Acute arterial ischemia

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

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

Diagnosis

ABI

• Measuring
  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 divided by the highest brachial SBP and record to 2 decimal places
• Using calculation
  • 0.91–1.30: normal
  • 0.70–0.90: mild occlusion
  • 0.40–0.69: moderate occlusion
  • <0.40: severe occlusion
  • >1.30: poorly compressible/calcified vessels

Imaging

• Angiogram considered gold standard
• CTA
• US

Management

1. Unfractionated heparin
   • 80 units/kg bolus; then infuse 18units/kg/hr
2. ASA
3. Dependent positioning
4. Pain control
5. Fluid resuscitation and treatment of heart failure as needed to improve limb perfusion
6. Vascular surgery consultation (clot retrieval, balloon angioplasty, intraarterial tPA, stenting, bypass)

Disposition

• Acute limb ischemia requires inpatient management

See Also

• Peripheral artery disease
• Vascular injury