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may not be femoral and popliteal pulses, but the pedal pulses will be absent Dependent rubor may be prominent with pallor on elevation The skin of the foot is generally cool, atrophic, and hairless
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ACUTE ARTERIAL OCCLUSION OF A LIMB
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Sudden pain in an extremity Generally associated with some element of neurologic dysfunction with numbness, weakness, or complete paralysis Absent extremity pulses
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The ABI may be quite low (in the range of 03), but ABIs may be falsely elevated because of the noncompressability of the calcified tibial vessels Wave-form analysis is important in these patients with a monophasic flow pattern denoting critically low flow Segmental pulse volume recordings will show a fall-off in blood pressure between the calf and ankle, although pulse volume recordings also may also be affected by tibial vessel calcification
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Acute occlusion may be due to an embolus or to thrombosis of a diseased atherosclerotic segment Arterial to arterial emboli such as in the cerebrovascular tree can occur, but emboli large enough to occlude proximal arteries in the lower extremities are almost always from the heart and tend to lodge at the bifurcation of major arteries Over 50% of the emboli from cardiac sources go to the lower extremities, 20% to the cerebrovascular circulation, and the remainder to the upper extremities and mesenteric and renal circulation Atrial fibrillation is the usual cause of the thrombus; other causes are valvular disease or ischemic heart disease where thrombus has formed on the ventricular surface of a transmural myocardial infarct Emboli from arterial sources such as arterial ulcerations or calcified excrescences are usually small and go to the distal arterial tree (toes) The typical patient with primary thrombosis has had a history of claudication and now has an acute occlusion If the stenosis has developed over time, collateral blood vessels will develop, and the resulting occlusion may only reduce walking distance or cause minimal increase in symptoms
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C Imaging
CTA, MRA, or angiography, is often needed to delineate the anatomy of the tibial-popliteal segment
Treatment
Good foot care may avoid ulceration, and most diabetic patients will do well with a conservative regimen However, if ulcerations appear and there is no significant healing within 2 3 weeks, revascularization will be required Infrequent rest pain is not an absolute indication for revascularization However, rest pain occurring nightly with monophasic wave forms requires revascularization to prevent threatened tissue loss
A Bypass and Endovascular Techniques
Bypass with vein to the distal tibial arteries or foot has been shown to be an effective mechanism to treat rest pain and heal gangrene or ischemic ulcerations of the foot Because the foot often has relative sparing of vascular disease, these bypasses have had good patency rates (70% at 3 years) Fortunately, in nearly all series, limb salvage rates are much higher than patency rates Endovascular techniques are beginning to be used in the tibial vessels with modest results, but bypass grafting remains the primary technique of revascularization
Clinical Findings
A Symptoms and Signs
The most common symptom is sudden onset of extremity pain, often accompanied by neurologic dysfunction, which can be numbness or paralysis in extreme cases With popliteal occlusion, symptoms may only affect the foot With proximal occlusions, the whole leg may be affected Signs include absence of pulses in the arteries distal to the occlusion and signs of severe arterial ischemia, such as pallor on elevation, coolness of the extremity, mottling, and impaired neurologic function with hyperesthesia progressing to anesthesia accompanied with paralysis
B Amputation
Patients with rest pain and tissue loss are at high risk for amputation, particularly if revascularization cannot be done, or it may be necessary to debride necrotic or severely infected tissue Toe amputations, even of the first toe, have little or no affect on the mechanics of walking A transmetatarsal amputation, removing all toes and the heads of the metatarsals, is durable but increases the energy required of walking by 5 10% Unfortunately, the next level that can be successfully used for a prosthesis is at the below knee level The energy expenditure of walking is then increased by 50% With an above knee amputation the energy required to ambulate may be increased as much as 100% While there are good prosthetic alternatives for these patients, activity levels are limited after amputation, and there are issues relating to self-image These factors combine to demand revascularization whenever possible to preserve the limb
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