Indication of non-surgical management for acute limb ischemia

Author(s): Haruya Yamane, Ryo Araki, Haruhiko Abe, Yasunori Ueda

Acute Limb Ischemia (ALI) is a sudden decrease in limb perfusion that has a potential threat of life and limb viability. Although, surgical thrombectomy using an occlusion catheter (Fogarty catheter) has been traditionally performed as the standard approach for ALI, endovascular treatment (EVT) has recently been developed as an alternative to surgical revascularization. However, its indication remains unclear. We reviewed the indication of conventional treatments and introduced our original technique. There are several non-surgical treatments for ALI such as Percutaneous Aspiration Thrombectomy (PAT), Catheter-Directed Thrombolysis (CDT), angioplasty and stenting. PAT is effective for the patients with ALI in small vessels such as below-the-knee arteries. CDT is recommended for Rutherford grade I patients. Angioplasty and stent implantation, which is a well-established strategy in peripheral arterial disease, is applicable for the ALI patients in any Rutherford grade. We previously reported an endovascular technique using a guide extension catheter in the non-stenting zone for ALI, which is named “Temporary Endoluminal Bypass (TEB) technique”. This technique is based on the concept of a perfusion catheter and applied for a treatment of ALI. This technique is composed of 3 steps. First, we measure the lesion length. Second, we deliver the guide extension catheter to fully cover the lesion. Finally, we confirm the distal blood flow by angiography. Subsequently, urokinase (10,000 U/hr) is selectively administered to the vessel from the sheath. The endpoint of thrombolysis is determined by the achievement of antegrade blood flow after removal of the guide extension catheter. TEB technique is basically recommended for the ALI patients with Rutherford grades IIa and IIb. TEB technique may be an alternative treatment option for ALI although further investigation is needed.