Effects of sudden arterial occlusion depends on state of collateral supply
	Collateral supply in leg usually inadequate unless pre-existing occlusive disease

Aetiology

Embolism   Left atrium in patients in atrial fibrillation Mural thrombus after myocardial infarct Prosthetic and diseases heart valves Aneurysm or atheromatous stenosis Tumour, foreign body, paradoxical Thrombosis Other Trauma Dissecting aneurysm Raynaud's Syndrome

Clinical Features

	Clinical diagnosis depends on the 6 'p' s
Pain Paraesthesia Pallor Pulselessness Paralysis Poikilothermia
	Fixed staining is a late sign
	Objective sensory loss requires urgent treatment
	Need to differentiate embolism from thrombosis
	Important clinical features include:
Rapidity of onset of symptoms Features of pre-existing chronic arterial disease Potential source of embolus State of pedal pulses in contralateral leg

Management

Initial

	Heparinise & analgesia
	Treat associated cardiac disease
	Treatment options are:
Embolic disease - embolectomy or intra-arterial thrombolysis Thrombotic disease - intra-arterial thrombolysis / angioplasty or bypass surgery

	Can be performed under either general or local anaesthesia
	Display and control arteries with slings
	Transverse arteriotomy performed over common femoral artery
	Fogarty balloon embolectomy catheters used to retrieve thrombus
	If embolectomy fails - on-table angiogram and consider
	Bypass graft or intraoperative thrombolysis

Intra-arterial thrombolysis

	Arteriogram and catheter advanced into thrombus
	Streptokinase 5000u/hr + heparin 250u/hr
	Alternative thrombolytic agents include urokinase or tissue plasminogen activator (TPA)
	Repeat arteriogram at 6 -12 hours
	Advance catheter and continue thrombolysis for 48 hours or until clot lysis
	Success 60-70% but needs careful case selection
	Not suitable if severe neuro-sensory deficit
	Thrombolysis can be accelerated by:
Pulse spray through multiple side hole catheter Aspiration thrombectomy - debulking thrombus aspiration High dose over shorter time
	Complications
	Mortality of 1-2%
	Bleeding - CVA, retroperitoneal