Rutherford's 103: Acute Limb Ischemia: Evaluation, Decision Making, and Medical Treatment

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This video provides a deep dive into Acute Limb Ischemia (ALI), drawing from Rutherford's Vascular Surgery and Endovascular Therapy 10th Edition. ALI is a sudden loss of blood supply to a limb, requiring rapid diagnosis and treatment. It can stem from various causes, primarily arterial embolism and arterial thrombosis.

Embolism involves a blockage travelling from elsewhere, often the heart (e.g., from AFib or mural thrombus), lodging at arterial bifurcations like the common femoral or popliteal arteries. This causes a sudden, severe "white leg" presentation due to lack of collateral circulation. Secondary thrombus formation is common.

Thrombosis is a clot forming within the artery itself, usually due to severe atherosclerosis. This presentation is often less sudden, potentially with a history of claudication that acutely worsens, as collaterals may have developed. Other causes include hypercoagulable states, aortic dissection extending into limb arteries, and blocked bypass grafts.

Assessment relies on history, physical exam (the six P's: Pain, Pallor, Paralysis, Pulselessness, Paresthesia, Perishingly cold), and bedside Doppler ultrasound. Severity is classified using the Rutherford system (Class I: Viable, II: Threatened, III: Irreversible), guiding urgency. Class IIb (Immediately Threatened) requires urgent revascularization.

Initial management includes immediate intravenous unfractionated heparin, supportive care, and pain relief. Treatment options are anticoagulation alone (for viable limbs or palliative care), open surgery (embolectomy, bypass), or endovascular interventions (mechanical thrombectomy, thrombolysis, angioplasty). The choice depends on limb severity (Rutherford class), cause, patient factors, and local expertise.

Outcome prediction tools exist, but prognosis is often guarded, with significant mortality and risk of limb loss, especially in older, comorbid patients. Acute upper limb ischemia is different, less often limb-threatening, with cardiac embolism being the main cause; treatment goals focus on long-term function. The COVID-19 pandemic added complexity, with potential links to clotting and impact on management. ALI remains a complex challenge requiring individualized, often multidisciplinary care.