Further considerations regarding acute limb ischemia

We thank the authors of a letter commenting on our review recently published in the American Journal of Emergency Medicine , “High Risk and Low Prevalence Diseases: Acute Limb Ischemia” [ ]. The letter to the editor discusses the importance of not relying on pain alone for triggering evaluation of acute limb ischemia. This is an important consideration. While pain is the most common presenting symptom, the clinician should incorporate other components of the history and examination, particularly in patients with more chronic peripheral vascular disease and ischemia [ ]. As our review states, these patients often have collateral circulation which may result in the gradual development of symptoms [ , , , ]. While sudden occlusion typically results in worsening pain, the clinician should also evaluate the color and temperature of the limb, presence of sensory changes or paresthesias, and motor function. Pulses must also be assessed. If any one of these is abnormal, acute limb ischemia should be considered, as our review discusses in detail [ ]. Importantly, skin changes, weakness, and temperature changes may not be present in the early stages of the disease, but if present, are highly suggestive of ischemia.

The authors of the letter also comment on other causes of ischemia, including paradoxical embolism associated with venous thromboembolism, left atrial myxoma, and aortic disease. While there are multiple etiologies for acute limb ischemia (e.g., native arterial thrombosis, arterial thrombosis after an intervention, arterial embolus, arterial injury), these are important considerations when obtaining the patient’s history and review of prior records if available.

We appreciate the letter emphasizing the need for focused history and examination in the assessment for acute limb ischemia.

CRediT authorship contribution statement

Brit Long: Validation, Visualization, Writing – original draft, Writing – review & editing. Alex Koyfman: Validation, Visualization, Writing – original draft, Writing – review & editing. Jacob Arnold: Visualization, Writing – original draft, Writing – review & editing.

Declaration of Competing Interest

None.

Acknowledgements

JA, AK, and BL conceived the idea for this manuscript and contributed substantially to the writing and editing of the review. This manuscript did not utilize any grants, and it has not been presented in abstract form. This clinical review has not been published, it is not under consideration for publication elsewhere, its publication is approved by all authors and tacitly or explicitly by the responsible authorities where the work was carried out, and that, if accepted, it will not be published elsewhere in the same form, in English or in any other language, including electronically without the written consent of the copyright-holder. This review does not reflect the views or opinions of the U.S. government, Department of Defense, U.S. Army, U.S. Air Force, or SAUSHEC EM Residency Program.

This is a response to the letter, AJEM34035 regarding our recent review: “High Risk and Low Prevalence Diseases: Acute Limb Ischemia”.