Updated: 3/16/2021

Acute Limb Ischemia

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Snapshot
  • A 61-year-old man presents to the emergency department for severe right lower extremity pain. He has a medical history of hypertension, hyperlipidemia, coronary artery disease requiring drug-eluting stents, and type 2 diabetes mellitus. Physical examination is remarkable for a pale right lower extremity, significant weakness and sensory impairment, and absent capillary refill. Arterial Dopplers do not reveal an audible pulse. Vascular surgery was consulted for emergent amputation.
Introduction
  • Overview
    • acute limb ischemic results from impaired blood perfusion to the affected limb
      • arterial occlusion, rather than venous occlusion, most commonly leads to acute limb ischemia
      • results in the 6 Ps 
        • pain
        • pallor
        • paresthesia
        • pulselessness
        • poikilothermia
        • paralysis/paresthesia
    • categories of acute limb ischemia
      • viable or marginally threatened
        • pain
          • mild
        • sensory and motor deficits
          • none
        • capillary refill
          • normal
        • arterial Doppler
          • audible
      • immediately threated
        • pain
          • severe
        • sensory and motor deficits
          • mild
        • capillary refill
          • delayed
        • arterial Doppler
          • absent
      • irreversibly ischemic
        • pain
          • variable
        • sensory and motor deficits
          • severe or complete
        • capillary refill
          • absent
        • arterial Doppler
          • absent
  • Epidemiology
    • risk factors
      • hypertension
      • hyperlipidemia
      • diabetes
      • smoking
      • peripheral artery disease
  • Etiology
    • atherosclerotic plaque
      • may result from progressively occluding atherosclerotic plaque or Intraplaque hemorrhage and local hypercoagulability
    • artery aneurysm
    • artery dissection
    • thrombophilia
    • traumatic or iatrogenic arterial injury
    • complication of vascular reconstruction (e.g., bypass graft)
    • arterial or paradoxical embolism
      • left ventricular aneurysm after myocardial infarction 
  • Associated conditions
    • peripheral artery disease
    • compartment syndrome
  • Prognosis
    • improved outcomes with immediate systemic anticoagulation and clot removal
Presentation
  • Symptoms/physical examination
    • 6 Ps
      • pain
      • pallor
      • paresthesia
      • pulselessness
      • poikilothermia
      • paralysis/paresthesia
Imaging
  • CT angiography or catheter-based arteriography
    • indication
      • in patients with a viable ischemic limb
  • Transthoracic echocardiogram can be used to confirm cardiac source of systemic embolism
    • indication
      • abrupt occlusion of major peripheral or visceral artery
      • high suspicion of left ventricular thrombus
Studies
  • This is a clinical diagnosis that can be supported by imaging
Differential
  • Chronic limb ischemia
    • differentiating factor
      • symptoms present for >2 weeks
  • Phlegmasia
    • differentiating factor
      • lower extremity edema
      • limb cyanosis
Treatment
  • Medical
    • systemic anti-coagulation (e.g., unfractionaed heparin)
      • indication
        • in all patients with acute limb ischemic
    • intra-arterial rtPA
      • indication
        • in patients with viable limb ischemia
  • Operative
    • embolectomy
      • indication
        • in immediately threatened limb ischemia 
    • amputation
      • indication
        • in irreversible limb ischemia
Complications
  • Acute renal failure
  • Hyperkalemia
  • Infection

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