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CDHB

Acute Limb Ischaemia

Common Causes

• Arterial embolism
  • Usually no previous history of peripheral occlusive arterial disease.
  • Sudden onset usually in a patient in atrial fibrillation but sometimes following myocardial infarction.
• Arterial thrombosis in situ
  • Often associated with previous history of occlusive arterial disease.
  • Examination findings may suggest widespread vascular disease (e.g., absent contralateral pulses).

Clinical Findings

• Acute limb ischaemia is a clinical diagnosis. Hand-held Doppler analysis of peripheral pulses is a valuable adjunct, but is not a substitute for clinical examination. This may or may not be supplemented by radiological imaging.
• Symptoms and signs: Ischaemic rest pain with/without paraesthesia or loss of function (paralysis) in the context of absent pulses, ± pallor, ± reduced temperature of the affected limb.
• Remember the 6 Ps: Painful, Pale, Pulseless, Paraesthesia, Paralysis, and Poikilothermy (cold). This is usually obvious with emboli but can be more subtle with acute-on-chronic ischaemia.

Actions

1. Assess severity:
   • Rutherford I: Pain resolves at rest and no paraesthesia or paralysis.

     Consider admission for heparin anticoagulation.

   • Rutherford II: Ischaemic rest pain ± moderate paraesthesia ± moderate weakness.

     Consider angiography ± intra-arterial thrombolysis.

   • Rutherford III: Ischaemic rest pain, profound paraesthesia, and profound paralysis.

     Consider immediate surgical exploration.

     Rutherford II and III should be managed as an emergency. The window for therapeutic intervention is approximately 6 hours from onset before muscular necrosis may occur. Urgent surgical consultation is mandatory.

2. Investigations: CBC + diff, Na, K, creatinine, urea and coagulation profile.
3. Contact Vascular Registrar/consultant on call.
4. Analgesia.
5. Give oxygen.
6. If no major contraindications, heparinize (5000 unit bolus of unfractionated heparin IV) to minimize secondary thrombosis.
7. Leave limb alone. Protect from trauma, take pressure off heel, and do not heat or cool.

Reference: Rutherford RB et al. J Vasc Surg 1997; 26:517-538.

Topic Code: 1714