Recommended European Standard Diagnostic Steps of Investigation

• Inspection, revealing pallor or cyanosis. Signs of chronic limb ischaemia (trophic skin changes) should also be sought in both extremities.

• Palpation, revealing coldness, pulselessness and loss of sensation. In cases of embolization, palpation may also disclose arrhythmia (atrial fibrillation).

• Doppler examination, revealing absence of flow in the extremity.

• Duplex ultrasonography can localize the point of arterial occlusion and identify patent proximal or distal vessels. It can also disclose the presence of an abdominal, femoral or popliteal aneurysm and rule out the diagnosis of phlegmasia cerulea dolens.

• Arteriography can help in the differential diagnosis between thrombosis and embolism. The typical angio-graphic characteristics of an embolic obstruction are an abrupt occlusion of an otherwise normal artery, with a reversed meniscus and absence of collateral circulation (Fig. 7.3.1). In contrast, a tapering occlusion of a diffusely atherosclerotic artery with a rich net-

Table 7.3.2 Classification of limb ischaemia based on severity of ischaemia

Category

Description/prognosis

Findings

Sensory loss

Muscle weakness

I. Viable

Not immediately threatened

None

None

II. Threatened

a. Marginally

Salvageable if promptly treated

Minimal (toes) or none

None

b. Immediately

Salvageable with immediate revascu-larization

More than toes, associated with rest pain

Mild, moderate

III. Irreversible

Major tissue loss or permanent nerve damage inevitable

Profound, anaesthetic

Profound, paralysis (rigor)

Fig. 7.3.1 Arteriogram revealing embolus in the popliteal artery, with the characteristic abrupt occlusion, reversed meniscus sign and absence of collateral circulation

work of collateral vessels denotes thrombosis. The site of occlusion is also indicative of its aetiology. Obstruction of the middle or distal portion of the superficial femoral artery is typical of thrombosis, while emboli usually lodge at arterial bifurcations.

Arteriography is especially helpful in cases of thrombosis, since these patients will most probably need a by-pass procedure. Such a procedure will be designed on the basis of information provided by arteriography, regarding the exact site and extent of obstruction, potential proximal in-flow sources and patent run-off vessels.

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