Acute Limb Ischemia
Acute Limb Ischemia
Acute Limb Ischemia
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2011 UpToDate
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Authors
Marc E Mitchell, MD
Emile R Mohler, III, MD
Jeffrey P Carpenter, MD
Section Editors
Denis L Clement, MD, PhD
James Hoekstra, MD
Deputy Editor
Kathryn A Collins, MD, PhD, FACS
Disclosures
Last literature review version 19.2: May 2011 | This topic last updated:
September 8, 2008 (More)
INTRODUCTION AND DEFINITIONS According to the 2007 Inter-Society
Consensus for the Management of Peripheral Arterial Disease (TASC II), acute limb
ischemia is defined as a sudden decrease in limb perfusion that causes a potential
threat to limb viability (manifested by ischemic rest pain, ischemic ulcers, and/or
gangrene) in patients who present within two weeks of the acute event [1]. Patients
with similar manifestations who present later than two weeks are considered to have
critical limb ischemia, which is by definition chronic.
The management of acute arterial occlusion remains a challenge for vascular
specialists. Surgical thromboembolectomy and bypass grafting were the mainstays of
therapy for many years [2]. Subsequently, thrombolytic therapy and percutaneous
transluminal angioplasty (PTA) have become treatment options for selected patients.
Despite these advances, the morbidity, mortality, and limb loss rates from acute
lower extremity ischemia remain high. Thus, regardless of the treatment modality
used, early diagnosis and rapid initiation of therapy are essential in order to salvage
the ischemic extremity.
The major causes and management approaches to acute limb ischemia will be
reviewed here. Issues related to critical limb ischemia (ie, similar manifestations in
patients who present more than two weeks after symptom onset) are discussed
separately. (See "Clinical manifestations and evaluation of chronic critical limb
ischemia" and "Treatment of chronic critical limb ischemia".)
ETIOLOGY Acute arterial occlusion can be the result of emboli from a distant
source, acute thrombosis of a previously patent artery, or direct trauma to an artery
(table 1).
Arterial emboli Eighty percent of arterial emboli originate in the heart and travel
to the extremities; the lower extremities are affected much more frequently than the
upper extremities [3]. The majority of these emboli occur in patients with significant
underlying cardiac disease; the severity of the patient's underlying cardiac condition
may increase the risk of surgery, and limit the options available for restoring blood
flow to the ischemic extremity.
Potential sources of emboli from the heart include left ventricular thrombus formation
following myocardial infarction, and atrial thrombus in patients with atrial fibrillation.
Up to 75 percent of patients with emboli to the lower extremities have a history of
recent myocardial infarction or atrial fibrillation. (See "Left ventricular thrombus after
acute myocardial infarction" and "Echocardiography in detection of intracardiac
sources of embolism".)
Arterial to arterial embolization of thrombus or plaque originating from aneurysms or
atherosclerotic lesions is another well described occurrence and accounts for 20
percent of peripheral emboli. (See "Embolism from aortic plaque:
Thromboembolism" and "Embolism from aortic plaque: Atheroembolism (cholesterol
crystal embolism)".)
Emboli typically lodge where there is an acute narrowing of the artery, such as an
atherosclerotic plaque or a point where the vessel branches; the common femoral,
common iliac, and popliteal artery bifurcations are the most frequent locations. In a
large series of arterial embolism, for example, the following frequencies were noted
[4]:
Femoral 28 percent
Arm 20 percent
Aortoiliac 18 percent
Popliteal 17 percent
Pain
Pulselessness
Pallor
Paresthesias
Paralysis
In addition, small vessel occlusion can cause the blue toe syndrome. (See 'Blue toe
syndrome' below.)
Pain Pain associated with acute ischemia is usually located distally in the
extremity, gradually increases in severity, and progresses proximally as the length of
ischemia increases. Later, the pain may decrease in severity due to progressive
ischemic sensory loss.
It is essential to determine if the patient had symptoms of chronic ischemia before
the acute event occurred. Patients with an embolus usually have no preexisting
ischemic symptoms, and can frequently pinpoint the exact time that symptoms
began. Thus, the sudden and dramatic development of ischemic symptoms in a
previously asymptomatic patient is most consistent with an embolus, while gradually
increasing symptoms in a patient with chronic ischemia is indicative of thrombosis.
Pulse The quality and character of the peripheral pulses must be evaluated. If
pulses are not palpable, a hand held Doppler should be used. It is rare to have acute
limb-threatening ischemia without a major pulse deficit.
The status of the pulses in the contralateral extremity is also important. The
presence of a pulse deficit in an asymptomatic contralateral extremity is an indication
of underlying chronic arterial occlusive disease and suggests that acute thrombosis of
an already diseased vessel is the most likely cause of the acute occlusion. By
contrast, the presence of normal pulses in the contralateral extremity suggests the
absence of chronic occlusive disease, and increases the likelihood that an embolus is
the etiology of acute occlusion.
Skin The skin of both the normal and affected extremity should be examined for
temperature, color, and capillary refill. The skin of the ischemic extremity is typically
cool and pale with delayed capillary filling. The level of arterial obstruction is usually
one joint above the line of demarcation between the normal and ischemic tissue.
Both extremities should also be examined for signs of chronic ischemia such as
atrophy of the skin, hair loss, and thickened nails.
Neurologic examination A careful neurologic examination must be performed.
Subjective sensory deficits such as numbness or paresthesias are signs of early
nerve dysfunction secondary to ischemia. Major loss of sensory or motor function is
indicative of advanced ischemia. The anterior compartment of the lower leg is most
sensitive to ischemia, and sensory deficits over the dorsum of the foot are often the
earliest neurologic sign of vascular insufficiency.
Blue toe syndrome The blue toe syndrome is characterized by the sudden
appearance of a cool, painful, cyanotic toe or forefoot in the often perplexing
presence of strong pedal pulses and a warm foot (picture 1). There may also be
scattered areas of petechiae or cyanosis of the soles of the feet.
The blue toe syndrome is usually due to embolic occlusion of digital arteries with
atherothrombotic material from proximal arterial sources. These episodes portend
similar and more severe episodes in the future. Thus, identification and eradication of
the embolic source is usually indicated [8].
Expeditious evaluation by angiography is required to evaluate the source; complete
exclusion and bypass of the diseased segment are indicated. However, caution is
advised for performing angiography in patients who have other signs suggestive of
multiple atheroemboli, such as livedo reticularis, since angiography may lead to
further embolization. (See "Embolism from aortic plaque: Atheroembolism
(cholesterol crystal embolism)".)
CLASSIFICATION The following clinical categories of acute limb ischemia have
been proposed (table 2) [7,9,10]:
Viable Viable limbs are under no immediate threat of tissue loss. There is
no sensory loss or muscle weakness and both arterial and venous Doppler
signals are audible
Although all patients with acute extremity ischemia would benefit from the
information obtained from arteriography, it is not possible to perform this test in
every case. Patients with a threatened extremity, for example, cannot tolerate the
several hour delay in revascularization while arteriography is being performed. Thus,
patients with a viable extremity should generally undergo diagnostic arteriography,
while those with a threatened extremity should have immediate surgical
revascularization with intraoperative arteriography as necessary.
TREATMENT It is difficult to compare published results of the treatment of acute
extremity ischemia because of different methods used to describe the severity of
ischemia and differences in the duration of ischemia. However, it is clear that acute
extremity ischemia is associated with a high hospital morbidity and mortality and
high rates of limb loss. Limb loss rates as high as 30 percent and hospital mortality
as high as 20 percent have been quoted in surgical series [2]. Cardiopulmonary
complications account for the majority of the deaths, underscoring the severity of the
baseline medical condition of these patients.
Heparin The best defense against limb loss is prompt initiation of therapy. Thus,
once the diagnosis of acute arterial occlusion has been made by history and physical
examination, the 2008 American College of Chest Physicians (ACCP) guideline on
antithrombotic therapy for peripheral artery occlusive disease and the 2007 TASC II
consensus document on the management of PAD recommend that the patient should
immediately receive intravenous heparin followed by a continuous heparin infusion
[1,11].
provided the maximum lytic efficacy at a minimal bleeding risk [15]; recanalization
was achieved in 80 percent and complete lysis of thrombus in 68 percent [16].
Part 2 included 544 patients with acute arterial occlusion of less than 14 days in
duration who were randomly assigned to the above rUK regimen or surgery [16]. The
following findings were noted:
Major (including intracranial) hemorrhage was more common with rUK (12.5
versus 5.5 percent, respectively).
The STILE trial consisted of 393 patients with nonembolic arterial and graft occlusion
who presented with new or progressive symptoms of limb ischemia symptoms of up
to six months duration [17,18]. The patients were randomly assigned to treatment
with surgery or intraarterial catheter-directed thrombolysis with recombinant tissue
plasminogen activator or urokinase. Failure of catheter placement occurred in 28
percent of patients assigned to thrombolytic therapy.
Patients with ischemia of 14 days or less who were treated with thrombolysis had a
significantly lower rate of amputation (6 versus 18 percent) and shorter hospital
stays compared to the surgical group. By contrast, patients with ischemia for longer
than 14 days did better with surgical revascularization with significant reductions at
one year in the rates of major amputation (0 versus 10 percent with thrombolytic
therapy [35 versus 65 percent]) [18].
For the patients receiving thrombolysis who subsequently required surgery, the
magnitude of the surgical procedure was reduced (compared to those not receiving
prior thrombolytic therapy) in 56 percent. Factors associated with a relatively poor
Although many patients treated with thrombolytic therapy will subsequently require
surgical or percutaneous revascularization, the magnitude and complexity of the
procedure required to revascularize the extremity is frequently less than in those not
receiving prior thrombolytic therapy.
Thus, patients found to have an ischemic but viable extremity on clinical examination
should undergo urgent arteriography in order to plan surgical or medical
revascularization. There are several findings on arteriography which are used to
determine if thrombolytic therapy, PTA, or surgical revascularization is the most
appropriate treatment. These include:
1.
2.
3.
4.
5.
Nasser TK, Mohler ER 3rd, Wilensky RL, Hathaway DR. Peripheral vascular
complications following coronary interventional procedures. Clin Cardiol 1995;
18:609.
6.
Messina LM, Brothers TE, Wakefield TW, et al. Clinical characteristics and
surgical management of vascular complications in patients undergoing cardiac
catheterization: interventional versus diagnostic procedures. J Vasc Surg 1991;
13:593.
7.
Rutherford, RB. Acute limb ischemia: Clinical assessment and standards for
reporting. Semin Vasc Surg 1992; 5:4.
8.
Karmody AM, Powers SR, Monaco VJ, Leather RP. "Blue toe" syndrome. An
indication for limb salvage surgery. Arch Surg 1976; 111:1263.
9.
Katzen BT. Clinical diagnosis and prognosis of acute limb ischemia. Rev
Cardiovasc Med 2002; 3 Suppl 2:S2.
10.
Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 Practice Guidelines for
the management of patients with peripheral arterial disease (lower extremity, renal,
mesenteric, and abdominal aortic): a collaborative report from the American
Association for Vascular Surgery/Society for Vascular Surgery, Society for
Cardiovascular Angiography and Interventions, Society for Vascular Medicine and
Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice
Guidelines (Writing Committee to Develop Guidelines for the Management of Patients
With Peripheral Arterial Disease): endorsed by the American Association of
Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood
Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and
Vascular Disease Foundation. Circulation 2006; 113:e463.
11.
Sobel M, Verhaeghe R, American College of Chest Physicians, American
College of Chest Physicians. Antithrombotic therapy for peripheral artery occlusive
disease: American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition). Chest 2008; 133:815S.
12.
Riggs P, Ouriel K. Thrombolysis in the treatment of lower extremity occlusive
disease. Surg Clin North Am 1995; 75:633.
13.
Huettl EA, Soulen MC. Thrombolysis of lower extremity embolic occlusions: a
study of the results of the STAR Registry. Radiology 1995; 197:141.
14.
Carpenter JP, Barker CF, Roberts B, et al. Popliteal artery aneurysms: current
management and outcome. J Vasc Surg 1994; 19:65.
15.
Ouriel K, Veith FJ, Sasahara AA. Thrombolysis or peripheral arterial surgery:
phase I results. TOPAS Investigators. J Vasc Surg 1996; 23:64.
16.
Ouriel K, Veith FJ, Sasahara AA. A comparison of recombinant urokinase with
vascular surgery as initial treatment for acute arterial occlusion of the legs.
Thrombolysis or Peripheral Arterial Surgery (TOPAS) Investigators. N Engl J Med
1998; 338:1105.
17.
Results of a prospective randomized trial evaluating surgery versus
thrombolysis for ischemia of the lower extremity. The STILE trial. Ann Surg 1994;
220:251.
18.
Weaver FA, Comerota AJ, Youngblood M, et al. Surgical revascularization
versus thrombolysis for nonembolic lower extremity native artery occlusions: results
of a prospective randomized trial. The STILE Investigators. Surgery versus
Thrombolysis for Ischemia of the Lower Extremity. J Vasc Surg 1996; 24:513.
19.
Ouriel K, Shortell CK, DeWeese JA, et al. A comparison of thrombolytic
therapy with operative revascularization in the initial treatment of acute peripheral
arterial ischemia. J Vasc Surg 1994; 19:1021.
20.
Kessel DO, Berridge DC, Robertson I. Infusion techniques for peripheral
arterial thrombolysis. Cochrane Database Syst Rev 2004; :CD000985.
GRAPHICS
Embolus
Thrombosis
Trauma
Cardiac source
Vascular grafts
Blunt
Atherosclerosis
Penetrating
Thrombosis of aneurysm
Iatrogenic
Atrial fibrillation
Myocardial infarction
Endocarditis
Valvular disease
Entrapment syndrome
Atrial myxoma
Hypercoagulable state
Prosthetic valves
Arterial source
Aneurysm
Atherosclerotic plaque
Paradoxical embolus
Threatened
Nonviable
Pain
Mild
Severe
Variable
Capillary refill
Intact
Delayed
Absent
Motor deficit
None
Partial
Complete
Sensory deficit
None
Partial
Complete
Arterial Doppler
Audible
Inaudible
Inaudible
Venous Doppler
Audible
Audible
Inaudible
Treatment
Urgent work-up
Emergency surgery
Amputation
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