ACUTE LIMB ISCHEMIA

14 Jul

manifests as:

  • ischemic rest pain
  • ischemic ulcers
  • gangrene

 

ETIOLOGY 

  • Embolus from a proximal source lodging into a more distal vessel
  • dissection of an artery or direct trauma to an artery

 

RISK FACTORS

  • atrial fibrillation,
  • Recent myocardial infarction
  • Aortic atherosclerosis,
  • aneurysmal disease (eg, aortic aneurysm, popliteal aneurysm)
  • Prior lower extremity revascularization (angioplasty/stent, bypass graft),
  • Risk factors for aortic dissection (HTN, etc)
  • Arterial trauma
  • Deep vein thrombosis (paradoxical embolism)
  • left ventricular dysfunction
  • debris from prosthetic valves and infected cardiac valves (septic emboli)

 

Arterial Trauma — Acute arterial occlusion following interventional procedures has become a more frequent cause — the incidence of arterial complications following interventional cardiac catheterization is ~1.5 to 9 percent 

 

6 P’s

  • paresthesia,
  • pain,
  • pallor,
  • pulselessness,
  • poikilothermia,
  • paralysis

 

Variations Blue toe syndrome — sudden appearance of a cool, painful, cyanotic toe(s) or forefoot in the often perplexing presence of strong pedal pulses and a warm foot.  The blue toe syndrome is usually due to embolic occlusion of digital arteries with atherothrombotic material from proximal arterial sources.

IMAGING 

First LineComputed tomographic angiography with runoff, noninvasive duplex ultrasonography, or magnetic resonance angiography

 

MANAGEMENT

intravenous heparin bolus followed by a continuous heparin infusion 

Preoperative eval, including blood tests (PT/PTT, CBC) and electrocardiography (ECG)

Surgical thromboembolectomy and bypass grafting – Were the mainstays of therapy for many years. Subsequently, thrombolytic therapy and percutaneous transluminal angioplasty (PTA) have become treatment options for selected patients. 

Consult Vascular Surgery.

Submitted by Christina Brown.

 

References: uptodate.com, Norgren L, Hiatt WR, Dormandy JA, et al. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg 2007; 45 Suppl S:S5Nasser TK, Mohler ER 3rd, Wilensky RL, Hathaway DR. Peripheral vascular complications following coronary interventional procedures. Clin Cardiol 1995; 18:609.Alonso-Coello P, Bellmunt S, McGorrian C, et al. Antithrombotic therapy in peripheral artery disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e669S.Yeager RA, Moneta GL, Taylor LM Jr, et al. Surgical management of severe acute lower extremity ischemia. J Vasc Surg 1992; 15:385.; picture 

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