Acute limb ischaemia

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Acute limb ischaemia
Other namesAcute limb ischemia
Arterial thrombosis causing cyanosis.jpg
Acute embolism to the right femoral artery resulting in ischemia
Symptoms Cold, painful, pulseless limb that cannot move
CausesEmbolism, thrombosis
TreatmentThrombectomy, embolectomy, thrombolysis
Medication Thrombolytic drugs

Acute limb ischaemia (ALI) occurs when there is a sudden lack of blood flow to a limb, [1] within 14 days of symptoms onset. [2] It is different from another condition which is more chronic (more than 14 days) [3] called critical limb ischemia (CLD). CLD is the end stage of peripheral vascular disease where there is still some collateral circulation (alternate circulation pathways} that bring some blood (but inadequate) to the distal parts of the limbs. [2] While limbs in both acute and chronic limb ischemia may be pulseless, a chronically ischemic limb is typically warm and pink due to a well-developed collateral artery network and does not need emergency intervention to avoid limb loss. [4]

Contents

Acute limb ischaemia is caused by embolism or thrombosis, or rarely by dissection or trauma. [5] Thrombosis is usually caused by peripheral vascular disease (atherosclerotic disease that leads to blood vessel blockage), while an embolism is usually of cardiac origin. [6] In the United States, ALI is estimated to occur in 14 out of every 100,000 people per year. [7] With proper surgical care, acute limb ischaemia is a highly treatable condition; however, delayed treatment (beyond 6 to 12 hours) can result in permanent disability, amputation, and/or death.

The New Latin term ischaemia as written, is a British version of the word ischemia, and stems from the Greek terms ischein 'to hold'; and haima 'blood'. [8] In this sense, ischaemia refers to the inhibition of blood flow to/through the limb.

Signs and symptoms

Acute limb ischaemia can occur in patients through all age groups. People who smoke tobacco cigarettes and have diabetes mellitus are at a higher risk of developing acute limb ischaemia. Most cases involve people with atherosclerosis problems. [9]

Symptoms of acute limb ischaemia include:

These symptoms are called "the six P's'"; [10] [11] [12] they are commonly mis-attributed to compartment syndrome. One more symptom would be the development of gangrene. Immediate medical attention should be sought with any of the symptoms. [1]

In late stages, paresthesia is replaced by anesthesia (numbness) due to death of nerve cells. [13] In some cases, gangrene can occur suddenly and spread rapidly, [14] and should be treated within six hours of ischaemia. [15]

When a limb is ischaemic in the non-acute (chronic) setting, the condition is alternatively called peripheral artery disease or critical limb ischaemia, rather than ALI. In addition to limb ischaemia, other organs can become ischaemic, causing: [15]

Diagnosis

Acute occlusion of the axillary artery resulting in an ischemic limb as seen on CT angiography Acuteoccluisionaxartery.png
Acute occlusion of the axillary artery resulting in an ischemic limb as seen on CT angiography

Once signs and symptoms of acute limb ischemia are identified, the cause and location of the occlusion and its severity need to be addressed. A clinical pulse examination can be done to detect the location of the occlusion by finding the area where the pulse is detected until the area where the pulse disappears. The skin temperature would also be colder in the pulseless area when compared to the area where the pulse is present. [1]

A Doppler evaluation is used to show the extent and severity of the ischaemia by showing flow in smaller arteries. Other diagnostical tools are duplex ultrasonography, computed tomography angiography (CTA), and magnetic resonance angiography (MRA). The CTA and MRA are used most often because the duplex ultrasonography although non-invasive is not precise in planning revascularization. CTA uses radiation and may not pick up on vessels for revascularization that are distal to the occlusion, but it is much quicker than MRA. [1] In treating acute limb ischaemia time is everything. [16]

In the worst cases, acute limb ischaemia progresses to critical limb ischaemia, and results in death or limb loss. Early detection and steps towards fixing the problem with limb-sparing techniques can salvage the limb. Compartment syndrome can occur because of acute limb ischaemia because of the biotoxins that accumulate distal to the occlusion resulting in edema. [1]

Causes

Most acute limb ischemia is caused by embolism (30% of the cases), thrombosis (40% of the cases), thrombosis by popliteal artery aneurysm (5%), major trauma (5%) and vascular graft thrombosis (20%). [2]

Treatment

Surgery

The primary intervention in acute limb ischaemia is emergency embolectomy using a Fogarty Catheter, providing the limb is still viable within the 4-6h timeframe. [17] Other options include a vascular bypass to route blood flow around the clot. [18]

Angiograph before and after thrombolytic treatment of acute limb ischemia. Angiograph before and after thrombolytic therapy in a case of thrombosis on the hand.png
Angiograph before and after thrombolytic treatment of acute limb ischemia.

Medications

Those unsuitable for surgery may receive thrombolytics. In the past, streptokinase was the main thrombolytic chemical. More recently, drugs such as tissue plasminogen activator, urokinase, and anistreplase have been used in their place. Mechanical methods of injecting the thrombolytic compounds have improved with the introduction of pulsed spray catheters—which allow for a greater opportunity for patients to avoid surgery. [19] [20] Pharmacological thrombolysis requires a catheter to be inserted into the affected area, attached to the catheter is often a wire with holes to allow for a wider dispersal area of the thrombolytic agent. These agents lyse the ischemia-causing thrombus quickly and effectively. [21] However, the efficacy of thrombolytic treatment is limited by hemorrhagic complications. Plasma fibrinogen level has been proposed as a predictor of these hemorrhagic complications. However, based on a systematic review of the available literature until January 2016, the predictive value of plasma is unproven. [22]

Mechanical thrombolysis

Another type of thrombolysis disrupts the clot mechanically using either saline jets or, more recently, ultrasound waves. Saline jets dislodge the clot using the Bernoulli effect. Ultrasound waves, emitted at low frequency, create a physical fragmentation of the thrombus. [23]

Considerations in treatment

The best course of treatment varies from case to case. The physician must take into account the details in the case before deciding on the appropriate treatment. No treatment is effective for every patient. [13]

Treatment depends on many factors, including:

Epidemiology

The major cause of acute limb ischaemia is arterial embolism (80%), while arterial thrombosis is responsible for 20% of cases. In rare instances, arterial aneurysm of the popliteal artery has been found to create a blood clot or embolism resulting in ischaemia. [24]

Related Research Articles

<span class="mw-page-title-main">Thrombosis</span> Medical condition caused by blood clots

Thrombosis is the formation of a blood clot inside a blood vessel, obstructing the flow of blood through the circulatory system. When a blood vessel is injured, the body uses platelets (thrombocytes) and fibrin to form a blood clot to prevent blood loss. Even when a blood vessel is not injured, blood clots may form in the body under certain conditions. A clot, or a piece of the clot, that breaks free and begins to travel around the body is known as an embolus.

<span class="mw-page-title-main">Interventional radiology</span> Medical subspecialty

Interventional radiology (IR) is a medical specialty that performs various minimally-invasive procedures using medical imaging guidance, such as x-ray fluoroscopy, computed tomography, magnetic resonance imaging, or ultrasound. IR performs both diagnostic and therapeutic procedures through very small incisions or body orifices. Diagnostic IR procedures are those intended to help make a diagnosis or guide further medical treatment, and include image-guided biopsy of a tumor or injection of an imaging contrast agent into a hollow structure, such as a blood vessel or a duct. By contrast, therapeutic IR procedures provide direct treatment—they include catheter-based medicine delivery, medical device placement, and angioplasty of narrowed structures.

<span class="mw-page-title-main">Peripheral artery disease</span> Medical condition

Peripheral artery disease (PAD) is a vascular disorder that causes abnormal narrowing of arteries other than those that supply the heart or brain. PAD can happen in any blood vessel, but it is more common in the legs than the arms.

<span class="mw-page-title-main">Ischemia</span> Restriction in blood supply to tissues

Ischemia or ischaemia is a restriction in blood supply to any tissue, muscle group, or organ of the body, causing a shortage of oxygen that is needed for cellular metabolism. Ischemia is generally caused by problems with blood vessels, with resultant damage to or dysfunction of tissue i.e. hypoxia and microvascular dysfunction. It also implies local hypoxia in a part of a body resulting from constriction.

<span class="mw-page-title-main">Thrombolysis</span> Breakdown (lysis) of blood clots formed in blood vessels, using medication

Thrombolysis, also called fibrinolytic therapy, is the breakdown (lysis) of blood clots formed in blood vessels, using medication. It is used in ST elevation myocardial infarction, stroke, and in cases of severe venous thromboembolism.

<span class="mw-page-title-main">Vascular surgery</span> Medical specialty, operative procedures for the treatment of vascular disorders

Vascular surgery is a surgical subspecialty in which vascular diseases involving the arteries, veins, or lymphatic vessels, are managed by medical therapy, minimally-invasive catheter procedures and surgical reconstruction. The specialty evolved from general and cardiovascular surgery where it refined the management of just the vessels, no longer treating the heart or other organs. Modern vascular surgery includes open surgery techniques, endovascular techniques and medical management of vascular diseases - unlike the parent specialities. The vascular surgeon is trained in the diagnosis and management of diseases affecting all parts of the vascular system excluding the coronaries and intracranial vasculature. Vascular surgeons also are called to assist other physicians to carry out surgery near vessels, or to salvage vascular injuries that include hemorrhage control, dissection, occlusion or simply for safe exposure of vascular structures.

<span class="mw-page-title-main">Cerebral infarction</span> Stroke resulting from lack of blood flow

Cerebral infarction, also known as an ischemic stroke, is the pathologic process that results in an area of necrotic tissue in the brain. In mid to high income countries, a stroke is the main reason for disability among people and the 2nd cause of death. It is caused by disrupted blood supply (ischemia) and restricted oxygen supply (hypoxia). This is most commonly due to a thrombotic occlusion, or an embolic occlusion of major vessels which leads to a cerebral infarct. In response to ischemia, the brain degenerates by the process of liquefactive necrosis.

An embolus, is described as a free-floating mass, located inside blood vessels that can travel from one site in the blood stream to another. An embolus can be made up of solid, liquid, or gas. Once these masses get "stuck" in a different blood vessel, it is then known as an "embolism." An embolism can cause ischemia—damage to an organ from lack of oxygen. A paradoxical embolism is a specific type of embolism in which the embolus travels from the right side of the heart to the left side of the heart and lodges itself in a blood vessel known as an artery. Thus, it is termed "paradoxical" because the embolus lands in an artery, rather than a vein.

<span class="mw-page-title-main">Vascular disease</span> Medical condition

Vascular disease is a class of diseases of the vessels of the circulatory system in the body, including blood vessels – the arteries and veins, and the lymphatic vessels. Vascular disease is a subgroup of cardiovascular disease. Disorders in this vast network of blood and lymph vessels can cause a range of health problems that can sometimes become severe, and fatal. Coronary heart disease for example, is the leading cause of death for men and women in the United States.

<span class="mw-page-title-main">Intestinal ischemia</span> Restriction of blood flow to the small intestine resulting in injury

Intestinal ischemia is a medical condition in which injury to the large or small intestine occurs due to not enough blood supply. It can come on suddenly, known as acute intestinal ischemia, or gradually, known as chronic intestinal ischemia. The acute form of the disease often presents with sudden severe abdominal pain and is associated with a high risk of death. The chronic form typically presents more gradually with abdominal pain after eating, unintentional weight loss, vomiting, and fear of eating.

<span class="mw-page-title-main">Peter H. Lin</span>

Peter Lin is an American vascular surgeon, medical researcher, specializing in minimally invasive endovascular treatment of vascular disease. He has published extensively in the area of vascular surgery and endovascular surgery.

Embolectomy is the emergency interventional or surgical removal of emboli which are blocking blood circulation. It usually involves removal of thrombi, and is then referred to as thromboembolectomy or thrombectomy. Embolectomy is an emergency procedure often as the last resort because permanent occlusion of a significant blood flow to an organ leads to necrosis. Other involved therapeutic options are anticoagulation and thrombolysis.

<span class="mw-page-title-main">Arterial embolism</span> Interruption of blood flow to an organ

Arterial embolism is a sudden interruption of blood flow to an organ or body part due to an embolus adhering to the wall of an artery blocking the flow of blood, the major type of embolus being a blood clot (thromboembolism). Sometimes, pulmonary embolism is classified as arterial embolism as well, in the sense that the clot follows the pulmonary artery carrying deoxygenated blood away from the heart. However, pulmonary embolism is generally classified as a form of venous embolism, because the embolus forms in veins. Arterial embolism is the major cause of infarction.

<span class="mw-page-title-main">Limb infarction</span> Medical condition

A limb infarction is an area of tissue death of an arm or leg. It may cause skeletal muscle infarction, avascular necrosis of bones, or necrosis of a part of or an entire limb.

Blood clots are a relatively common occurrence in the general population and are seen in approximately 1-2% of the population by age 60. Typically, blood clots develop in the deep veins of the lower extremities, deep vein thrombosis (DVT) or as a blood clot in the lung, pulmonary embolism. A very small number of people who develop blood clots have a more serious and often life-threatening condition, known as thrombotic storm (TS). TS is characterized by the development of more than one blood clot in a short period of time. These clots often occur in multiple and sometimes unusual locations in the body and are often difficult to treat. TS may be associated with an existing condition or situation that predisposes a person to blood clots, such as injury, infection, or pregnancy. In many cases, a risk assessment will identify interventions that will prevent the formation of blood clots.

Percutaneous intentional extraluminal revascularization is a percutaneous technique used in interventional radiology for limb salvage in patients with lower limb ischemia due to long superficial femoral artery occlusions. This method is intended for those patients who make poor candidates for infrainguinal arterial bypass surgery. A guide wire is intentionally introduced in the subintimal space, after which balloon dilatation is performed to create a new lumen for the blood to flow through. The technique is not without complications but may serve as a "temporary bypass" to provide wound healing and limb salvage.

Chronic limb threatening ischemia (CLTI), also known as critical limb ischemia (CLI), is an advanced stage of peripheral artery disease (PAD). It is defined as ischemic rest pain, arterial insufficiency ulcers, and gangrene. The latter two conditions are jointly referred to as tissue loss, reflecting the development of surface damage to the limb tissue due to the most severe stage of ischemia. Compared to the other manifestation of PAD, intermittent claudication, CLI has a negative prognosis within a year after the initial diagnosis, with 1-year amputation rates of approximately 12% and mortality of 50% at 5 years and 70% at 10 years.

Blood vessel disorder generally refers to the narrowing, hardening or enlargement of arteries and veins. It is often due to the build-up of fatty deposits in the lumen of blood vessels or infection of the vessel wall. This can occur in various locations such as coronary blood vessels, peripheral arteries and veins. The narrowed arteries would block the blood supply to different organs and tissues. In severe conditions, it may develop into more critical health problems like myocardial infarction, stroke or heart failure, which are some of the major reasons of death.

<span class="mw-page-title-main">Arterial occlusion</span>

Arterial occlusion is a condition involving partial or complete blockage of blood flow through an artery. Arteries are blood vessels that carry oxygenated blood to body tissues. An occlusion of arteries disrupts oxygen and blood supply to tissues, leading to ischemia. Depending on the extent of ischemia, symptoms of arterial occlusion range from simple soreness and pain that can be relieved with rest, to a lack of sensation or paralysis that could require amputation.

References

  1. 1 2 3 4 5 Walker T. Gregory (2009). "Acute Limb Ischemia". Techniques in Vascular and Interventional Radiology. 12 (2): 117–129. doi:10.1053/j.tvir.2009.08.005. PMID   19853229.
  2. 1 2 3 Olinic DM, Stanek A, Tătaru DA, Homorodean C, Olinic M (August 2019). "Acute Limb Ischemia: An Update on Diagnosis and Management". Journal of Clinical Medicine. 8 (8): 1215. doi: 10.3390/jcm8081215 . PMC   6723825 . PMID   31416204.
  3. ↑ Fabiani I, Calogero E, Pugliese NR, Di Stefano R, Nicastro I, Buttitta F, Nuti M, Violo C, Giannini D, Morgantini A, Conte L, Barletta V, Berchiolli R, Adami D, Ferrari M, Di Bello V (July 2018). "Critical Limb Ischemia: A Practical Up-To-Date Review". Angiology. 69 (6): 465–474. doi:10.1177/0003319717739387. PMID   29161885. S2CID   22281024.
  4. ↑ Farber, A (12 July 2018). "Chronic Limb-Threatening Ischemia". The New England Journal of Medicine. 379 (2): 171–180. doi:10.1056/NEJMcp1709326. PMID   29996085. S2CID   51623293.
  5. ↑ Creager, Mark A.; Kaufman, John A.; Conte, Michael S. (2012). "Acute Limb Ischemia". New England Journal of Medicine. 366 (23): 2198–2206. doi:10.1056/NEJMcp1006054. PMID   22670905.
  6. ↑ Klonaris, C; Georgopoulos, S; Katsargyris, A; Tsekouras, N; Bakoyiannis, C; Giannopoulos, A; Bastounis, E (March 2007). "Changing patterns in the etiology of acute lower limb ischemia". International Angiology. 26 (1): 49–52. PMID   17353888.
  7. ↑ Dormandy J, Heeck L, Vig S (June 1999). "Acute limb ischemia". Semin Vasc Surg. 12 (2): 148–53. PMID   10777242.
  8. ↑ "Ischaemia." Merriam-Webster. Last modified 2012. http://www.merriam-webster.com/dictionary/ischemia?show=0&t=1334804041
  9. ↑ Brooks Marcus; Jenkins Michael P (2008). "Acute and chronic ischaemia of the limb". Surgery (Oxford). 26 (1): 17–20. doi:10.1016/j.mpsur.2007.10.012.
  10. ↑ Brearley, S (May 8, 2013). "Acute leg ischaemia". BMJ (Clinical Research Ed.). 346: f2681. doi:10.1136/bmj.f2681. PMID   23657181. S2CID   33617691.
  11. ↑ "CKS is only available in the UK". NICE. Retrieved 2020-10-15.
  12. ↑ "Acute Limb Ischaemia - Clinical Features - Management". TeachMeSurgery. Retrieved 2020-10-15.
  13. 1 2 Obara, H.; Matsubara, K.; Kitagawa, Y. (25 December 2018). "Acute Limb Ischemia". Annals of Vascular Diseases. 11 (4): S5–S67443–448. doi:10.3400/avd.ra.18-00074. PMC   6326052 . PMID   30636997.
  14. ↑ Norgren, L.; Hiatt, W.R.; Dormandy, J.A.; Harris, K.A.; Fowkes, F.G.R. (1 January 2007). "Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II)". Journal of Vascular Surgery. 45 (1): S5–S67. doi: 10.1016/j.jvs.2006.12.037 . PMID   17223489 . Retrieved June 25, 2021.
  15. 1 2 "Acute Limb Ischemia". The Lecturio Medical Concept Library. Retrieved 2021-06-25.
  16. ↑ Fluck, F.; Augustin, A.M.; Augustin, T.; Kickuth, R (April 2020). "Current Treatment Options in Acute Limb Ischemia". RöFo. 192 (4): 319–326. doi: 10.1055/a-0998-4204 . PMID   31461761.
  17. ↑ Goldberg, Andrew (2012). Surgical Talk: Lecture Notes in Undergraduate Surgery. Imperial College Press. p. 234. ISBN   978-1-84816-6141.
  18. ↑ Bowley, Douglas, and Andrew Kingsnorth, eds. Fundamentals of Surgical Practice: A Preparation Guide for the Intercollegiate Mrcs Examination. 3rd ed. N.p.: Cambridge University Press, 2011. 506-11. Web. 20 Apr. 2012.
  19. 1 2 Andaz S.; Shields D.A.; Scurr J.H.; Smith P.D. Coleridge (1993). "Thrombolysis in acute lower limb ischaemia". European Journal of Vascular Surgery. 7 (6): 595–603. doi:10.1016/S0950-821X(05)80702-9. PMID   8270059.
  20. ↑ ABC of Arterial and Venous Disease: Acute Limb Ischaemia Ken Callum and Andrew Bradbury BMJ: British Medical Journal, Vol. 320, No. 7237 (Mar. 18, 2000), pp. 764-767
  21. ↑ Wardlaw J.M.; Warlow C.P. (1992). "Thrombolysis in acute ischemic stroke: does it work?". Stroke. 23 (12): 1826–1839. doi: 10.1161/01.str.23.12.1826 . PMID   1448835.
  22. ↑ Poorthuis, Michiel H. F.; Brand, Eelco C.; Hazenberg, Constantijn E. V. B.; Schutgens, Roger E. G.; Westerink, Jan; Moll, Frans L.; de Borst, Gert J. (2017-03-05). "Plasma fibrinogen level as a potential predictor of hemorrhagic complications after catheter-directed thrombolysis for peripheral arterial occlusions". Journal of Vascular Surgery. 65 (5): 1519–1527.e26. doi: 10.1016/j.jvs.2016.11.025 . ISSN   1097-6809. PMID   28274749.
  23. ↑ Sean P. Lyden, Endovascular Treatment of Acute Limb Ischemia: Review of Current Plasminogen Activators and Mechanical Thrombectomy Devices PERSPECT VASC SURG ENDOVASC THER December 2010 22: 219-222, first published on March 16, 2011
  24. ↑ Mitchell ME, Carpenter JP. Overview of acute arterial occlusion of the extremities (acute limb ischemia). In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/overview-of-acute-arterial-occlusion-of-the-extremities-acute-limb-ischemia?source=search_result&search=Classification%20of%20acute%20extremity%20ischemia&selectedTitle=1~90#H506059593. Last updated May 31, 2016. Accessed December 13, 2016.
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