The AHA Guidelines and Scientific Statements Handbook

Chapter 9 Lower Extremity Peripheral Artery Disease

Rapid or sudden decrease in limb perfusion

threatens tissue viability

History and physical examination;

determine time of onset of symptoms

Emergent assessment of severity of

ischemia:

Loss of pulses

Loss of motor and sensory function

Vascular laboratory assessment

ABI, TBI, or duplex US

No or minimal

PAD

Severe PAD documented:

• ABI less than 0.4


• Flat PVR waveform


• Absent pedal flow
  Consider
  atheroembolism,
  thromboembolism,
  or phlegmasia
  cerulea dolens

Go to Figure 9.7B,

Treatment of acute

limb ischemia

Evaluation of source

(ECG or Holter monitor;

TEE; and/or abdominal

ultrasound, MRA, or

CTA);

or venous duplex

Fig. 9.7 A, Diagnosis of acute limb ischemia. Adapted from J Vasc Surg 26, Rutherford RB, Baker JD, Ernst C, et al., Recommended
standards for reports dealing with lower extremity ischemia: revised version, 517–38, Copyright 1997, with permission from Elsevier.
ABI, ankle-brachial index; CTA, computed tomographic angiography; ECG, electrocardiogram; MRA, magnetic resonance angiography; PVR, pulse volume
recording; TBI, toe-brachial index; TEE, Transesophageal echocardiography.

Class III
Surgical and endovascular intervention is not indi-
cated in patients with severe decrements in limb
perfusion (e.g., ABI less than 0.4) in the absence of
clinical symptoms of CLI. (Level of Evidence: C)

Infl ow procedures: aortoiliac occlusive disease
Class I
1 When surgery is to be undertaken, aortobifemoral
bypass is recommended for patients with symptom-
atic, hemodynamically signifi cant, aorto-bi-iliac
disease requiring intervention. (Level of Evidence: A)

2 Iliac endarterectomy, patch angioplasty, or aor-

toiliac or iliofemoral bypass in the setting of accept-

able aortic infl ow should be used for the treatment

of unilateral disease or in conjunction with femoral-

femoral bypass for the treatment of a patient with

bilateral iliac artery occlusive disease if the patient is

not a suitable candidate for aortobifemoral bypass

grafting. (Level of Evidence: B)

3 Axillofemoral-femoral bypass is indicated for the

treatment of patients with CLI who have extensive

aortoiliac disease and are not candidates for other

types of intervention. (Level of Evidence: B)