Routine tourniquet use has significantly improved early survival in both military and civilian settings for extremity hemorrhage in trauma patients. However, most supporting evidence revolves around short-duration tourniquet use stemming from trauma systems with rapid evacuation and early surgical care. Emerging military operations and austere civilian settings risk prolonged prehospital times, introducing uncertainty in the management of prolonged tourniquet application. These scenarios present high-risk situations for medical providers and potentially life-threatening complications for patients. Despite this, management strategies during these scenarios remain poorly defined. This review synthesizes current military and civilian literature to address key challenges in prolonged ischemia, including tourniquet conversion, decision-making surrounding limb salvage versus early amputation, and the pathophysiology and management of ischemia reperfusion injury.

A persistent sciatic artery is a rare congenital vascular anomaly resulting from the failed regression of the sciatic artery during fetal development. It is associated with complications such as thrombosis, aneurysm formation, and acute limb ischemia. A 49-year-old female presented with acute limb ischemia of the left lower limb. Computed tomography angiography confirmed bilateral persistent sciatic arteries with thrombosis affecting only the left limb. She underwent successful endovascular balloon angioplasty and percutaneous thrombectomy, resulting in symptom resolution. Acute limb ischemia is the second most common presentation of persistent sciatic artery, occurring in 33.3% of cases. While computed tomography angiography is the gold standard for diagnosis, magnetic resonance angiography has been used in select cases. Management includes conservative treatment, endovascular intervention, or surgical repair. A bilateral persistent sciatic artery with unilateral thrombosis is rare. Early diagnosis and appropriate intervention, such as endovascular therapy, are essential to prevent complications. Long-term vascular surveillance is crucial for optimal patient outcomes.

Major hand replantation at the carpometacarpal level is rare and technically demanding. We report the case of a 69-year-old right-hand-dominant man who sustained traumatic amputation of the right hand while cleaning a metal-cutting guillotine. On admission, he was hemodynamically stable, and physical examination showed complete amputation at the carpometacarpal level with exposed bone and tendons. Radiography confirmed the level of injury. The patient underwent urgent replantation under general anesthesia with Kirschner-wire fixation from the metacarpals to the carpus, arterial anastomosis of the ulnar artery and a radial arterial branch, repair of multiple flexor and extensor tendons, and neurorrhaphy of the median and ulnar nerves. Postoperatively, the replanted hand remained viable, with preserved distal perfusion. The patient developed acute anemia and multifactorial acute kidney injury with concern for ischemia-reperfusion injury, which improved with medical treatment and monitoring. At discharge, the wound was well approximated, distal filling was preserved in all digits, and limited but present motion and partial sensory recovery were noted. Follow-up demonstrated maintained perfusion, stable fixation, and no evidence of infection. This case underscores that carpometacarpal-level hand replantation can achieve successful limb salvage in selected patients when timely multidisciplinary microsurgical management is available.

The preservation of a below-knee amputation (BKA) stump is essential for maintaining optimal limb function and facilitating future prosthetic use. Salvaging an infected stump is particularly challenging due to the loss of healthy soft tissue necessary to preserve adequate limb length. Patients with peripheral artery disease are often not considered candidates for complex reconstruction given concerns for poor perfusion, active smoking, and medical comorbidities. This case demonstrates a patient who underwent a BKA after failed revascularization for acute limb ischemia. Successful salvage of a BKA stump with a polymicrobial infection was achieved using an anterolateral thigh free flap with vastus lateralis muscle. At 4 months postoperatively, the patient was successfully ambulating with a prosthetic leg. This case demonstrates that advanced reconstruction for preservation of BKA stump may be feasible in patients with underlying peripheral artery disease.

Despite significant advances in angiosurgery, the treatment of acute limb ischemia remains a challenging clinical problem. Historically, the mainstay of therapy consisted of open thrombectomy and bypass surgery, later supplemented by selective thrombolysis and percutaneous angioplasty techniques. However, even with these approaches, there remains a high risk of adverse outcomes, including amputations and mortality. A breakthrough in the treatment of occlusive-stenotic lesions in the femoropopliteal segment has been the advent of modern endovascular technologies. Numerous studies confirm their clinical efficacy and promise in acute ischemia. Particular importance has been given to a multidisciplinary approach combining advancements in vascular surgery, interventional radiology, and intensive care. Among innovative methods, rotational atherectomy deserves special attention as a technology demonstrating excellent results in treating acute occlusions of the femoropopliteal zone. The article presents clinical cases of successful treatment of femoral-popliteal lesions in acute ischemia of the lower extremities using rotational atherectomy devices.