In light of emerging technology, is it time to reassess an endovascular-first approach to treating acute limb ischemia?
In a recently published retrospective study in the Journal of Vascular Surgery involving 60 patients with acute limb ischemia, researchers assessed the use of catheter-directed thrombolysis (CDT) only in 19 patients, CDT plus aspiration and/or rheolytic thrombectomy (19 patients), and aspiration and/or rheolytic thrombectomy (16 patients).1 Six patients had covered stent placement only, according to the study. The study population included Rutherford class I presentations of acute limb ischemia (15 patients), class IIa (23 patients), class IIb (13 patients) and class III (9 patients).
Noting technical success of the procedures in 97 percent of the study population, Poursina and colleagues found a survival rate of 87 percent and successful limb salvage in 88 percent of the patients at 30 days postoperatively.1 At one year post-op, researchers noted Kaplan-Meier estimates of 58 percent amputation-free survival, a 74.3 percent limb salvage success rate and a 73.3 percent survival rate. The study authors noted that their findings with endovascular-first treatment approaches were similar to those reported in previous open surgery studies.
Leigh Ann O’Banion, MD, RPVI, FACS, FSVS, praises the “excellent” work of the study authors in demonstrating contemporary outcomes of an endovascular-first approach to treating acute limb ischemia.
“This study highlights the importance of having an additional tool in your toolbox that can aid in successful limb salvage in a common vascular emergency,” notes Dr. O’Banion, an Assistant Clinical Professor of Surgery in the Department of Surgery at the University of California San Francisco-Fresno. “As we continue to push the limits of limb salvage, having both open and endovascular options to treat patients in any situation is going to be critical. I think further studies will demonstrate that in appropriately selected patients, an endovascular-first approach may be warranted.”
Dr. O’Banion says there have been significant developments in endovascular technologies over the past decade. For example, she notes vacuum-assisted percutaneous aspiration thrombectomy (Indigo System, Penumbra) has “significantly impacted” the way she approaches certain patients presenting with acute limb ischemia.
“The ability to perform an endovascular thrombectomy not only allows for debulking of the clot quickly, but it reserves the ability to perform CDT for any residual clot burden, especially in those patients with extensive clot burden or severe outflow thrombosis,” explains Dr. O’Banion. “Intravascular ultrasound and the ability to treat underlying disease are also appealing with endovascular treatment of acute limb ischemia. Often times in patients with severe vasculopathy, the source may be a heavily calcified lesion or bypass graft stenosis that can be easily treated, and otherwise would have been missed with an open thrombectomy.”
In the aforementioned study, Poursina and colleagues note a 9-day median length of stay and two days in the intensive care unit (ICU).1 Dr. O’Banion has seen similar length of stay with endovascular treatment of her patients. She says initiation of CDT typically results in a two-day ICU stay at her institution and sometimes more if the patient is lysed over a longer period. Additionally, patients who have higher Rutherford classes of acute limb ischemia often have prolonged hospital stays due to fasciotomies and associated comorbidities, according to Dr. O’Banion. That said, she says the endovascular-first treatment approach can be “significant” for avoiding incisional complications in high-risk patients such as people with diabetes, those who are morbidly obese, smokers and cases involving redo-groin procedures.
“With the advent of newer technology, I have also found that a number of patients can be successfully treated without CDT, thereby avoiding an ICU stay and decreasing overall length of stay, especially if fasciotomies are not required,” points out Dr. O’Banion.
When it comes to post-op management of patients treated with endovascular therapy, Dr. O’Banion emphasizes a strong awareness of potential complications immediately after these procedures and close monitoring of the patient thereafter.
“Education is critical to the success of these patients in the immediate post-operative setting. The ICU nursing staff, residents and trainees, and OR staff all need to be aware of the potential complications of CDT (bleeding, ischemia, stroke, disseminated intravascular coagulation (DIC)), says Dr. O’Banion. “Additionally, close surveillance is key especially if an underlying lesion was the source of the event and was treated endovascularly. I typically obtain non-invasive studies for a baseline prior to discharge and then at one, three, and six months prior to maintenance surveillance in this situation. Antiplatelet and antithrombotic medication are essential.”
While noting the promise of emerging endovascular treatments, Dr. O’Banion says there are clinical circumstances that call for open surgery procedures in the management of acute limb ischemia. She agrees with the study authors in favoring open thromboembolectomy for appropriate risk patients with a focal thromboembolic event to the common femoral artery (CFA) and its bifurcation.1 Additionally, for patients presenting with a higher Rutherford class of acute limb ischemia and/or prolonged ischemia time who require fasciotomies, if one can address a focal popliteal or proximal tibial clot through a medial below-knee incision, Dr. O’Banion says “open surgery may be the more expeditious choice.”
- Poursina O, Elizondo-Adamchik H, Montero-Baker M, Pallister Z, Mills JL, Chung J. Safety and efficacy of an endovascular-first approach to acute limb ischemia. J Vasc Surg. 2021;73(5):1741-1749.