ACUTE ARTERIAL OCCLUSION
Patrick Nee
BACKGROUND
Peripheral vascular disease (PVD) is a generalised disease, usually caused
by atherosclerosis. The major vessels of the arterial system are usually
affected, especially the superficial femoral artery. Diabetes, Buergher’s
disease and the vasculitides cause narrowing of the smaller vessels. Ten per
cent of males over 65 may report symptoms (intermittent claudication). Most
patients also have coronary heart disease and cerebrovascular disease,
leading to death in 20% of arteriopaths from MI or stroke within 5 years of
diagnosis.
HISTORY
Determine the background history of claudication; duration and frequency and
severity of attacks, walking distance, rest pain. Enquire about buttock pain,
impotence (Leriche syndrome). Could lumbar spinal stenosis be contributing
to symptoms? Enquire about associated cardiac, cerebral or intestinal
symptoms. Family history, diabetes, hypertension, hyperlipidaemia, drugs
(e.g. beta blockers) and smoking history should be noted.
EXAMINATION
Look for evidence of atherosclerosis (arcus, xanthelasmata, tendon
xanthomata) and polycythaemia. General examination should include
temperature, pulse (AF?) and BP in both arms. Evaluate for cardiac murmur,
abdominal aneurysm.
Specific examination of the limbs includes skin colour, temperature, loss of
digit pulp and skin appendages, ulceration or gangrenous change. Determine
for arterial pulses (diminished, or augmented by aneurysm) and record
findings. Doppler ultrasound may be required to identify the femoral, popliteal,
PTA and DP pulses. Ankle Doppler pressure may be compared to the brachial
pressure. Record the ankle / brachial ratio.
Raise the patient’s legs to 60 degrees and observe for pallor. Now allow the
legs to hang down and note the time taken for the veins to fill. This should
occur within 10 seconds.
Order ECG and CXR. Draw bloods for FBC, U&E, PV.
ACUTE ARTERIAL OCCLUSION
DIAGNOSIS.
A clinical diagnosis: Pain, pallor, pulselessness, paralysis, paraesthesia and
perishing (cold). Sometimes due to embolus from the heart; MI, AF, valvular
heart disease. Less commonly due to atheroma, infective endocarditis or
trauma. Palpate for AAA
TREATMENT.
Treatment includes oxygen, IV fluids, morphine and the management of
arrhythmias. Start IV Heparin; 5000 unit bolus over 5 minutes, followed by
infusion1400 units(2.8ml) per hour (25000units /50ml). Adjust to maintain
APTT 2-3. See emergency Prescribing handbook. Refer surgically for
embolectomy.