Saving the Foot from “Bliss of Ignorance”

Abstract

Context: Acute limb ischemia (ALI) is an emergency. The diagnosis of ALI can be missed. However, little is known about predisposing factors. Objective: The objective of the study was to determine the factors leading to misdiagnosis of lower limb ALI based on our experience and to suggest steps in overcoming the shortcomings. Materials and Methods: It is a single-center prospective observational study done from June 2016 to May 2019. All nontraumatic lower limb ALIs were included. Those with prior arterial interventions and thrombophilia were excluded from the study. Referral notes were scrutinized. Chronology of symptoms, time delay by a patient, category of first-contact health-care provider, initial diagnosis, and time lapse by clinician were noted. Patients were quizzed regarding ALI awareness. Statistical Analysis: Not applicable. Results: Twenty-six cases of lower limb ALI were included. Most common presentation was sudden onset claudication (n = 11), followed by pain (n = 9) and sudden onset weakness (n = 6). None were aware of ALI. A clinician was the first contact in 19 and local healer in 7. Eighteen presented late with an average delay of 18 days. Clinician misdiagnosed in 19 with an initial diagnosis of musculoskeletal pain (n = 9), arthritis of hip/knee (n = 4), neurological weakness (n = 2), sciatica (n = 2), and backache (n = 2). Lower limb pulse examination was missed in all 19. Thrombectomy with or without additional procedure was successful in 12 and bypass in one. The limb was salvaged in 20. There were six amputations and two deaths. Conclusion: Lower limb ALI is missed due to its variable presentation and failure to consider its possibility. Poor awareness among the public leads to late presentation. Better awareness needs be created by the education of both common public and the physicians to salvage the limbs in time.