Acute Distal Limb Ischemia After Large-Bore Arterial Access: An Expert Review and Consensus Recommendations

Although large-bore arterial access (LBAA) enables lifesaving structural heart interventions and mechanical circulatory support, it increases patients' risk of acute distal limb ischemia (ADLI). Morbidity includes the potential need for fasciotomy or amputation, prolonged hospitalization, and death, yet practice patterns remain variable across centers. This consensus statement by multidisciplinary experts aims to define ADLI in the context of LBAA and to standardize best practices.

A 1-day consensus conference was convened with experts in critical care, anesthesiology, interventional cardiology, and vascular and cardiac surgery. A premeeting literature synthesis framed priority questions on physiology, prevention, detection, and management. Draft statements were refined through plenary and breakout sessions, finalized by recorded vote, and confirmed by the entire panel. Meeting transcripts and notes informed the narrative rationales.

Consensus was reached on a definition, 3 consensus statements, and 18 recommendations regarding ADLI after LBAA. Core elements were standardized prevention and monitoring standards, ultrasound-guided common femoral anterior wall puncture above the bifurcation by trained operators, a documented baseline neurovascular examination followed by at least hourly reassessment, consideration of near-infrared tissue oximetry for continuous trend monitoring, anticoagulation according to institutional protocols, and early vascular surgery engagement with predefined escalation and transfer criteria. For patients supported by centrifugal pumps, a prophylactic distal perfusion cannula with hourly flow checks is recommended. The resulting algorithms emphasize early trend recognition and rapid reperfusion.

This expert review provides minimum standards and consensus recommendations to shorten recognition-to-action time and improve limb salvage, thereby supporting quality improvement and multicenter learning.