Acute arterial ischemia

Background

• Sudden decrease in perfusion that may result in irreversible limb loss
  • Amputation occurs in 10%-15% of patients during hospitalization
• Etiology may be thrombotic or embolic
  • Thrombosis occurs in vessels with existing atherosclerosis
    • Generally have formed collateral circulation
  • Embolism occurs in vessels usually free of atherosclerosis
    • Generally do not have existing collateral circulation
    • Results in higher level of limb ischemia than thrombosis

Clinical Features

6 Ps

• Pain - Claudication or pain with leg elevation; typically earliest sign
• Paraesthesia - May be associated with weakness; preservation of light touch is good guide to viability
• Pallor
• Paralysis
• Pulselessness - May be accompanied by skin changes; late finding
• Poikilothermia - Limb is cool to touch when compared to other side; late finding

Differential Diagnosis

• Peripheral artery disease
• Vascular injury

Blue Digit

• Acute arterial ischemia
  • Atheroembolism (AKA Blue Toe Syndrome)
  • Arterial embolism
  • Arterial thrombosis
• Vasospastic Disorders
  • Raynaud’s disease
  • Primary erythromelalgia
• Autoimmune
  • Scleroderma
  • SLE
• Idiopathic
  • Thromboangiitis obliterans (Buerger's disease)
• Chronic peripheral artery disease
  • Atherosclerosis obliterans

Foot diagnoses

Acute

• Foot and toe fractures
• Subtalar dislocation
• Metatarsophalangeal joint sprain (turf toe)
• Acute arterial ischemia
• Calcaneal bursitis

Subacute/Chronic

• Diabetic foot infection
• Peripheral artery disease
• Plantar fasciitis
• Trench foot
• Ingrown toenail
• Paronychia
• Tinea pedis
• Morton's neuroma
• Diabetic neuropathy

Evaluation

Ankle-brachial index (ABI)

Ankle-Brachial Index performance.

How to measure:

1. Position patient supine
2. Measure SBP from both brachial arteries using cuff and handheld Doppler over the AC fossa
3. Measure SBP from both DP and PT arteries using cuff placed just proximal to the malleoli with Doppler over artery (5-8% of normal patients have absent DP pulse)
4. Calculate ABI on each leg by taking the highest ankle SBP (between DP and PT) on that leg divided by the highest brachial SBP and record to 2 decimal places

ABI	Meaning
<0.40	Severe occlusion
0.40–0.69	Moderate occlusion
0.70–0.90	Mild occlusion
0.91–1.30	Normal
>1.30	Poorly compressible/calcified vessels

Imaging

• Formal angiogram considered gold standard
• CTA as a diagnostic is near the level of formal angiography (96% sensitive, 95% specific)
• US is sensitive for proximal extremity occlusions, but sensitivity markedly falls off distally and is operator dependent

Thrombosis vs Embolus

Key features	Thrombosis	Embolus
Source	Usually unknown	Heart (A-fib most common)
History	PAD, claudication	Less likely to have PAD and claudication
Physical exam	Absent pulse. Consistent with PAD: hair loss, thickened nails etc	Absent pulse. Usually no evidence of PAD
Degree of arthersclerosis	Diffuse	Minimal
Collaterals	Well-developed	Few

Rutherford Classification

Rutherford Classfication

Management

• Unfractionated heparin
  • 80 units/kg bolus → 18units/kg/hr gtt
• ASA
• Dependent positioning
• Pain control
• Vascular surgery consultation (clot retrieval, balloon angioplasty, intraarterial tPA, stenting, bypass)
  • Management of embolism = embolectomy (limb salvage decreases after 4-6 hours)
  • Management of thrombus = intra-arterial thrombolysis (if non-limb threatening), thrombectomy (if limb-threatening ischmia)
• Interventional radiology if delay in vascular surgery intervention or if unavailable

Disposition

• Admit

See Also

• Peripheral artery disease
• Vascular injury