Current Options in the Diagnosis and Management of Acute Limb Ischemia

Karthikeshwar Kasirajan, MD, Kenneth Ouriel, MD


Prog Cardiovasc Nurs. 2002;17(1) 

In This Article

Clinical Presentation

The classical description of patients with acute limb ischemia is represented by the "six Ps": pain, pallor, paralysis, pulse deficit, paresthesia, and poikilothermia. Pain may be either constant or elicited by passive movement of the involved extremity. History should include the duration, location, intensity, and suddenness of the onset of pain and changes over time. Embolic occlusions are usually very sudden and of great intensity, such that patients often present within a few hours of onset. The history should include a history of intermittent claudication, previous leg bypass or other vascular procedures, and history suggestive of embolic sources, such as cardiac arrhythmias and aortic aneurysms. General cardiac risk factors (smoking, hypertension, diabetes, hyperlipidemia, amputations, other vascular procedures, family history of cardiac or vascular events, age of parents at time of death) should be recorded, as these can be predictors of periprocedural mortality.

The duration of symptoms is of prime importance in the planning of therapy.[2] Percutaneous endovascular options are more effective in patients with ischemia of less than 2 weeks' duration. On the other hand, symptoms of greater than 2 weeks' duration are better served with nonthrombotic options.[2] Pallor and the level of coldness (poikilothermia) are important to record, to evaluate the progression of ischemia. Propagation of thrombus after the initial occlusive event may convert a marginally ischemic limb into a severely threatened extremity. Occasionally, propagation may occur due to a decrease in blood flow secondary to low cardiac output resulting from congestive heart failure or myocardial infarction. The pulse deficit is helpful is determining the site of occlusion; for example, a palpable femoral pulse and an absent popliteal pulse indicate an occlusion at the level of the superficial femoral artery. It should also be remembered that sensory capabilities, such as light touch, two-point tactile discrimination, proprioception, and vibratory perception, are lost early on. Finally, profound paralysis with complete lack of sensation indicates an irreversible state of ischemia, and the patient may be best treated with primary amputation.


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