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ESSENTIALS OF DIAGNOSIS

  • Sudden pain in an extremity with absent extremity pulses.

  • Usually some neurologic dysfunction with numbness, weakness, or complete paralysis.

  • Loss of light touch sensation requires revascularization within 3 hours for limb viability.

GENERAL CONSIDERATIONS

Acute occlusion may be due to an embolus or to thrombosis of a diseased atherosclerotic segment. Emboli large enough to occlude proximal arteries in the lower extremities are almost always from the heart. Over 50% of the emboli from the heart go to the lower extremities, 20% to the cerebrovascular circulation, and the remainder to the upper extremities and mesenteric and renal circulation. Atrial fibrillation is the most common cause of cardiac thrombus formation; other causes are valvular disease or thrombus formation on the ventricular surface of a large anterior myocardial infarct.

Emboli from arterial sources such as arterial ulcerations or calcified excrescences are usually small and go to the distal arterial tree (toes).

The typical patient with primary thrombosis has had a history of claudication and now has an acute occlusion. If the stenosis has developed over time, collateral blood vessels will develop, and the resulting occlusion may cause only minimal increase in symptoms.

CLINICAL FINDINGS

A. Symptoms and Signs

The sudden onset of extremity pain, with loss or reduction in pulses, is diagnostic of acute arterial occlusion. This often will be accompanied by neurologic dysfunction, such as numbness or paralysis in extreme cases. With popliteal occlusion, symptoms may affect only the foot. With proximal occlusions, the whole leg may be affected. Signs of severe arterial ischemia include pallor, coolness of the extremity, and mottling. Impaired neurologic function progressing to anesthesia accompanied with paralysis suggests a poor prognosis.

B. Doppler and Laboratory Findings

There will be little or no flow found with Doppler examination of the distal vessels. Imaging, if done, may show an abrupt cutoff of contrast with embolic occlusion. Blood work may show myoglobin and metabolic acidosis.

C. Imaging

Whenever possible, imaging should be done in the operating room because obtaining angiography, MRA, or CTA may delay revascularization and jeopardize the viability of the extremity. However, in cases with only modest symptoms and where light touch of the extremity is maintained, imaging may be helpful in planning the revascularization procedure.

TREATMENT

Immediate revascularization is required in all cases of symptomatic acute arterial thrombosis. Evidence of neurologic injury, including loss of light touch sensation, indicates that collateral flow is inadequate to maintain limb viability and revascularization should be accomplished within 3 hours. Longer delays carry a significant risk of irreversible tissue damage. This risk approaches 100% at 6 hours.

A. Heparin

As soon as the diagnosis is made, unfractionated heparin should be administered (5000–10,000 units) intravenously, ...

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