+

Sudden Onset of
Cold, Painful Leg

Samyuktha Balabhadra
June 29, 2016
1
+ 2

Patient

81 y/o F with right lower extremity coolness and pain

Acute limb ischemia

Occurs due to sudden lack of blood flow to extremity

Multiple etiologies possible

+ 3

Pertinent Clinical History

Difficult to elicit history given mental status changes

Believes her foot has been cool for 2 days

ADL: Ambulates with walker at baseline

PMH:
Atrial fibrillation
Hypertension
Hyperlipidemia
CAD s/p MI in 2009

Surgical Hx: ICD implantation in 2009

Cr 1.14, eGFR>45

Warfarin, per HMC Anticoagulation Clinic (last INR 2.0)

+ 4

Differential Diagnosis
Arterialembolus
Acute arterial thrombosis
Thrombosed aneurysm
Aortic dissection
Traumatic arterial disruption
Acute venous thrombosis
Nerve/spinal compression or infarction
Screen capture from ACR Appropriateness Criteria 5
+ 6

ACR Appropriateness Criteria

Literature Review Comments

#1 cause is arterial occlusion

Important to determine whether it is thrombotic or embolic using
imaging
Requires urgent treatment

Arteriography (DSA) is the gold standard for diagnosis and only

modality that allows simultaneous treatment

Noninvasive imaging with MRA or CTA before arteriography (DSA)

or surgery is accepted for diagnosis and to help with planning
intervention
+ 7

#1 study- Arteriography

Radiation
.1 1 mSv

Cost:
Professional: $572

Technical: $2,811

Why #1
Visualize blockage in vessel and possibly treat with
thrombolytic, angioplasty, and/or stent
+ 8

Contraindications
Absolute Contraindication: Multisystem dysfunction

Relative Contraindications
Recent MI, serious arrhythmia, substantial serum electrolyte
imbalance
Serious documented past contrast reaction
Impaired renal status consider carbon dioxide for eGFR<45 mL/min
Coagulopathies or seriously altered coagulation profile
Inability to lie flat on angiography table due to congestive heart
failure or compromised respiratory status
Residual barium in abdomen from recent examination (will obscure
details of visceral angiography)
Pregnancy (risk of fetus to ionizing radiation)
+ 9

Examination Details Femoral

Artery Puncture
+ 10
+ 11
+ 12

Images From Procedure

+ 13

Complications

Hematoma

Nephrotoxicity

Dissection

Embolization of dislodged plaques

Contrast reaction

Site infection
+ 14

References and Resources

References
Dormandy JA, Rutherford RB. Management of peripheral arterial
disease (PAD). TransAtlantic Inter-Society Consensus (TASC). J
Vasc Surg. 2000;31(1 pt 2):S1S296.
Kandarpa, Krishna, and John E. Aruny. Handbook of Interventional
Radiologic Procedures. Philadelphia: Lippincott Williams &
Wilkins, 2002. Print.

Images
http://cardiaccathpro.com/VascularAccess.html
http://emedicine.medscape.com/article/460178-overview
http://www.yoursurgery.com/ProcedureDetails.cfm?BR=1&Proc=
33