Acute Limb Ischaemia

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Last updated: December 26, 2021
Revisions: 25

Last updated: December 26, 2021
Revisions: 25

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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:

  • Embolisation whereby a thrombus from a proximal source travels distally to occlude the artery (most common)
    • The original thrombus source may be as a result of AF, post-MI mural-thrombus, abdominal aortic aneurysm, or prosthetic heart valves
  • Thrombosis in situ whereby an atheroma plaque in the artery ruptures and a thrombus forms on the plaque’s cap (presenting as acute or acute-on-chronic)
  • Trauma (less common), including compartment syndrome

Clinical Features

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):

  • Pain
  • Pallor
  • Pulselessness
  • Paresthesia
  • Perishingly cold
  • Paralysis

Figure 1 – The 6 Ps of Acute Limb Ischaemia

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

Venous 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

Differential Diagnosis

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).

Fig 2 - Reconstructed 3D CT angiogram, showing complete occlusion of the right femoral artery.

Figure 2 – Reconstructed 3D CT angiogram, showing complete occlusion of the right femoral artery


Initial Management

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

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

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

Figure 3 – Schematic demonstrating how angioplasty is performed

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 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 exercisesmoking 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:
    • Kions causing hyperkalaemia
    • Hions 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.

Key Points

  • 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