[Acute peripheral arterial occlusive disease]

Romy Schumann, Johannes Rieger, Malte Ludwig
Medizinische Klinik 2007 June 15, 102 (6): 457-71; quiz 472-3
Acute lower limb ischemia is not infrequently associated with limb loss 10-30%) or death of the affected patient (15-30%). Thus, acute lower limb ischemia is an emergency. There are two categories of acute arterial occlusion: embolism (70-80%) and thrombosis (20-30%). Early diagnosis is a prerequisite for optimal management. Initial clinical examination is the crucial point: it makes the diagnosis of acute ischemia, localizes the level of occlusion, collects etiologic information and allows for assessing the local and general impact of ischemia on the patient. If sensation and motor function are present, viability of the limb is not threatened (incomplete limb ischemia), and good results can be obtained by utilizing anticoagulation and delayed elective revascularization, if the latter is indicated. If the patient, however, presents symptoms of a complete limb ischemia (paralysis or anesthesia is present), then ultimate limb loss is likely. Most patients present with subtle findings and lack classic symptoms, which makes the diagnosis difficult. The standard office-based tests to determine the presence of acute peripheral vascular disease are calculation of the ankle-brachial index and color duplex sonography. Up to now, digital subtraction angiography is used as standard of reference for definitive localization of the occlusion before revascularization. Magnetic resonance arteriography may be helpful when symptoms or findings do not correlate with the noninvasive ultrasound methods. Therapeutic choices are high-dose heparin therapy, surgical removal of the clot, mechanical interventional thrombectomy, and/or catheter-directed thrombolysis - the ultimate choice being dependent on the particular status of the patient. Patients with severe ischemia require immediate surgical intervention. In patients with contraindications to surgical management or incomplete ischemia, interventional revascularization is the therapy of primary choice. Successful outcome is dependent on careful clinical assessment and a prompt multidisciplinary approach to revascularization.

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