CathLabHub complications toolkitcathlabhub.com/toolkit/limb-ischemiaIn review, October 24, 2026
Recognize
The signs on the monitor, the image and the patient.
- PatientPain, pallor, paralysis, pulse deficit, paresthesias and a cold limb 1.
- ImageOcclusion, dissection or thrombus at the access artery on angiography; ultrasound or CT outside the lab 1.
- MonitorNear infrared tissue saturation under 50 percent, or over 15 percent below the other leg, with a large cannula 2.
- PatientCauses: thrombosis, dissection, embolism, a closure device, or an occlusive sheath or support device 1.
Act now
In the order the operator does them. The first three come first, whatever else is happening.
- Check both legs and the Doppler signals now; note the time.
- Call vascular surgery early.
- Give heparin unless bleeding forbids it.
- Remove or downsize an occlusive sheath or device if the patient can tolerate it 21.
- Contralateral access and angiography to find the cause 1.
- Treat: balloon angioplasty, endovascular thrombectomy or thrombolysis; surgery if needed 1.
- Large bore cannula that must stay: an antegrade distal perfusion sheath 2.
Equipment
From the complications cart. Linked items open in the equipment directory.
- Crossover sheathDirectory: Pinnacle Destination guiding sheath.
- Antegrade perfusion sheath6 Fr 24 cm sheath that resists kinking 2. Directory: Super Arrow-Flex sheath.
- Peripheral balloons and stentsDirectory: Armada 35, Absolute Pro.
- ThrombectomyDirectory: AngioJet thrombectomy system, Lightning Bolt 7.
- Near infrared spectroscopy padsFor limb perfusion on ECMO or large bore support 2.Not in the directory yet.
Drugs
Adult doses as the cited source gives them. Check your formulary and the label.
- HeparinSystemic anticoagulation unless contraindicated.Weight based dose in the Cath Med App
- Alteplase, catheter directedPer the vascular team protocol.Product in the directory
Who to call
The escalation ladder, first call first.
- Vascular surgery: at recognition.
- Interventional cardiology or radiology: for endovascular treatment.
- Shock team: when a support device is the cause and still needed.
The bailout step by step
Antegrade distal perfusion sheath for a large bore cannula 2
- Ultrasound the ipsilateral common or superficial femoral artery below the cannula 2.
- Micropuncture antegrade access under ultrasound 2.
- Place a 6 Fr 24 cm kink resistant sheath pointing down the leg 2.
- Connect its side arm to the side port of the arterial cannula or return line.
- Confirm flow and recheck the near infrared saturation and Doppler signals.
- Secure both lines; check the leg often.
Prevent
After care and documentation
- Frequent limb checks; watch for compartment syndrome after reperfusion.
- Document the time of onset, the cause and the treatment.
Practice
No emergency simulator case for limb ischemia yet; the mechanical support cases watch the limb. Browse the case library.
References
- Brilakis ES. Manual of Percutaneous Coronary Interventions. Elsevier; 2021. Chapter 29, Vascular access complications.
- Brilakis ES. Manual of Percutaneous Coronary Interventions. Elsevier; 2021. Chapter 14, Hemodynamic support.
Educational reference for cath lab teams, not medical advice and not a standard of care. Your local policy, the device instructions for use and current guidelines govern. Verify every dose before use. Printed from cathlabhub.com/toolkit/limb-ischemia. First version, in clinical review: an interventional cardiologist is checking every card before it is final. Every number cites its source on the card.