Sudden painful, pale leg
A 72-year-old man with atrial fibrillation develops sudden severe pain in the left leg. The leg is pale and cold below the mid-thigh, with absent femoral and distal pulses, reduced sensation over the foot but preserved power.
Questions & answers
Q1 Distinguish embolism from thrombosis in situ.
Embolism: abrupt onset in a patient with atrial fibrillation or recent myocardial infarction, no claudication history, a normal contralateral pulse examination and a sharply demarcated level. Thrombosis on existing atherosclerotic disease: more insidious onset, prior claudication, absent pulses bilaterally and collaterals on angiography.
Q2 What is the immediate management?
Oxygen, analgesia, fluid resuscitation and an immediate intravenous heparin bolus followed by infusion, unless contraindicated. Urgent vascular referral. Rutherford IIb (sensory loss with motor deficit) requires revascularisation within hours — usually surgical embolectomy with a Fogarty catheter under local or general anaesthesia. Category III (fixed mottling, rigid muscle) is irreversible and needs amputation or palliation.
Q3
References
- ESVS 2020 Clinical Practice Guidelines on acute limb ischaemia.
- Rutherford RB. Recommended standards for reports dealing with lower extremity ischemia.
