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©2013 UpToDate ® Print Email ACC/AHA guideline summary: Treatment of critical limb ischemia Class I - There is evidence and/or generalagreement for the following approach to the management of critical limbischemia •  Rapid evaluation and treatment of factors known to increase the risk of primary amputation. These include significant necrosis of weight-bearing parts of the foot in ambulatory patients, an uncorrectable flexion contracture, paresis of the extremity, ischemic rest pain, sepsis, or limited life expectancy due to comorbid disease •  The development of acute limb symptoms in patients at risk for CLI (those with diabetes, neuropathy, chronic renal failure, or infection) is a potential vascular emergency that should be assessed immediately and treated by a specialist in vascular disease. •  Prompt initiation of systemic antibiotics in patients with skin ulceration and evidence of limb infection. •  Evaluation for aneurysmal disease (eg, in the abdominal aorta or popliteal or common femoral artery) in patients with evidence of atheroembolization, such as blue toe syndrome or livedo reticularis. •  Catheter-based thrombolysis for acute limb ischemia (Rutherford category I or IIa) of less than 14 days duration. •  Preoperative estimation of cardiovascular risk if open surgical repair is anticipated. •  When endovascular treatment or surgery is performed for combined inflow and outflow disease, the inflow lesions should be addressed first. If symptoms or infection persist after inflow revascularization, an outflow revascularization should be performed. •  If it is uncertain if there is hemodynamically significant inflow disease, intraarterial pressure should be measured before and after administration of a vasodilator. •  Patients with skin breakdown should be referred to a healthcare provider with expertise in wound care. •  Patients who have been successfully treated for CLI are at relatively high risk for recurrence. They should be evaluated at least twice yearly by a vascular specialist and be given verbal and written instructions for self-surveillance for recurrence. Class IIa - The weight of evidence oropinion is in favor of benefit for the following modality in themanagement of critical limb ischemia •  Mechanical thrombectomy as adjunctive therapy for acute limb ischemia due to peripheral artery occlusion.

•  Patients who have been successfully treated for CLI are at relatively high risk for recurrence. They should be evaluated at least twice yearly by a vascular specialist and be given verbal and written instructions for self-surveillance for recurrence. Class IIa - The weight of evidence oropinion is in favor of benefit for the following modality in themanagement of critical limb ischemia •  Mechanical thrombectomy as adjunctive therapy for acute limb ischemia due to peripheral artery occlusion. Class IIb - The evidence or opinion isless well established for the following modalities in the management ofcritical limb ischemia •  Angiogenic growth factors. •  Catheter-based thrombolysis or thrombectomy for acute limb ischemia (Rutherford category IIb) of more than 14 days duration. Class III - There is evidence and/orgeneral agreement that the following modalities are not useful in themanagement of critical limb ischemia •  Parenteral pentoxifylline. •  Oral iloprost. •  Surgery or endovascular treatment for severe hypoperfusion (eg, ABI less than 0.4) in the absence of symptoms. Adapted from Hirsch, AT, Haskal, ZJ, Hertzer, NR, et al. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation 2006; 113:e463.