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CLINICAL STATEMENTS AND GUIDELINES June 11, 2024 Circulation. 2024;149:e1313–e1410. DOI: 10.1161/CIR.0000000000001251 e1372 and to perform fasciotomy of all involved compartments is an effective approach. In patients who present with ALI with prolonged or severe tissue ischemia, fasciotomy is indicated to mitigate the sequelae of reperfusion syndrome. 2. In patients with ALI with a threatened but salvageable limb (category IIa or IIb), the performance of prophylactic fasciotomies at the time of revascularization or early in the presentation (ie, before the clinical development of elevated compartment pressures) can avoid a later delay in diagnosis of compartment syndrome and devastating complications associated with this delayed diagnosis (eg, tissue necrosis, infection, limb amputation, and systemic metabolic toxicity). Observational studies have shown that early fasciotomy is associated with lower rates of limb amputation and shorter hospitalization among patients with ALI.1,2 The benefits of prophylactic fasciotomy should be balanced with the knowledge that the procedure is associated with a risk of complications, including dysesthesia related to nerve injury, incisional site complications, and infection.8 If, after fasciotomy, minimal tissue bulge is noted, resolves, or both with systemic diuresis and leg elevation, early delayed primary closure of fasciotomy incisions may mitigate associated wound morbidity. For those patients in whom delayed primary closure is not possible, NPWT is an effective option to reduce patient discomfort and facilitate incisional closure or prepare the wound bed for skin graft placement. Diligent postacute wound care should be used to mitigate wound complications, facilitate incisional management to closure, and obtain the ultimate goal of restoration of the functional limb. 3. In patients with ALI who present with prolonged ischemia and dense regional symptoms, concurrent amputation with revascularization can be clinically appropriate (eg, the patient presenting with acute multilevel occlusion with severe inflow and outflow disease and prolonged leg ischemia with limited functional motor activity of the foot or calf). In such cases, partial or complete revascularization can be performed with inflow with or without outflow revascularization, followed by concurrent major amputation of severely ischemic issue, leaving the amputation site open for a delayed closure at a later time. Such an approach expedites the conduct of the procedure and allows for surveillance of tissue viability over the days after revascularization. A delayed primary closure can then occur when the patient is more clinically stable and the level of tissue viability has been declared. Other scenarios in which this approach can be beneficial include patients with poor premorbid functional status or frailty or severe comorbidity profile (eg, CAD, heart failure, CKD) for whom the metabolic burden of limb ischemia and reperfusion injury may be poorly tolerated. 11.2.3 Anticoagulation for ALI Recommendation for Anticoagulation for ALI COR LOE Recommendation 1 C-EO 1 In patients with ALI, regardless of cause or anatomic level of occlusion, systemic anticoagulation with unfractionated heparin should be administered on diagnosis unless contraindicated. Synopsis All patients with ALI should be evaluated for revascularization, and all should receive medical therapy while revascularization plans are being determined (Figure 8). The mainstay of medical therapy for ALI is systemic anticoagulation, typically with unfractionated heparin, which serves to mitigate the impact of ischemia and help the process of thrombolysis begin. However, certain patients may not be candidates for anticoagulation for ALI, including those at high risk of bleeding, or those with ALI associated with aortic dissection or major vascular trauma. Recommendation-Specific Supportive Text 1 In the absence of contraindication (eg, active bleeding or high bleeding risk), therapeutic doses of intravenous unfractionated heparin are given to patients with ALI on diagnosis. Intravenous unfractionated heparin is preferred to other agents given its short half-life and titratability, especially as revascularization plans are being determined. The goal of systemic anticoagulation is to limit the propagation of existing thrombus and distal embolization. Heparin may also provide an anti-inflammatory effect that lessens ischemia. This practice is widely accepted, although no randomized trials have established improved outcomes with anticoagulation versus none or comparing different classes of systemic anticoagulants. For patients with a history of heparin-induced thrombocytopenia, a direct thrombin inhibitor rather than heparin can be administered.1,2 Anticoagulation for ALI should be weighed against the risk of bleeding. 11.3 Diagnostic Evaluation for the Cause of ALI Recommendations for Diagnostic Evaluation for the Cause of ALI COR LOE Recommendations 1 C-EO 1 In patients with ALI, a comprehensive medical history and physical examination should be performed to determine the cause of thrombosis or embolization. 2a C-LD 2. In patients with ALI, testing for a cardiovascular cause of thromboembolism can be useful.1–4 Downloaded from http://ahajournals.org by on October 7, 2026