• Muhammad Iqbal Khan Department of Surgery, Shifa International Hospital, Shifa Tameer e Millat University, Islamabad
  • Irfan Ahmed Nadeem Department of Surgery, Abbas Institute of Medical Sciences, AJK Medical College Muzaffarabad


Background: Late-presenting acute limb ischaemia represents a challenging vascular emergency. The purpose of this study was to evaluate the outcome in patients following revascularization and management of existing or impending reperfusion injury of ischaemic limbs over a 12-year period (2002–2014). Methods: Routine procedural codes were used to label consecutive patients admitted 72 hours following onset of symptoms for surgical revascularization of an acutely ischaemic limb. Data collected included demography, clinical presentation, synchronous morbidities, procedural specifics and outcomes of surgical management of all patients. Results: The study sample included 206 patients, (117 male and 89 female, average age =49.4±14.6 years) presenting with a diagnosis of acute limb ischemia. The most frequent cause of acute thromboembolic limbs was cardiac disease (n=148). Femoral artery exploration with embolectomy was the most common procedure and was used for aortic, iliac, infrainguinal and distal occlusion. Thirty-four patients required additional vascular surgery due to failure of revascularization by embolectomy. Fasciotomy was performed in 45.6% of cases for existing or impending compartment syndrome when the patient presented very late. Surgical site infection occurred in 8.25% of cases, repeat embolectomy was required in 10.68% of cases; amputation in 13.1% and mortality was 5.8%. Predictors of morbidity and mortality included age of the patient, time of presentation and specific comorbidities. The 5-year amputation-free and survival estimate was 80%. Conclusion: Our study suggests that late revascularization of acute leg ischaemia improves blood supply to the limb, thereby reducing the number of amputations. The results suggest that revascularization is clinically warranted, even one week following the onset of acute ischaemia. Additional surgical procedures including fasciotomy further reduce the morbidity and mortality.Keywords: Acute ischaemia, revascularization, embolectomy, fasciotomy, amputation, reperfusion injury, compartment syndrome


Ouriel K. Acute limb ischemia. In: Rutherfort RB, editor. Vascular surgery. 6th ed. Philadelphia: Elsevier; 2005;959–86.

Fogarty TJ. Management of arterial emboli. Surg Clin North Am1979;59(4):749–53.

Eliason JL, Wainess RM, Proctor MC, Dimick JB, Cowan Jr JA, Upchurch Jr GR, et al. A national and single institutional experience in the contemporary treatment of acute lower extremity ischemia. Ann Surg 2003;238(3):382–90.

Ouriel K, Veith FJ. Acute lower limb ischemia: determinants of outcome. Surgery 1998;124(2):336–41.

Abbott WM, Maloney RD, McCabe CC, Lee CE, Wirthlin LS. Arterial embolism: a 44 year perspective. Am J Surg 1982; 143(4):460–4.

Elliott JP Jr, Hageman JH, Szilagyi E, Ramakrishnan V, Bravo JJ, Smith RF. Arterial embolization: problems of source, multiplicity, recurrence and delayed treatment. Surgery 1980; 88(6):833–45.

Iyem H, Eren MN. Should embolectomy be performed in late acute lower extremity arterial occlusions? Vasc Health Risk Manag 2009; 5:621–6.

Blecha MJ. Critical Limb Ischemia. Surg Clin North Am 2013; 93(4):789–812.

Shifrin EG, Anner H, Eid A, Romanoff H. Practice and theory of ‘delayed’ embolectomy. A 22 year perspective. J Cardiovasc Surg (Torino) 1986;27(5):553–6.

Panetta T, Thompson JE, Talkington CM, Garrett WV, Smith BL. Arterial embolectomy: A 34-year experience with 400 cases. Surg Clin North Am 1986;66(2):339–53.

Yangni AH, Adoubi A, Adoh M, Yapobi Y, Coulibaly AO. Acute nontraumatic limb ischemia. West Afr J Med. 2006;25(2):101–4.

Morris-Stiff G, D'Souza J, Raman S, Paulvannan S, Lewis MH. Update experience of surgery for acute limb ischaemia in a district general hospital - are we getting any better? Ann R Coll Surg Engl 2009;91(8):637–40.

Karapolat S, Dag O, Abanoz M, Aslan M. Arterial embolectomy: a retrospective evaluation of 730 cases over 20 years. Surg Today 2006;36(5):416–9.

Tiwari A, Haq AI, Myint F, Hamilton G. Acute compartment syndromes. Br J Surg 2002;89(4):397–412.

Creager MA, Kaufman JA, Conte MS. Clinical practice. Acute Limb Ischemia. N Engl J Med 2012;366(23):2198–206.

Ernst CB, Kaufer H. Fibulectomy-fasciotomy: An important adjunct in the management of lower extremity arterial trauma. J Trauma 1971;11(5):365–80.

Elsharawy MA. Elsaid A, Elsharawi I. Reperfusion of Delayed Acute Occlusive Limb Ischemia: Is It Worthwhile? World J Cardiovasc Dis. 2014;4(12):580.

Rush DS, Frame SB, Bell RM, Berg EE, Kerstein, MD, Haynes JL. Does open fasciotomy contribute to morbidity and mortality after acute lower extremity ischemia and revascularization? J Vasc Surg 1989;10(3):343–50.

Arumugam TV, Shiels IA, Woodruff TM, Granger DN, Taylor SM. The role of the complement system in ischemia-reperfusion injury. Shock 2004;21(5):401–9.

Rutherford RB. Clinical staging of acute limb ischemia as the basis for choice of revascularization method: when and how to intervene; Semin Vasc Surg 2009;22(1):5–9.

J. P. Simons, P. P. Goodney, B. W. Nolan, J. L. Cronenwett, L. M. Messina, and A. Schanzer, “Failure to achieve clinical improvement despite graft patency in patients undergoing infrainguinal lower extremity bypass for critical limb ischemia,” Journal of Vascular Surgery, vol. 51, no. 6, pp. 1419–1424, 2010

Dag O, Kaygın, M, Erkut B. Analysis of risk factors for amputation in 822 cases with acute arterial emboli. Sci World J 2012;2012:673483.

Kempe K, Starr B, Stafford JM, Islam A, Mooney A, Lagergren E, et al. Results of surgical management of acute thromboembolic lower extremity ischemia. J Vasc Surg 2014;60(3):702–7.