Acute Arterial Ischemia

Abstract

Acute limb ischemia (ALI) is defined as a sudden decrease in arterial perfusion to an extremity causing a potential threat to limb viability. There are many etiologies of ALI including trauma, embolism from the heart or other vascular beds, in-situ thrombosis, or iatrogenic causes. With ALI secondary to trauma, it is important to recognize the mechanism of injury (blunt, high or low velocity penetrating).

Rapid diagnosis is imperative to mitigate ischemic time and reperfusion injury. Physical exam is very sensitive for injuries to axial blood vessels. Immediate operative exploration for hard signs of vascular injury (pulsatile bleeding, expanding hematoma, absent distal pulses, palpable thrill, or audible bruit) should be considered in the context of other injuries. Decision making in subtle cases may be aided by computed tomography angiography (CTA) in the trauma context.

The concept of life over limb is standard of care, dictating potentially fatal concomitant injuries be addressed first. Non-life-threatening injuries involved in the mechanism of the ALI, such as orthopedic, should be handled simultaneously in a well-orchestrated fashion using a multidisciplinary approach. When repair is deemed necessary, degree of soft tissue injury and ischemic time should be considered in the selection of autologous versus prosthetic conduit.

The decision whether or not to perform fasciotomies is based on the time of ischemia, and should be considered if ischemia is 4 or more hours. Patients are best suited to intensive care unit (ICU) care post-operatively for close neurovascular monitoring.