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Arterial Occlusion, Emergency Medicine

Basics

Description

- Arterial embolization - Thrombus or plaque - Originates from aneurysms or atherosclerotic lesions - Emboli typically lodge where there is an acute narrowing of the artery - 75% of emboli involve an axial limb vasculature - Femoral 28% - Arm 20% - Aortoiliac 18% - Popliteal 17% - Visceral and other 9%

- Penetrating trauma - Gunshot, stab wounds, shotgun, shrapnel - IV drug use

- Blunt trauma - Joint displacement - Fracture - Compartment syndrome

- Sudden onset of a cold, painful leg - The 6 Ps: - Pain - Gradual, initially increasing in severity then decreasing with progressive sensory loss - Distal progressing proximally - Sudden onset with embolization

- Pallor - Paresthesias - Paralysis - Pulseless (late finding) - Polar (Cold)

- Progressive peripheral nerve dysfunction - Early loss of proprioception and light touch - Loss of sensation and weakness follows

- Time of onset - History of claudication or cramps - Reproducible discomfort of a defined group of muscles that is induced by exercise and relieved with rest

- Sensory loss - Muscle weakness - Skin color changes - Loss of pulse - Signs of chronic arterial insufficiency: - Ankle-brachial pressure index measurement - Measure arm systolic pressure with the Doppler flowmeter for accuracy - Record pressure in both arms and both tibial arteries at the ankle. - Ratio of systolic BP in the lower legs to the brachial pressure in the arm: - Place cuff above malleoli to measure pressure in lower legs - Use Doppler at posterior tibial or dorsalis pedis artery

- MRI - Viable alternative to angiography. - Noninvasive - Does not required contrast material

- Class 2: Threatened but salvageable - Immediate surgical revascularization - Embolectomy if indicated - Angiography and oral anticoagulation post op

Immediate and severe compromise of the blood supply to a limb, threatening its viability, secondary to the sudden blockage of a peripheral artery пїЅ

  • Arterial embolizationThrombus or plaqueOriginates from aneurysms or atherosclerotic lesionsEmboli typically lodge where there is an acute narrowing of the artery75% of emboli involve an axial limb vasculatureFemoral 28%Arm 20%Aortoiliac 18%Popliteal 17%Visceral and other 9%
  • Thrombosis
  • Arterial dissection
  • TraumaCrush injuriesCompressionArterial contusion and thrombosisArterial transection
  • Limb ischemia >6 hr usually results in functional impairment or limb loss.If acute on chronic, collateral circulation may preserve tissue beyond 6 hr.

Etiology

  • Embolus:Atrial fibrillationMyocardial infarctionValvular diseaseEndocarditisAtrial myxomaAneurysmAtherosclerotic plaquesParadoxical embolus
  • ThrombosisVascular graftsAtherosclerosisThrombosis of an aneurysmEntrapment syndromeBlood clotting disordersLow flow stateHeparin-induced thrombosis
  • Arterial dissection
  • Arterial injury:Intimal flapDissectionPseudoaneurysmsIatrogenicCatheterizationArteriographyBalloon angioplastyComplication of arterial puncturePenetrating traumaGunshot, stab wounds, shotgun, shrapnelIV drug useBlunt traumaJoint displacementFractureCompartment syndrome

Diagnosis

Signs and Symptoms

  • Sudden onset of a cold, painful leg
  • The 6 Ps:PainGradual, initially increasing in severity then decreasing with progressive sensory lossDistal progressing proximallySudden onset with embolizationPallorParesthesiasParalysisPulseless (late finding)Polar (Cold)
  • Progressive peripheral nerve dysfunctionEarly loss of proprioception and light touchLoss of sensation and weakness follows
  • Blue toe syndrome:Development of blue or violaceous discoloration in one or more toesThe affected digits are often painful.The cyanosis initially blanches with pressure or leg elevation.
  • Signs of severe obstruction and poor prognosisAbsent capillary flowSkin marblingLoss of distal pulsesParalysis

History

  • Time of onset
  • History of claudication or crampsReproducible discomfort of a defined group of muscles that is induced by exercise and relieved with rest
  • Past medical history to identify risk factors for thrombosis or embolus

Physical Exam

  • Sensory loss
  • Muscle weakness
  • Skin color changes
  • Loss of pulse
  • Signs of chronic arterial insufficiency:
  • Ankle-brachial pressure index measurementMeasure arm systolic pressure with the Doppler flowmeter for accuracyRecord pressure in both arms and both tibial arteries at the ankle.Ratio of systolic BP in the lower legs to the brachial pressure in the arm:Place cuff above malleoli to measure pressure in lower legsUse Doppler at posterior tibial or dorsalis pedis arteryChronic PVD <0.9Acute arterial occlusion <0.5
  • Demarcation of the warm part of the extremity to the cold part to estimate level of the obstruction

Essential Workup

Elevation, cool compress or ice, or warm compress to the affected extremity is contraindicated. пїЅ

Diagnosis Tests & Interpretation

Lab

  • Electrolytes/anion gap
  • BUN
  • Creatinine
  • CBC
  • Creatine phosphokinase

Imaging

  • The utility of imaging in the ED is limited as most of the decision making is based on the clinical presentation
  • Duplex USProvides a "roadmap"пїЅ of stenosis of the arteries of the lower extremities
  • CT angiographyWith multidetectors, performance is similar to angiographyLike angiography it requires IV contrast bolus and exposure to radiation
  • MRIViable alternative to angiography.NoninvasiveDoes not required contrast material
  • Angiography

Classification

  • Class 1: ViablePain but no paralysis or sensory lossNeeds attention, not in immediate danger
  • Class 2: Threatened but salvageable2A: Some sensory loss, no paralysis: No immediate threat.2B: Sensory and motor loss: Needs immediate treatment
  • Class 3: Irreversible/nonviable:Sensory loss, paralysis, absent capillary flow, skin marbling, absent arterial Doppler flowWill require amputation

Differential Diagnosis

  • Lumbar spine disorders
  • Back pain, mechanical
  • Decreased cardiac output owing to advanced atherosclerotic disease
  • Frostbite
  • Peripheral neuropathy
  • Aneurysm, abdominal
  • Ankle injury, soft tissue
  • Deep venous thrombosis
  • Septic thrombophlebitis
  • Superficial thrombophlebitis
  • Trauma, peripheral vascular injuries

Treatment

Pre-Hospital

  • Early recognition and rapid transport to an emergency department
  • Place the limb in a dependent position
  • Keeping the limb warm
  • Oxygen by nasal cannula
  • Aspirin

Ed Treatment/Procedures

  • Prompt consultation with vascular surgeon
  • Heparin bolus followed by an infusion
  • Class 1: ViableMost often due to thrombosisIntra-arterial thrombolytic agents versus surgical revascularization or endovascular repair depending on viability of limb
  • Class 2: Threatened but salvageableImmediate surgical revascularizationEmbolectomy if indicatedAngiography and oral anticoagulation post op
  • Class 3: NonviablePrompt amputationClinical assessment, imaging usually not required
  • Pain control

Medication

  • Heparin: Weight-based protocol anticoagulation with typical 80 U/kg loading bolus; 18 U/kg/h IV

Follow-Up

Disposition

Admission Criteria

  • All patients with clinical diagnosis of acute arterial occlusion or (ABI <0.5) should be admitted after an emergency consultation with a vascular surgeon.

Discharge Criteria

  • Patients with chronic occlusive disease, resolved pain, and stable ABI measurements
  • No other acute medical issues (e.g., new atrial fibrillation)
  • Vascular surgical follow-up can be ensured.
  • Patients should be instructed to return for any recurrent or progressive symptoms.

Issues for Referral

  • PVD patents in which illness is not severe or acute as to require inpatient treatment may be discharged with appropriate follow-up with a vascular surgeon.
  • Potential effects of various activities and medications on the course of their illness should be discussed.
  • Education on smoking cessation, temperature extremes, and vasoconstricting medications should be considered.

Additional Reading

  • Clair пїЅD, Shah пїЅS, Weber пїЅJ. Current state of diagnosis and management of critical limb ischemia. Curr Cardiol Rep. 2012;14(2):160-170.
  • Katzen пїЅBT. Clinical diagnosis and prognosis of acute limb ischemia. Rev Cardiovasc Med. 2002;3(suppl 2):S2-S6.
  • Setacci пїЅC, De Donato пїЅG, Setacci пїЅF, et al. Hybrid procedures for acute limb ischemia. J Cardiovasc Surg. 2012;53(1 suppl 1):133-143.
  • Van den Berg пїЅJC. Thrombolysis for acute arterial occlusion. J Vasc Surg. 2010;52(2):512-515.

See Also (Topic, Algorithm, Electronic Media Element)

Peripheral Vascular Disease пїЅ

Codes

ICD9

  • 444.9 Embolism and thrombosis of unspecified artery
  • 444.21 Arterial embolism and thrombosis of upper extremity
  • 444.22 Arterial embolism and thrombosis of lower extremity
  • 415.19 Other pulmonary embolism and infarction

ICD10

  • I74.2 Embolism and thrombosis of arteries of the upper extremities
  • I74.3 Embolism and thrombosis of arteries of the lower extremities
  • I74.9 Embolism and thrombosis of unspecified artery
  • I26.99 Other pulmonary embolism without acute cor pulmonale

SNOMED

  • 2929001 Occlusion of artery (disorder)
  • 54687002 Arterial embolism (disorder)
  • 195147006 Atrial thrombosis
  • 59282003 Pulmonary embolism (disorder)
  • 302300004 Femoral popliteal occlusion (disorder)
  • 314188009 Femoral artery occlusion (disorder)
  • 69357003 pulmonary thrombosis (disorder)