[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Clinical exam](https://durgical.com/en/clinical-exam/) › [Cardiovascular system](https://durgical.com/en/clinical-exam/#a-cardiovascular) › Acute limb ischemia and chronic arterial insufficiency [Clinical exam](https://durgical.com/en/clinical-exam/) · [Cardiovascular system](https://durgical.com/en/clinical-exam/#a-cardiovascular) # Acute limb ischemia and chronic arterial insufficiency - Syndrome A leg that suddenly turns cold, pale and pulseless is an emergency; pain on walking that stops with rest is the chronic form. Updated 2026-11-01 **See it in 3D:** [Abdominal aorta](https://durgical.com/en/anatomy/abdominal-aorta/) · [Femoral artery](https://durgical.com/en/anatomy/femoral-artery/) · [Popliteal artery](https://durgical.com/en/anatomy/popliteal-artery/) · [Posterior tibial artery](https://durgical.com/en/anatomy/posterior-tibial-artery/) · [Dorsalis pedis artery](https://durgical.com/en/anatomy/dorsalis-pedis-artery/) ## Key points - Six Ps: pain, pallor, pulselessness, paresthesia, paralysis, coldness. - Paralysis or sensory loss = threatened limb, emergency. - Sudden embolism in atrial fibrillation, with normal pulses in the other limb. - Calf claudication = femoropopliteal; buttock claudication = aortoiliac. ## What it is Arterial ischemia of a limb can be acute, from an embolus or thrombosis that closes the artery within minutes or hours, or chronic, from progressive atherosclerosis. The acute form threatens limb viability within hours; the chronic form presents as claudication, rest pain and ulcers. ## Key findings - The six Ps of acute ischemia: pain, pallor, pulselessness, paresthesia, paralysis and poikilothermia (coldness). - Paresthesia, weakness or muscle rigidity: advanced ischemia threatening the limb. - Chronic: intermittent claudication, night pain relieved by hanging the leg down, shiny hairless skin, thick nails, weak or absent pulses. - Pallor on elevation and rubor on dependency (Buerger test); slow capillary refill. - Arterial ulcer: toes and pressure points, punched-out edges, painful, pale base. Venous ulcer: medial malleolus, less painful, with edema and pigmentation. ## Pathophysiology - Acute: muscle and nerve tolerate little time without flow; loss of sensation and movement means a threatened limb. - Embolism: the embolus (usually from the heart) lodges at a bifurcation with no prior collaterals: sudden onset. - Chronic: atherosclerotic stenosis limits flow with exercise (claudication) and, as it progresses, at rest; collaterals develop. - Claudication appears in the muscle group below the lesion: calves (femoropopliteal), buttocks and thighs (aortoiliac). ## Common causes - Acute embolic: atrial fibrillation, recent infarction with mural thrombus, endocarditis. - Acute thrombotic: thrombosis on an existing plaque (prior claudication), thrombosed popliteal aneurysm. - Arterial trauma (knee fractures and dislocations) and dissection. - Chronic: atherosclerosis from smoking, diabetes, hypertension, dyslipidemia and older age. ## Tests that confirm it - Ankle–brachial index for the chronic form; Doppler and CT angiography to localize the lesion. - In the acute form urgent vascular assessment is not delayed for tests. - Diabetic neuropathy can hide pain, and calcified arteries give a falsely normal index. ## Memory aid 'Pale, cold and silent': a pulseless leg that stops feeling is a vascular emergency. ## Test yourself Think of the answer, then tap the question to see it. ## What are the six Ps of acute limb ischemia? Pain, pallor, pulselessness, paresthesia, paralysis and poikilothermia (coldness). ## Which findings mean a limb with acute ischemia is threatened? Loss of sensation and muscle weakness or paralysis. ## Which arrhythmia is the most common source of arterial emboli to the legs? Atrial fibrillation, through thrombi in the left atrial appendage. ## How is an arterial ulcer told from a venous one? The arterial ulcer is on the toes or pressure points, very painful, with punched-out edges; the venous ulcer is usually at the medial malleolus, with edema and pigmentation. [Add to my cards (4)](https://durgical.app/estudiar/?add=/en/clinical-exam/acute-limb-ischemia-and-chronic-arterial-insufficiency/) ## See it in 3D The structures of Durgical's 3D anatomy where it is found. - [Abdominal aorta](https://durgical.com/en/anatomy/abdominal-aorta/) - [Femoral artery](https://durgical.com/en/anatomy/femoral-artery/) - [Popliteal artery](https://durgical.com/en/anatomy/popliteal-artery/) - [Posterior tibial artery](https://durgical.com/en/anatomy/posterior-tibial-artery/) - [Dorsalis pedis artery](https://durgical.com/en/anatomy/dorsalis-pedis-artery/) ## Related - [Peripheral pulses and the ankle–brachial index](https://durgical.com/en/clinical-exam/peripheral-pulses-and-the-ankle-brachial-index/) - [Capillary refill time](https://durgical.com/en/clinical-exam/capillary-refill-time/) - [Signs of deep vein thrombosis: Homans and the Wells score](https://durgical.com/en/clinical-exam/signs-of-deep-vein-thrombosis-homans-and-the-wells-score/) - [Pallor, cyanosis and jaundice](https://durgical.com/en/clinical-exam/pallor-cyanosis-and-jaundice/) ## Related conditions - [Acute limb ischaemia](https://durgical.com/en/conditions/acute-limb-ischaemia/) - [Peripheral artery disease](https://durgical.com/en/conditions/peripheral-artery-disease/) - [Atrial fibrillation](https://durgical.com/en/conditions/atrial-fibrillation/) - [Venous leg ulcer](https://durgical.com/en/conditions/venous-leg-ulcer/) - [Popliteal Artery Injury](https://durgical.com/en/conditions/popliteal-artery-injury/) [← All of the clinical exam](https://durgical.com/en/clinical-exam/) Educational content on the clinical exam; it is learned and practised under supervision. It does not replace assessment by a health professional and is not for self-diagnosis. Sources: [Peripheral artery disease - legs: MedlinePlus Medical Encyclopedia](https://medlineplus.gov/ency/article/000170.htm) (MedlinePlus, U.S. National Library of Medicine, 2026); [6.4 Bedside Physical Assessment in Medical-Surgical Nursing - Medical-Surgical Nursing | OpenStax](https://openstax.org/books/medical-surgical-nursing/pages/6-4-bedside-physical-assessment-in-medical-surgical-nursing) (OpenStax (Rice University), 2024); [24.3 Nursing Assessment - Clinical Nursing Skills | OpenStax](https://openstax.org/books/clinical-nursing-skills/pages/24-3-nursing-assessment) (OpenStax (Rice University), 2024). ## **Spotted a mistake?** We are always improving for the community. Tell us what is wrong and our team will review it. Report a mistake Representative model, for educational purposes only. --- Source: https://durgical.com/en/clinical-exam/acute-limb-ischemia-and-chronic-arterial-insufficiency/ License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/clinical-exam/acute-limb-ischemia-and-chronic-arterial-insufficiency/