Acute Limb Ischemia

Definition, Etiology & Patophysiology

Clinical Evaluation & Classes

Ali SABBOUR

Prof. of Vascular Surgery, Ain Shams University

Management

Definition of Acute Limb Ischemia

Sudden decrease of
arterial limb perfusion
causing threat to limb
viability

Etiology of acute limb ischemia

Acute arterial embolism:

Acute arterial thrombosis:

Acute traumatic ischemia:

Of a relatively health arterial tree

Of a previously diseased arterial tree

Acute Embolic
Ischemia

Patho-pysiology

Acute Thrombotic
Ischemia

An embolus can originate from the heart (MS with atrial fibrillation,
MI with mural thrombus) or dilated diseased arteries (aortic aneurism)

An embolus
suddenly
occludes a
relatively
healthy
arterial tree
It usually
arrest at
arterial
bifurcation
Aortic bifurcation
Iliac bifurcation
Femoral bifurcation
Popliteal trifurcation

Atherosclerosis
causes
progressive
narrowing of the
arterial tree
Stimulates
development of
collaterals
Sluggish flow &
rough surface
will favor acute
thrombosis

It is important to differentiate between embolic &

thrombotic ischemia:
Because the
management
is different
Clinical Features Suggestive of acute Embolism:
Sudden onset of symptoms

Known embolic source

Absence of previous claudication
Normal pulse in the other limb

Postgraduates

The severity of acute ischemia depends on:

a) Capability of existing collaterals to carry blood around the acute obstruction
(collaterals are more developed
b) The location of obstruction in relation to the in
number
of with
axialpreexisting
arteries
patients
chronic ischemia)
Accordingly, arterial embolism is
c) The extent of obstruction
more likely to produce sudden
One axial a. with limited collateral pathways
Aorta & common iliac
The larger the obstruction,
the&more
collaterals
symptoms
severe
ischemiaare
d) The duration
lost
then arterial thrombosis
Internal & external iliac

Superficial & deep femoral

Popliteal artery

Tibial arteries

Two axial aa. With better collateral potentials

Flow distal to the obstruction is sluggish. If collaterals

cannot
For Example:
increase the flow above a critical point, a stagnation clot will
Popliteal a occlusion (a
developTwo
in axial
the distal
arterial
tee. Thispotentials
the reason
whyaxial
heparin
aa. With
better collateral
single
a.) results in
should be given as early as possible
severe ischemia, while
One axial a. with limited collateral pathways

Three axial aa. with better collateral potentials

posterior tibial occlusion

may be asymptomatic if
other leg arteries are
patent

Definition: Sudden decrease of arterial limb perfusion causing threat to limb viability
Etiology: 1-Embolic (Rh.heart w mitral stenosis & AF or Ischemic heart w acute myocardial
infarction & mural thrombus or extra-cardiac embolism from aneurismal arteries)
2-Thrombotic

acute ischemia on top of atherosclerotic arterial stenosis

Pathology: onset of symptoms is more acute in embolic ischemia (absent collaterals)

Other factors determine the severity of acute ischemia
Clinical Picture

Management

Clinical Evaluation of Acute Ischemia

(Clinical Picture)
Symptoms of acute ischemia:
Pain: Diffuse foot & leg severe aching pain of acute onset (more acute in
embolic ischemia)
Pain may diminish in intensity by time if collaterals open improving circulation, or if
ischemia progresses causing ischemic sensory loss

Coldness is an early symptom

Numbness followed by sensory loss (late)
Muscle weakness (heavy limb) followed by paralysis (late)

Clinical Evaluation of Acute Ischemia

(Clinical Picture)
History
Aim of your questions
1- To know whether these symptoms are of acute ischemia or not
(DD of acute ischemia : acute DVT [phlegmasia] , hypo-perfusion states [e.g. heart
failure specially if associated with chronic ischemia]

2- To know the severity of acute ischemia

(ask about symptoms of different classes of acute ischemia see later)

3- To look for the underlying etiology

(ask about Rh. Heart Ds, claudication, recent arterial intervention e.g. cardiac cath.,
risk factors for atherosclerosis: hypertension, diabetes, smoking, hyperlipedemia,
family history of cardio-vascular disease)

Clinical Evaluation of Acute Ischemia (Clinical Picture)

Signs of acute ischemia

5Ps
Pain: symptom

+
Pale
Pulseless
Parathesia
Paralysis

Inspection
COLOR:

Fixed
mottling &
cyanosis

Early: pale

Later: cyanosed
mottling
mottling & cyanosis

fixed

An area of
Pallor
fixed
cyanosis
surrounded by
reversible
Reversible
mottling
mottling

Empty veins:
compare the Rt.
(ischemic) & Lt.
(normal)

Clinical Evaluation of Acute Ischemia (Clinical Picture)

Signs of acute ischemia

Palpation

5Ps
Pain: symptom

Femoral

Popliteal

Posterior tibial

Dorsalis pedis

Pale
Pulseless
Parathesia

Palpate peripheral pulses, compare with the

other side & write it down on a sketch

Paralysis

Temperature: the limb is cold with a level of

temperature change (compare the two limbs)
Slow capillary refilling of the skin after
finger pressure

Clinical Evaluation of Acute Ischemia (Clinical Picture)

Signs of acute ischemia

5Ps
Pain: symptom

+
Pale
Pulseless
Parathesia
Paralysis

Palpation
Loss of sensory function
Numbness will progress to anesthesia
Progress of Sensory loss
Light touch
Vibration sense
Proprioreception

Deep pain
Pressure sense

Late

Clinical Evaluation of Acute Ischemia (Clinical Picture)

Signs of acute ischemia

5Ps
Pain: symptom

Palpation
Loss of motor function:
Indicates advanced limb threatening
ischemia
Late irreversible ischemia: Muscle turgidity

Pale
Pulseless
Parathesia
Paralysis

Postgraduates

Intrinsic foot muscles are affected

first, followed by the leg muscles
Detecting early muscle weakness is
difficult because toes movements are
produced mainly by leg muscles

Postgraduates

Classes of Acute Ischemia

Clinical Findings

Prognosis

Sensory
loss

weakness

-ve

-ve

audible

audible

Not immediately
threatened

II.a Marginal
threat

Minimal
sensory loss

No muscle
weakness

Often not
audible

audible

Salvageable if prompt
ttt (there is time for

II.b Immediate
threat

Rest pain w
sensory loss

III.Irreversible

Severe
anesthesia

Class
I. Viable

Motor

Doppler
Arterial Venous
signals Signals

angiography)

Mild to
moderate

more than toes

Usually
not
audible

audible

Paralysis w Inaudible Inaudible

muscle rigor

Salvageable with
immediate ttt (no time
for angiography)

Not salvageable,
permanent N. & muscle
damage , needs amputation

Definition: Sudden decrease of arterial limb perfusion causing threat to limb viability
Etiology: 1-Embolic (Rh.heart w mitral stenosis & AF or Ischemic heart w acute myocardial
infarction & mural thrombus or extra-cardiac embolism from aneurismal arteries)
2-Thrombotic

acute ischemia on top of atherosclerotic arterial stenosis

Pathology: onset of symptoms is more acute in embolic ischemia (absent collaterals)

Other factors determine the severity of acute ischemia

Clinical Picture

The limb is described as having 5 Ps :

Pain, Pale, Pulseless, Parathesia, Paralysis

Management

Investigations of acute limb ischemia

The severity and duration of ischemia at the time of presentation provides a
narrow margin of time for investigations
Postgraduates

Doppler US
It is important to look for
arterial Doppler signals
to assess the level of
obstruction & severity of
ischemia

The presence of pedal signals

usually indicates that there is
time for conventional
arteriography & proper patient
preparation
The ABI is not of value in
acute ischemia. If it can be
measured, the limb is not
threatened

Investigations of acute limb ischemia

Arteriography
Patients with high clinical probability of embolic ischemia do NOT need angiography
If the differentiation between
embolic & thrombotic ischemia is
not clear clinically, and if the limb
condition permits,

DO ANGIOGRAPHY
Value of angiography
Localizes the obstruction
Visualize the arterial tree & distal
run-off
Can diagnose an embolus:
Sharp cutoff, reversed meniscus or clot
silhouette

Popliteal embolism

Lt. iliac embolism

Reversed meniscus sign

Clot silhouette

Treatment of acute limb ischemia

A Once you diagnose
Immediate anticoagulation with heparin to avoid clot
propagation
Appropriate analgesia
Simple measures to improve existing perfusion:

Keep the foot dependant

Avoid pressure over the heal
Avoid extremes of temperature (cold induces vasospasm, heal raises the
metabolic rate)

Maximum tissue oxygenation (oxygen inhalation)

Correct hypotension
Start treatment of other associated cardiac conditions (CHF, AF)

Treatment of acute limb ischemia

B Catheter directed thrombolysis
Indications:

Agents used: Streptokinase,

Urokinase, tissue plasminogen
activator

1. Viable or marginally threatened limb (class I, IIa)

2. Recent acute thrombosis (not suitable for embolism or old thrombi)
3. Avoid patients with contraindications

Contraindications:
Absolute:
1. Cerebro-vascular stroke within previous 2 months
2. Active bleeding or recent GI bleeding within previous 10 days
3. Intracranial trauma or neurosurgery within previous 3 months
Relative:
1. Cardio-pulmonary resuscitation within previous 10 days
2. Major surgery or trauma within previous 10 days
3. Uncontrolled hypertension

Treatment of acute limb ischemia

C Surgery
1- Acute embolism: Catheter embolectomy under local anesthesia

2- Immediate surgical revascularization is indicated in class IIb, or class I, IIa

when thrombolysis is not possible or contraindicated

A combination of different procedures can be done:

Arterial exploration at different sites
Arterial thrombectomy

Bypass surgery based on pre-operative

angiography if available or intra-operative
angiography

Following revascularization:
The sudden return of oxygenated blood to the acutely
ischemic muscles generates & releases oxygen free radicals
that causes cellular injury and severe edema

Compartment syndrome
& muscle necrosis

ttt
Fasciotomy
Longitudinal incision of the skin & deep fascia to release pressure over swollen muscles

Amputation:
Done for irreversible ischemia with permanent tissue
damage (turgid muscles, fixed cyanosis)
The level of amputation is decided according to the level of
palpable pulse.

Palpable popliteal pulse -------------- Below knee amputation

Absent popliteal pulse ---------------- Above knee amputation

Definition: Sudden decrease of arterial limb perfusion causing threat to limb viability
Etiology: 1-Embolic (Rh.heart w mitral stenosis & AF or Ischemic heart w acute myocardial
infarction & mural thrombus or extra-cardiac embolism from aneurismal arteries)
2-Thrombotic

acute ischemia on top of atherosclerotic arterial stenosis

Pathology: onset of symptoms is more acute in embolic ischemia (absent collaterals)

Other factors determine the severity of acute ischemia
Clinical Picture

The limb is described as having 5 Ps :

Pain, Pale, Pulseless, Parathesia, Paralysis
Investigations

Treatment

Doppler to evaluate level & degree of ischemia

Conventional angiography in class I & IIa
Intraoperative angiography in class IIb
Heparin
Catheter directed thrombolysis
Operative revascularization
Amputation in irreversible ischemia