Patient handout

Acute Limb Ischemia

PRODUCTION

1. Your condition

This handout is for acute limb ischemia. Your care team identified this based on: six ps — pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia (2024 acc/aha/svs pad).

Other reasons your team may use this plan: sudden severe limb pain with cold/mottled extremity (esvs 2020); new af / recent mi with mural thrombus / prosthetic graft / mechanical valve (2024 acc/aha/svs pad); absent distal pulses with abi <0.4 or non-recordable (esvs 2020).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
heparin	Bolus 80 U/kg IV; infusion 18 U/kg/h titrated to aPTT 1.5-2.5x control (60-80 sec)	IV	continuous infusion	UFH first-line immediately on suspected ALI (Class I) — propagates clot less; rapid titration; reversible (protamine). 2024 ACC/AHA/SVS PAD Section 8 (PMID 38752899); ESVS 2020 ALI Recommendation 7 (PMID 31899099)
bivalirudin	0.75 mg/kg bolus then 1.75 mg/kg/h	IV	continuous infusion	Alternative when HIT history / current; direct thrombin inhibition not requiring AT-III; renally cleared so dose-reduce CrCl<30 (2024 ACC/AHA/SVS PAD)

Plan: Acute limb ischemia — Rutherford-driven anticoagulation + revascularization (2024 ACC/AHA/SVS PAD; ESVS 2020)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Rutherford III — paralysis + sensory loss + tense / non-compressible muscle + doppler silent venous + arterial; muscle is dead — reperfusion is LETHAL (Rutherford 1997)(life-threatening)
Rutherford IIb — motor deficit + sensory loss + audible venous but no arterial doppler — limb salvageable only with immediate revasc (Rutherford 1997)(life-threatening)
Rutherford IIa — minimal sensory loss (toes only), no motor deficit, audible venous, inaudible arterial doppler (Rutherford 1997)
K >6.0 with EKG changes (peaked T, widened QRS) — pre-revasc from necrotic muscle / post-revasc from reperfusion (ESVS 2020)(life-threatening)
Post-revasc tense compartment, pain with passive stretch, elevated CK, or measured delta-P <30 mmHg (DBP minus compartment pressure) (AAOS; McQueen 1996 PMID 8898137)(life-threatening)

5. Follow-up

Long-term anticoagulation (DOAC or warfarin) if embolic source; antiplatelet + high-intensity statin if thrombotic; smoking cessation; vascular medicine follow-up; ABI / duplex at 1 month (2024 ACC/AHA/SVS PAD)

6. Sources

Guideline: 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease (Gornik 2024) + ESVS 2020 Clinical Practice Guidelines on Management of Acute Limb Ischaemia (Bjorck 2020)