Arterial Occlusion, Part 1

Arterial Occlusion, Part 1 Posted By:

Today we are going to discuss arterial occlusion, as I have seen multiple lawsuits brought against advanced practice providers (APPs) for missed diagnoses of this—despite the clinical presentation being drilled into our heads as early as matriculation. We all know that arterial occlusion is synonymous with acute limb ischemia and is considered a vascular emergency, but what I have commonly seen is that we do not all document a thorough physical exam as a means to potentially refute a plaintiff's lawyer's allegation of a missed diagnosis. This will be a 2-part discussion, with presentation discussed in part 1.

This is of particular relevance since acute thromboembolic events such as acute limb ischemia have been linked to COVID-19. Further, in patients who present with acute limb ischemia without known risk factors or causes, it may behoove us as providers to suspect a diagnosis of COVID-19.

The diagnosis of any acute extremity ischemia can generally be made solely by the history and physical examination, but a thorough examination of both lower limbs is imperative to adequately detect signs of ischemia and thus render the appropriate diagnosis. Symptom timing can be variable—they may develop over hours or days without a known trauma—and can range from new or worsening claudication to relatively sudden paralysis of the affected limb. Typically, the level of arterial obstruction is 1 joint above the boundary between normal and ischemic tissue.

The classic "6 P's" of limb ischemia can occur anywhere distal to the occlusion. Typically, patients present with pain, pallor, pulselessness, and then poikilothermia. The area of pain is much less with the limb in a dependent position. With treatment delay, limb paresthesia replaces pain, and the final stages of injury cause paralysis. Onset tends to be more sudden, and symptoms more severe, in patients with embolic occlusion, as collateralization of the vasculature has not yet occurred. As stated above, it is important to understand that these symptoms can develop over the course of hours to days and present as new or recurring.

I will briefly discuss 2 types of limb ischemia: acute limb ischemia and acute-on-chronic limb ischemia. In acute ischemia, patients have normal underlying vasculature. If these patients experience an acute arterial insult (most often an embolism), the blocked artery cannot be mitigated quickly enough by collateral blood vessels, and signs of acute ischemia rapidly develop. These patients can often pinpoint the exact time that their symptoms began. This is where you typically see the classic 6 P's of limb ischemia.

Acute-on-chronic ischemia is a more complex condition. In this scenario, there is an acute—and commonly an embolic—event in a patient with a known history of peripheral arterial disease. Alternatively, patients with acute-on-chronic ischemia may have undergone prior revascularization (eg, arterial repair, arterial bypass, arterial stent). Due to their history, these patients are sub-classified; they also typically have a longer period in which the affected limb is able to be rescued.

In part 2 of this series, I will discuss the evaluation that should be performed on all patients with suspected arterial occlusion.

  • Creager M, et al. Acute limb ischemia. N Engl J Med. 2012;366:2198.
  • Engledow A, Crinnion J. Acute lower limb ischaemia. Hosp Med. 2002;63:412.
  • Gonzalez-Urquijo M, et al. Unexpected arterial thrombosis and acute limb ischemia in COVID-19 patients. Results from the Ibero-Latin American acute arterial thrombosis registry in COVID-19: (ARTICO-19). Vascular. 2021. Online ahead of print.
  • Tayebi P, et al. Extensive acute lower extremity arterial thrombosis: a major thrombus formation caused by COVID-19. Vasc Specialist Int. 2021;37:36.


Filed under: Curbside Consultations , Cardiometabolic

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