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In this episode of Hospital Medicine Unplugged, we tackle ischemic limb—act fast for ALI, plan smart for CLTI, save the patient and the leg.



We open with the two phenotypes:

• ALI (acute limb ischemia)—sudden arterial cut-off with the 6 Ps: pain, pallor, pulselessness, poikilothermia, paresthesia, paralysis.

• CLTI (chronic limb-threatening ischemia)—rest pain, non-healing ulcers, or gangrene on a PAD backdrop (diabetes, renal disease, smoking, age).



Rapid bedside triage—decide viability, not vocabulary: inspect color/temp/mottling; check sensory & motor; palpate pulses; handheld Doppler (arterial/venous signals). Stage it (Rutherford for ALI; Rutherford/WIfI for CLTI) to set urgency.



Imaging that doesn’t slow you down: CTA or duplex to map anatomy only if the limb is viable or marginally threatened; unstable or immediately threatened limbs go straight to revascularization.



ALI do-firsts—time is muscle & nerve:

• Heparin now (bolus 5,000–10,000 U, then aPTT-titrated infusion) unless contraindicated.

• STAT vascular consult; analgesia, resuscitation, labs (CK, lactate, K⁺ for reperfusion risk).

• Revascularize based on stage/etiology: catheter-directed thrombolysis for fresh thrombus or graft/stent occlusion; open embolectomy/bypass for immediately threatened (IIb) limbs, older thrombus, or when speed matters.

• Avoid revascularization in Rutherford III (non-viable)—go to primary amputation and optimize physiology.

• Post-flow vigilance: monitor for compartment syndrome; low threshold for fasciotomy.



CLTI foundations—treat the patient and the pathway:

• Guideline-directed medical therapy for all PAD/CLTI: antiplatelet (aspirin or clopidogrel), high-intensity statin, ACEi/ARB, tight BP/glucose, smoking cessation (behavioral + meds).

• Infection & tissue loss: culture-guided antibiotics; sharp debridement; off-loading and advanced wound care.

• Revascularization is the rule unless futile:

– Surgery (autologous vein bypass): favored in selected anatomy and good conduit—often superior durability in CLTI.

– Endovascular (angioplasty/stent/atherectomy): preferred for high-surgical-risk patients or focal/amenable lesions.

– Hybrid when needed (e.g., common femoral endarterectomy + endovascular tibials).

• After revascularization: consider dual antiplatelet (short course) or dual-pathway inhibition (aspirin + low-dose rivaroxaban) in appropriate patients to reduce MALE/MACE.



When to amputate: non-reconstructable disease, extensive necrosis, overwhelming infection, or prohibitive risk—prioritize a functional level and early rehab planning.



Pearls & pitfalls:

• Don’t wait for perfect imaging—reperfuse threatened limbs now.

• Neurologic deficits mean the clock is nearly out—escalate to OR.

• Completion angiography after open surgery catches fixable issues and reduces reinterventions.

• Reperfusion kills, too—anticipate hyperkalemia, acidosis, rhabdo; manage fluids, bicarbonate as needed, and watch compartments.

• Toe pressures/TcPO₂ outperform ABI in calcified vessels (diabetes/CKD).



Discharge & durability: statin adherence, antiplatelet/antithrombotic plan, wound follow-up, smoking cessation, foot care, and a clear reintervention pathway. Multidisciplinary CLTI teams (vascular, cardiology, wound, podiatry, rehab, diabetes educators) improve limb salvage and survival.



We close with the hospitalist bundle: (1) Heparin now for ALI → Rutherford stage; (2) Call vascular early; (3) Imaging only if it won’t delay; (4) Choose revascularization by anatomy/urgency/comorbidity (endo vs. bypass vs. hybrid); (5) Post-flow monitor for compartments & electrolytes; (6) GDMT for PAD + smoking cessation; (7) Structured wound and infection plan; (8) Document WIfI and book follow-up.



Fast triage, decisive revascularization, and relentless risk-factor control—that’s how you keep legs (and lives) attached.