Acute Limb Ischaemia
Acute limb ischaemia is defined as the sudden decrease in limb perfusion that threatens the viability of the limb.
Complete or even partial occlusion of the arterial supply to a limb can lead to rapid ischaemia and poor functional outcomes within hours.
In this article, we shall look at the causes, clinical features and management of a patient with acute limb ischaemia.
Acute limb ischaemia has an incidence of around 1.5 per 10,000 person years. Its causes can be classified into 3 main groups:
- Thrombosis in situ (60%) whereby an atheroma plaque in the artery ruptures and a thrombus forms on the plaque’s cap
- Can present as an acute or an acute-on-chronic (on a background of peripheral arterial disease) presentation
- Embolisation (30%) whereby a thrombus from a proximal source travels distally to occlude the artery (Fig. 1)
- The original thrombus source may be as a result of AF, post-MI mural-thrombus, abdominal aortic aneurysm, or prosthetic heart valves
- Trauma (10%), including compartment syndrome
Classically, the signs and symptoms of acute limb ischaemia can be described using the 6 Ps (the first three here being the most common initial features):
- Perishingly cold
Acute limb ischaemia is often characterised by a sudden onset of these symptoms. A normal, pulsatile contralateral limb is a sensitive sign of an embolic occlusion.
In the history, the causes of potential embolisation should be explored. These include chronic limb ischaemia, atrial fibrillation, recent MI (resulting in a mural thrombus), or a symptomatic AAA (ask about back/abdominal pain) and peripheral aneurysms.
The later the patient presents to a hospital, the more likely that irreversible damage to the neuromuscular structures will have occurred (more common >6hrs post-symptom onset), which will ultimately result in a paralysed limb.
|Category||Prognosis||Sensory Loss||Motor Deficit||Arterial Doppler||
|I – Viable||No Immediate threat||None||None||Audible||Audible|
|IIA – Marginally Threatened||Salvageable, if promptly treated||Minimal (toes) or none||None||Inaudible||Audible|
|IIB – Immediately Threatened||Salvageable if immediately revascularised||More than toes, rest pain||Mild/Moderate||Inaudible||Audible|
|III – Irreversible||Major tissue loss, permanent nerve damage inevitable||Profound||Profound, paralysis||Inaudible||Inaudible|
Table 1 – Clinical Categories of Acute Limb Ischemia, adapted from Rutherford et al., 2009
The differential diagnoses for acute limb ischaemia include critical chronic limb ischaemia, acute DVT (can present as Phlegmasia cerulea dolens and Phlegmasia alba dolens), or spinal cord or peripheral nerve compression.
Routine bloods, including a serum lactate (to assess the level of ischaemia), a thrombophilia screen (if <50yrs without known risk factors), and a group and save, should be taken, along with an ECG.
Suspected cases should be initially investigated with beside Doppler ultrasound scan (both limbs), followed by considering a CT angiography (Fig. 2).
If the limb is considered to be salvageable, a CT arteriogram can provide more information regarding the anatomical location of the occlusion and can help decide the operative approach (such as femoral vs. popliteal incision).
Acute limb ischaemia is a surgical emergency. Complete arterial occlusion will lead to irreversible tissue damage within 6 hours. Early senior surgical support is vital.
Start the patient on high-flow oxygen and ensure adequate IV access. A therapeutic dose heparin or preferably a bolus dose then heparin infusion should be initiated as soon as is practical.
Conservative management can often be considered those Rutherford 1 and 2a; a prolonged course of heparin may be the most effective non-operative management of acute limb ischaemia.
Any patient started on conservative management via heparin will need regular assessment to determine its effectiveness through monitoring APPT and clinical review. Surgical interventions may be warranted if no significant improvement is seen.
Surgical intervention is mandatory for cases presenting in Rutherford 2b
If the cause is embolic, the options are:
- Embolectomy via a Fogarty catheter
- Local intra-arterial thrombolysis*
- Bypass surgery (if there is insufficient flow back)
If the cause is due to thrombotic disease, the options are:
- Local intra-arterial thrombolysis
- Angioplasty (Fig. 3)
- Bypass surgery
Irreversible limb ischaemia (mottled non-blanching appearance with hard woody muscles) requires urgent amputation or taking a palliative approach.
Most post-operative cases require a high level of care, typically at a surgical high dependency unit, due to the ischaemia reperfusion syndrome.
*Intra-arterial thrombolysis is often difficult to conduct within 6 hours, therefore often used for Rutherford 2a
Long Term Management
Reduction of the cardiovascular mortality risk in this patient group is key. Promoting regular exercise, smoking cessation, and weight loss as necessary.
Most cases should be started on an anti-platelet agent, such as low-dose aspirin or clopidogrel, or even anticoagulation with warfarin or a DOAC. Any underlying predisposing conditions to the acute limb ischaemia should be treated, e.g. uncontrolled AF.
Cases resulting in amputation will require occupational therapy and physiotherapy, with a long term rehabilitation plan discussed and transfer to an intermediate rehabilitation centre.
Acute limb ischaemia has a mortality rate of around 20%, with the 30-day mortality rate following the surgical treatment of acute limb ischaemia at 15%.
An important complication of acute limb ischaemia is reperfusion injury; sudden increase in capillary permeability can result in:
- Compartment syndrome
- Release of substances from the damaged muscle cells, such as:
- K+ ions causing hyperkalaemia
- H+ ions causing acidosis
- Myoglobin, resulting in significant AKI
It is imperative that patients at risk of compartment syndrome are closely monitored and rapidly treated. Electrolyte imbalance due to reperfusion injury requires close monitoring and potentially haemofiltration.
- Most cases of acute limb ischaemia will present with sudden onset pain and pallor, caused by either acute thrombus-in-situ or embolisation
- CT angiography is the gold-standard investigation
- A variety of treatment options are available, depending on underlying cause, regional anatomy, and co-morbid status
- Ensure to monitor for reperfusion syndrome in cases of acute limb ischaemia