0071643192.pdf

DIAGNOSIS

■ Suspect based on clinical presentation

■ Doppler ultrasound: Will confirm a decreased ankle brachial index(ABI)

in the affected extremity:

■ Divide systolic BP in the ankle by systolic BP in the radial artery.

■ Normal>0.9

■ Moderate arterial insufficiency =0.5–0.7

■ Severe arterial insufficiency <0.5

■ Arteriogramis definitive.

■ Shows abrupt cutoff at branch point in atherosclerotic artery

■ Duplex ultrasonographyis reasonably accurate alternative.

TREATMENT

■ Depends on degree of collateral flow and location of thrombus.

■ Patients with limb-threatening ischemia need aggressive therapy.

■ Options include:

■ Heparinization alone

■ Catheter-directed thrombolysis

■ Reperfusion with this modality frequently takes hours.

■ Nota good choice for limb-threatening ischemia

■ Percutaneous thrombectomy

■ Surgical thrombectomy or vascular bypass

■ The likelihood of return to normal limb function is minimal after 4–6 hours

of complete ischemia.

CHRONICLIMBISCHEMIA

The vast majority of chronic limb ischemia is due to atherosclerotic arterial

disease. Another less common cause is thromboangiitis obliterans (Buerger

disease), an inflammatory disease of young, typically male, smokers.

PATHOPHYSIOLOGY

■ Peripheral vascular atherosclerotic lesions reduce arterial luminal dia-

meter and blood flow →tissues ischemia when blood flow does not meet

O 2 demand.

■ Buerger disease:Segmental acute and chronic inflammation in smaller

arteries of arms and leg (infrapopliteal in legs) →tissue ischemia.

■ Eventual fibrous encasement of neurovascular bundle →visible tender,

dark nodules =phlebitis migrans.

SYMPTOMS

■ Claudication: Fatigue, pain, or weakness in involved extremity or digit

■ Exertional symptoms become rest symptoms as disease progresses.

■ Painful ulcerations

■ Leriche syndrome: Triad of bilateral hip claudication, erectile dysfunc-

tion, absent femoral pulses =aortoiliac occlusive disease

■ Raynaud’s-like response to cold: Associated with Buerger disease.

EXAM

■ Atrophy of skin and soft tissues

■ Hair loss, cool pale skin

■ Ulcers: Typically at end of digits, less commonly at pressure points

CARDIOVASCULAR EMERGENCIES

Most patients with acute

arterial thrombosis have

collateral circulation and

therefore will not need

immediate surgical

intervention.

Phlebitis migrans =segmental

inflammation of the

neurovascular bundle in

patients with Buerger

disease.