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Updated: Dec 8 2021

Acute Limb Ischemia

  • 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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