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Acute Peripheral Arterial Occlusion

by John W. Hallett, Jr., MD

Peripheral arteries may be acutely occluded by a thrombus, an embolus, aortic dissection, or acute compartment syndrome.

Acute peripheral arterial occlusion may result from:

  • Rupture and thrombosis of an atherosclerotic plaque

  • Embolus from the heart or thoracic or abdominal aorta

  • Aortic dissection

  • Acute compartment syndrome (see Compartment Syndrome)

Symptoms and signs are sudden onset in an extremity of the 5 P’s: severe p ain, p olar sensation (coldness), p aresthesias (or anesthesias), p allor, and p ulselessness. The occlusion can be roughly localized to the arterial bifurcation just distal to the last palpable pulse (eg, at the common femoral bifurcation when the femoral pulse is palpable; at the popliteal bifurcation when the popliteal pulse is palpable). Severe cases may cause loss of motor function. After 6 to 8 h, muscles may be tender when palpated.

Diagnosis is clinical. Immediate angiography is required to confirm location of the occlusion, identify collateral flow, and guide therapy.

Treatment consists of embolectomy (catheter or surgical), thrombolysis, or bypass surgery. The decision to do surgical thromboembolectomy vs thrombolysis is based on the severity of ischemia, the extent or location of the thrombus, and the general medical condition of the patient.

A thrombolytic (fibrinolytic) drug, especially when given by regional catheter infusion, is most effective for patients with acute arterial occlusions of <2 wk and intact motor and sensory limb function. Tissue plasminogen activator and urokinase are most commonly used. A catheter is threaded to the occluded area, and the thrombolytic drug is given at a rate appropriate for the patient’s size and the extent of thrombosis. Treatment is usually continued for 4 to 24 h, depending on severity of ischemia and signs of thrombolysis (relief of symptoms and return of pulses or improved blood flow shown by Doppler ultrasonography). About 20 to 30% of patients with acute arterial occlusion require amputation within the first 30 days.

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