A 65-year-old woman presents with acute limb ischaemia (ALI) of her right leg — cold, pale, pulseless, with paraesthesia but preserved motor function. She has atrial fibrillation. Ankle-brachial index cannot be measured. This represents Rutherford Class IIa ALI. What is the immediate treatment of choice?
- A Intravenous heparin followed by catheter-directed thrombolysis ✓
- B Emergency surgical embolectomy using Fogarty balloon catheter
- C Systemic thrombolysis with IV tPA
- D Urgent angioplasty and stenting of the occluded segment
Explanation
Rutherford Class IIa ALI (marginally threatened — sensory loss but no motor deficit) is salvageable and the leg is not immediately threatened. Anticoagulation with unfractionated heparin is started immediately, followed by catheter-directed thrombolysis (CDT) which is preferred over surgical embolectomy for Class IIa when the occlusion is thrombotic or embolic in a native vessel with no clear cut-off. CDT has lower complication rates and better long-term patency. Class IIb (motor deficit, immediately threatened) requires emergency surgical intervention. Class III (irreversible ischaemia) requires amputation.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.