Management of primary acute arterial occlusion

The management of primary acute arterial occlusion depends upon distinguishing between embolism and thrombosis. Emboli are sudden in onset, have a demonstrable source and lodge most frequently at the common femoral bifurcation. Embolectomy is the treatment of choice. Acute thrombosis is usually preceded by prolonged, progressive, ischemia, is less abrupt in onset and occurs most commonly in the superficial femoral artery. The initial treatment is anticoagulation with heparin, followed by artery repair if indicated. Emergency surgical reconstruction is necessary if the condition of the limb deteriorates despite heparin therapy. Nonviable limbs are best amputated early, and ischemic myositis is the best clinical predictor of viability. The use of streptokinase intra-arterially is a reasonable alternative in patients with thrombosis, although the selection of patients is difficult. It must be followed by treatment of the underlying lesion, using either balloon angioplasty or surgical repair.