Contemporary Practice Patterns and Outcomes of Revascularization for Acute Limb Ischemia.

OBJECTIVE: Acute limb ischemia (ALI) is a surgical emergency associated with substantial morbidity and mortality. Although management has traditionally emphasized a 6-hour revascularization threshold, emerging evidence suggests that earlier intervention may be critical to limb salvage. The extent to which these data have been incorporated into clinical practice remains unclear. We therefore evaluated contemporary treatment patterns and perioperative outcomes among patients with ALI. METHODS: Patients with ALI who underwent surgical thrombectomy between March 2018 and April 2025 were identified from a large statewide collaborative. Time from symptom onset to surgical incision and hospital arrival to incision were assessed. Primary outcomes were major amputation at 30 days and 1 year. Multivariable logistic regression was performed to assess association between patient characteristics, time to surgery, and post-thrombectomy outcomes. RESULTS: A total of 1,015 patients underwent open thrombectomy for ALI. Major amputation occurred in 7% of patients within 30 days and in 15.2% within 1 year. Mortality was 2.1% at 30-days and increased to 14% at 1 year. Mean time from hospital presentation to incision was 7.8 + 5.9 hours, with 78% of patients undergoing revascularization >3 hours after arrival. Surgical incision occurring >6 hours after arrival was significantly associated with increased risk of 30-day and 1-year major amputation. CONCLUSIONS: ALI requiring surgical thrombectomy continues to result in high morbidity and mortality. Delays from hospital arrival to surgical incision are common and associated with increased amputation risk, identifying door-to-incision time as an important target for system led interventions to improve ALI outcomes.