2016 AHA/ACC Lower Extremity PAD Guideline

Jibran Mohsin
Resident, Surgical Unit I
SIMS/Services Hospital, Lahore
J Am Coll Cardiol. 2017 Mar 21;69(11):e71-126.
 Components
• PAD (Peripheral arterial disease)

• CLI (Critical Limb ischemia)

• ALI (Acute Limb ischemia)

ACUTE LIMB ISCHEMIA
 Definition
• Acute Limb Ischemia (ALI)

• Acute (<2 wk), severe hypoperfusion of the limb characterized by these

features
• Pain
• Pallor
• Pulselessness
• Poikilothermia(cold)
• Paraesthesias, and
• Paralysis

• 3 categories
Categories Class Sensory loss Motor loss Capillary refill Arterial flow Venous Tissue loss
(Doppler) flow
(Doppler)
Viable (not I No No Audible Audible Minor
immediately
threatened)
Threatened II a (marginally Limited to toes if No muscle Slow-to-intact Inaudible audible Minor
(salvageable) threatened) present weakness
II b (immediately > Toes and with Mild-moderate slow-to-absent
threatened) rest pain muscle
weakness
Irreversible III Profound profound Inaudible inaudible Major tissue
(nonsalvageabl sensory loss, muscle loss
e) Anesthetic weakness or inevtible
paralysis (rigor)
Permanent nerve damage
inevitable
 Clinical Presentation of ALI:
Recommendations

• Patients with ALI should be emergently evaluated by a clinician with

sufficient experience to

1. assess limb viability and

2. implement appropriate therapy.
 Clinical Presentation of ALI:
Recommendations

• In patients with suspected ALI, initial clinical evaluation should rapidly

assess limb viability and potential for salvage and does not require
imaging
 Medical Therapy for ALI: Recommendations

• In patients with ALI, systemic anticoagulation with heparin should be

administered unless contraindicated.

(Heparin (generally IV UFH) is given to all patients acutely. This can stop thrombus propagation and may provide an
anti-inflammatory effect that lessens the ischemia)
(in case of HIT and thrombosis direct thrombin inhibitor)
Revascularization for ALI: Recommendations

• In patients with ALI, the revascularization strategy should be

determined by local resources and patient factors (e.g., etiology and
degree of ischemia)

(Emergently vs urgent)
(Catheter-directed thrombolysis vs surgical thromboembolectomy)
RAPID RESTORATION of arterial flow with least risk to patient
Revascularization for ALI: Recommendations

• Catheter-based thrombolysis is effective for patients with ALI and a

salvageable (viable or marginally threatened) limb

(Particularly in setting of recent occlusion, thrombosis of synthetic grafts, and stent thrombosis)
Revascularization for ALI: Recommendations

• Amputation* should be performed as the first(index) procedure in

patients with a nonsalvageable (class III) limb

(low potential of limb salvage ad risk of reperfusion syndrome and associated MOF)

*may be deferred if pain under control and no infection and meets with patients goals
 Revascularization for ALI: Recommendations

• Patients with ALI should be monitored and treated (e.g., fasciotomy) for compartment syndrome
after revascularization

(due to reperfusion causing cellular edema)

Indications
1. Raised intra compartment pressure (> 30 mmHg) – not always easily accessible
2. Clinical: increased pain, tense muscle, or nerve injury
3. Category IIb ischemia for whom time to revascularization is > 4 hours
 Revascularization for ALI: Recommendations

• In patients with ALI with a salvageable limb, percutaneous mechanical

thrombectomy (PMT) can be useful as adjunctive therapy to
thrombolysis (pharmacologic therapy)
 Revascularization for ALI: Recommendations

• In patients with ALI due to embolism* and with a salvageable limb, surgical
thromboembolectomy can be effective

*arterial embolism with absent pulse ipsilateral to ischemic limb

1. may benefit from adjunctive intraoperative fibrinolytics

2. if fails, bypass can be performed
Revascularization for ALI: Recommendations

• The usefulness of ultrasound-accelerated catheter-based

thrombolysis (delivery of thrombolytic agents) for patients with ALI
with a salvageable limb is unknown
 Diagnostic Evaluation of the Cause of ALI:
Recommendations

• In the patient with ALI, a comprehensive history should be obtained to determine

the cause of thrombosis and/or embolization.

(Predisposing conditions: Atrial fibrillation, LV thrombus, aortic dissection, trauma, hypercoagulable

state, and limb artery bypass graft)

(History: MI, LV dysfunction  CCF, endocarditis, DVT with intracardiac shunt ( paradoxical artrial
embolism)
 Diagnostic Evaluation of the Cause of ALI:
Recommendations

• In the patient with a history of ALI, testing for a cardiovascular cause of

thromboembolism can be useful
(most useful in patient without underlying PAD)

1. ECG: rhythm (Atrial fibrillation) or evidence of MI

2. Echocardiography: cardiac etiology – valvular vegetation, LALV thrombus, or intracardiac shunt
Available at surgicalpresentations