A 72-year-old man presents with acute limb ischemia of the left leg with onset 4 hours ago. He has atrial fibrillation. The limb is cold, pale, pulseless, with paresthesias but no paralysis (Rutherford IIa). The most appropriate treatment is:
- A Immediate surgical embolectomy via Fogarty catheter
- B Systemic anticoagulation with heparin and observe for 24 hours
- C Catheter-directed thrombolysis (CDT) with tPA ✓
- D Emergency CT angiography then immediate fasciotomy
Explanation
Rutherford class IIa acute limb ischemia (threatened, marginally, sensory deficit only) is salvageable and can be treated with catheter-directed thrombolysis (CDT) when onset is within 14 days. CDT achieves lysis of emboli/thrombus and uncovers underlying stenoses amenable to angioplasty or surgical correction. The TOPAS and STILE trials showed CDT has similar 1-year limb salvage rates to surgery with lower short-term morbidity. Surgical embolectomy is preferred for class IIb (immediate threat, motor deficit) or CDT contraindications (active bleeding, recent surgery). Heparin alone is insufficient.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.