Acute Limb Ischemia — Management Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Rutherford grade
   Rutherford grade (sensory/motor loss and Doppler signals)? (Acute limb ischemia — the 6 P's: Pain, Pallor, Pulselessness, Perishing cold, Paraesthesia, Powerlessness; usually embolic (AF) or thrombotic. Give every salvageable limb immediate IV unfractionated heparin + analgesia + CTA. Grade by sensory/motor loss and Doppler arterial/venous signals.)
   • Class I (viable) → Class I (viable)
   • IIa (marginally threatened) → IIa (marginally threatened)
   • IIb (immediately threatened) → IIb (immediately threatened)
   • Class III (irreversible) → Class III (irreversible)
2. [End] Class I (viable)
   Not immediately threatened: no sensory/motor loss, arterial + venous Doppler audible. → IV heparin anticoagulation; urgent imaging to localize, revascularization can be elective/semi-urgent (endovascular or open); treat the underlying cause (anticoagulate for AF, etc.).
3. [End] IIa (marginally threatened)
   Salvageable if treated promptly: minimal sensory loss (toes) or none, no motor deficit, arterial signal often inaudible, venous audible. → Revascularize as soon as possible (catheter-directed thrombolysis/endovascular or surgery), heparin throughout.
4. [End] IIb (immediately threatened)
   Needs immediate revascularization: sensory loss beyond the toes + rest pain, mild–moderate motor weakness, arterial signal inaudible, venous audible. → Emergency surgical revascularization (embolectomy/bypass) ± fasciotomy, possibly with thrombolysis; heparin throughout. Watch for reperfusion injury (compartment syndrome, hyperkalemia, rhabdomyolysis).
5. [End] Class III (irreversible)
   Profound anesthesia + muscle rigor/paralysis, both arterial and venous signals inaudible. → Limb is non-salvageable, perform amputation; revascularization is futile and harmful (reperfusion can be fatal). Multidisciplinary assessment, manage metabolic complications.

Source guidelines & references

• Rutherford clinical classification of acute limb ischemia (J Vasc Surg 1997); ESVS/SVS peripheral arterial disease guidelines

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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