Acute limb ischemia (ALI) is one of the medical emergencies where time literally is money. Prompt diagnosis and intervention within the golden hours (6-8) before the tissues become irreversibly damaged ensure the best outcome for the patient.
In most cases, the symptoms of ALI are severe and the signs characteristic. However, failure to do a proper clinical examination or elicit relevant history may cause missed diagnoses of ALI.
We present a case where a 45-year-old female initially had severe pain in her left lower leg and feet with some degree of weakness. She promptly sought treatment and was administered pain killers and advised to get MRI of spine. Her pain continued to worsen and by day 5 she had started to develop skin changes with restriction of toe movements. Unfortunately, a proper pulse examination wasn’t done, and she went on to develop calf tenderness and skin mottling – telltale signs of irreversible ischemia.
When she came to the Vascular Surgery Department, her left leg had color changes of the skin up to the lower 3rd of the leg, hypothermia till mid leg, flickers of movement at the ankle and absent left lower limb pulses. CT angiogram of the lower limb demonstrated thrombus in the iliac artery, occluded common and superficial femoral arteries and scant reformation of the tibial arteries. The prognosis was explained to the patient and attenders and emergency femoral and if needed, popliteal thrombectomy was offered as a last-ditch effort to save the leg. As the presentation was very much delayed, high probability of failure and need for major amputation were stressed upon.
The image shows the CT angiogram of the patient showing occluded iliac and femoral arteries. The tibial arteries are poorly visualized as well. Note the relatively well-preserved right-side vasculature.
She underwent emergency left transfemoral thrombectomy and puncture angiogram of the left iliac artery at the hybrid cath suite. Chronic thrombus was retrieved from the iliac and femoral artery and evidence of a proximal (iliac) occlusion was seen in the angiogram. It was akin to keeping a sinking ship afloat as she kept thrombosing again and again on table even after multiple thrombectomies. Further attempts were stopped, and she was maintained on high dose IV anticoagulation while investigations were done to deduce a cause for thrombophilia. She was found to have thrombocytosis. Her cardiac system was normal and there was no source of emboli upstream. The left leg developed progressive gangrene, and she had to undergo a below knee amputation of her left leg.
ALI usually presents dramatically with a sudden onset of severe pain that is sometimes associated with weakness. Patients often remember the exact time of occurrence and can often recollect the activity they were engaged in at the time of onset. An embolus at the bifurcation of aorta can cause paraplegia that can easily be mistaken for a stroke. Examination should be comprehensive assessing all peripheral pulses and the contralateral extremity should always be compared with. In advanced ischemia, tissues will appear cyanotic, clammy with reduced sensations and movements will be restricted. Foot drop, skin mottling and calf turgor with tenderness indicate ischemia with likely irreversible damage. Those with delayed presentation are also at risk of acute kidney injury, acute coronary events and multi-organ failure. Rutherford’s classification of ischemia helps in deciding on the type of management.
Imaging – duplex USG, CT angiogram or MR angiogram help in operative planning. Basic blood investigations – hemogram, renal functions, serum homocysteine and coagulation profile are done. A transthoracic echocardiogram is done to rule out cardiac emboli.
Traditionally, thrombectomy/embolectomy was done to revascularize. Bypasses with reversed saphenous vein or a prosthetic graft are sometimes required when the thrombus is chronic and thrombectomy fails. ALI is also managed with endovascular interventions which include catheter directed thrombolysis, thrombosuction, angioplasty and stenting. Patients with ALI tend to have other comorbidities as well – diabetes, hypertension, dyslipidemia, thrombophilia, CAD, CVD and addictions. Involving other specialties will give better outcomes.
An act as simple as touching her feet to feel for pulses could have possibly changed the entire episode and avoided the amputation. The patient’s complaints and observations always warrant proper attention and scrutiny. When the treatment administered doesn’t evoke expected outcomes, it’s better to pause and strategize better. The patient and the attenders should always be informed about progress or deterioration and given realistic expectations about the outcomes. After all, acute limb ischemia is unforgiving and takes no prisoners.
Dr. Jan Sujith Associate Consultant Vascular Surgery, Kauvery Hospital, Chennai
Dr. N. Sekar Chief Vascular and Endovascular Surgeon, Kauvery Hospital, Chennai
