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The history of the recognition and surgical treatment of lower limb ischemia dates back to the Middle Ages. The twin Saints Comas and Damian were ascribed to have saved a gangrenous limb in the thirteenth century and became patrons of future surgeons. The physicians who followed developed the theories of blood flow, anatomy of the arterial circulation, and recognition that occlusive disease was the cause of limb ischemia and gangrene. Innovative physicians developed the techniques of arterial surgery and bypass grafting to restore limb blood flow and allow the healing of lesions. In the 1960s, the era of endovascular intervention began through the pioneering work of Charles Dotter who developed techniques to image diseased arteries during a recanalization procedure. The development of guide wires, angioplasty balloons, and stents quickly followed. Management of lower limb ischemia and the diabetic foot will continue to evolve, building on the history and passion of preceding physicians and surgeons.1

Acute limb ischemia (ALI) is defined as a sudden decrease in limb perfusion that threatens the viability of the limb. Diagnosis of acute ischemia of a limb can be a challenging clinical concern for vascular surgeons and interventionalists. Compounded with the degree of potential ischemia is the need for a timely and accurate diagnosis to best determine the urgent course of revascularization as significant delays risk limb loss resulting in amputation or even death, with historic rates ranging from 10% to 25%.2

This chapter will discuss basic etiology, clinical presentation, differential diagnosis, evaluation, and treatment options. With the continued advancement of endovascular techniques, multiple interventional modalities are available but as with other vascular conditions, they are predicated on appropriate and accurate initial diagnosis.


Complete or major partial occlusion of the arterial supply to a limb can lead to rapid ischemia and poor functional outcomes within hours. ALI has an incidence of about 1.5 per 10,000 years.3 The two main causes of ALI are arterial embolism and thrombosis. Other nonvascular causes include trauma and iatrogenic injury. Other than understanding the precipitating cause for ALI in an effort to reduce or eliminate it from recurring, the acute management of limb occlusion is essentially independent of its cause—restoring perfusion to the limb urgently is crucial.


Embolism is whereby a thrombus from a more proximal source travels to a distal segment and obstructs a peripheral vessel. The usual source is the heart or thoracic aorta where embolization can affect any segment of the arterial tree. These emboli generally lodge at bifurcations as the vessels naturally narrow. In the upper extremity, this includes the brachial bifurcation. In the lower extremity, it is generally at the common femoral artery or popliteal trifurcation.

Arterial embolic ischemia generally has a dramatic presentation due to an acute occlusion of otherwise normal vessels, where the body has ...

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