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CLINICAL STATEMENTS AND GUIDELINES

June 11, 2024 Circulation. 2024;149:e1313–e1410. DOI: 10.1161/CIR.0000000000001251 e1370

11.2 Management of ALI

11.2.1 Revascularization for ALI

Recommendations for Revascularization for ALI Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations

1 A 1.	 In patients with ALI and a salvageable limb,

revascularization (endovascular or surgical, including catheter-directed thrombolysis) is indicated to prevent amputation.1–5

2a C-EO 2 In patients with ALI and a salvageable limb who are

treated with catheter-directed thrombolysis, adjunctive revascularization (ie, endovascular or surgical) procedures can be useful.

2b C-LD 3 In patients presenting with ALI from

chemotherapeutic or prothrombotic viral states, it may be reasonable to take a more deliberate planning strategy before engaging in a definitive revascularization or medical treatment plan.6–14

3: Harm C-EO 4.	 In patients with ALI with a nonsalvageable limb,

revascularization of nonviable tissue should not be performed.

Synopsis Revascularization is indicated in patients with ALI and a salvageable limb to prevent irreversible tissue damage and major amputation (Figure 8). Both surgical thromboembolectomy and catheter-based thrombolysis are effective therapies for ALI. Historically, surgical thromboembolectomy, generally performed via arterial cut down and an embolectomy catheter (eg, Fogarty catheter), was the primary mode of revascularization in the setting of ALI.15 Catheter-based thrombolysis was the initial method of endovascular revascularization for ALI, and the utilization of additional endovascular therapies to treat ALI has advanced significantly in recent years. Ultrasound-accelerated, catheter-based thrombolysis and newer techniques including pharmacomechanical and vacuum-assisted percutaneous mechanical thrombectomy have expanded the endovascular armamentarium for the treatment of ALI.16–20 Patient-specific and anatomic factors and local resource availability are important in selecting the revascularization strategy for the individual patient with ALI. All patients should be monitored for compartment syndrome and reperfusion injury (see Section 11.2.2, “Adjunctive Therapies to Minimize Tissue Loss in ALI”). After initial revascularization to address the thrombosis, definitive treatment of any underlying culprit lesion can be useful to optimize procedural success and prevent ALI recurrence.

Recommendation-Specific Supportive Text

1 Revascularization is indicated in patients with ALI

and a salvageable limb (categories I, IIa and IIb) (Figure 8). Multiple large observational studies have documented the association of ALI with high rates of mortality and limb loss21–25 for which expedited recognition, classification, and rapid treatment to remove clot by either open or endovascular means is critically important. The use of catheter-based thrombolysis as a revascularization strategy has been extensively studied within the context of ALI. Despite this, assessment of the comparative effectiveness of catheter-based thrombolysis versus open surgery is complicated by variable definitions of ALI in the literature. Four RCTs1,3–5 comparing catheter-based thrombolysis to surgery as well as multiple meta-analyses2,26,27 have shown similar limb salvage rates between the 2 approaches, with higher rates of bleeding associated with thrombolysis. Several of these RCTs included patients with relatively chronic ischemia. Several observational studies have shown improved in-hospital outcomes and long-term outcomes with endovascular therapies compared with open surgery, even after controlling for baseline differences in patient characteristics.28,29 Acuity and severity of ALI are both factors to consider in the decision to pursue thrombolysis.1,3–5 For patients with ALI attributable to bypass graft occlusion within 14 days of the primary operation and a salvageable limb, the benefits of thrombolysis should be weighed against the risks of surgical site bleeding. Beyond conventional catheter-directed thrombolysis, ultrasoundaccelerated catheter-based thrombolysis has also been studied in the context of ALI.19,30–32 The single RCT comparing this technique to standard catheter-based thrombolytic therapy showed a significantly lower thrombolysis time and total amount of lytic agent required for treatment of ALI.19,32 More recently, case series have provided initial support for the use of mechanical thrombectomy (eg, pharmacomechanical or vacuum assisted) in the treatment of ALI.16–18,20,30 These studies have reported excellent safety using these newer techniques, with limb salvage rates exceeding 80% in most of these series.16–18

2 Multiple retrospective nonrandomized studies and

2 RCTs3,33–42 have shown that catheter-directed thrombolysis can be effective for bypass grafts and native arteries that are occluded for <14 days’ duration. Thrombolysis unmasks culprit lesions that can then be addressed depending on the nature of the lesion (eg, diffuse or focal atherosclerotic lesions, retained valves, neointimal hyperplasia). Durability of revascularization after thrombolysis can be improved by revascularization of the underlying culprit lesion using adjunctive surgical and endovascular procedures such as endarterectomy, patch angioplasty, interposition or jump extension grafts, or PTA without or with stenting. However, if the duration of arterial occlusion exceeds 14 days

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