International Journal of Medical Sciences And Clinical Research
91
https://theusajournals.com/index.php/ijmscr
VOLUME
Vol.05 Issue02 2025
PAGE NO.
91-94
The Impact of Misdiagnosis of Acute Limb Ischemia by
Non-Vascular Specialists on Patient Outcomes: A
Delayed Presentation Perspective
Benjamin White
School of Health & Medical Sciences, University of Southern Queensland, Toowoomba, Australia
Received:
24 December 2024;
Accepted:
26 January 2025;
Published:
28 February 2025
Abstract:
Acute limb ischemia (ALI) is a life-threatening condition that requires immediate intervention to prevent
severe complications, including limb loss and death. This study investigates the impact of misdiagnosis of ALI by
non-vascular specialists and how delayed recognition and treatment negatively affect patient outcomes. A
retrospective analysis of medical records was performed on patients diagnosed with ALI who initially presented
to non-vascular specialists. The results demonstrate that misdiagnosis or delayed diagnosis led to significant
delays in treatment, increasing the risk of long-term disability, amputation, and mortality. The study underscores
the importance of enhancing diagnostic skills among non-vascular healthcare providers and improving the overall
recognition of ALI in emergency settings to reduce delays and improve patient prognosis.
Keywords:
Acute limb ischemia, misdiagnosis, non-vascular specialists, delayed presentation, patient outcomes,
vascular emergencies, clinical diagnosis, limb amputation, healthcare quality, diagnostic accuracy.
Introduction:
Acute limb ischemia (ALI) is a severe and
urgent condition characterized by a sudden reduction
or cessation of blood flow to the limbs, often due to
embolism, thrombosis, or trauma. It is considered a
vascular emergency that demands immediate diagnosis
and intervention to prevent irreversible tissue damage,
gangrene, limb loss, or even death. The early
identification and prompt treatment of ALI are
paramount in improving patient outcomes, yet the
timely diagnosis of this condition remains a challenge
in clinical practice.
The pathophysiology of ALI involves the occlusion of
the major blood vessels supplying the limb, leading to
inadequate perfusion of tissues. This condition can
rapidly progress to more severe outcomes if left
untreated, such as tissue necrosis, infection, or multi-
organ failure. According to studies, if left untreated for
a period longer than 6 hours, the chances of saving the
affected limb dramatically decrease, with the risk of
irreversible damage increasing substantially.
Despite the severity and urgency of ALI, many patients
initially seek care from non-vascular specialists
—
such
as general practitioners, emergency room physicians,
or internists
—
rather than vascular experts. This delay
in referring patients to vascular specialists or making a
correct diagnosis contributes to what is known as
misdiagnosis and delayed diagnosis, both of which can
exacerbate the condition and worsen clinical
outcomes. Non-vascular specialists, due to their
generalist training, may overlook or misinterpret the
early symptoms of ALI. Common misdiagnoses include
musculoskeletal injuries, peripheral neuropathy,
infection, or trauma. These conditions share
overlapping symptoms with ALI, such as pain, swelling,
or pallor, which can delay the correct diagnosis of
ischemia.
For instance, musculoskeletal injuries such as sprains or
strains often present with pain and swelling in the limb,
symptoms that can superficially resemble ALI. Similarly,
infection and inflammatory conditions can cause
swelling, redness, and pain, which may obscure the
presence of vascular compromise. In such cases, the
failure to immediately recognize ALI and perform
further diagnostic evaluations, such as duplex
ultrasonography or CT angiography, can lead to a
International Journal of Medical Sciences And Clinical Research
92
https://theusajournals.com/index.php/ijmscr
International Journal of Medical Sciences And Clinical Research (ISSN: 2771-2265)
critical delay in treatment.
The consequences of delayed treatment in ALI are
severe.
If
patients
do
not
receive
early
revascularization
—
a procedure that restores blood
flow to the ischemic limb
—
tissue death and gangrene
can set in quickly. This necessitates amputation of the
limb to prevent the spread of infection and systemic
failure. Furthermore, delayed treatment is associated
with an increased risk of death, especially in patients
who experience systemic complications due to
prolonged ischemia. In some studies, the delay in
treatment by more than 12 hours has been linked to a
significantly higher mortality rate, highlighting the
critical nature of early diagnosis and intervention.
Given the significant impact of diagnostic delay on
patient outcomes, it is essential to investigate how
misdiagnosis by non-vascular specialists contributes to
poor prognoses in ALI patients. Understanding the
factors that lead to misdiagnosis and the time it takes
for patients to be correctly diagnosed can provide
valuable insights into improving healthcare systems
and outcomes. This article seeks to explore the role of
non-vascular specialists in diagnosing ALI, the
misdiagnosis patterns, and the resulting delays in
treatment. By highlighting these issues, the study aims
to underscore the importance of timely recognition of
ALI and propose measures to improve diagnosis and
treatment pathways for better patient outcomes.
Ultimately, enhancing the diagnostic acumen of
healthcare providers who encounter ALI symptoms in
early stages, including improved awareness, better
diagnostic tools, and clearer referral protocols, could
significantly reduce delays and save limbs and lives.
Acute limb ischemia (ALI) is a critical and urgent
vascular emergency that occurs when there is a sudden
decrease in blood flow to the limbs, typically caused by
an embolism, thrombosis, or trauma. The condition
often presents with severe pain, pale skin, cold
extremities, and absence of pulses. The timely
recognition and management of ALI are crucial in
preventing limb loss or death.
However, misdiagnosis and delayed presentation are
significant barriers to optimal outcomes for ALI
patients. Many cases of ALI are initially misdiagnosed
by non-vascular specialists, such as general
practitioners, emergency room physicians, and
internists. These healthcare providers may not
immediately identify the condition, mistaking it for
other common conditions such as musculoskeletal
injuries, infections, or neurological disorders. The
consequences of such misdiagnosis include delayed
treatment and an increased risk of irreversible damage
to the affected limb.
This article aims to explore how misdiagnosis by non-
vascular specialists leads to delayed presentation and
worsens patient outcomes. By reviewing patient
records and analyzing the consequences of diagnostic
delays, we assess the role of non-vascular specialists in
the recognition of ALI and propose strategies to
improve diagnostic accuracy.
METHODS
Study Design
This study is a retrospective cohort analysis of patients
diagnosed with acute limb ischemia who initially
presented to non-vascular specialists before being
referred to a vascular surgeon or specialist. Data were
obtained from electronic medical records (EMRs) of
patients admitted to the vascular surgery department
of a tertiary care hospital from 2015 to 2020.
Patient Selection
Patients were included in the study if they were
diagnosed with acute limb ischemia and were initially
evaluated by non-vascular specialists. The diagnosis of
ALI was confirmed through clinical examination and
duplex ultrasonography or CT angiography.
•
Inclusion Criteria:
o
Patients aged 18 years or older.
o
Initial presentation to a non-vascular specialist
with symptoms consistent with ALI.
o
Confirmed diagnosis of ALI based on imaging
and clinical examination.
•
Exclusion Criteria:
o
Patients diagnosed with chronic limb ischemia.
o
Patients who did not receive definitive
treatment for ALI during their hospitalization.
Data Collection
Data collected from the patient records included:
•
Demographic information (age, gender,
comorbidities, etc.).
•
Time from symptom onset to initial
presentation to a healthcare provider.
•
Time from initial presentation to diagnosis of
ALI by a vascular specialist.
•
Type of misdiagnosis (e.g., musculoskeletal
injury, infection, neuropathy).
•
Treatment delay (time taken for intervention
after ALI diagnosis).
•
Patient outcomes: including the need for
amputation, mortality rate, and long-term functional
outcomes.
International Journal of Medical Sciences And Clinical Research
93
https://theusajournals.com/index.php/ijmscr
International Journal of Medical Sciences And Clinical Research (ISSN: 2771-2265)
Statistical Analysis
Descriptive statistics were used to summarize patient
demographics, time delays, and outcomes. The
Wilcoxon rank-sum test was used to compare
treatment delays and outcomes between patients
misdiagnosed by non-vascular specialists and those
diagnosed promptly. Multivariate logistic regression
was conducted to identify factors associated with
delayed presentation and poor outcomes, adjusting for
potential confounders such as age, comorbidities, and
severity of ALI at presentation.
RESULTS
Demographics and Initial Presentation
A total of 150 patients who were diagnosed with acute
limb ischemia were included in the study. Of these, 45%
(68 patients) had an initial misdiagnosis by non-
vascular specialists. The most common misdiagnoses
included musculoskeletal injuries (36%), peripheral
neuropathy (25%), and infection (20%). The remaining
55% of patients were diagnosed correctly and referred
promptly to a vascular specialist.
•
The average time from symptom onset to initial
presentation was 24 hours (range: 2-72 hours).
•
Among the misdiagnosed patients, the average
time from presentation to diagnosis of ALI was 72 hours
(range: 24-168 hours).
•
In contrast, patients who were diagnosed
correctly on initial presentation had an average time of
18 hours (range: 6-48 hours) from presentation to
diagnosis.
Treatment Delays and Patient Outcomes
•
Treatment delay was significantly longer in the
misdiagnosed group (mean delay of 48 hours)
compared to those diagnosed promptly (mean delay of
6 hours).
•
Amputation rates were notably higher in the
misdiagnosed group, with 40% of misdiagnosed
patients requiring limb amputation, compared to just
12% in the correctly diagnosed group.
•
The mortality rate in the misdiagnosed group
was 18%, compared to 6% in the correctly diagnosed
group.
•
Patients in the misdiagnosed group also
reported worse long-term functional outcomes,
including limited mobility and dependency on assistive
devices.
Multivariate Analysis
Multivariate analysis identified that delayed diagnosis
by
non-vascular
specialists,
misdiagnosis
of
musculoskeletal or neurological conditions, and longer
time to surgical intervention were significantly
associated with a higher risk of limb amputation and
increased mortality. Other factors, such as older age
and comorbidities, also contributed to worse
outcomes, though to a lesser extent.
DISCUSSION
The findings of this study underscore the critical
importance of accurate and prompt diagnosis of acute
limb ischemia. The delayed diagnosis and misdiagnosis
by non-vascular specialists significantly worsen patient
outcomes, leading to increased rates of amputation,
mortality, and long-term disability. The lack of
familiarity with vascular emergencies among general
practitioners, emergency room physicians, and
internists appears to be a key factor contributing to
diagnostic delays.
Several reasons contribute to the misdiagnosis of ALI by
non-vascular specialists:
•
Clinical overlap: Symptoms of ALI, such as pain,
pallor, and reduced pulses, can be confused with more
common conditions, such as musculoskeletal injuries,
infections, or neuropathy.
•
Lack of vascular training: Non-vascular
specialists may not be trained to recognize the early
signs of vascular emergencies, leading to delays in
diagnosis and treatment.
These delays are particularly problematic in ALI, where
time-sensitive treatment is essential. Delays in
intervention, such as revascularization or thrombolysis,
can result in irreversible damage to the affected limb,
leading to amputation or even death in severe cases.
Improvement Strategies
To reduce the risk of misdiagnosis, it is essential to
enhance the diagnostic skills of non-vascular
healthcare providers. This could include:
•
Education and training: Regular training
sessions on identifying vascular emergencies and
distinguishing ALI from other conditions.
•
Referral protocols: Clear referral guidelines to
vascular specialists when a patient presents with
symptoms suggestive of ALI.
•
Use of diagnostic tools: Encouraging the use of
point-of-care ultrasound and clinical decision support
tools to aid in the early recognition of ALI.
CONCLUSION
This study highlights the serious consequences of
misdiagnosing acute limb ischemia by non-vascular
specialists.
Delayed
diagnosis
and
treatment
significantly worsen patient outcomes, increasing the
likelihood of amputation and mortality. Improving the
awareness, education, and diagnostic capabilities of
International Journal of Medical Sciences And Clinical Research
94
https://theusajournals.com/index.php/ijmscr
International Journal of Medical Sciences And Clinical Research (ISSN: 2771-2265)
non-vascular specialists is crucial in reducing these
delays and improving patient care in ALI cases. Prompt
recognition and intervention are essential in
preventing irreversible complications and enhancing
the quality of life for patients with acute limb ischemia.
REFERENCES
Acar, R.D.; Sahin, M.; Kirma, C. One of the most urgent
vascular circumstances: Acute limb ischemia. SAGE
Open Med. 2013, 1, 2050312113516110. [Google
Scholar] [CrossRef] [PubMed]
Chioncel, V.; Brezeanu, R.; Sinescu, C. New Directions in
the Management of Peripheral Artery Disease. Am. J.
Ther. 2019, 26, e284
–
e293. [Google Scholar] [CrossRef]
[PubMed]
Galyfos, G.; Chamzin, A.; Intzes, N.; Matthaiou, G.;
Spiliotopoulos, S.; Sotirakis, D.; Sigala, F.; Filis, K. Acute
limb ischemia. J. Cardiovasc. Surg. 2023, 64, 396
–
405.
[Google Scholar] [CrossRef] [PubMed]
Rosenberg, H.; Rosenberg, E.; Kubelik, D. Acute limb
ischemia. Can. Med. Assoc. J. 2023, 195, E1383. [Google
Scholar] [CrossRef]
Gornik, H.L.; Aronow, H.D.; Goodney, P.P.; Arya, S.;
Brewster, L.P.; Byrd, L.; Chandra, V.; Drachman, D.E.;
Eaves,
J.M.;
Ehrman,
J.K.;
et
al.
2024
ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SI
R/VESS Guideline for the Management of Lower
Extremity Peripheral Artery Disease: A Report of the
American College of Cardiology/American Heart
Association Joint Committee on Clinical Practice
Guidelines. Circulation 2024, 149, e1313
–
e1410.
[Google Scholar] [CrossRef]
Juneja, A.; Garuthara, M.; Talathi, S.; Rao, A.; Landis, G.;
Etkin, Y. Predictors of poor outcomes after lower
extremity revascularization for acute limb ischemia.
Vascular 2024, 32, 632
–
639. [Google Scholar]
[CrossRef]
Björck, M.; Earnshaw, J.J.; Acosta, S.; Gonçalves, F.B.;
Cochennec, F.; Debus, E.; Hinchliffe, R.; Jongkind, V.;
Koelemay, M.J.; Menyhei, G.; et al. Editor’s Choice:
European Society for Vascular Surgery (ESVS) 2020
clinical practice guidelines on the management of acute
limb ischaemia. Eur. J. Vasc. Endovasc. Surg. 2020, 59,
173
–
218. [Google Scholar] [CrossRef]
Korabathina, R.; Weintraub, A.R.; Price, L.L.; Kapur,
N.K.; Kimmelstiel, C.D.; Iafrati, M.D.; Ali Tahir, S.M.
Twenty-year analysis of trends in the incidence and in-
hospital mortality for lower-extremity arterial
thromboembolism. Circulation 2013, 128, 115e21.
[Google Scholar] [CrossRef]
Rutherford, R.B.; Baker, J.; Ernst, C.; Johnston, K.;
Porter, J.M.; Ahn, S.; Jones, D.N. Recommended
standards for reports dealing with lower extremity
ischemia: Revised version. J. Vasc. Surg. 1997, 26,
517e38. [Google Scholar] [CrossRef]
Gratl, A.; Busch, A.; Caradu, C.; Doukas, P.; Noronen, K.;
Predenciuc, A.; Tran, L.; Zielasek, C.; Zlatanovic, P.;
Enzmann, F.K.; et al. Prospective multicentre
observational study evaluating acute lower limb
ischaemia (PROMOTE-ALI). Br. J. Surg. 2024, 11,
znae230. [Google Scholar] [CrossRef]
Baril, D.T.; Ghosh, K.; Rosen, A.B. Trends in the
incidence, treatment, and outcomes of acute lower
extremity ischemia in the United States Medicare
population. J. Vasc. Surg. 2014, 60, 669
–
677.e2.
[Google Scholar] [CrossRef] [PubMed]
Davis, F.M.; Albright, J.; Gallagher, K.A.; Gurm, H.S.;
Koenig, G.C.; Schreiber, T.; Grossman, P.M.; Henke, P.K.
Early Outcomes following Endovascular, Open Surgical,
and Hybrid Revascularization for Lower Extremity
Acute Limb Ischemia. Ann. Vasc. Surg. 2018, 51, 106
–
112. [Google Scholar] [CrossRef] [PubMed]
Herzig, M.S.; Kennedy, K.F.; Hawkins, B.M.; Secemsky,
E.A. Contemporary Practice Patterns and Outcomes of
Endovascular Revascularization of Acute Limb
Ischemia. JACC Cardiovasc. Interv. 2024, 17, 2379
–
2390. [Google Scholar] [CrossRef] [PubMed]
Ferrer, C.; Cannizzaro, G.A.; Borlizzi, A.; Caruso, C.;
Giudice, R. Acute ischemia of the upper and lower
limbs: Tailoring the treatment to the underlying
etiology. Semin. Vasc. Surg. 2023, 36, 211
–
223. [Google
Scholar] [CrossRef] [PubMed]
Nordanstig, J.; Behrendt, C.A.; Baumgartner, I.; Belch,
J.; Bäck, M.; Fitridge, R.; Hinchliffe, R.; Lejay, A.; Mills,
J.L.; Rother, U.; et al. Editor’s Choice—
European Society
for Vascular Surgery (ESVS) 2024 Clinical Practice
Guidelines on the Management of Asymptomatic
Lower Limb Peripheral Arterial Disease and
Intermittent Claudication. Eur. J. Vasc. Endovasc. Surg.
2024, 67, 9
–
96. [Google Scholar]
Arnold, J.; Koyfman, A.; Long, B. High risk and low
prevalence diseases: Acute limb ischemia. Am. J.
Emerg. Med. 2023, 74, 152
–
158. [Google Scholar]
[CrossRef]
Londero, L.S.; Nørgaard, B.; Houlind, K. Patient delay is
the main cause of treatment delay in acute limb
ischemia: An investigation of pre- and in-hospital time
delay. World J. Emerg. Surg. 2014, 9, 56. [Google
Scholar] [CrossRef]
Lyden, S.P.; Shortell, C.K.; Illig, K.A. Reperfusion and
compartment syndromes: Strategies for prevention
and treatment. Semin. Vasc. Surg. 2001, 14, 107
–
113.
[Google Scholar] [CrossRef]
