Internal Medicine I.M.

Acute Limb Ischemia A.L.I

Harrison’s Principle of Internal Medicine, 21st Edition 12/23/2023

abnormal placement of the medial head of the gastrocnemius

I. Acute Limb Ischemia muscle
● Associated with acute arterial thrombosis:
● Occurs when arterial occlusion results in - Polycythemia
the sudden cessation of blood flow to an - Hypercoagulable disorders
extremity
● Severity of ischemia and the viability of the Clinical Features
extremity depend on the location and ● Symptoms of an acute arterial occlusion depend on the location, duration,
extent of the occlusion and the presence and severity of the obstruction
and subsequent development of collateral ○ Severe Pain
blood vessels ○ Paresthesia
● Arterial emboli tend to lodge at vessel ○ Numbness
bifurcations ○ Coldness Develop In The Involved Extremity Within 1 H
- the vessel caliber decreases at ○ Paralysis
those sites - occur with severe and persistent
ischemia
Principal causes of acute arterial ○ Embolism
occlusion ○ Thrombus In Situ Physical Findings:
○ Arterial Dissection ● Loss Of Pulses Distal To The Occlusion
○ Trauma ● Cyanosis Or Pallor
Most common sources of arterial ○ Heart ● Mottling
emboli ○ Aorta ● Decreased Skin Temperature
○ Large Arteries ● Muscle Stiffening
Emboli lodge most frequently ○ Femoral Artery ● Loss Of Sensation
○ Iliac Artery ● Weakness, And/Or Absent Deep Tendon
○ Aorta Reflexes
○ Popliteal
○ Tibioperoneal Arteries Severity Classification

Cardiac disorders that cause thromboembolism

● Atrial Fibrillation
● Acute Myocardial Infarction
● Ventricular Aneurysm
● Cardiomyopathy
● Infectious And Marantic Endocarditis
● Thrombi Associated With Prosthetic Heart Valves
● Atrial Myxoma

Pathophysiology

Imaging Modalities:
● Trauma to an artery may disrupt continuity of blood flow and cause acute
limb ischemia via formation of an acute arterial thrombus or by
disruption of an artery’s integrity and extravasation of blood.
● Arterial occlusion may complicate arterial punctures and placement of
catheters
● May result from arterial dissection if the intimal flap obstructs the artery.
● Less common causes include:
- thoracic outlet compression syndrome, which causes subclavian
artery occlusion, and entrapment of the popliteal artery by
Diagnostics
● Digital subtraction angiography
- considered the standard investigation for ALI
- can delineate etiology and offers the advantage of
allowing treatment in the same setting
● Duplex ultrasound
- accurate modality with which to detect complete or
incomplete obstruction in common femoral, superficial
femoral and popliteal arteries and in bypass grafts
● Computed tomography angiography
- allows evaluation of the thoracic and abdominal aorta
to seek a potential embolic source, and also the
mesenteric vessels to look for other emboli
- combine evaluation of the possible primary cause of
ALI with high resolution evaluation of the outflow
tract and provide a roadmap to guide treatment
- Extravascular findings may be seen that are related to
the etiology of ALI
● Contrast enhanced magnetic resonance angiography

A.Y. 2023 to 2024 Transcribers: Villaruel; Ganaden 1 of 2

 Internal Medicine I.M.
Acute Limb Ischemia A.L.I
Harrison’s Principle of Internal Medicine, 21st Edition 12/23/2023

- enables the generation of images that can visualize

both arteries and veins

Management

IV Unfractionated ○ To prevent propagation of the clot and

heparin recurrent embolism

Catheter directed ○ To restore blood flow to the ischemic

thrombolysis/thrombect extremity promptly, particularly when
omy, surgical a large proximal vessel is occluded
thromboembolectomy
and arterial bypass
procedures

Intra-arterial ○ Reteplase or Tenecteplase

thrombolytic therapy ○ Most effective when acute arterial
with rTPA occlusion is recent (<2 weeks) and
caused by a thrombus in an
atherosclerotic vessel, arterial bypass
graft or occluded stent
Percutaneous ○ Uses devices that employ
mechanical hydrodynamic forces or rotating
thrombectomy baskets to fragment and remove the
clot
Surgical ○ Used when restoration of blood flow
revascularization must occur within 24 hrs to prevent
limb loss
○ Symptoms of occlusion have been
present for >2 weeks

Amputation ○ Performed when limb is not viable

Long-term ○ Indicated when acute limb ischemia is
anticoagulation caused by cardiac thromboembolism

References
Book
Harrison’s Principle of Internal Medicine 21st Edition
Others
ESVS 2020 Clinical Practice Guidelines in the Management of ALI

A.Y. 2023 to 2024 Transcribers: Villaruel; Ganaden 2 of 2