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Acute Limb Ischaemia

In This Article
This occurs when there is blockage of a peripheral artery, either from a thromboembolism, or sometimes from an embolic plaque:
  • Thrombus in situ - 40%
  • Emboli – 38%
  • Angioplasty occlusion – 15%
  • Trauma
  • Compartment syndrome - rare
 

Signs and Symptoms

Classically, the SIX P’s
  • Pulseless
  • Parasthaesia
  • Pain – muscles also become tender to palpation after about 6-8hours
  • Paralysis
  • Pallor
  • Perishing cold
  • Fixed mottling of the skin implies irreversibility
  • BEWARE – hot red leg may sometimes be present, which can result in misdiagnosis of gout or cellulitis
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Diagnosis

You can roughly localise the blockage by locating the bifurcation distal to the last palpable pulse.
Diagnosis is clinical
 
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Treatment

  • It is an EMERGENCY!
    • 22% of cases are fatal
    • 16% of cases result in amputation
  • Thrombolytic agent e.g. tissue plasminogen activator (tPA)– most effective when given via local arterial catheter (Fogarty Catheter), particularly for occlusions <2 weeks. Therapy is usually given via the catheter for 8-24hr
  • Open surgery / angioplasty – DON'T BE AFRAID TO DO THESE! – equally, don’t be afraid to do angiography in cases of an unsure diagnosis.
  • The decision to opt for thrombolysis over surgery depends on risk assessment on an individual patient basis (i.e. risks of surgery vs risks of thrombolysis)
  • You should use heparin anticoagulation after both surgery and thrombolysis!
 
After initial treatment
  • Look for a source of emboli – e.g. ultrasounds of aorta, popliteal and femoral arteries for signs of aneurysm
  • Watch out for reperfusion injury – which can lead to compartment syndrome

 

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Case Example

  • 92 year old nursing home patient
  • Painful left leg, sudden onset
  • Deaf and dementia
  • Comfortable after 5mg morphine (relatively small dose)
  • BP 110/40 – probably slightly low
  • HR 80 irregular
  • RR 16
  • Heart sounds normal
  • Apyrexic
  • Whole left leg is white and cold
  • Some mottling from foot to just above knee
  • Calf is very tender
  • Can barely move right leg, but can wiggle toes. Cannot move left leg at all.
  • Pulses on the right are normal.
  • No palpable aortic aneurysm
  • No obvious swelling of the leg. 

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