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ACUTE LIMB ISCHAEMIA

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Acute Limb Ischaemia

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Acute limb ischaemia is defined as the sudden decrease in limb

perfusion that threatens the viability of the limb.
Complete or even partial occlusion of the arterial supply to a limb can
lead to rapid ischaemia and poor functional outcomes within hours.
In this article, we shall look at the causes, clinical features and
management of a patient with acute limb ischaemia.

Aetiology
Blausen gallery 2014. Wikiversity Journal of Medicine. [CC BY 3.0], via Wikimedia Commons

Fig 1 – Arterial embolic occulusion

Acute limb ischaemia has an incidence of around 1.5 per 10,000 person
years. Its causes can be classified into 3 main groups:
 Thrombosis in situ (60%) whereby an atheroma in the artery
ruptures and a thrombus forms on the atheromatous plaque’s cap
o Can present as an acute presentation or an acute-on-chronic
 Embolisation (30%) whereby a thrombus from a proximal source
travels distally to occlude the artery
o The original thrombus source may be as a result of AF, post-MI
mural-thrombus, abdominal aortic aneurysm, or prosthetic heart
valves.
 Trauma (10%), including compartment syndrome
Clinical Features
Classically, the signs and symptoms of acute limb ischaemia can
be described using the 6 Ps (the first three here being the most common
initial features):
 Pain
 Pallor
 Pulselessness
 Paresthesia
 Perishingly cold
 Paralysis
Acute limb ischaemia is often characterised by a sudden onset of these
symptoms. A normal, pulsatile contralateral limb is a sensitive sign of
an embolic occulsion.
In this history, the causes of potential embolisation should be explored.
These include chronic limb ischaemia, atrial fibrillation, recent MI (resulting
in a mural thrombus), or a symptomatic AAA (ask about back/abdominal
pain) and peripheral aneurysms.
The later the patient presents to a hospital, the more likely that irreversible damage to the
neuromuscular structures will have occurred (more common >6hrs post-symptom onset), which will
ultimately result in a paralysed limb.

Category Prognosis Sensory Loss Motor Deficit Arterial Venous

Doppler Doppler

I – Viable No Immediate threat None None Audible Audible

IIA – Marginally Salvageable, if Minimal (toes) None Inaudible Audible

Threatened promptly treated or none

IIB – Salvageable if More than toes, Mild/Moderate Inaudible Audible

Immediately immediately rest pain
Threatened revascularised
III – Irreversible Major tissue loss, Profound Profound, Inaudible Inaudible
permanent nerve paralysis
damage inevitable
Table 1: Clinical Categories of Acute Limb Ischemia, adapted from
Rutherford et al., 2009
Differential Diagnosis
The differential diagnoses for acute limb ischaemia include critical chronic
limb ischaemia, acute DVT (can present as Phlegmasia cerulea dolens and
Phlegmasia alba dolens), or spinal cord or peripheral nerve compression.

Investigation
Routine bloods, including a serum lactate (to assess the level of
ischaemia), a thrombophilia screen (if <50yrs without known risk factors),
and a group and save, should be taken, along with an ECG.
Suspected cases should be initially investigated with beside Doppler
ultrasound scan (both limbs), followed by considering a CT angiography;
if the limb is considered to be salvageable, a CT arteriogram can provide
more information regarding the anatomical location of the occlusion and
can help decide the operative approach (such as femoral vs. popliteal
incision).
By Milorad Dimic MD [GFDL], via Wikimedia Commons

Fig 2 – Reconstructed 3D CT angiogram, showing complete occlusion of the right femoral artery.

Management
Initial Management
Acute limb ischaemia is a surgical emergency. Complete arterial
occlusion will lead to irreversible tissue damage within 6 hours. Early
senior surgical support is vital.
Start the patient on high-flow oxygen and ensure adequate IV access.
A therapeutic dose heparin or heparin infusion should be initiated as
soon as is practical.
Conservative Management
Prolonged course of heparin may be the most effective non-operative
management of acute limb ischemia.
Any patient started on conservative management via heparin will
need regular assessment to determine its effectiveness. Surgical
interventions may be warranted if no significant improvement is seen.
By TeachMeSeries Ltd (2017)

Figure 3 – Angioplasty, one of the surgical options available for the treatment of acute limb ischaemia.

Surgical Intervention
If the cause is embolic, the options are:

 Embolectomy via a Fogarty catheter

 Local intra-arterial thrombolysis
 Bypass surgery (if there is insufficient flow back)
If the cause is due to thrombotic disease, the options are:

 Local intra-arterial thrombolysis

 Angioplasty
 Bypass surgery
Irreversible limb ischaemia (mottled non-blanching appearance with hard
woody muscles) requires urgent amputation or taking a palliative. Most
post-operative cases require a high level of care, typically at a surgical high
dependency unit.
Long Term Management
Reduction of the cardiovascular mortality risk in this patient group is
key. Promoting regular exercise, smoking cessation, and weight loss
as necessary. Most cases should be started on an anti-platelet agent,
such as low-dose aspirin or clopidogrel, and any underlying predisposing
conditions to the acute limb ischaemia should be treated, e.g. uncontrolled
AF.
Cases resulting in amputation will require occupational therapy and
physiotherapy, with a long term rehabilitation plan discussed and transfer
to an intermediate rehabilitation centre.
Complications
Acute limb ischaemia has a mortality rate of around 20%, with the 30-day
mortality rate following the surgical treatment of acute limb ischaemia
at15%.
An important complication of acute limb ischaemia is reperfusion injury;
sudden increase in capillary permeability can result in:
 Compartment syndrome

 Release of substances from the damaged muscle cells, such as:

o K+ ions causing hyperkalaemia

o H+ ions causing acidosis
o Rhabdomyolysis, resulting in significant AKI
http://teachmesurgery.com/vascular/peripheral/acute-ischaemia/