• This is a time critical condition.

• Early recognition and referral to senior vascular team essential.

• Correct imaging of arteries to be arranged as soon as possible.

• Anticoagulation with IV heparin until surgical plan arranged.

This is a controlled document. If you are using a printed copy, check it against the guidelines site to ensure you are using the latest edition. Print copies must be destroyed after use.

Abbreviations

• Thrombosis in situ

• Emboli

• Graft / angioplasty / stent occlusion

• Trauma

• Post operative complication of vascular surgery

The 6 Ps:

• Pale

• Pain

• Pulseless

• Paraesthesia

• Paralysis

• Perishingly cold

This may occur in chronic arteriopaths with known peripheral arterial disease; or de novo in those with risk factors, such as patients with AF.

Acute Limb Ischaemia may present as a post operative complication.

Risk factors for peripheral arterial disease

• ischaemic heart disease

• stroke

• hypertension

• smoking

• dyslipidaemia

• family history of cardiovascular disease

• diabetes.

Those with symptomatic chronic peripheral arterial disease may have a sudden deterioration in their usual claudication symptoms; an acute event on a chronic background.

• Risk factors

• Document any absent pulses

• Document the ABPI. This may not be accurate in diabetics or in severe ischaemia, the Doppler trace may not be found.

• Document the limb sensation and movement strength

• Features of the 6 Ps.

Nil by Mouth

Patients referred with a suspected diagnosis of ALI should be prioritised for immediate review by the on call vascular team. Contact on 0300 613 3727.

Patients with ALI needing surgery or endovascular intervention are considered a priority. Not all patients are appropriate to undergo major vascular surgery or major limb amputation and, in this circumstance, the surgical advice will be not to transfer and should be discussed with on call consultant.

As soon as a diagnosis of ALI is suspected or confirmed, the patient should be started on an unfractionated heparin infusion without delay.

The patient should be given a 5000iu bolus intravenously followed by 1000iu an hour infusion rate aiming for an aPTT ratio of 2-3.

Patients presenting at vascular spokes may have heparin stopped prior to transfer, if this speeds up the transfer process.

• Check bloods – FBC and Renal function, group and screen, coagulation studies

• Arrange appropriate imaging – CTA or Arterial duplex.

If the cause of ALI is an occluded prosthetic bypass graft of less than 14 days duration, discuss the options of thrombolysis or lysis free thrombectomy with the IR vascular team.

On table check angiography should be carried out in theatres if there is clinical doubt about the technical success of embolectomy or thrombectomy.

When compartment syndrome is suspected following revascularisation, have a low threshold for performing fasciotomies early.

Patients with ALI and a diagnosis of an irreversibly ischaemic leg that is dead (fixed mottling, anaesthetic, paralyzed) should not be revascularised but instead be offer major limb amputation as a primary index procedure.

N.B. don’t forget about the risk of re-perfusion injury and or compartment syndrome.

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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