Chronic arterial thrombosis of the lower extremity!!

This is a 60-year-old patient who arrived at the emergency room with limb pain, lameness, cold and pale extremities. He was diagnosed with arterial thrombosis with limb ischemia and subsequent necrosis, and evolved with waiting for the public medical service. Unfortunately, due to the severity of his gangrene, the only way out was limb amputation. Arterial thrombosis usually occurs after the erosion or rupture of an atherosclerotic plaque and, through platelet-mediated thrombi, can cause ischemic injuries especially in tissues with a terminal vascular bed. Acute ischemia is defined as a sudden loss of limb perfusion for up to 2 weeks after the initiating event. The occlusion can occur in any peripheral artery of the upper and lower extremities. Once arterial blood flow is impeded, malperfused tissues switch from aerobic to anaerobic metabolism, causing lactate production, acidosis, and an increased concentration of free radicals. Prolonged and untreated ischemia will cause the hypoxic muscle to deplete its ATP stores; this is followed by dysfunction in the sodium/potassium-ATPase and calcium/sodium pump leading to intracellular calcium leakage into the myocytes. Increasing free calcium negatively interacts with the muscle's myosin, actin, and proteases and eventually causes muscle fiber necrosis. The classic presentation of limb ischemia is known as the "six Ps": pallor, pain, paresthesia, paralysis, pulselessness, and poikilothermia. The surgical approach is directed at reperfusion of the affected extremity. This can be accomplished by the surgical bypass, endarterectomy, or embolectomy. Photo by @arthurreimann