Acute limb ischaemia
Acute limb ischaemia | |
---|---|
Other names | Acute limb ischemia |
Thrombolytic drugs |
Acute limb ischaemia (ALI) occurs when there is a sudden lack of blood flow to a limb,
Acute limb ischaemia is caused by
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
Symptoms of acute limb ischaemia include:
- Pain
- Pallor (pale appearance of the limb)
- Paresthesias (abnormal sensations in the limb)
- Perishingly cold
- Pulselessness
- Paralysis
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]
Related conditions
When a limb is
- Renal ischemia(nephric ischaemia)
- Mesenteric ischaemia
- Cerebral ischaemia
- Cardiac ischaemia
Diagnosis
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
In the worst cases, acute limb ischaemia progresses to
Causes
Most acute limb ischemia is caused by
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]
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,
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:
- Location of lesions
- Anatomy of lesions
- Individual risk factors
- Procedural risk
- Clinical presentation of symptoms
- Duration of symptoms
- etc.[19]
Epidemiology
The major cause of acute limb ischaemia is
References
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- ^ "Ischaemia." Merriam-Webster. Last modified 2012. http://www.merriam-webster.com/dictionary/ischemia?show=0&t=1334804041
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- ^ "CKS is only available in the UK". NICE. Retrieved 2020-10-15.
- ^ "Acute Limb Ischaemia - Clinical Features - Management". TeachMeSurgery. Retrieved 2020-10-15.
- ^ PMID 30636997.
- PMID 17223489. Retrieved June 25, 2021.
- ^ a b "Acute Limb Ischemia". The Lecturio Medical Concept Library. Retrieved 2021-06-25.
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- ISBN 978-1-84816-6141.
- ^ 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.
- ^ PMID 8270059.
- ^ 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
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- ^ 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
- ^ 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.