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Quick Consult: Painful Lower Leg and Foot

Wiler, Jennifer L. MD, MBA

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doi: 10.1097/01.EEM.0000424144.97017.fc
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    A 65-year-old man presented with a painful right lower leg and foot. He said he developed 10/10 pain just below his right knee immediately before arrival. He has a history of peripheral vascular disease and a 40-year pack-a-day cigarette history, but has not seen a doctor in more than 20 years.

    You are unable to appreciate pulses in his right foot by Doppler. This is what you see on physical exam. What is the evaluation and treatment for this condition?

    See p. 26.

    Diagnosis: Acute Arterial Occlusion

    Acute limb ischemia is a limb-threatening condition that requires prompt identification and treatment. The etiology of acute arterial occlusion is rather circumscribed, and is the result of emboli from a distant source, acute thrombus at the site of a previous patent artery, or direct trauma to the artery.

    Emboli can result from dysfunction proximal to the site of acute arterial occlusive injury, and can be the result of cardiac dysfunction including atrial fibrillation, myocardial infarction (resulting in intracardiac thrombus formation), endocarditis, valvular heart disease, atrial thrombus, or myxoma. It can also stem from direct arterial pathology including aneurysm, vasospasm from vasculitides, or atherosclerotic plaque. Arterial thrombus formation can be the result of atherosclerosis, local aneurysm, vascular graft occlusion, low flow, or a hypercoagulable state. Penetrating, blunt, or iatrogenic trauma (e.g., catheterization) can result in acute arterial occlusion.

    Nearly 80 percent of limb injuries resulting from arterial emboli originate from the heart. (Vascular Surgery. A Comprehensive Review. Moore, WS [Ed], Philadelphia: WB Saunders, 1993; p. 648.) Lower extremities are affected more often than the upper ones. Emboli most commonly become wedged in arterial branch points or areas of acute narrowing (e.g., artery narrowed by atherosclerotic plaque). The most common areas of occlusion are the femoral artery (28%), upper extremity (20%), aortoiliac bifurcation (18%), popliteal (17%), and visceral organ (9%). (Am J Surg 1982;143[4]:460.)

    Classically, patients with acute limb ischemia resulting from arterial occlusion present with some combination of the five Ps: pain, pallor, paresthesias, paralysis, and pulselessness. Pain stemming from ischemia tends to be most intense distal from the site of occlusion and progressively moves toward the lesion as time progresses. Pain can decrease if enough time passes, the result of sensory nerve ischemia. Patients with thrombotic disease tend to have symptoms of claudication with progressive rest pain, while patients with acute embolic occlusion have acute onset of severe pain.

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    Pallor in these patients typically is of the affected extremity, which is cool to the touch. The limb may also be pale and capillary refill may be impaired with more advanced injury. Paresthesias or subjective numbness of the dorsum of the foot is an early warning sign of ischemia because the anterior compartment is the most sensitive to impaired blood flow. Paralysis — severe sensory or motor loss — is indicative of advanced ischemia. Pulselessness or impaired pulses in the affected limb as compared with the contralateral extremity will be noted. If the unaffected limb has an impaired pulse, this suggests underlying atherosclerotic disease, but a normal contralateral limb pulse suggests an embolic event. Clearly the presentation of an acute arterial occlusion can be on a continuum from minimal or no immediate limb threat to not salvageable, requiring amputation because of the risk of sepsis from gangrene.

    Patients can present with rest pain, gangrene, and ulcers within two weeks of the acute ischemic event. The Inter-Society Consensus for the Management of Peripheral Arterial Disease noted that symptoms occurring more than two weeks after the event are considered chronic. (J Vasc Surg 2007;45[Suppl S]:S5.)

    Lesions resulting from atherosclerotic embolic disease tend to have a less acute presentation. This is because plaques are often irregularly shaped and nondistensible, and tend to produce an incomplete occlusion as a result. Arterial thrombotic events also tend to have a subacute presentation compared with arterial embolic events. Arterial thrombosis can occur from plaque rupture with a subsequent localized inflammatory response, which progresses to an acute occlusion at a previously stenotic vessel location, or from progressive arterial narrowing with progressive low arterial flow and stasis. Collateral circulation often develops because of the progressive nature of these lesions, and that can blunt the effect of major arterial vessel occlusion.

    The diagnostic study of choice is arteriography. A sharp cutoff will be seen at the occlusion site of an embolus, possibly with a rounded reverse meniscus sign, absence of collateral vessels or an intralumenal filling defect (if a partial occlusion). Patients with an immediately limb-threatening acute occlusion, however, should not have definitive revascularization delayed for diagnostic imaging.

    Patients with confirmed or suspected acute arterial occlusion should have an emergent vascular surgery consultation and heparin (bolus and infusion) initiated immediately. This is used to improve distal flow and prevent further thrombotic propagation. (J Vasc Surg 2007;45[Suppl S]:S5.) Definitive treatment can consist of intrarterial thrombolytics, surgical intervention (i.e., embolectomy or bypass) or a combination of the two. (Ann Vasc Surg 2012;26[6]:858l AJR Am J Roentgenol 2011;196[5]:1189.) The decision for the type of treatment depends on the duration of symptoms, location and size of the lesion, suitability of vein graft harvesting, comorbid conditions, and surgical risk. (Circulation 2006;113[11]:e463; Chest 2012;141[2 Suppl]:e669S.) Patients with a nonviable limb require amputation to prevent complications including infection, rhabodomyolysis, and acute renal failure. (Ann Fr Anesth Reanim 2004;23[12]:1160.) Limb loss can be as high as 30 percent and mortality as high as 20 percent despite treatment. (J Vasc Surg 1992;15[2]:385.)

    A stat vascular consult was obtained for this patient, and he was found to be in new onset atrial fibrillation of an unknown duration. Heparin was started immediately. The intraoperative arteriogram of his right lower leg showed a popliteal artery occlusion with no flow in the foot. An embolectomy was performed.

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