ACUTE LIMB ISCHAEMIA GUIDELINE

DEFINITION
Acute limb ischaemia results from sudden interruption of the limb blood supply by thrombus,
embolus or trauma. It carries a high morbidity, including loss of limb. There are two major
categories:
Acute limb ischaemia

Most commonly caused by emboli that:

are usually of cardiac origin
often occur in otherwise normal arteries
often lodge at artery bifurcations, femoral artery bifurcation most commonly, followed by
brachial
carry higher morbidity because the extremity has not had time to develop collateral
circulation
Whether embolus or thrombus, occlusion results in both proximal and distal thrombus
formation due to stagnant flow

Acute-on-chronic limb ischaemia

Existing atherosclerosis in a patient with a history of peripheral vascular disease (PVD) is

acutely compounded by thrombus and this must be regarded as a vascular
emergency

RISK FACTORS

Diabetes
Hypertension
Hypercholesterolaemia
Smoking
Pre-existing PVD
AAA/popliteal aneurysm
Atrial fibrillation

SYMPTOMS AND SIGNS

The limb becomes:

pale (later mottled and cyanosed)
painful
pulseless
perishing cold
paraesthetic
paralysed
Acute total ischaemia with an acute 'white leg' indicates the threat of muscle necrosis
within 12 hours

ASSESSMENT

Ask about:
claudication
night pain
previous tissue necrosis (e.g. ulcers)
Determine site of occlusion
check presence of all peripheral pulses, including abdominal aortic pulse
assess quality and regularity of pulse, noting AF in particular
auscultate for bruits (e.g. subclavian, axillary, femoral)

Assess likely nature of occlusion

Thrombus suggested by:
pre-existing claudication with sudden deterioration
no obvious source for emboli
reduced or absent pulses in contralateral limb
evidence of widespread vascular disease (e.g. myocardial infarction, stroke, TIA,
previous vascular surgery)
Embolus suggested by:
sudden onset of painful leg (<24 hr)
no history of claudication
clinically obvious source of embolus (e.g. atrial fibrillation, recent
myocardial infarction)
no evidence of peripheral vascular disease (normal pulses in
contralateral limb)
evidence of proximal aneurysm (e.g. abdominal or popliteal)

Assess neurosensory deficit

Grade I

Variable

Grade II

Threatened

Reduced sensation in foot

No audible Doppler signal

Grade III

Irreversible

Cold extremity with tense muscles

Complete neurological deficit
No audible Doppler signal

Painful, tender
calf/painful plantar flexion

No neurosensory deficit

Audible Doppler signal

INVESTIGATIONS

Bloods:
FBC, U&E
INR, APTT, platelet count, group & save
creatine kinase
ECG
Chest X-ray
Ankle Brachial Pressure Index (ABPI)
If aneurysm suspected
abdominal USS
duplex Doppler scan of popliteal arteries

IMMEDIATE TREATMENT
General
Assess airway, breathing and circulation, and resuscitate as required
Give oxygen, starting with a 24% Venturi mask to improve oxygen supply to leg
Give adequate analgesia

morphine with an anti-emetic

Give IV fluids as increased viscosity can easily lead to dehydration see Fluid
Replacement in Medical guidelines
Nil-by-mouth until opinion of vascular team obtained
Catheterize and monitor input/output

Specific see Flowchart

Seek opinion from vascular team as soon as possible. Include in discussion:
Angiography (if evidence of renal impairment, consider cover with N-acetylcysteine 600
mg IV 12 hrly on day of procedure and, if possible, on day before procedure
Length of history
if long history >1 week, discuss giving pain relief until next working day as ischaemia
likely to be irreversible

if <1 week, discuss immediate operation with vascular surgeon

If not for surgery within 4 hr, start IV heparin infusion (see IV unfractionated heparin) to
prevent propagation of thrombus
If signs of infection, seek advice of consultant microbiologist (4666)
Monitor vital signs and condition of the leg regularly
Acute leg ischaemia

Neurosensory deficit

No

Criteria for embolus

Yes

IV heparin
No
Vascular surgical opinion and
angiography
(next day, if out-of-hours)

Probable embolus
Proceed to embolectomy

Urgent vascularopinion
Consider Duplex Doppler and/or angiography

SUBSEQUENT MANAGEMENT

Monitor condition of leg closely post-operatively/post-thrombolysis to detect early reocclusion

Continue IV heparin infusion for at least a further 48 hr
Vascular surgeon to decide regarding subsequent anticoagulation
Ensure therapeutic anticoagulation with regular INR
Treat AF as required (see Atrial fibrillation in Medical Guidelines)
Encourage early mobilization
Identify risk factors
Give patient appropriate advice regarding lifestyle change:
smoking cessation
exercise

 diet
Treat hypertension and/or raised cholesterol appropriately
Ensure appropriate out-patient follow-up with vascular team