Definition
The ‘acute cold leg’ is a clinical syndrome comprising sudden onset of symptoms indicative of the presence of ischaemia sufficient to threaten the viability of the limb or part of it.
Key Points
- Remember the ‘6 Ps’ of acute ischaemia – pain, pallor, paraesthesia, paralysis, pulselessness, perishing cold.
- An acute cold leg is a surgical emergency and requires prompt diagnosis and treatment.
- 80% of acute cold legs presenting as an emergency have underlying chronic vascular pathology.
- Fasciotomies should always be considered as part of treatment if a leg is being revascularized.
- Despite appropriate treatment up to 25% of patients have a major amputation.
Important Diagnostic Features
Isolated Arterial Embolus
- Sudden-onset severe ischaemia, no previous symptoms of vascular disease, previous history of atrial fibrillation/recent myocardial infarction/valvular heart disease, all peripheral pulses on the unaffected limb normal (suggesting no underlying PVD).
- Limb usually acutely threatened due to complete occlusion with no collateral supply.
- Common sites of impaction are: popliteal bi(tri)furcation, distal superficial femoral artery (adductor canal), origin of the profunda femoris. ‘Saddle’ embolus at aortic bifurcation causes bilateral acute ischaemic limbs.
Trauma
- May be due to direct injury to the vessel or by secondary compression due to bone fragments or haematoma.
- Direct injuries may be due to complete division of the vessel, distraction injury, intimal damage and in situ thrombosis, foreign body, false aneurysm.
Thrombosis (In Situ)
- Usually associated with underlying atheroma predisposing to thrombosis after minor trauma or immobility (after a fall or illness).
- May be subacute in onset, previous history of known vascular disease or intermittent claudication, associated risk factors for peripheral vascular disease, abnormal pulses in the unaffected limb.
- Paradoxically, the limb may not be as acutely threatened as in isolated arterial embolus because collateral vessels may already be present due to underlying disease.
Graft Thrombosis
Often subacute in onset, limb not acutely threatened, progressive symptoms, loss of graft pulsation.
Aneurysm Thrombosis
- Most common site – popliteal aneurysms.
- Sudden-onset limb ischaemia, acutely threatened, may be associated embolization as well, non-pulsatile mass in popliteal fossa, many have contralateral asymptomatic popliteal aneurysm.
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