Acute limb ischaemia represents the sudden blockage of the arterial flow in the

interested limb. It’s a critical situation which needs rapid intervention because it
leads to extensive tissue necrosis in a short time spam.

The effects of this sudden occlusion depends on

the collateral blood flow available.
Etiology of Acute limb ischaemia
The most frequent causes of acute ischaemia are embolism and in situ thrombosis.

The starting points of embolism are the heart and the big arteries. Cardiac embolism can happen
in various diseases, such as: atrial fibrillation, myocardial infarction, ventricular aneurysm,
cardiomyopathy, infectious endocarditis, valvular prosthetics, atrial mixoma etc.
Extracardiac embolism usually originates from the ulcerated atheromatous plague on the walls of
the vessel.

Embolism happen in 80% of the times, while thrombosis is the culprit just in 20% of the times.

thrombosis occurs in unstable atheroma plagues.

Other causes , but less common, can be trauma, Raynaud’s Syndrome , compartment syndrome
( insufficient blood supply to the muscles and nerves due to increased pressure in a closed
space of the body; usually happens after trauma) or even congenital causes, for example aortic
hypoplasia.

Pathophysiology
The severity of the ischaemia deeply depends on the importance of the occluded vessel and the
presence of collateral supply. Without rapid treatment , ischaemia will lead to tissue necrosis very
fast, in a matter of a few hours.

Nerves and muscles are the first ones to be affected before any visible changes- in a matter of 4
hours, then in 6 hours irreversible damage happens if complete occlusion of the vessel and no
collateral circulation is available..

There are also many changes on the molecular level. Lactic acid, thromboxane and potassium
will be produced and accumulated due to anaerobic metabolism. Along with these, myoglobin
( resulted from muscle fiber infarction) will lead to renal failure, myocardial depression and
arrhythmias.

These effects are more present on reperfusion.

Diagnosis
Clinical diagnosis
The simple 6 p’s that make up the ”image” of acute limb ischaemia are:

1. Pain – can be absent in complete ischaemia;

2. Pallor – also present in chronic ischaemia;

3. Pulselessness – present as well in chronic ischeamia;

4. Paraesthesia – leads to anaesthesia;

5. Paralysis – unable to shake toes or fingers;

6. Poikilothermia – inability to regulate core body temperature.

The presence of paralysis and anaesthesia indicates complete ischaemia and requires
EMERGENCY surgical treatment.

How to differentiate embolus and thrombosis in situ

Following we’ll discuss the clinical features of both

Embolus
 severity: complete because there are no collaterals;

 onset: second or minutes;

 limb affected: leg 3:1 arm;

 multiple sites: up to 15%;

 embolic source: ( +) ( cardiac embolism);

 previous claudication: ( – ) ;

 palpation of artery: soft, tender;

 contralateral leg pulses : (+);

 diagnosis: clinical;

 treatment: embolectomy, warfarin.

Thrombosis in situ
 severity: incomplete ( + collateral);

 onset: hours or days;

 limb affected: leg 10:1 arm;

 multiple site: rare;

 embolic source: (-);

 previous claudication: ( +);

 palpation of artery: hard, calcified;

 contralateral leg pulses: ( +);

 diagnosis: angiography;

 treatment: medical, bypass, thrombolysis;

Rutherford Classification of Acute Limb Ischaemia

1. Category I: Viable (no immediate threat)

2. Category IIA: Marginally threatened (salvageable if promptly treated)

3. Category IIB: Immediately Threatened (salvageable if immediately

revascularised)

4. Category III: Irreversible (major tissue loss with permanent nerve injury)

Paraclinical diagnosis
Although the diagnose is most of the time evident clinically, complementary exams confirm the
disease and show the exact level of the occlusion, its degree and the causal mechanism.

 Doppler evaluation – shows the blood flow in smaller arteries, so it allows you
to see the extend and degree of the ischaemia;

 Duplex ultrasonography – It’s a medical ultrasonography composed of two

elements

1. Grayscale ultrasound which shows you the layout of the body part; there’s no
motion or blood flow evaluated; this way the plague is easily imaged in the blood
vessel.

2. Color Doppler ultrasound evaluates flow and movement , mostly used for
imaging blood flow within an artery;

– the speed of the blood through a narrowed region of the artery increases, indicating a region of
resistance.

As the name implies, both elements are presented together on the same scree, greatly
facilitating interpretation.

Another advantage is that is an inexpensive and non- invasive way to determine pathology.

It’s usually done before any invasive investigation or surgical procedure.

 CTA vs MRI

I’ve previously discussed ( peripheral artery occlusive disease) the advantages/disadvantages of

both.

In this case TIME is everything, and although CTA uses radiation is much quicker than MRI.

Compared to Duplex Ultrasound, they are used more often because are more precise in planning
revascularisation.

Treatment of Acute limb ischaemia

Initial management
 First of all any life threatening medical conditions must be assessed;

 Eventually will follow correction of fluid and electrolyte imbalance;

 Start coagulation as soon as possible ( Heparin);

 i.v analgesics – Opioids;

 ECG ( AF, recent AMI) ;

 blood test .

The role of Heparin anticoagulation

It is used Unfractioned Heparin in i.v infusion. The dose is adjusted to APTT ( 2-2,5X).

The standard contraindications apply when giving heparin. It’s not necessary to administer if
intervention is planned soon ( less than 90 min) , otherwise is very important to give.

Definitive management
In case of EMBOLUS

 conservative: anticoagulation only;

 balloon catheter embolectomy ( Fogarty);

 endovascular procedures;

 arterial bypass/ reconstruction;

In case of THROMBUS

 conservative: anticoagulation only;

 thrombolytic therapy : Streptokinase, Urokinase, rTPA;

 arterial reconstruction;

 endovascular;

 catheter thrombectomy.
http://www.heartupdate.com/vessels/acute-limb-ischaemia_323/