1.4%. There were 105 operations performed for 156 cases of ALI.The
most common operation performed for ALI was thrombectomy (43 [28%]), followed by fasciotomies (20 [13%]); percutaneous intervention (6 [4%]), endarterectomy (5 [3%]), and lower extremity bypass operations (4 [3%]) were less commonly
performed. There were 21 major (13%) and six minor (4%) amputations performed
on the index hospitalization, including two upper extremity amputations. ALI was
associated with a signicant reduction in long-term survival (hazard ratio, 3.72;
95% CI, 2.97–4.65; P<.0001). This study suggests that acute limb ischemia after
open cardiac operations is associated with a signicant risk of amputation and
decreased long-term survival.
13.3.3.2 Management ofAcute Limb Ischemia inPaediatric Patients
Wang et al. [24] reported the long-term morbidity associated with infants who
develop ALI and are not offered initial surgical intervention A total of 25 (28%
female) infant patients were diagnosed with ALI.The average age for this cohort
was 3.5±3.2months (standard deviation). Most cases were secondary to iatrogenic
injury (88%) from arterial cannulation. Injury sites were more concentrated to the
lower extremities (84%) compared with the upper. Absence of Doppler signals was
noted in 64% of infants, whereas limb cyanosis was observed in 60% at the time of
presentation. Infants were initially treated with anticoagulation (80%) when possible. Two patients failed to respond to nonoperative management and required
thrombolysis secondary to progression of thrombus burden while anticoagulated.
There were no major (above-ankle) amputations at 30days. Three deaths occurred
within 30days; all were unrelated to limb ischemia. In the 30-day survivors, overall
duration of follow-up was 53.5± 38.5 months. One infant required above-knee
amputation 6weeks after diagnosis, resulting in an overall limb salvage rate of 96%
on follow-up. In contrast to the adult population, ALI in infants can be managed
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with anticoagulation alone with good results. Long-term follow-up continues to
demonstrate excellent functional results and minimal disability.
The Healthcare Cost and Utilization Project State Inpatient Database (California,
Iowa, and NewYork) between 2007 and 2013 was queried by Lim etal. [25]. A total
of 1576 pediatric patients with ALI were identied among 6,122,535 pediatric
admissions (26 per 100,000 admissions). Average age was 9.9±7.1years. There
were 263 patients who underwent surgical revascularization. Overall, the amputation rate was low (<2%; n=28), especially in the upper extremities. Infants demonstrated the highest limb preservation rate compared with older age groups. Mortality
rate for patients with ALI was statistically different between groups (8.5% in infants,
4.2% in children, and 3.0% in adolescents; P<.01). Open surgical revascularization
is not associated with improved major amputation or in-hospital mortality.
Nonoperative management may be considered an initial treatment modality for
most pediatric ALI.
13.4 Conclusions forClinical Practice
1. Patients with ALI should be emergently evaluated by a clinician with sufcient
experience to assess limb viability and implement appropriate therapy.
2. For marginally or immediately threatened limbs (Category IIa and IIb ALI),
revascularization should be performed emergently (within 6h). For viable limbs
(Category I ALI), revascularization should be performed on an urgent basis
(within 6–24h).
3. For patients with acute limb ischemia awaiting revascularization, heparin is
recommended.
4. In patients with ALI, the revascularization strategy should be determined by
local resources and patient factors (e.g., etiology and degree of ischemia).
5. Catheter-based thrombolysis is effective for patients with ALI and a salvageable
limb. An endovascular-rst approach seems to be associated with lower odds of
in-hospital mortality compared with an open-rst approach.
6. ALI in infants can be managed with anticoagulation alone with good results.
References
1. Aboyans V, Ricco JB, Bartelink MEL, etal. 2017 ESC guidelines on the diagnosis and treatment of peripheral arterial diseases, in collaboration with the European Society for Vascular
Surgery (ESVS): document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries. Endorsed by: the European Stroke
Organization (ESO)the task force for the diagnosis and treatment of peripheral arterial diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular
Surgery (ESVS). Eur Heart J. 2018;39:763–816.
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