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  • • Sudden occlusion of previously patent artery supplying an extremity

    • Abrupt onset of ischemia: pain, coldness, numbness, motor weakness, absent pulses

    • Tissue viability determined by collaterals and surgical intervention

    • Line of demarcation occurs between viable and nonviable tissue

    • Caused by embolus, thrombosis, trauma, or dissection

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Embolus

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  • • Heart source of embolus in 85%; higher risk in patients with atrial fibrillation, LV thrombus, mechanical valves; septic emboli from infective endocarditis

    • Aneurysms in aortofemoral or popliteal arteries can be the source of emboli

    • Cardiac tumors and paradoxic emboli (through patent foramen ovale) rarely source

    • Source is unknown in 5-10% of cases (cryptogenic)

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Thrombosis

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  • • Sudden thrombosis in hypercoagulable states, patients with malignancy, or atherosclerotic vessel

    • May be difficult to distinguish thrombotic from embolic event

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Trauma

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  • • Arterial damage by bone fracture or dislocation, penetrating injury, complication of catheterization or percutaneous transluminal angioplasty (PTA)

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Dissection

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  • • Most common in thoracic aorta and propogates distally

    • May cause limb ischemia with iliofemoral involvement

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Symptoms and Signs

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  • • 5 Ps: pain, pallor, pulselessness, paresthesias, paralysis

    • Sudden pain present in 80% indicates time of occlusion, may be absent with prompt onset of paresthesia/paralysis

    • Pallor followed by mottled cyanosis

    • Hyperesthesia followed by anesthesia; light touch lost, pressure, pain, and temperature often more preserved

    • Motor paralysis: impending gangrene

    • Symptoms > 12 h, unlikely salvageable

    • Tense swelling and acute tenderness of gastrocnemius denotes irreversible infarction

    • 4-6 hrs nerves and muscles ischemic; skin more resistant to ischemia

    • Level of demarcation varies with site of occlusion

    • Collateral flow may result in return of warmth and color of skin, lessening of sensory deficit with symptoms of chronic occlusion of artery

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  • • Consider both thrombosis and embolic events

    • Must evaluate for secondary tissue loss or compartment syndrome

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  • • Immediate administration of heparin

    • Arteriography may help differentiate thrombosis from embolus

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Embolisms/Thrombosis

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  • • Immediate administration of heparin

    • Arteriography can help if no delay in treatment

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Traumatic

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  • • Repair arterial injury in addition to other injuries

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Surgery

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Indications

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  • • Advanced, reversible ischemia

    • Fasciotomy often required with long ischemia time

    • Thrombolysis, surgical embolectomy (least delay in reestablishing flow)

    • Arterial reconstruction in thrombotic event with atherosclerosis (alternative to thrombolytic therapy)

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Contraindications

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  • • Irreversible ischemia

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Medications

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  • • Heparin

    • Thrombolytics

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Complications

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  • With reperfusion: Myoglobinuria, renal failure, hyperkalemia

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Prognosis

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  • • Good if reestablish blood flow within 6 hours

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References

Berridge DC, Kessel D, Robertsson I: Surgery versus thrombolysis ...

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