Our Approach and Review of Current Concepts of Catheter Directed Procedures in Acute Limb Ischemia

Acute lower limb ischemia (ALI) is defined as sudden reduction of limb perfusion, leading to a threat to viability of the extremity. With better access to technology and better training in endovascular management in peripheral arterial disease, catheter-directed procedures are an attractive and feasible option in ALI patients. This article deals with our approach to ALI, the basic guidelines and clinical pathway adopted for its management, the hardware and drugs used, and also intraoperative and postprocedural care. It also briefly delves into our experience in using this protocol as also the recent modifications to standard techniques that have been employed, keeping in mind drawbacks such as bleeding and failure of recanalization when employing standard procedures. All patients who presented with ALI from the period of June 2016 to May 2021 with a short history of symptoms <14 days, Class 1, 2a, 2b ALI, and those that were fit and adequately consented for the procedure were studied. Those with age over 80 years, history of gastrointestinal bleed, and history of central nervous system bleed in the last 30 days were automatically excluded from undergoing these procedures. During this period, we saw 112 ALIs in our department, of which 74 cases were primarily deemed suitable for catheter-directed procedures, 60 for catheter-directed thrombolysis, 6 for AngioJet (TM), and 8 using the CAT6 Penumbra (TM) catheter. 6 (8.1%) cases subsequently failed the procedure and were converted to open surgery, of which only 2 of 6 had limb/s salvaged, meaning that 4 of 6 converted cases had major amputations. The high amputation rates (25 out of 112, i.e. 22.32%) were clearly attributable on audit, to a delayed referral to a tertiary care center, leading to a large number of Class 3 cases. In our part of the world, open surgical embolectomy is still the mainstay of treatment for ALI. However, an endovascular approach is an option that may be used in selected cases. The structural, personal, and technical conditions of each department must be considered before advocating this modality for therapy in patients.