• Clinical science

Acute limb ischemia

Summary

Acute limb ischemia (ALI) is a vascular emergency in which the arterial blood supply to one or more extremities is critically reduced. Arterial thrombosis and cardiac emboli are responsible for the majority of cases. The typical signs and symptoms of ALI include pain, pallor, pulselessness, poikilothermia, paralysis, and paresthesia of the limb distal to the site of vascular occlusion (the 6 Ps). Diagnosis relies on examination and arterial Doppler studies. Clinical findings in combination with Doppler studies are then used to categorize the limb as viable, threatened, or nonviable. Further imaging studies, e.g., digital subtraction angiography, should only be performed if they do not result in treatment delays. Management of viable and threatened limb ischemia begins with intravenous heparin followed by revascularization. Irreversible limb ischemia will inevitably progress to gangrene and requires amputation of the nonviable parts of the limb. Whether long-term anticoagulation and/or further diagnostic studies are required depends on the suspected etiology (e.g., echocardiography in suspected left atrial thrombus formation).

Etiology

References:[4]

Clinical features

  • The lower limb is affected in > 80% of cases.
  • Arterial thrombosis: subacute onset; history of claudication pain
  • Embolism: acute onset; history of heart disease (e.g., atrial fibrillation)
  • The 6 Ps distal to the site of occlusion(according to Pratt)
    • Pain
    • Pallor
    • Pulselessness
    • Paralysis
    • Paresthesia
    • Poikilothermia

References:[4]

Subtypes and variants

Leriche syndrome (aortoiliac occlusive disease)

Occlusion at the level of the aortic bifurcation or bilateral occlusion of the iliac arteries that usually presents with:

Hair tourniquet syndrome

  • Definition: : a condition in which a hair or thread becomes wound around an appendage tightly, putting the appendage at risk of ischemic damage
  • Epidemiology: usually affects infants
  • Pathophysiology: hairs or threads inside socks or under bed sheets can become spontaneously tied round a toe and tighten with the child's movement → venous and lymphatic return is impaired → further obstruction may cause arterial occlusion and ischemic injury
  • Clinical features: painful, swollen, reddened appendage with a deep groove proximal to it, in which the constricting fiber may be visible
  • Treatment: prompt removal of the constricting hair or fiber, either by means of a hair-dissolving product or a scalpel

References:[5]

Stages

The severity of ALI is assessed through physical examination and Doppler studies. Affected limbs can range from viable to nonviable (irreversible ischemia).

Sensory loss Muscle weakness Pain Hand-held Doppler signal
Arterial Venous
Viable None None Mild to moderate Audible flow Audible flow
Threatened Minimal Mild to moderate Severe No flow Audible flow
Nonviable Anesthetic limb Paralysis None No flow No flow

References:[4]

Diagnostics

  • Tests to confirm the diagnosis and identify the site(s) of occlusion
    • Best initial test: arterial and venous Doppler
      • Diminished or absent Doppler flow signal distal to site of occlusion.
    • Confirmatory test: angiography (DSA, CTA, MRA)
      • Digital subtraction angiography (DSA) is the imaging modality of choice.
      • Should only be performed if delaying treatment for further imaging does not threaten the extremity
  • Depending on the suspected etiology, other tests may be indicated (e.g., echocardiography if an arterial embolism is suspected).

References:[4]

Treatment

  • Acute limb ischemia due to thromboembolism
    • Systemic anticoagulation with an IV heparin bolus followed by continuous infusion unless a contraindication is present
    • Further management depends on the severity of acute limb ischemia.
      • Viable, non-threatened limb
        1. Urgent angiography to localize the site of the occlusion
        2. Revascularization procedure (open or catheter-directed thrombectomy or thrombolysis) within 6–24 hours
      • Threatened limb: emergent revascularization procedure within 6 hours
        • First-line: catheter-directed thrombolysis and/or percutaneous mechanical thromboembolectomy (e.g., balloon catheter embolectomy)
        • Second-line: open thromboembolectomy
      • Non-viable limb: limb amputation
  • Acute limb ischemia due to compartment syndrome: fasciotomy (see compartment syndrome)
  • Acute limb ischemia due to a dissecting aneurysm: stenting and/or surgical repair

Complications

References:[4]

We list the most important complications. The selection is not exhaustive.