Arterial Occlusion, Acute


Article Author:
David Smith


Article Editor:
Craig Lilie


Editors In Chief:
Michael Firstenberg
Lawrence Greiten


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Trevor Nezwek
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
2/5/2019 7:24:13 PM

Introduction

Acute arterial occlusion is synonymous with acute limb ischemia and is considered a vascular emergency. Acute limb ischemia is defined as a sudden loss of limb perfusion for up to 2 weeks after the initiating event. Acute arterial occlusion can occur in any peripheral artery of the upper and lower extremities. Acute occlusion can lead to a limb or life-threatening ischemia. Diagnostic measures, treatment, and management depend on the artery affected and the patient's past medical history. Acute arterial occlusion is time sensitive and left untreated can quickly progress to infarction and loss of limb and life. Acute arterial occlusion is associated with increased morbidity, significant disability, and emergent operation in high-risk patients. [1][2][3]

Etiology

The most common cause of acute limb ischemia is in situ thrombotic occlusion. It is more common in the lower extremities, and the initiating event is a preexisting history of peripheral artery disease (PAD). Thrombotic occlusions can occur in any segment of the upper and lower extremities but most commonly affects the superficial femoral artery. Patients who have a preexisting history of PAD tend to have the well-established development of collateral vessels creating variability in symptoms and severity. Other causes include embolic occlusion from the left heart, aorta, and iliac vessel, as well as penetrating or blunt trauma.  [4] 

Epidemiology

Published studies regarding the true incidence of acute limb ischemia are lacking. In a prospective population-based study in Oxford, England over a 10-year time frame the incidence of critical limb ischemia was determined to be 22 per 100,000 per year. Acute limb ischemia affects older men and women equally with a median age of 75 years. Risk factors include age, smoking, diabetes, obesity, sedentary lifestyle, family history of vascular disease, high cholesterol, and high blood pressure. Non-traumatic ischemia of the lower extremities is more common than the upper extremities and is more likely to result in limb loss. 

Pathophysiology

In situ thrombosis most commonly affects the femoral or popliteal arteries, while emboli most commonly lodge in aortic, iliac, femoral, and popliteal bifurcations. Once arterial blood flow is impeded, malperfused tissues switch from aerobic to anaerobic metabolism, causing lactate production, acidosis, and an increased concentration of free radicals. Prolonged and untreated ischemia will cause the hypoxic muscle to deplete its ATP stores; this is followed by dysfunction in the sodium/potassium-ATPase and calcium/sodium pump leading to intracellular calcium leakage into the myocytes. Increasing free calcium negatively interacts with the muscle's myosin, actin, and proteases and eventually causes muscle fiber necrosis. Intracellular potassium, phosphate, creatinine kinase, and myoglobin are released into the systemic circulation as a result of the necrotic muscle. 

History and Physical

The classic presentation of limb ischemia is known as the "six Ps"; they are as follows: pallor, pain, paresthesia, paralysis, pulselessness, and poikilothermia. These clinical manifestations can occur anywhere distal to the occlusion. Most patients initially present with pain, pallor, pulselessness, and poikilothermia. Pain is often localized and less severe when the limb is in the dependant position. As the ischemia prolongs, paresthesia replaces pain and the final stages of injury cause paralysis. Patients with embolic occlusion tend to have an abrupt onset with more severe symptoms, as collateralization of the vasculature has not occurred at this point. It is important to realize that symptoms can develop over the course of hours to days and present as new or recurring.   

Evaluation

Initial evaluation of acute arterial occlusion begins with the physical exam. A detailed physical examination should assess for changes in temperature along the extremity affected with a bilateral comparison. A complete bilateral pulse exam should be initially conducted with manual palpation and include an arterial Doppler exam when the deficient pulse is noted. Muscle strength and sensation testing should also be assessed. When occlusion has been identified, confirmatory testing with CTA is generally conducted as it is quicker and more readily available. However, the time required to order, perform and interpret imaging must be balanced against the urgency for treatment to preserve life and limb. Since most episodes of acute limb ischemia present to the Emergency Department, an immediate vascular surgery consult must be initiated. The severity of ischemia can be further assessed with the physical exam alone utilizing the Rutherford Classification of Acute Limb Ischemia. Finding the cause of occlusion is also important. For example, a patient with a history of atrial fibrillation with abrupt initial symptoms is more likely to have an embolic occlusion as opposed to the patient with a history of PAD and claudication who is more prone to having a thrombotic source. [5]        

Treatment / Management

Cases of limb-threatening ischemia require emergent vascular surgery consult. The surgical approach is directed at reperfusion of the affected extremity. This can be accomplished by the surgical bypass, endarterectomy, or embolectomy. Results are variable and will ultimately depend on the duration of the ischemia and the extent of occlusion. Catheter-directed thrombolysis (CDT) by an interventional radiologist is becoming more common and is reserved for patients with a salvageable limb (Rutherford class II, IIa, and IIb). Patients presenting with profound paralysis and absent pain with inaudible arterial and venous pulses are considered to have irreversible damage and will require amputation. While the patient waits for surgical or interventional radiology assessment, initial therapy should include fluid resuscitation, pain control, and administration unfractionated heparin to minimize thrombus propagation. The general goal of anticoagulation is to achieve an increase in partial thromboplastin by a factor 2.0 to 2.5 above baseline. Management after revascularization requires close and frequent observation. Prolonged ischemia (>4 hours) increases the risk of compartment syndrome and must be monitored with hourly neurovascular checks.   [6][7][8]

Staging

The Society for Vascular Surgery has created a classification of an acutely ischemic limb:

  • Class I: Non-threatened extremity; elective revascularization may or may not be necessary.
  • Class II: Threatened extremity; immediate revascularization is indicated to prevent tissue loss.
  • Class III: Ischemia has progressed to infarction and salvage of the extremity is not possible.

Complications

  • Compartment syndrome
  • Amputation
  • Necrosis and gangrene
  • Bleeding
  • Stroke
  • MI
  • Death

Postoperative and Rehabilitation Care

Once the acutely ischemic limb has been managed, these patients need to be monitored in the ICU. Aspirin or an oral anticoagulant may be required if the patient has peripheral vascular disease or atrial fibrillation. The cause of the ischemic limb must be investigated to prevent a recurrence. Since many of these patients are frail, physical therapy should be involved in the restoration of function.

Deterrence and Patient Education

  • Discontinue smoking
  • Control hypertension
  • Manage diabetes
  • Maintain a healthy weight
  • Remain compliant with medications

Pearls and Other Issues

Reperfusion injury may result to the target limb after therapy. This can include profound edema, causing increased compartmental pressures. Signs and symptoms of reperfusion injury include severe pain, focal weakness, and hypoesthesia. Laboratory studies may reveal elevated creatine kinase and myoglobinuria. Most cases of compartment syndrome secondary to reperfusion injury involve the anterior compartment of the leg; therefore, assessment of peroneal nerve function is critical. Reperfusion injury also can cause cardiac, renal, and pulmonary complication making prompt recognition and treatment just as important as the initial diagnosis of acute arterial occlusion. 

Enhancing Healthcare Team Outcomes

Patients with an acutely ischemic limb need a multidisciplinary approach with collaboration with an interprofessional team consisting of a vascular surgeon, interventional radiologist, wound care clinician and nurse, infectious disease, and critical care. Early therapy is critical if one wants to salvage the limb. In addition, the majority of these patients have other comorbidities like heart disease, obstructive lung disease, diabetes and obesity which also affect survival. The patient is best managed in the ICU where the vital signs and peripheral pulses can be closely monitored by a nurse. The American College of Radiology has established guidelines which are evidence-based to determine the type of imaging in these patients.[4][9] (Level V)

For those not deemed to be surgical candidates, catheter-directed thrombolysis may be undertaken. The pharmacist must be fully aware of all the indications and contraindications of this therapy to prevent additional morbidity. For those who undergo thrombolysis or an angiogram, the nurse is responsible for monitoring the leg for viability and bleeding in the groin, where access to the artery was obtained.

Outcomes

The outcomes for patients with an acutely ischemic limb are guarded. Even if the limb is salvaged, these patients have other comorbidities which can lead to a heart attack, renal failure, stroke or wound infection. Unless an interdisciplinary team is involved, the mortality for these individuals remains high. Expert opinion is highly recommended when these patients present to the emergency room because the earlier the comorbidity is managed, the lower the risk of complications.[10][11] (level V)


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Arterial Occlusion, Acute - Questions

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A 56-year-old patient with diabetes presents with acute arterial occlusion of his right common femoral artery. Which is true regarding his treatment?



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A 71-year-old with atrial fibrillation presents with a cold left arm. On examination, she has no pulses in the brachial, ulnar, or radial arteries. Vital signs reveal that she has an irregular pulse and rate of 120 beats/min, blood pressure of 210/100 mmHg, respiratory rate of 14, and a temperature of 37 C. It is decided not to use fibrinolytic therapy because the patient is at high risk for which of the following conditions?



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A patient develops acute leg pain with loss of pulses, pallor, paresthesias, pain, and paralysis. Which of these is the worst prognostic sign?



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Which of the following is true in regards to acute vessel closure post percutaneous transluminal coronary angioplasty?



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Which of the following is not true about an acutely ischemic limb?



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Which of the following signs listed is the first to manifest in an ischemic extremity?



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Which of the following statements is not true with respect to arterial disease?



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A male presents to the ER with sudden onset of pain in his right leg. He claims he was walking home and noticed his right leg was painful and cold. He denies any other medical history. He is a non smoker and does not drink alcohol. He has no recent trauma. He is on no medications and has no allergies. Examination reveals no pulse in the right popliteal, posterior tibial, and dorsalis pedis artery. There is no mass palpable behind the knee. The leg is cold to touch and pale. His ECG is normal sinus rhythm. His diagnosis may be related to:



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Which of the following is not seen with acute, peripheral arterial occlusion?



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A 71-year-old man is seen on day 6 after abdominal surgery. He complains of sudden onset of right leg pain. The right leg is cold and mottled. The right femoral pulses are palpable, but there are no distal pulses. What is the most likely diagnosis?



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A middle-aged male who is a heavy smoker presents to the emergency room with complaints of severe pain and discoloration of his right leg. He says that over the past twelve hours his right leg has become cold and numb. He is a heavy smoker, hypertensive, diabetic and has chronic kidney disease. He is allergic to aspirin. Examination reveals that the patient has critical ischemia of his right leg with no palpable pulse below the groin. You consult the vascular surgeon who recommends an endovascular procedure instead of a surgical procedure. Why is an endovascular procedure the favored approach in this patient?



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A 73-year-old male patient with a past medical history of coronary artery disease, atrial fibrillation, and a 60 pack-year history presents with sudden onset of upper right leg pain with radiation into his foot. The patient complains of profound sensory loss and muscle weakness. On physical exam, the patient is unable to move his leg and has no response to pain. Your doppler exam reveals inaudible arterial and venous pulses. A bedside ultrasound is performed, revealing a noncompressible common femoral artery with visualized echogenic material. What is the patient's prognosis using the Rutherford classification system for acute limb ischemia?



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Arterial Occlusion, Acute - References

References

Curtis W,Yano M, Acute non-traumatic disease of the abdominal aorta. Abdominal radiology (New York). 2018 May     [PubMed]
Sedghi Y,Collins TJ,White CJ, Endovascular management of acute limb ischemia. Vascular medicine (London, England). 2013 Oct     [PubMed]
Walker TG, Acute limb ischemia. Techniques in vascular and interventional radiology. 2009 Jun     [PubMed]
Engledow AH,Crinnion JN, Acute lower limb ischaemia. Hospital medicine (London, England : 1998). 2002 Jul     [PubMed]
O'Connell JB,Quiñones-Baldrich WJ, Proper evaluation and management of acute embolic versus thrombotic limb ischemia. Seminars in vascular surgery. 2009 Mar     [PubMed]
Khan MI,Nadeem IA, Revascularization Of Late-Presenting Acute Limb Ischaemia And Limb Salvage. Journal of Ayub Medical College, Abbottabad : JAMC. 2016 Apr-Jun     [PubMed]
Shin HS,Kyoung KH,Suh BJ,Jun SY,Park JK, Acute limb ischemia: surgical thromboembolectomy and the clinical course of arterial revascularization at ankle. The International journal of angiology : official publication of the International College of Angiology, Inc. 2013 Jun     [PubMed]
Nelson JA, Compartment pressure measurements have poor specificity for compartment syndrome in the traumatized limb. The Journal of emergency medicine. 2013 May     [PubMed]
Weiss CR,Azene EM,Majdalany BS,AbuRahma AF,Collins JD,Francois CJ,Gerhard-Herman MD,Gornik HL,Moriarty JM,Norton PT,Ptak T,Reis SP,Rybicki FJ,Kalva SP, ACR Appropriateness Criteria{sup}®{/sup} Sudden Onset of Cold, Painful Leg. Journal of the American College of Radiology : JACR. 2017 May     [PubMed]
Akagi D,Hoshina K,Akai A,Yamamoto K, Outcomes in Patients with Critical Limb Ischemia due to Arteriosclerosis Obliterans Who Did Not Undergo Arterial Reconstruction. International heart journal. 2018 Aug 11     [PubMed]
Schaumeier MJ,Hawkins AT,Hevelone ND,Sethi RKV,Nguyen LL, Association of Treatment for Critical Limb Ischemia with Gender and Hospital Volume. The American surgeon. 2018 Jun 1     [PubMed]

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