MANAGEMENT OF ACUTE LOWER-EXTREMITY ARTERIAL ISCHEMIA DUE TO EMBOLISM AND THROMBOSIS

Abstract

The current mortality rate for acute arterial ischemia, approximately 25%, apparently relates to toxins and procoagulants released from the dying limb, a tendency which may be enhanced further by attempts at revascularization. Selective management of acute arterial ischemia was attempted to minimize deaths and to salvage the maximum number of limbs. If the patient presents within 6-8 h of the onset of acute arterial occlusion and if paralysis or anesthesia is present, then ultimate limb loss is likely. The therapeutic choices are high-dose heparin therapy, operative removal of the clot, or amputation of the limb, the choice being dependent on the particular status of the patient. If sensation and motor function are present, viability of the limb is not threatened and good results can be obtained by utilizing anticoagulation and delayed elective revascularization, if the latter is indicated. Revascularization attempts after 10-12 h of severe ischemia often are unsuccessful, and ischemia is followed either by recurrent thrombosis and ultimate limb loss, or by death from the systemic effects of reperfusion of ischemic tissue. This type of limb is best managed by using high-dose heparin therapy if viable, or by amputation if it is not. Employing these criteria, 54 patients with acute arterial ischemia, averaging 59 yr of age, were treated. Seventeen had immediate thrombectomy, yielding 2 deaths and 4 subsequent amputations. Twenty-nine received anticoagulation treatment, resulting in 1 death and 5 amputations, and 6 had immediate amputation, yielding 1 death. Three had no specific treatment, with 1 poor result. There were 4 deaths in the entire series, a mortality rate of 7.5%, and 2/3 of the limbs were salvaged. Selective management was responsible for a significant decrease in mortality rate with no corresponding increase in limb loss, and high-dose heparin therapy may prove the initial treatment of choice in all cases of acute arterial ischemia.