A thorough clinical evaluation is the most useful diagnostic tool for the assessment of occlusive arterial disease. A history of an abruptly ischemic limb in a patient with atrial fibrillation or recent myocardial infarction is highly suggestive of an embolus. Acute ischemia in the limb of a patient known to have advanced peripheral vascular disease is more likely due to thrombosis or a low cardiac output state.
At the bedside, blanching the involved extremity with finger pressure and noting a delay in the return of blood as compared with the uninvolved extremity indicates decreased perfusion. However, several factors can influence capillary refill; thus one cannot rely on the presence or absence of this finding alone.
A hand-held Doppler can document the amplitude of flow or its absence when held over the dorsalis pedis, posterior tibial, popliteal, or femoral arteries in the lower limb and over the radial, ulnar, brachial, or axillary arteries in the arm. If time permits or the diagnosis of arterial occlusion is in question, duplex ultrasonography can be undertaken to detect an obstruction to flow. Cardiac monitoring and an electrocardiogram will detect an dysrhythmia and an echocardiogram can be done to look for an intracardiac thrombus if such is clinically suspected.
In consultation with a vascular surgeon and during the period of preoperative and/or medical management, an arteriogram can be done to confirm the diagnosis, define the vascular anatomy and perfusion, and guide aggressive management. A particular advantage of arteriography is the ability to perform this test on the operating room table before and during surgery. Scanning a limb with a spiral CT or MRI, though accurate and noninvasive, is not usually practical, given the time constraints, in the face of an acutely ischemic limb. However, when an aortic dissection or sources of microemboli such as aortoiliac or femoral aneurysms are suspected, an aorotogram, CT, or MRI can be useful. Transesophageal echocardiography is gaining acceptance as the choice modality for detecting cardiac or aortic root pathology.
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