ACUTE LIMB ISCHEMIA

Definition

Acute limb ischemia is defined as a sudden decreased in limb perfusion that threatens the
viability of the limb. It is caused by embolism or thrombosis, or rarely by dissection or trauma.
Thrombosis is usually caused by peripheral vascular disease (atherosclerotic disease that leads to blood
vessel blockage), while an embolism is usually of cardiac origin.

When a limb is ischemic in the non-acute (chronic) setting, the condition is alternatively called
peripheral artery disease or critical limb ischemia, rather than ALI.

Incidence

1.5 cases per 10,000 persons per year

Anatomy

Layers of blood vessels:

Signs and symptoms

 Pain
 Pallor
 Pulseless
 Perishing Cold
 Paresthesia
 Paralysis

*site of occlusion: Femoral and popliteal artery, the signs and symptoms are:

 Intermittent claudication (calf, foot; may radiate)

 Leg pallor and coolness
 Dependent rubor
 Blanching of feet on elevation
 No palpable pulses in ankles and feet
 Gangrene
Etiology and Risk Factors:

Atherosclerosis as the underlying cause of occlusive disease, with its known etiologic and
associated risk factors. PAD correlates most strongly with cigarette smoking and either diabetes or
impaired glucose tolerance. Other risk factors include male gender, hypertension, low levels of HDL
cholesterol, and etc.

Pathogenesis

The arterial narrowing or obstruction that occurs as a result of the atherosclerotic process
reduces blood flow to the limbs during exercise or at rest. Muscular reactivity is also adversely affected
in PAD. Prostacyclin and nitric oxide usually activate vascular relaxation. In PAD, these relaxation factors
are reduced and constrictive factors such as endothelin increase. This imbalance of vascular reactivity
contributes to decreased blood flow.

The ensuing inflammatory process promotes cholesterol deposition and, ultimately the build up of
plaque. The lesions may be stable, or they may develop a thin, unstable fibrous cap that is vulnerable to
ulceration. Once the lesion ulcerates, the underlying plaques is exposed to the bloodstream, and the
potential for thrombotic or embolization increases.
Differential Diagnosis

ALI/PAD DVT
 Obstruction of blood flow into an arterial  occurs when a blood clot (thrombus)
tree forms in one or more of the deep veins in
 few hours history of a painful cold white your body, usually in your legs
leg  Pain in your leg. The pain often starts in
 Pain your calf and can feel like cramping or
 Pallor soreness.
 Paresthesia  Red or discolored skin on the leg.
 Perishinly cold  A feeling of warmth in the affected leg.
 Pulselessness

Diagnosis

Diagnosis is based on client history and clinical examination. Diagnostic tools may include
noninvasive vascular tests (e.g., ankle/brachial index, segmental limb pressures, pulse volume
recordings, duplex ultrasonography) or, if invasive tests are required, arteriography with contrast or
with MRI. An in-depth discussion of the diagnosis and intervention strategies for chronic arterial
insufficiency of the lower extremities is available.

Prevention and Treatment

 Risk factor reduction and lifestyle measures

 Dietary management to decrease cholesterol and fat, pain control, and daily physical training
and exercise
 Preventive skin care
 Recommendations for antiplatelet and antithrombotic drugs include administering of aspirin in a
wide range of doses (75-325 mg) as an antiplatelet agent.
 Surgical Intervention ( Revacularization Procedures)