Danica Kaye A.

Barredo – Rehab 105

Acute Arterial Occlusion

a. Definition (Goodman, 2007, pp. 309,310)
 Arterial diseases include acute and chronic arterial occlusion. Acute arterial occlusion may be
caused by:
1. Thrombus, embolism, or trauma to an artery,
2. Arteriosclerosis obliterans
3. Thromboangiitis obliterans or Buerger's disease
4. Raynaud's disease
 Synonymous with acute limb ischemia and is considered a vascular emergency.
 Can occur in any peripheral artery of the upper and lower extremities.
 Can lead to a limb or life-threatening ischemia.
 Time-sensitive and if left untreated can quickly progress to infarction and loss of limb and life.
 Associated with increased morbidity, significant disability, and emergent operation in high-risk
patients. (Smith, 2019)
b. Epidemiology (Goodman, 2007, p. 310)
 Diabetes mellitus increases the susceptibility to coronary heart disease.
 People with diabetes have abnormalities that affect a number of steps in the development of
atherosclerosis.
RISK FACTORS:
1. Smoking
2. Hypertension
3. Hyperlipidemia (elevated levels of fats in the blood)
4. Older age (men older than 50, although women are at significant risk because of their
increased smoking habits)
5. Obesity
6. Sedentary lifestyle
7. Family history of vascular disease
8. High blood pressure (Smith, 2019)
c. Etiology (Smith, 2019)
 The most common cause of acute limb ischemia is in situ thrombotic occlusion.
 The lower limbs are far more susceptible to arterial occlusive disorders and atherosclerosis than
the upper limbs (Goodman, 2007, p. 310)
 The initiating event is a pre-existing history of peripheral artery disease (PAD).
 Thrombotic occlusions can occur in any segment of the upper and lower extremities but most
commonly affects the superficial femoral artery.
 Other causes include embolic occlusion from the left heart, aorta, and iliac vessel, as well as
penetrating or blunt trauma.
Etiology of acute ischemia (Donnelly, 2009, p. 10)
Etiology Cause
Thrombosis Atherosclerosis
Bypass graft occlusion
Prothrombotic conditions; protein C and S deficiency
Popliteal aneurysm
Embolism Atrial fibrillation
Cardiac vegetations; rheumatic fever, i.v. drug users
Mural thrombus; myocardial infarction
Peripheral aneurysms
Atheromatous plaque; blue toe syndrome
Atrial myxoma
Rarities Aortic dissection
Trauma
Intra-arterial drug injection
Venous gangrene
Saddle embolus
Popliteal entrapment
Cervical rib
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d. Brief and related Anatomy and Physiology

 Anatomy (Tortora, 2012, p. 803)
 The five main types of blood vessels are arteries, arterioles, capillaries, venules, and veins.
 Arteries carry blood away from the heart to other organs.
 Large elastic arteries  medium-sized muscular arteries  small arteries  arterioles 
capillaries
 Basic Structure of a Blood Vessel
 The wall of a blood vessel consists of three layers, or tunics, of different tissues:
1. an epithelial inner lining,
2. a middle layer consisting of smooth muscle and elastic connective tissue, and
3. a connective tissue outer covering.
 The three structural layers of a generalized blood vessel from innermost to outermost are the
1. tunica interna (intima),
2. tunica media, and
3. tunica externa (adventia).
 The wall of an artery has the three layers of a typical blood vessel, but has a thick muscular-
to-elastic tunica media.
 Due to their plentiful elastic fibers, arteries normally have high compliance, which means that
their walls stretch easily or expand without tearing in response to a small increase in pressure.

 Physiology (Hall, 2016, p. 173)

 Turbulent Flow of Blood Under Some Conditions.
 The flow may then become turbulent, or disorderly, rather than streamlined when:
1. the rate of blood flow becomes too great,
2. it passes by an obstruction in a vessel,
3. it makes a sharp turn, or
4. it passes over a rough surface.
 Turbulent flow: the blood flows crosswise in the vessel and along the vessel, usually forming
whorls in the blood, called eddy currents.
 Eddy currents are similar to the whirlpools that one frequently sees in a rapidly flowing river
at a point of obstruction.
 When eddy currents are present, the blood flows with much greater resistance than when
the flow is streamlined, because eddies add tremendously to the overall friction of flow in the
vessel.
 Danica Kaye A. Barredo – Rehab 105

A. Two fluids (one dyed red, and the

other clear) before flow begins.

B. the same fluids 1 second after

flow begins.

C. Turbulent flow, with elements of

the fluid moving in a disorderly
pattern.

e. Pathophysiology (Dieter, 2009, p. 737)

Macroembolic disease with atrial

arrhythmias or recent MI

Trauma Thrombosis Embolization Vasculitis

Lack of collateralization

Emboli is lodged in vessel

Clot propagation

Stasis  further clot formation

and propagation

Acute Arterial Occlusion /

Acute Limb Ischemia

f. Clinical Manifestations (Goodman, 2007, pp. 310,311)

 Signs and Symptoms
Arterial Disease
1. Intermittent claudication
2. Burning, ischemic pain at rest
3. Rest pain aggravated by elevating the extremity; relieved by hanging the foot over
the side of the bed or chair
4. Color, temperature, skin, nail bed changes
5. Decreased skin temperature
6. Dry, scaly, or shiny skin
7. Poor nail and hair growth
8. Possible ulcerations and gangrene on weight bearing surfaces (e.g., toes, heel)
9. Vision changes (diabetic atherosclerosis)
10. Fatigue on exertion (diabetic atherosclerosis)
“Six P’s” (Smith, 2019)
1. Pain
 Danica Kaye A. Barredo – Rehab 105

 Described as dull, aching tightness deep in the muscle, but it may be

described as a boring, stabbing, squeezing, pulling, or even burning sensation.
 Pain is sometimes referred to as a cramp, but there is no actual spasm in the
painful muscles.
 The location of the pain is determined by the site of the major arterial
occlusion.
 Painful cramping symptoms occur during walking and disappear quickly with
rest.
 Ischemic rest pain is relieved by placing the limb in a dependent position,
using gravity to enhance blood flow.
Aortoiliac ▪ Pain in the gluteal and quadriceps
muscles
Superficial Femoral Artery ▪ Most frequent lesion; present in
about two thirds of clients
▪ Pain in the calf that sometimes
radiates upward to the popliteal
region and to the lower thigh
Popliteal or more distal arteries ▪ Pain in the foot
2. Pallor
 The foot may be cold, pale, and chalky white, which is an indication that the
circulation has been diverted to the arteriolar bed of the leg muscles.
 Blood in regions of sluggish flow becomes deoxygenated, inducing a red-
purple mottling of the skin.
3. Pulselessness
 In the typical case of superficial femoral artery occlusion, there is a good
femoral pulse at the groin but arterial pulses are absent at the knee and foot,
although resting circulation appears to be good in the foot.
4. Paresthesia
 After exercise the client may have numbness in the foot as well as pain in the
calf.
5. Paralysis
6. Poikilothermia
 Physical Examination
1. Rutherford Classification of Acute Limb Ischemia (Donnelly, 2009, p. 10)
Class Viability Description
I Viable No sensorimotor impairment;
Doppler signals audible
Ia Marginally threatened Mild sensory loss; inaudible Doppler signals
IIb Immediately at risk Significant sensory and motor loss; prompt treatment
required to prevent limb loss
III Irreversible Complete sensory and motor loss with fixed skin
mottling; attempts to restore circulation may be
hazardous

2. Complete bilateral pulse exam should be initially conducted with manual palpation. (Smith,
2019)
3. Thorough pulse exam of both upper and lower extremities is of outmost importance.
 Absence of palpable pulses at any level indicates hemodynamically significant lesion(s)
to the main artery proximal to that level.
 Thus, absence of palpable femoral pulses is suggestive of severe stenosis or occlusion of
the ipsilateral iliac artery. (Bakris, 2005, p. 24)
 Danica Kaye A. Barredo – Rehab 105

4. Looking for decreased capillary filling time and skin trophic changes, listening for bruits,
assessing arterial pulse volumes, and testing for decreased vibratory sensation on the ankles.
(Bakris, 2005, p. 224)
 Complications (Smith, 2019)
1. Compartment syndrome
2. Amputation
3. Necrosis and gangrene
 Ulceration and gangrene are common complications and may occur early in the course of
some arterial diseases (e.g., Buerger's disease). Gangrene usually occurs in one extremity
at a time. (Goodman, 2007, p. 311)
4. Bleeding
5. Stroke
6. Myocardial infarction
7. Death
 In advanced cases the extremities may be abnormally red or cyanotic, particularly when
dependent. Edema of the legs is fairly common. Color or temperature changes and
changes in nail bed and skin may also appear. (Goodman, 2007, p. 311)
g. Diagnostics / Laboratory Results (Bakris, 2005, pp. 24-26)
1. Systolic pressures
 Can be taken at different locations in the lower extremities to help identify the location
of arterial disease.
 Pressures are taken at the high thigh, lower thigh, calf, and ankle.
 A pressure gradient > 20 mmHg between cuffs is considered indicative of significant
arterial disease.
2. The ankle-brachial index (ABI)
 Best screening test to evaluate the presence or absence of arterial disease in the lower
extremities.
 It is a ratio between the systolic pressure at the ankle in the arms.
 Normal: the ankle pressures should be equal or greater than the brachial pressures; ABI
value is 1 or higher.
 Any patient with an ABI <0.9 has lower extremity arterial occlusive disease.
 The ABI is an important tool in diagnosing and following up arterial disease.
 It is helpful in the follow-up of patients who have undergone revascularization procedures
such as angioplasty or bypass grafting.

3. Continuous-wave (CW) Doppler waveforms

 Danica Kaye A. Barredo – Rehab 105

 Commonly used in conjunction with segmental pressures or ABIs.

 Waveforms can help in identifying the location of arterial disease in the lower extremity.
 Usually taken from the common femoral, superficial femoral, popliteal, dorsalis pedis, and
posterior tibial arteries and recorded on a strip chart recorder.
 The presence of triphasic waveforms at any level indicates absence of a hemodynamically
significant arterial lesion proximal to that level.
 Attenuated waveforms that have lost their triphasic appearance indicate an arterial
stenosis proximally.
4. Magnetic resonance angiogram (Donnelly, 2009, p. 11)5. Arteriogram

A patient with previous claudication Incidental asymptomatic left popliteal

presenting with thrombosis of the right aneurysm during the presentation of acute
common and external iliac arteries: right limb ischaemia from a thrombosed
ischaemia was incomplete due to right popliteal aneurysm: the right-sided
extensive collateralization aneurysm is not seen due to loss of run-off

h. Differential Diagnosis
Comparison of Arterial and Venous Disease Symptoms (B., 2001, p. 179)
Arterial Venous
Pain Intermittent claudication, Chronic, dull aching pain
may progress to pain at rest which progresses throughout
the day
Color Pale to dependent rubor, dull Normal to cyanotic
to bright reddish color
Skin Temperature Takes on environmental Normal
temperature, cool
Pulses Diminished to absent Normal but difficult to
palpate due to edema
Edema Not present with isolated PAD Present, can be pitting. Can
have weeping of serous fluid
Tissue Changes Skin is shiny with hair loss. Stasis dermatitis with flaky
Trophic changes in nails, dry and scaly skin. Can have
muscle wasting brownish discoloration.
Fibrosis with narrowing of the
lower legs (“bottle legs”)
Wounds Occur distally especially at Shallow ulcers on the foot and
toes and web spaces. May ankle, usually medially
develop gangrene and tissue
loss
Comparison of Acute and Chronic Arterial Symptoms (Goodman, 2007, p. 310)
Symptom Analysis Acute arterial symptoms Chronic arterial symptoms
 Danica Kaye A. Barredo – Rehab 105

Location Varies; distal to occlusion; may Deep muscle pain, usually in calf,
involve entire leg may be in lower leg or dorsum of
foot.
Character Throbbing Intermittent claudication; feels
like cramp, numbness, and
tingling; feeling of cold
Onset and duration Sudden onset (within 1 hour) Chronic pain; onset gradual
following exertion
Aggravating factors Activity such as walking or Same as Acute Arterial
stairs; elevation
Relieving factors Rest (usually within 2 Same as Acute Arterial
minutes); dangling (severe
involvement)
Associated symptoms 6 P's: Pain, pallor, Cool, pale skin
pulselessness, paresthesia,
poikilothermia (coldness),
paralysis (severe)
At risk History of vascular surgery, Older adults; more males than
arterial invasive procedure, females; inherited
abdominal aneurysm, trauma predisposition, history of
(including injured arteries), hypertension, smoking,
chronic atrial fibrillation diabetes, hypercholesterolemia,
obesity, vascular disease

i. Medical / Surgical Management (Donnelly, 2009, pp. 10-11)

General Measures
 Initial treatment should include IV fluids, and IV heparin unless absolutely
contraindicated.
 The heparin is to limit the damage by further propagation of thrombus, but may also
improve outcomes.
 Need for immediate vascular imaging such as angiography.
 A completely ischemic limb should be explored in the operating theatre without delay,
especially if the clinical picture suggests a likelihood of embolus (a rapid deterioration in
the limb with normal pulses in the contralateral limb often indicates an embolic cause).
 Other timely therapeutic options to be considered, including thrombolysis, angioplasty,
stenting or bypass.
 Danica Kaye A. Barredo – Rehab 105

 A completely non-viable limb needs to be recognized, as revascularization would be

inappropriate and hazardous.
 Amputation or even terminal care in the moribund patient should be considered early.
Surgery
 Balloon embolectomy remains the standard initial operative treatment of an embolus.
 The technique can be performed quickly under local anesthetic, without the need for pre-
operative angiography which may cause unnecessary delay.
 Following embolectomy, angiography can be performed in the operating theatre to check
the result.
 If the initial procedure is unsatisfactory, further surgical options might include immediate
popliteal exposure, bypass or on-table thrombolysis.

(Dieter, 2009, p. 741)

j. Pharmacological Management (Bakris, 2005, pp. 226,234,235)
Name Indication Side Effects
Cilostazol Treatment of intermittent Headache, diarrhea,
claudication palpitations, and dizziness
Increased possibility of
sudden cardiac death
Simvastin Reduction of triglyceride Possibility of hepatoxicity and
Finofibrate blood levels and LDL-C rhabdomyolysis
Long-acting niacin Raising HDL-cholesterol Facial vasodilatation and
flashing
Enteric-coated aspirin Facial vasodilatation and ---
flashing

k. PT Assessment and Evaluation (Finkel, 2011, pp. 6-10)

Examination
1. Cardiopulmonary
 Monitoring vital signs
 auscultating lungs for present of rales, rhonchii, wheezes; and observing patient for signs
of dyspnea
 Patient’s response to activity should be measured using the Borg Scale; this indicates how
hard a patient feels they are working during activity.
2. Integument
 Observe surgical incisions for presence of drains, integrity of sutures/staples, amount and
quality of drainage, type of dressing being used.
 Note presence of open areas (e.g. open toe amputations or incisions that have been left
open due to edema)
 Danica Kaye A. Barredo – Rehab 105

 Check skin integrity, including color, trophic changes (thickness, hairlessness, flaking).
 Note presence of open wounds. Note size (length, width, and depth), type of tissue
present and amount of each.
 Examine extremities for edema. Edema after surgery can be acute or chronic.
Circumferential measurements can be used to monitor changes in edema
3. Musculoskeletal
 Range of motion is measured using goniometric measurements. Incisions that cross the
joint line increase risk of contracture due to pain and edema that make patients hesitated
to move the operative area
 Strength is measured using manual muscle test (MMT) if patient is able to participate. If
not, functional and spontaneous active motion can be observed and documented. In
many cases a patient will not tolerate resistance to a newly operative limb, so
measurement may restricted to a MMT of 3/5 or less
4. Neuromuscular
 Pain is measured using Visual Analog Scale (VAS) (0-10). Consider pre-medication for
pain. Communicate to nursing regarding pain during activity, need for additional pain
medication. Instruct patient in deep breathing and relaxation techniques for pain control
 Always assess patient’s ability to perceive light touch. If it is impaired, assess ability to
perceive sharp-dull and deep pressure sensations as sensation impairments can impact
skin integrity and balance.
 Also assess patient’s proprioception which is also commonly impaired in patients with
PAD. These patients often have peripheral neuropathy which can cause the sensation
impairments
 Balance can be impaired in patients with vascular insufficiency. Balance can be affected
by sensation deficits.
Assessment
1. Problem List (This is not an exhaustive list and problems can vary among individual patients)
 Impaired range of motion of involved extremities
 Edema
 Presence of/risk for skin breakdown
 Impaired mobility
 Impaired endurance
 Impaired respiratory status
 Impaired balance
 Impaired strength
 Knowledge deficit regarding precautions, activity progression, healing process
 Pain
 Sensation deficits
Prognosis
 Group participation in a supervised treadmill program and lower extremity resistance
training improved 6 minute walk performance, brachial artery flowmediated dilation,
stair climbing ability and quality of life.
 Other studies document that exercise increases quality of life and activity level even
without improvement in brachial artery flow.
 These findings show that a progressive walking program and exercises can be beneficial
in any person with vascular disease admitted to the hospital and improve their functional
and vascular prognosis.
 Early activity and an active lifestyle can also benefit those people who do require surgical
intervention.
 Individuals who were more active and functional did better than more impaired or
sedentary patients.
 Danica Kaye A. Barredo – Rehab 105

 Non-ambulatory patients “infrequently experience improvement in functional status

after LEAR (lower extremity arterial revascularization), they frequently experience AEs
(adverse effects) and reinterventions and have especially poor long-term survival rates”.
 Even during a hospitalization following vascular surgery, working to optimize a patient’s
mobility and activity is beneficial.
 The earlier a patient starts moving and mobilizing, the better the functional outcome.
Suggested Goals
 ROM: ankle dorsiflexion to at least neutral and knee flexion at least 90 degrees to allow
heel-toe gait pattern
 Prevent or minimize skin breakdown
 Strength at least 3/5
 Independent mobility with appropriate assistive devices, specialized footwear as needed
 Tolerates physical therapy intervention with appropriate hemodynamic response to
activity
 Demonstrates knowledge of healing process, activity progression, precautions,
independent exercise program
Interventions most commonly used for this case type/diagnosis:
 Mobility progression functional activities such as bed mobility, transfers, gait on level and
unlevel surfaces with an appropriate assistive device, stairs
 Positioning appropriate splints to protect, immobilize, relieve pressure and elevate
extremities should be provided. Prevalon boots are commonly used for pressure relief of
the heels. Rolyan resting foot splints are used for pressure relief, immobilization and
ankle/foot positioning
 Edema management especially for individuals with venous disease, it is important to
minimize edema. Management can include compression using ace wraps, coban or elastic
stockinette. Skin integrity should also be assessed to ensure that it will tolerate the
pressure of the compressive items. Active exercise and elevation are also components of
edema control
Integument
 Specialized footwear prescription to off-load portions of the foot depending on the
surgical site.
 Flat soled post-op shoes, heel weightbearing shoes and forefoot weightbearing shoes are
available.
 Custom-made footwear may be needed in isolated cases.
 Offloading is important for reducing foot pressure points and for prevention, as well as
for healing
 Wound care such as pulsatile lavage can be initiated for open wounds that have been
slow to heal and contain necrotic tissue
Range of Motion, Stretching and Strengthening
 Active, active assisted, passive ROM and stretching as tolerated can be performed to
preserve and increase flexibility and strength
 Resistive exercises as tolerated can increase strength but also improve circulation and
decrease claudication.
Endurance
 A progressive activity program that includes progressive ambulation, exercises performed
in increasing repetition and frequency can increased a patient’s activity tolerance.
 A stationary bike, treadmill, elliptical can also be used.
Pulmonary Conditioning
 Progressive activity and exercise program for home use.
 Individuals can walk, use a treadmill, stationary bicycle or other type of aerobic
equipment and start at a low duration.
 Danica Kaye A. Barredo – Rehab 105

 They can then increase the amount of time they exercise, with a goal of RPE of
“moderate” or rating of 3-5/10 on the Modified Borg Scale.
 These conditioning activities have added benefits of increasing muscle strength and blood
flow.
 Exercises can be done that focus on strengthening respiratory muscles such as the
diaphragm and trunk musculature.
 For people with a lower activity tolerance as well as all patients, education about pacing,
modification of activities, energy conservation, and effective deep breathing can be useful
in improving quality of life and level activity
l. PT Management / Intervention (Bakris, 2005, pp. 247-249)
Exercise Mode
 Walking combined with some other forms of leg exercise such as running, cycling, stair
climbing, dancing, jumping, and other dynamic and static leg exercises.
 Walking appears to be superior to other forms of exercise training, especially when the
exercise protocol requires that patients perform intermittent bouts of walking to near-
maximal or maximal pain
Intensity
 Not well described in any of the studies.
 It is assumed that the exercise intensity depends on the onset of claudication pain.
 It is estimated that only 16% of patients who do not experience pain at rest can walk a
distance of 1000 m or more on a flat surface at 4 km/hour or 2.5 miles/hour.
 The average metabolic equivalent (MET) level calculated from the studies included in the
meta analysis was about 3.8.
 Collectively, this information supports an exercise intensity of approximately 2-4
miles/hour walking speed on a flat surface.
Duration and Frequency
 The exercise duration was 30 to 60 minutes per session and some reported an exercise
duration of 30 minutes or less.
Length of Training Program
 Exercise programs of at least 6 months in duration and approximately as many studies
trained the patients for less than 6 months.
 Improvements in walking distance were noted even after four weeks of training.
m. Evidence Based Practice / Current Research (Donnelly, 2009, p. 12)
The attractive prospect of being able to remove thrombus rapidly without the attendant risks of
thrombolytic therapy or general anaesthesia has helped to drive the development and
implementation of new techniques. Aspiration thrombectomy can be performed by the
interventionalist and is a useful technique to remove small quantities of thrombus.
Mechanical thrombectomy involves breaking up existing thrombus, and aspirating it. Thrombus
is broken up from solid material into particulate matter either by means of a high-speed rotating
brush or basket (Cragg brush), or by creation of vortices at the catheter tip which suck up and
disperse thrombus using the Venturi effect (Angiojet). Haemolysis and blood loss do occur,
particularly with prolonged use. Evidence for these devices is currently lacking, but with further
refinements to the technique and equipment they may offer future potential.
n. Reference

B., S. C.-J. (2001). Wound Care; A Collaborative Practice Manual for Physical. Gaithersburg: MD: Aspen
Publishers, Inc.

Bakris, G. L. (2005). Lower extremity arterial disease. Totowa: Humana Press.

Dieter, R. S. (2009). In Peripheral arterial disease. New York: McGraw-Hill Medical.

Donnelly, R. &. (2009). Abc of arterial and venous disease. Chichester: UK: Wiley-Blackwell/BMJ.
 Danica Kaye A. Barredo – Rehab 105

Finkel, A. ,. (2011). Standard of Care: Physical Therapy Management of the Patient with Peripheral
Vascular Disease .

Goodman, C. C. ( 2007). Differential diagnosis for physical therapists: screening for referral. St. Louis,
MO: Saunders/Elsevier.

Hall, J. E. (2016). In Guyton and Hall textbook of medical physiology. Philadelphia: Elsevier.

Smith, D. A. (2019, November 12). NCBI. Retrieved from Arterial Occlusion, Acute. :
https://www.ncbi.nlm.nih.gov/books/NBK441851/

Tortora, G. J. (2012). Principles of Anatomy & Physiology. Hoboken: NJ: John Wiley & Sons.