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Acute arterial occlusion is one of the most devastating diseases in vascular surgery, resulting in limb loss, long-term morbidity, and death. Early recognition of symptoms of limb ischemia is necessary in order to salvage limb function and prevent an increased risk of mortality. Patients with acute limb ischemia often present soon after the onset of symptoms and are able to describe the exact moment symptoms began. This process should be differentiated from chronic limb ischemia, which occurs over a prolonged period of time with progression of symptoms. Severity of symptoms is dependent on the amount of arterial collateralization around the site of occlusion which can often reflect underlying chronic vascular disease.

The aim of this chapter is to discuss the diagnosis, etiology, pathophysiology, and treatment of patients with acute limb ischemia.


Acute arterial ischemia occurs as a result of embolization, thrombosis, trauma, or vasculitis (Figures 36-1 and 36-2). A central source can be found in the vast majority of patients with macroembolic disease (Table 36-1). These patients are likely to have atrial arrhythmias or recent myocardial infarction. The presentation of embolization is sometimes difficult to distinguish from thrombosis. Patients with arterial emboli typically have a discrete onset of symptoms, have a history of or are at risk of emboli, have no history of claudication, and have preserved flow in the contralateral extremity. In contrast, patients with arterial thrombosis are more likely to have preexisting vascular disease and a history of claudication and physical findings of disseminated disease or previous extremity bypass (Table 36-2).

FIGURE 36-1.

Embolus to the popliteal artery in a patient with atrial fibrillation (arrow).

FIGURE 36-2.

Intimal injury of the subclavian artery from blunt trauma as the source of distal emboli.

TABLE 36-1.

Sources of Peripheral Embolization

TABLE 36-2.

Distinguishing Embolic Disease from Thrombosis

Factors affecting the clinical outcome of embolic disease include the size of the affected vessel, the amount of collateral flow, and the degree of obstruction. In patients with underlying atherosclerotic vascular disease, an embolus may have little clinical significance because of preexisting collaterals. However, embolization ...

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