The management of acute limb ischemia: techniques for dealing with thrombus

Acute limb ischemia (ALI) has long been a major clinical problem, producing significant risks for limb loss and death. It is most commonly caused by arterial thrombosis in the setting of underlying atherosclerotic peripheral vascular disease or by arterial embolism, usually of cardiac origin. Over the past several decades, preferred treatment options for ALI have alternated between medical and surgical approaches. More recently, direct intra-arterial thrombolysis became the standard of care after several randomized trials demonstrated the benefit of this approach as compared with acute surgical intervention. Despite all of the experience with direct intra-arterial thrombolysis for the treatment of ALI, the optimal thrombolytic approach not been clearly established. Current investigation is directed at identifying the ideal thrombolytic agent for this purpose and the appropriate dosing regimen. In addition, there is interest in the newer mechanical thrombectomy devices and the use of platelet glycoprotein IIb/IIIa inhibitors to speed the time to reperfusion of the acutely ischemic limb.