Clinical Features of Acute on Chronic Lower Limb Ischemia and the Importance of Underlying Arterial Disease for Revascularization

Abstract

Background: Acute lower extremity limb ischemia (ALI) is a common vascular surgery emergency, primarily caused by embolism or atherosclerotic in situ thrombosis–acute on chronic limb ischemia (AoCLI). This study aimed to examine the clinical features and treatment challenges of AoCLI.

Methods and Results: Between January 2014 and December 2022, 73 patients with AoCLI (n=35) or embolic ALI (n=38) were analyzed. The time from ALI onset was significantly longer (P<0.01), and the rate of contralateral diseases was higher in AoCLI than embolic ALI (P<0.01). Treatment and intraoperative findings showed higher rates of failed thrombectomy (P=0.027), difficulty in crossing lesions (P<0.01), defined as failure of Fogarty catheter crossing despite guidewire navigation and requirement of the balloon angioplasty for the lesions, additional revascularization (P<0.01), and multi-segment treatment (P<0.01) in AoCLI. In multivariate analysis, unfavorable factors for endovascular therapy (EVT) were >2.5 days from ALI onset (odds ratio [OR] 1.4; 95% confidence interval [CI] 1.0–2.0), non-atrial fibrillation (OR 4.2; 95% CI 1.0–16.7), and collateral development (OR 9.0; 95% CI 1.0–81.5). Rates of failed EVT were 0% for no factors, 18% for 1 factor, 43% for 2 factors, and 90% for 3 factors.

Conclusions: AoCLI had more complex and multi-segment arterial lesions, making limb perfusion restoration difficult. The unfavorable factors for EVT could help stratify the optimal treatment of ALI in emergency settings.