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Choosing the Correct Therapeutic Option for Acute Limb Ischemia

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Choosing the Correct Therapeutic Option for Acute Limb Ischemia REVIEW Choosing the correct therapeutic option for acute limb ischemia Acute limb ischemia (ALI) occurs due to abrupt interruption of arterial flow to an extremity, which may lead to loss of limb or life. ALI is typically caused by either a thrombotic or embolic arterial occlusion. Management strategies, which may not be mutually exclusive, include anticoagulation and observation, catheter-directed thrombolysis and/or surgical thrombectomy. The therapeutic choice depends on the patient functional status, severity of ischemia and time required for treatment. A logical approach to the evaluation and management of patients with ALI is presented in this article. 1 KEYWORDS: acute limb ischemia n arterial embolus n arterial thrombosis Jeffrey A Goldstein & n catheter‑directed thrombolysis n limb salvage n peripheral arterial disease Gregory Mishkel†1 n thrombectomy n thrombolysis 1Prairie Cardiovascular Consultants, PO Box 19420, Springfield, IL 62794-9420, USA Present day cardiology has evolved from exclu- disease (PAD) may eventually develop ALI †Author for correspondence: sively directing the cardiologic health of patients, [3]. The majority of ALI cases (85%) are due Tel.: +1 217 788 0708 Fax: +1 217 788 8794 to additionally managing their vascular health. to in situ thrombosis, with the remaining 15% [email protected] Increasingly, both general and particularly inter- of cases due to embolic arterial occlusion. The ventional cardiologists are called upon to man- vast majority of emboli, upwards of 90%, are age the care of the patients in their practice when cardiac in etiology [6] and are usually due to they present with acute vascular emergencies. either atrial fibrillation or acute myocardial inf- Unfortunately, subsequent to their subspecialty arction. Emboli tend to lodge at arterial bifur- training, many cardiologists have lost the ability cations such as the aorto iliac, femoral and the to manage limb ischemia, forfeiting their patients distal popliteal artery [6]. Thrombotic occlusions to vascular surgeons or interventional radiologists. usually occur at the site of pre-existing athero- This article will provide a basis for the diag- sclerosis, so patients with thrombotic ALI can nosis and treatment of patients who present be expected to have pre-existing symptomatic with acute limb ischemia (ALI), so that at the PAD with associated collateralization. By con- very least, appropriate medical management can trast, embolic ALI patients may have a relatively be instituted and a rationale treatment plan can healthy arterial tree without preconditions nec- be implemented. essary for collateral formation, and so when the embolus occurs, symptoms are more abrupt and Incidence & etiology severe. Thrombotic occlusions of peripheral arte- Acute limb ischemia occurs due to abrupt inter- rial bypass grafts are currently the most common ruption of arterial blood flow to an extremity. cause of ALI [6]. This results in profound limb ischemia leading Less frequent causes of ALI include entities to rest pain, ischemic ulcerations and gangrene. such as endocarditis, air and fat embolism, The true incidence worldwide is not reliably trauma and dissection, and hypercoagulable known, but a few national registries and regional states. Of these less frequent etiologies, embo- surveys estimate an annual incidence of 140 mil- lism from a proximal aneurysm such as the pop- lion cases per year and occurs at a rate of 14 per liteal artery is an important cause. Thrombosis 100,000 US hospital admissions [1,2]. If treated of, or embolization from a popliteal aneurysm promptly, restoration of perfusion may lead to is indeed a more frequent complication than limb salvage. However, delay is likely to result rupture [7]. ALI occurs in 17–46% of sympto- in limb loss and possibly death. ALI is associated matic popliteal artery aneurysms [7–10]. ALI due with limb loss rates of 5–30% and mortality rates to popliteal artery aneurysms has a 20–60% of 11–18% [3–5]. incidence of limb loss and 12% mortality [10]. Acute limb ischemia is either due to embolic Massive deep venous thrombosis can lead to a or in situ thrombotic arterial occlusion. A total condition known as phlegmasia cerulea dolens, of 15–20% of patients with peripheral arterial which due to the associated soft-tissue swelling 10.2217/ICA.11.28 © 2011 Future Medicine Ltd Interv. Cardiol. (2011) 3(3), 381–389 ISSN 1755-5302 381 REVIEW Goldstein & Mishkel can result in local pressure sufficient to impede mottling appears owing to stagnation in capil- arterial flow to the extremity resulting in ALI. A lary beds. Blanching typically represents revers- more complete listing of the causes of embolism ibility of ischemia (FIGURE 1). An early physical and thrombosis is presented in BOX 1. finding that establishes the level of disease is pulselessness in the affected extremity. The more Presentation proximal the occlusion, the more significant the Limb salvage is dependent on timely clinical findings of ischemia will be. Signs of ischemia evaluation, identification of the etiology and are usually most pronounced one joint distal to early intervention. Delay in treatment results the level of occlusion. For example, if there is from a failure of diagnosis, and results in a high occlusion at the distal popliteal or tibial trifurca- risk of morbidity and mortality. When treat- tion, classically the calf will appear relatively well ment begins within 12 h of onset of ischemia, perfused and the foot will appear ischemic. If the the mortality and limb salvage rate is 19 and occlusion is at the femoral bifurcation, the foot 93%, respectively. With delay of treatment and lower leg will often be ischemic. Paresthesia longer than 12 h, these rates worsen to 31 and and the subsequent development of paralysis 78%, respectively [11,12]. occur later in the course of ALI and represent ALI is confirmed by the presence of the six urgency to avoid limb loss. Sensory deficits typi- ‘P’s’: pain, pallor, polar (cold), pulselessness, cally occur in the order of the diameter of the paresthesia and, ultimately, paralysis [13]. Pain, nerve fibers, beginning with light touch, vibra- pallor and a cool extremity (polar) are early indi- tion and proprioception and then much later cations. Pain generally progresses with the dura- deep pain and pressure sense. Paralysis is the tion of ischemia, but may diminish over time if last to occur, beginning with the intrinsic foot collaterals are recruited or if ischemia progresses muscles followed by the leg muscles. Detecting to ischemic sensory loss. Pallor develops owing early muscle weakness is difficult because toe to emptying and vasospasm of arteries and is movements (other than abduction/adduction) an early manifestation. As ischemia progresses, are produced mainly by the larger leg muscles. Once paralysis occurs, limb salvage is much less Box 1. Common causes of embolism and thrombosis in acute likely and reperfusion injuries more likely. limb ischemia. Identification of the underlying cause can Embolism often direct management strategies. Acute arte- Atherosclerotic heart disease rial embolism can often be treated directly with – Acute myocardial infarction, left ventricle aneurysm a surgical embolectomy without prior diagnostic Arrhythmia (atrial fibrillation) testing. In addition, because an embolus often Valvular heart disease occurs in the setting of a previously normal arte- – Rheumatic, degenerative, congenital, bacterial, prosthetic rial circulation without collaterals, emboli tend Artery-to-artery to produce more acute and limb-threatening – Aneurysm (popliteal), atherosclerotic plaque ischemia. Patients with embolic occlusions tend Idiopathic to remember the moment of onset. In arterial Iatrogenic thrombosis, the onset of symptoms and ischemic Paradoxical embolus manifestation tends to be more gradual (TABLE 1). Trauma Just as the history and physical exam are help- Other ful in identifying patients with ALI and distin- – Air, amniotic fluid, fat, tumor, drugs guishing between thrombosis versus embolism, Thrombosis peripheral angiography will also provide clues to Atherosclerosis and arterial plaque rupture Low-flow states the etiology. Significant disease proximal to the – Congestive heart failure, hypotension, systemic shock level of the occlusion along with a plethora of col- Hypercoagulable states lateral vessels suggests thrombosis. Conversely, Vascular grafts a clean proximal vasculature and the absence of – Disease progression, intimal hyperplasia, mechanical collaterals in association with an arterial cutoff Trauma or meniscus suggests embolism (FIGURE 2). Dissection The management options available for the External compression (popliteal entrapment or adventitial cyst with thrombosis) treatment of ALI all depend on the appropri- Iatrogenic ate categorization of the patient’s limb ischemia. Vasospasm with thrombosis (ergotism) Typically, ankle brachial indices are not of much Arteritis or HIV arteriopathy with thrombosis clinical utility other than confirming the clini- Data taken from [15]. cal exam. Of the greatest utility is the use of a 382 Interv. Cardiol. (2011) 3(3) future science group Choosing the correct therapeutic option for acute limb ischemia REVIEW bedside Doppler to document both arterial and venous signals in addition to an assessment of the patient’s sensory and motor function. The presence of pedal signals usually indicates that there is time for conventional arteriography and proper patient preparation. Other clinical
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