Acute limb ischemia (Acute arterial occlusion of an extremity)

Abstract

Acute limb ischemia is a vascular emergency with a critically reduced arterial blood supply
of one or more extremities. Most cases are caused by arterial embolisms originating in the
heart, especially the left atrium. Arterial thrombosis is responsible for the majority of
remaining cases. Regardless of the severity, ALI almost always presents with limb pain.
Further symptoms include, e.g., pallor, coldness, and no pulse in the affected extremity.
Diagnostics should always include a physical examination and arterial and venous doppler
studies. Further imaging studies, such as digital subtraction angiography, should only be
performed if this delay of treatment does not threaten the extremity. Clinical findings in
combination with doppler studies are then used to categorize the limb as either viable,
threatened, or nonviable. Management of viable and threatened limb ischemia begins with
intravenous heparin followed by revascularization. Irreversible limb ischemia requires
immediate amputation of the limb. Postoperatively and depending on the etiology, longterm
anticoagulation and further diagnostic studies might be necessary (e.g., echocardiography in
suspected left atrial thrombus formation).

Etiology
 Arterial embolism (∼ 80% of cases) [1]

 Origin of the embolus

 Heart (90%)
 Left atrium in patients with atrial fibrillation (most common)
 Valvular heart disease (e.g., endocarditis) → valvular thrombus
 Ventricular aneurysms (e.g., following severe anterior STEMI)
 Arterial aneurysms (e.g., aortic aneurysm, aneurysm of the popliteal
artery)
 Location of the obstruction

 Most common: femoropopliteal artery (∼ 50% of cases)

 Brachial artery (∼20%)

 Abdominal aorta (∼10%

 Iliac artery ∼ 10%

 Arterial thrombosis (∼ 20% of cases) [1]

 Atherosclerosis → peripheral artery disease

 Vascular stent → stent restenosis
 Trauma
  Prothrombotic states (e.g., thrombocytosis, Use of oral contraceptive pills)
 Dissecting aneurysm [1]

Pathophysiology
 Ischemic tolerance time, after which irreversible tissue damage begins to take place
 Skin: 12 h
 Musculature: 6–8 h
 Neural tissue: 2–4 h

Clinical features
 The 6 Ps (according to Pratt)
 Pain
 Pallor
 Pulselessness
 Paralysis
 Paresthesia
 Poikilothermia
 Embolism: acute onset; medical history of heart disease (e.g., atrial fibrillation)
 Arterial thrombosis: subacute onset; medical history of arterial occlusion
 Exam shows decreased peripheral sensitivity, pulse, and motor skills
References: [1]

Subtypes and variants

(Acute) Leriche syndrome

Occlusion at the bifurcation of the aorta usually presenting with:

 Pain in both legs

 Diminished inguinal or peripheral pulse
 Neurological impairment
 Impotence
 Shock

Hair tourniquet syndrome

 Definition: a medical condition wherein a hair or other thread gets wound around an
appendage tightly, so as to put it at risk of ischemic damage.
 Epidemiology: usually affects infants
 Pathophysiology: hairs or thread inside socks or under bed sheets become
spontaneously tied round a toe and tighten with the child's movement → the 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 fibre may be visible.
 Treatment prompt removal of the constricting hair or fiber, either by means of a hair
dissolving product or a scalpel.
Stages

The severity of ALI is assessed through physical examination and doppler studies and
can range from viable to nonviable limb (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: [1]

Diagnostics
 Best initial test: arterial and venous doppler
 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: [1]

Treatment
 Acute limb ischemia due to thromboembolism
 Systemic anticoagulation with an IV heparin bolus followed by continuous
infusion
 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)

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

Complications
 Compartment syndrome
 Tourniquet syndrome (reperfusion syndrome, postischemic syndrome)

 Following reperfusion, detached metabolites may trigger further

complications, especially after extended occlusion (more than 6 h)
 Possible complications:
 Acidosis, hyperkalemia → cardiac arrhythmia
 Rhabdomyolysis → myoglobinemia → Crush syndrome
 Ischemia/reperfusion edema → compartment syndrome
 Massive edema → hypovolemic shock
 Severe complications: DIC (disseminated intravascular
coagulation), multiorgan dysfunction
 Symptomatic treatment, monitoring (amputation of the affected extremity if
necessary)

References: [1]

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

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