Ischemic Limb Gangrene with Pulses
Warkentin TE.
N Engl J Med. 2015 Aug 13;373(7):642-55.
There are two distinct syndromes of microthrombosis-associated ischemic limb injury (Table 1). Venous limb gangrene can complicate thrombocytopenic disor- ders that are strongly associated with deep-vein thrombosis (e.g., cancer-associat- ed disseminated intravascular coagulation and heparin-induced thrombocytope- nia). In these conditions, microthrombosis occurs in the same limb with acute large-vein thrombosis, resulting in acral (distal-extremity) ischemic necrosis. Usually, only one limb is affected. The potentially reversible, prodromal state of limb-threatening ischemia is phlegmasia cerulea dolens, indicating the respective features of a swollen, blue (ischemic), and painful limb (Fig. 1A).
In contrast, two and sometimes all four limbs are affected in symmetric pe- ripheral gangrene, also featuring acral limb ischemic necrosis but usually without deep-vein thrombosis (Fig. 1B). The limb necrosis is often strikingly symmetric; lower limbs are most often affected, with additional involvement of fingers or hands in approximately one third of patients. When there is additional or pre- dominant nonacral tissue necrosis, the term purpura fulminans is applicable. Patients are usually critically ill, with cardiogenic or septic shock. In 1904, Barraud discussed limb gangrene as a complication of acute infection, a complication that continues to occur today. The two syndromes have common pathophysiological features of micro- thrombosis associated with a disturbed procoagulant–anticoagulant balance (Fig. 1C).
The concept that venous limb gangrene and sym- metric peripheral gangrene are usually associated with microvascular thrombosis with underlying disseminated intravascular coagulation provides a framework for a rational approach to diagnos- ing and treating these diverse and potentially devastating disorders. Prevention and treatment of venous gangrene requires correction of abnor- malities associated with the use of vitamin K an- tagonists and aggressive anticoagulation, whereas treatment of symmetric peripheral gangrene (with or without purpura fulminans) theoretically in- volves heparin-based anticoagulation and the sub- stitution of natural anticoagulants.
Warkentin TE.
N Engl J Med. 2015 Aug 13;373(7):642-55.
There are two distinct syndromes of microthrombosis-associated ischemic limb injury (Table 1). Venous limb gangrene can complicate thrombocytopenic disor- ders that are strongly associated with deep-vein thrombosis (e.g., cancer-associat- ed disseminated intravascular coagulation and heparin-induced thrombocytope- nia). In these conditions, microthrombosis occurs in the same limb with acute large-vein thrombosis, resulting in acral (distal-extremity) ischemic necrosis. Usually, only one limb is affected. The potentially reversible, prodromal state of limb-threatening ischemia is phlegmasia cerulea dolens, indicating the respective features of a swollen, blue (ischemic), and painful limb (Fig. 1A).
In contrast, two and sometimes all four limbs are affected in symmetric pe- ripheral gangrene, also featuring acral limb ischemic necrosis but usually without deep-vein thrombosis (Fig. 1B). The limb necrosis is often strikingly symmetric; lower limbs are most often affected, with additional involvement of fingers or hands in approximately one third of patients. When there is additional or pre- dominant nonacral tissue necrosis, the term purpura fulminans is applicable. Patients are usually critically ill, with cardiogenic or septic shock. In 1904, Barraud discussed limb gangrene as a complication of acute infection, a complication that continues to occur today. The two syndromes have common pathophysiological features of micro- thrombosis associated with a disturbed procoagulant–anticoagulant balance (Fig. 1C).
The concept that venous limb gangrene and sym- metric peripheral gangrene are usually associated with microvascular thrombosis with underlying disseminated intravascular coagulation provides a framework for a rational approach to diagnos- ing and treating these diverse and potentially devastating disorders. Prevention and treatment of venous gangrene requires correction of abnor- malities associated with the use of vitamin K an- tagonists and aggressive anticoagulation, whereas treatment of symmetric peripheral gangrene (with or without purpura fulminans) theoretically in- volves heparin-based anticoagulation and the sub- stitution of natural anticoagulants.
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