Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 8  |  Issue : 1  |  Page : 48-54

Saving the Foot from “Bliss of Ignorance”: Tackling Missed Acute Lower Limb Ischemia


1 Department of Surgery, Division of Vascular Surgery, Command Hospital Air Force, Bengaluru, Karnataka, India
2 Department of Surgery, Division of Vascular Surgery, Command Hospital Air Force, Bengaluru, Karnataka; Department of Vascular Surgery, Army Hospital (RandR), Delhi, India
3 Department of Vascular Surgery, Army Hospital (RandR), Delhi, India

Date of Submission08-Apr-2020
Date of Decision05-May-2020
Date of Acceptance06-May-2020
Date of Web Publication20-Feb-2021

Correspondence Address:
Vikram Patra
Department of Surgery, Division of Vascular Surgery, Command Hospital Air Force, Bengaluru, Karnataka; Department of Vascular Surgery, Army Hospital (RandR), Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_34_20

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  Abstract 


Context: Acute limb ischemia (ALI) is an emergency. The diagnosis of ALI can be missed. However, little is known about predisposing factors. Objective: The objective of the study was to determine the factors leading to misdiagnosis of lower limb ALI based on our experience and to suggest steps in overcoming the shortcomings. Materials and Methods: It is a single-center prospective observational study done from June 2016 to May 2019. All nontraumatic lower limb ALIs were included. Those with prior arterial interventions and thrombophilia were excluded from the study. Referral notes were scrutinized. Chronology of symptoms, time delay by a patient, category of first-contact health-care provider, initial diagnosis, and time lapse by clinician were noted. Patients were quizzed regarding ALI awareness. Statistical Analysis: Not applicable. Results: Twenty-six cases of lower limb ALI were included. Most common presentation was sudden onset claudication (n = 11), followed by pain (n = 9) and sudden onset weakness (n = 6). None were aware of ALI. A clinician was the first contact in 19 and local healer in 7. Eighteen presented late with an average delay of 18 days. Clinician misdiagnosed in 19 with an initial diagnosis of musculoskeletal pain (n = 9), arthritis of hip/knee (n = 4), neurological weakness (n = 2), sciatica (n = 2), and backache (n = 2). Lower limb pulse examination was missed in all 19. Thrombectomy with or without additional procedure was successful in 12 and bypass in one. The limb was salvaged in 20. There were six amputations and two deaths. Conclusion: Lower limb ALI is missed due to its variable presentation and failure to consider its possibility. Poor awareness among the public leads to late presentation. Better awareness needs be created by the education of both common public and the physicians to salvage the limbs in time.

Keywords: “Missed” limb ischemia, acute lower limb ischemia, delayed treatment-limb ischemia


How to cite this article:
Dabas AK, Patra V, Dhillan R. Saving the Foot from “Bliss of Ignorance”: Tackling Missed Acute Lower Limb Ischemia. Indian J Vasc Endovasc Surg 2021;8:48-54

How to cite this URL:
Dabas AK, Patra V, Dhillan R. Saving the Foot from “Bliss of Ignorance”: Tackling Missed Acute Lower Limb Ischemia. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2021 Feb 25];8:48-54. Available from: https://www.indjvascsurg.org/text.asp?2021/8/1/48/309709




  Introduction Top


Acute lower limb ischemia (ALLI) carry high morbidity and mortality.[1] A missed diagnosis is catastrophic.[1],[2] The actual incidence of missed diagnosis of ALLI is not known and a rough estimate can be gauzed by medicolegal cases.[2] Moreover, the reasons for a missed diagnosis are not well brought out in the literature. This article presents a 3-year experience of managing ALLI at a tertiary care hospital. The reasons for the delayed presentation/referral were looked into with a special attention to delayed/missed diagnosis by a clinician. A few steps are also suggested to avoid missing ALLI.


  Materials and Methods Top


It is a prospective observational study done at a single tertiary care center from June 2016 to May 2019.

Inclusion criteria

All patients with nontraumatic ALLI presenting (either directly or referred) to our center were included in the study. Despite late presentation (beyond 14 days), if the history and imaging suggested an acute arterial occlusion, these were included in the study. This is imperative because if these patients presented timely to a vascular surgeon, then all would have qualified as acute limb ischemia (ALI) as per the definition of reporting standards.[3]

Exclusion criteria

Patients with upper limb ALI, lower limb ALI due to trauma or previous arterial intervention, and known thrombophilia were excluded from the study.

The medical records of the included patients were thoroughly examined for symptoms at onset, their temporal progression, time delay in seeking medical attention by the patient, category of first health-care provider, time lapse between reaching a clinician (at least MBBS) and diagnosis of ALLI, and initial diagnosis by the clinician. All patients were also quizzed about their knowledge about limb ischemia, myocardial infarction (heart attack), and stroke. Each case was also evaluated to determine the likely etiology of ALLI.

Treatment provided was according to the existing guidelines, the stage of clinical presentation, and after discussion with the patient about the pros and cons of the modality selected.

Ethical committee approval

This study was approved by the institutional ethical committee approval.


  Results Top


A total of 42 cases of ALI were either referred or directly admitted to our institute during the period of study. Sixteen cases were excluded from the study. These were five cases of upper limb ischemia, five due to trauma, two cases of recurrent limb ischemia due to antiphospholipid antibody syndrome, and four were graft occlusions. Hence, 26 cases of ALLI were included in the study. This is depicted in the flowchart [Figure 1].
Figure 1: Flowchart depicting case selection, time delay, symptomatology, and initial diagnosis

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Symptoms at the onset and temporal progression

Sudden onset of short distance claudication or significant deterioration of walking distance was the most common presenting complaint. This was present in 11 cases. All 11 had no pain in the limb, to begin with. However, four of these patients developed pain in the lower limb, over the next 7–20 days, and developed gangrenous patches over the toes and forefoot. In this group of patients, there was a prior history of claudication in three cases which was missed during the initial evaluation.

In nine cases, the presenting symptom was the pain which worsened over the next few hours.

In six cases, there was a sudden onset of lower limb weakness followed by paresthesia. Pain appeared later but was only transient in three cases. Two of these patients were initially referred for neurological evaluation.

On the initiation of therapy at our hospital, ten had Class I, six each had IIA and IIB, and four had Class III ALI as per the Rutherford classification of ALI.

The delay in time in seeking treatment by the patient

In eight cases (30.7%), there was no delay by the patient. In 18 cases (69% cases), there was a delay in seeking medical attention by the patient. The average delay was 18 days (range: 0–60 days).

Initial medical attention was sought by the patient from the local healer (n = 7), orthosurgeon (n = 6), and casualty medical officer/general practitioner (n = 13).

A clinician for this study as sat least a medical graduate with an MBBS degree. All patients who approached the local healer ultimately sought attention from the clinician.

Missed diagnosis by the clinician

The diagnosis was initially missed in 19 (73%) cases by the clinician. Lower limb pulse examination was missed/not documented in all these cases. [Table 1] depicts the age, gender, risk factors/co- morbid conditions presentation, salient investigations and time delay. The initial diagnosis in these patients was assigned as musculoskeletal pain (n = 9), osteoarthritis knee/hip (n = 4), backache (n = 2), sciatica (n = 2), and neurological weakness (n = 2).
Table 1: Age, gender, risk factors/co- morbidities, presentation, salient investigations and time delay

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The average delay in diagnosis was 17 days (range: 1–120 days).

Only in seven cases (27%) ALLI was correctly diagnosed, and timely therapy was instituted after the patient reached a medical facility.

All but three patients (88%) were aware of heart attack (myocardial infarction). Thirteen (50%) were aware of stroke, but none were aware of ALI/ALLI. They had not seen a program, poster, and were unaware of any friends or relatives who have suffered from ALI/ALLI.

Management

On evaluation at our center, aortoiliac segment was involved in four, common femoral artery (including profunda femoris and proximal superficial femoral) in five, superficial femoral–above-knee popliteal segment in seven, and below-knee popliteal artery and distal vessels in five patients.

Thrombectomy with or without fluoroscopic guidance was done in 17 cases. In addition, endarterectomy was required in four and endovascular procedures (angioplasty/stenting) in six cases. Leg fasciotomy was done in three cases. Perioperative unfractionated heparin followed by enoxaparin was given for 5–7 days.

In two patients (both with malignancy), this was followed by prophylactic enoxaparin for 1 more month on the advice of hematologist.

Thrombectomy failed in five cases. Of these, two required amputation and three were observed conservatively without further deterioration.

One patient underwent femoropopliteal bypass using a synthetic graft.

Four patients were observed conservatively. They were claudicants and refused any intervention.

Six patients required amputation (four above the knee and two below the knee). In four, it was done as the primary procedure, as limbs were unsalvageable and in two after the failure of thrombectomy. Minor amputations (toes) were done in six cases. All were started on antiplatelets and statins.

Two patients required dialysis in the perioperative period for hyperkalemia. The limbs were salvaged in 19 patients. The pedal pulse was palpable or ankle-brachial index (ABI) improved in 13 cases. These were 12 of the 17 cases which underwent thrombectomy and one case of bypass. None required further intervention on average follow-up of 10 months.

There were two deaths: one in the primary amputation group and was due to stroke and the other was due to myocardial infarction and sepsis following failed thrombectomy. Both the deaths occurred in the perioperative period.

Etiology

Two-dimensional ECHO and/or transesophageal ECHO was done in all cases in the perioperative period and was negative for any atrial or ventricular clot. Computed tomography (CT) angiography and/or color Doppler was done in all but three patients before intervention. Angiography was done during the thrombectomy in 12 patients.

Taking into account imaging (CT angiography/color Doppler/perioperative angiography) and operative findings, thrombosis over preexisting atherosclerotic plaque was the most probable cause in 17 cases.

However, a definite cause could not be identified in nine cases. Two patients had malignancy: one was on chemotherapy for non-Hodgkin's lymphoma and the other had adenocarcinoma lung and was awaiting chemotherapy.


  Discussion Top


The management of ALLI is challenging.[1],[4],[5] A missed diagnosis compounds the problem.[2],[4],[5] Literature is sparse about the incidence and the factors leading to missed diagnosis by the clinician. An indirect inference can be made about missed diagnosis by case reports and reports of litigation.[2],[6],[7],[8]

In the present series, the clinician missed the diagnosis of initial assessment in 19 (73%) cases. However, this by no means suggests that a physician is unaware of ALI or signs and symptoms of ALI.

The reason for delayed/missed diagnosis can be an incomprehension of the varied presentation of ALI and underlying pathophysiology. This merits a discussion.

Onset of symptoms and their chronological progression of ALI is based on the status of native arteries and status of collateral circulation in the limb, as depicted in [Figure 2].
Figure 2: Explanation of signs/symptoms based on pathophysiology

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Briefly, two scenarios occur: one with normal arterial tree and little or no collateral circulation and the other with the diseased artery with collaterals.

In the first case, thromboembolic occlusion results in near-total ischemia. The first symptom is usually pain with the rapid development of sensory loss and motor weakness. Furthermore, the acute-onset motor weakness (inability to bear weight/a sudden feeling of giving way) could be the another presentation followed by the pain.

In the current study, nine patients had pain as the first symptom, and in six, it was sudden-onset weakness/inability to bear weight. Two of these six were initially referred for neurological evaluation.

Motor weakness as the presenting sign and symptom of ALLI has been reported.[9],[10],[11],[12] Mnemonic six Ps is used to describe signs and symptoms of ALI. The two Ps paresthesia and paralysis need to be elaborated. Paresthesia refers to a burning or prickling sensation that is usually felt in the hands, arms, legs, or feet. The sensation is usually painless and described as tingling or numbness, skin crawling, or itching.[13] However, in the context of ALI, it is sensory loss what needs to be looked for.

The term paralysis is incorrect in the context of ALI. The correct term is weakness/motor deficit of the specific muscle groups. Muscles first affected are those involved in the toe movement.

Both the sensory loss and the motor deficit appear first at the foot, hence sensory and motor loss should be looked for at the foot. With the progress of time, the sensory loss and motor deficit increase and involve distal leg.

In the current study, sudden-onset weakness/inability to bear weight was the presenting complaint in six patients. Two of these six were wrongly referred for neurological evaluation.

ALI can be misjudged as a neurological condition. In one series of 24 patients of acute aortic embolus, 95% had motor and sensory deficits, but only 85% had pain.[9]

Meagher et al. reported that three of eight patients with acute aortic occlusion were wrongly referred for neurological evaluation because of the presence of paraplegia (motor weakness).[11]

The second scenario is the occlusion occurring due to thromboembolism in an artery with preexisting arterial disease and well-developed collaterals. Pain is unlikely the presenting complaint, and even if the pain is present, it is would be transient. A short-distance claudication is more likely the presentation and Ps would be absent. In the present study, 11 cases presented with sudden-onset short-distance arterial claudication. This resulted in misinterpretation of findings, and the diagnosis of ALI was not considered.

Further course would be determined by the propagation of secondary thrombus with progression leading to rest pain, paresthesia, and tissue loss. The rate of progression is difficult to predict. Four of eleven patients progressed to have pain and tissue loss in this series.

In the absence of point-of-care tests like electrocardiogram or rapid card test for cardiac enzymes for myocardial infarction, high index of suspicion and diligent examination are the only tools for detecting ALLI. Hence, an appreciation of pitfalls of the symptomatology and clinical methods is required. From the current study, it can be appreciated that mnemonic 6Ps has limitations. Sudden motor weakness/feeling of giving way or recent onset claudication (exertional pain) is ischemic equivalents. Correct terms sensory loss or motor weakness should be used and these signs should be elicited on the foot. The “target organ” in lower limb ischemia is the foot, also has to be appreciated. The focus ought to be on “ruling out ALI rather than ruling in” akin to the efforts taken by clinician in a case of chest pain evaluation.[14]

The absence of pulse at the foot is the sine qua non of ALLI. However, pulse palpation could be unreliable and it improves with experience.[15] A doubtful pulse can be confirmed by counting the pulse and handheld Doppler.[2] Pulse status in lower limb examination should be documented in every case.

Unawareness and unavailability of appropriate facilities result in a visit to local healers in lower middle-income countries.[16] The fact that none of the patients were aware of ALI highlights a lack of awareness in the general population. In the present study, there was an average delay of 18 days by the patients.

Similar delays in patient arrival are reported from developing countries.[17],[18] Turel et al. reported that only 21 out of 84 cases presented within 24 h of onset of symptoms and 63 arrived after 24 h.[17]

In a series by Nekkanti et al., of 80 ALI cases of lower limb, 19 (18.75%) presented after 14 days, 67% presented between 6 h to 7 days, and only five cases presented within 6 h.[18]

This is in contrast with the delay of few hours reported from developed nations, where the paramedical staff is well trained to diagnose ALI, evacuations and consultation are prioritized, and round-the-clock vascular surgical consultation is available.[4],[19],[20] Awareness programs have shown to improve the response of the masses in case of myocardial infarction.[21]

The present study brings out the reasons for delayed treatment. Suggested measures have been summarized in [Figure 3].
Figure 3: Suggested steps to avoid missing diagnosis of lower limb acute limb ischemia

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Limitation of the study

The number of cases is less in the study. A comment cannot be made about the facilities available around the patients' neighborhoods. However, 3 years is a reasonable period to discern a pattern in the presentation and management of cases.


  Conclusion Top


Diagnosis and treatment of lower limb ALI is delayed due to various reasons. ALLI has variable presentations and diagnosis is often not considered by the clinician. Mnemonic 6 Ps has limitations. Patients are unaware of ALLI and present late. A high index of suspicion and palpation of pulses at the foot in patients with lower limb symptoms would avoid the misdiagnosis of ALI. Finally, awareness programs are required to educate the masses to avoid reporting late.

Acknowledgment

We are grateful to our revered teacher Mr. RPS Gambhir MS, DNB, FRCSEd, FFSTEd, FRCS, FACS, FEBS Consultant Vascular Surgeon and Honorary Clinical Senior Lecturer, King's College Hospital London, and Dr. Ramanthan Saranga Bharathi for their support in preparing this manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Creager MA, Kaufman JA, Conte MS. Clinical practice. Acute limb ischemia. N Engl J Med 2012;366:2198-206.  Back to cited text no. 1
    
2.
Brearley S. Acute leg ischaemia. BMJ 2013;346:f2681.  Back to cited text no. 2
    
3.
Rutherford RB, Baker JD, Ernst C, Johnston KW, Porter JM, Ahn S, et al. Recommended standards for reports dealing with lower extremity ischemia: Revised version. J Vasc Surg 1997;26:517-38.  Back to cited text no. 3
    
4.
Londero LS, Nørgaard B, Houlind K. Patient delay is the main cause of treatment delay in acute limb ischemia: An investigation of pre- and in-hospital time delay. World J Emerg Surg 2014;9:56.  Back to cited text no. 4
    
5.
Morris-Stiff G, D'Souza J, Raman S, Paulvannan S, Lewis MH. Update experience of surgery for acute limb ischaemia in a district general hospital-Are we getting any better? Ann R Coll Surg Engl 2009;91:637-40.  Back to cited text no. 5
    
6.
Aniedi VU, Tochkwu A. Acute limb ischemia masquerading as stroke: A case report. Nigerian Health J 2012;12:110-14.  Back to cited text no. 6
    
7.
Campbell WB, France F, Goodwin HM; Research and Audit Committee of the Vascular Surgical Society of Great Britain and Ireland. Medicolegal claims in vascular surgery. Ann R Coll Surg Engl 2002;84:181-4.  Back to cited text no. 7
    
8.
Shearman A, Shearman C. Failure to diagnose acute limb ischaemia (ALI); an avoidable cause of limb loss. Association of Surgeons of Great Britain and Ireland, International Surgical Congress. Br J Surg 2012;99 Suppl 6:1-82.  Back to cited text no. 8
    
9.
Busuttil RW, Keehn G, Milliken J, Paredero VM, Baker JD, Machleder HI, et al. Aortic saddle embolus. A twenty-year experience. Ann Surg 1983;197:698-706.  Back to cited text no. 9
    
10.
Surowiec SM, Isiklar H, Sreeram S, Weiss VJ, Lumsden AB. Acute occlusion of the abdominal aorta. Am J Surg 1998;176:193-7.  Back to cited text no. 10
    
11.
Meagher AP, Lord RS, Graham AR, Hill DA. Acute aortic occlusion presenting with lower limb paralysis. J Cardiovasc Surg (Torino) 1991;32:643-7.  Back to cited text no. 11
    
12.
Shaw A, Anwar H, Targett J, Lafferty K. Cauda equina syndrome versus saddle embolism. Ann R Coll Surg Engl 2008;90:W6-8.  Back to cited text no. 12
    
13.
National Institute of Neurological Disorders and Stroke. Available from: https://www.ninds.nih.gov/Disorders/All-Disorders/Paresthesia-Info rmation-Page. [Last accessed on 2020 Apr 23].  Back to cited text no. 13
    
14.
Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, et al. ESC Scient?ific Document Group. Fourth universal definition of myocardial infarction (2018). Eur Heart J 2019;40:237-6.  Back to cited text no. 14
    
15.
Brearley S, Shearman CP, Simms MH. Peripheral pulse palpation: An unreliable physical sign. Ann R Coll Surg Engl 1992;74:169-71.  Back to cited text no. 15
    
16.
Awiti JO. Poverty and health care demand in Kenya. BMC Health Serv Res 2014;14:560.  Back to cited text no. 16
    
17.
Turel M, Kumar PP, Stephen E, Agarwal S. A 10-year experience of managing acute limb ischaemia in India. Natl Med J India 2008;21:284-7.  Back to cited text no. 17
    
18.
Nekkanti MK, Vivekanand, Suresh KR, Motukuru V, Kolalu S, Kabra A. Outcomes of limb and life in patients with acute lower limb ischemia presenting before and after the “golden six hours”. Int J Adv Med 2018;5:788-97.  Back to cited text no. 18
    
19.
Normahani P, Standfield NJ, Jaffer U. Sources of delay in the acute limb ischemia patient pathway. Ann Vasc Surg 2017;38:279-85.  Back to cited text no. 19
    
20.
Langenskiöld M, Smidfelt K, Karlsson A, Bohm C, Herlitz J, Nordanstig J. Weak Links in the Early Chain of Care of Acute Lower Limb Ischaemia in Terms of Recognition and Emergency Management. Eur J Vasc Endovasc Surg 2017;54:235-40.  Back to cited text no. 20
    
21.
Fang J, Luncheon C, Ayala C, Odom E, Loustalot F. Awareness of heart attack symptoms and response among adults-United States, 2008, 2014, and 2017. MMWR Morb Mortal Wkly Rep 2019;68:101-6.  Back to cited text no. 21
    


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