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CLINICAL STATEMENTS AND GUIDELINES

Circulation. 2024;149:e1313–e1410. DOI: 10.1161/CIR.0000000000001251 June 11, 2024 e1369

should be performed by a clinician able to either complete the revascularization or rapidly triage the patient to one who is able to do so.2 Lowerextremity symptoms in ALI can include pain, loss of sensation, and loss of function. The longer these symptoms are present, the less likely the possibility of limb salvage.3,4 Bedside clinical assessment for ALI includes querying the patient for symptom characteristics and duration and pain intensity and assessment of severity of motor and sensory deficits to distinguish a threatened (category IIa/IIb) from an irreversibly ischemic, nonsalvageable limb (category III). A handheld continuous wave Doppler device is used to assess the limb because of the inaccuracy of pulse palpation in this setting and to allow for identification of venous signals.6 The loss of an arterial signal on continuous wave Doppler indicates that the limb is threatened. The absence of both arterial and venous Doppler signals indicates that the limb may be irreversibly damaged (category III) and nonsalvageable. Comorbidities should be identified and managed aggressively, but this must not delay therapy. In most cases, additional noninvasive imaging studies (ie, duplex ultrasound, CTA, or MRA) are unnecessary to implement treatment for ALI except in unusual circumstances that may alter revascularization strategy and timing, such as a suspected aortic dissection, in the setting of multiple previous revascularization procedures, or in other unusual clinical scenarios. Even in the setting of rapid and effective revascularization, the 1-year morbidity and mortality rates associated with ALI are high.1,3,7

3 Patients who present with ALI and a history of

lower extremity revascularization procedures are a unique challenge. Decision-making for revascularization strategy in these patients may be improved by obtaining noninvasive imaging (ie, duplex ultrasound, CTA, MRA) in an expedited manner to define the anatomy and whether ALI is caused by occlusion at the site of previous revascularization (eg, bypass graft or stent) or at another site.

Figure 8. Algorithm for Diagnosis and Management of ALI. Colors correspond to Table 3. ALI indicates acute limb ischemia; CV, cardiovascular; and ECG, electrocardiogram.

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