Patterns in the Management of Acute Limb Ischemia: A VESS Survey

Treatment strategies for acute limb ischemia (ALI) are abundant with few established guidelines. We sought to determine nationwide ALI treatment patterns in the modern era.

Anonymous electronic surveys examining the management of ALI involving native vessel and bypass occlusion were sent to all members of the Vascular and Endovascular Surgery Society (n = 738). Treatment options included catheter-directed lysis (CDL) or pharmacomechanical (PMT) thrombolysis and open surgery. CDL management strategies were evaluated for lytic and heparin dosing, fibrinogen monitoring, and treatment duration. Influence of Rutherford category (RC), time from training, practice type, hospital size, region, and protocol use was assessed. Data were analyzed by univariate contingency tables and multinomial regression analysis.

A total of 117 (response rate of 16%) surveys were completed. The most common management strategy RC 2a ischemia in all conduit occlusions was endovascular (prosthetic graft, 96 [82%] respondents; vein graft 96 [82%] respondents; native artery occlusion 79 [68%] respondents), while those with RC 3 ischemia were more commonly treated with open techniques (prosthetic graft, 96 [83%]; vein graft 94 [81%]; native artery occlusion 94 [80%]). Of those respondents using endovascular therapy, CDL was most commonly used in RC 2a patients, while PMT was most commonly used in RC 3 patients. Multivariate analysis identified prosthetic and vein graft occlusion were more likely to be treated via endovascular approach (odds ratio, 2.45 and 2.78, respectively; P < 0.001), while those with RC 2b (odds ratio, 0.19; P < 0.001), RC 3 (odds ratio, 0.01; P < 0.001), or in centers without a hybrid operating room (odds ratio, 0.49; P = 0.017) were more likely to be treated by open approach. Tissue plasminogen activator (TPA) dosing during catheter directed therapy was usually 1 mg/hr (77%) with variable concentrations and duration of the initial treatment of 8-24 hr (78%). Most respondents indicated having developed their own protocols and patterns of treatment varied but were influenced by training and practice environment variables.

Management strategies vary widely in ALI. Some effects of provider training and individual protocol development were observed, and TPA protocols were influenced by increased institutional responsibility for thrombolysis. Further efforts are needed to develop consensus guidelines for ALI management.