acute peripheral arterial occlusion (severe acute limb ischemia)
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Introduction
Sudden onset of severe limb ischemia.
Etiology
- thrombosis
- may form at site of stenosis in an atherosclerotic artery or bypass graft
- procoagulant disorders may cause thrombus formation in normal arteries
- embolism
- most common cause
- 85% originate from cardiac thrombi
- systemic emboli from deep venous thrombosis (DVT) that enters arterial circulation via a patent foramen ovale or an atrial septal defect (ASD)
- emboli originating from aneurysms of the aorta or peripheral arteries
- dissection
- trauma
Pathology
- progression of severe atherosclerosis with superimposed arterial thrombosis or arterial embolization
- irreversible changes occur as early as 4-6h after acute arterial occlusion
Clinical manifestations
- pulseless
- painful -> paresthesia -> complete sensory loss with necrosis
- pallor
- paralysis
- poikilothermy (coolness)
Radiology
- arteriography (angiography)
- anticoagulation with heparin prior to arteriography
- identify the site & nature of acute arterial occlusion
- distinguish thrombosis in situ from arterial embolism
Complications
- tissue necrosis
- compartment syndrome from tissue swelling after reperfusion[1]
Management
- severe claudication but no pain at rest
- revascularization in a threatened, but viable limb[1][2]
- angioplasty or embolectomy catheter
- intra-arterial thrombolytic therapy
- urokinase or tPA better than streptokinase
- 82% salvage rate at 1 year
- surgical reconstruction (bypass) when angioplasty/embolectomy & thrombolysis are not feasible or ineffective
- below-the-ankle interventions are feasible & provide good clinical outcome[7]
- careful monitoring after reperfusion
- frequent reocclusion, limb edema, compartment syndrome
- amputation if limb not viable[1][2]
- anesthesia, paralysis, absent doppler, muscle rigor
- blacks more likely than hispanics or whites to undergo limb amputation[3]
More general terms
References
- ↑ 1.0 1.1 1.2 1.3 Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2006, 2009, 2012, 2015, 2018, 2022.
- ↑ 2.0 2.1 2.2 BASIL Trial Participants. Bypass versus angioplasty in severe ischaemia of the leg (BASIL): Multicentre, randomised controlled trial. Lancet 2005; 366:1925 PMID: https://www.ncbi.nlm.nih.gov/pubmed/16325694
Goy JJ & Urban P Life and limb: Bypass versus angioplasty in the ischaemic limb. Lancet 2005; 366:1905 PMID: https://www.ncbi.nlm.nih.gov/pubmed/16325681 - ↑ 3.0 3.1 Durazzo TS et al Influence of Race on the Management of Lower Extremity Ischemia. Revascularization vs Amputation. JAMA Surg. 2013;():1-6. March 20, 2013 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23552850 <Internet> http://archsurg.jamanetwork.com/article.aspx?articleid=1669979
- ↑ Feiring AJ, Krahn M, Nelson L et al Preventing leg amputations in critical limb ischemia with below-the-knee drug-eluting stents: the PaRADISE (PReventing Amputations using Drug eluting StEnts) trial. J Am Coll Cardiol. 2010 Apr 13;55(15):1580-9. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20378075
- ↑ Creager MA, Kaufman JA, Conte MS. Clinical practice. Acute limb ischemia. N Engl J Med. 2012 Jun 7;366(23):2198-206. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22670905
- ↑ Lou N. Revascularization Feasible for Below-The-Ankle CLI Limbs salvaged in most severe cases per single-center study MedPage Today. March 20, 2018 https://www.medpagetoday.com/meetingcoverage/sir/71890
Arslan B, et al Midterm outcomes after below the ankle interventions for Rutherford 5-6 critical limb ischemia patients. Society of Interventional Radiology (SIR) 2018. - ↑ 7.0 7.1 Misra S, Shishehbor MH, Takahashi EA, et al AHA SCIENTIFIC STATEMENT. Perfusion Assessment in Critical Limb Ischemia: Principles for Understanding and the Development of Evidence and Evaluation of Devices. A Scientific Statement From the American Heart Association. Circulation. Aug 2019 PMID: https://www.ncbi.nlm.nih.gov/pubmed/31401843 https://www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000708