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Acute limb ischemia
 

Acute limb ischemia

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  • This is the rutherford classification of acute limb ischemia .

Acute limb ischemia Acute limb ischemia Presentation Transcript

  •  64 yr old male with previous history of heart attack came to casualty with c/o sudden onset of pain in the right leg below the knee. On examination….
  •  Absent popliteal and lower pulsations Decreased sensations Inability to move toes
  • Acute limb ischemia
  • Etiology of acute limb ischemiaAcute arterial embolism: Of a relatively health arterial treeAcute arterial thrombosis: Of a previously diseased arterial treeAcute traumatic ischemia:
  • Patho-pysiology
  • Acute Embolic Ischemia An embolus can originate from An embolus the heart (MS with atrial suddenly fibrillation, MI with mural occludes a thrombus) or dilated diseased relatively arteries (aortic aneurism) healthy arterial tree It usually arrest at arterial bifurcation Aortic bifurcation Iliac bifurcation Femoral bifurcation Popliteal trifurcation
  • Example ofacutearterialembolus“Saddle”Embolus ofright iliacartery
  • Acute Thrombotic Ischemia Atherosclerosis causes progressive narrowing of the arterial tree Stimulates development of collaterals Sluggish flow & rough surface will favor acute thrombosis
  • Clinical Picture
  • Clinical Evaluation of Acute Ischemia (Clinical Picture)Signs of acute ischemia Inspection 5Ps COLOR: Fixed Early: pale EarlyPain: symptomPain mottling & + Later: cyanosed Later mottling fixed cyanosis mottling & cyanosis An area of fixed cyanosis Pale surrounded by reversible mottling Pulseless Pallor Reversible mottling Parasthesia Empty veins: Paralysis compare the Rt. (ischemic) & Lt. (normal)
  • Clinical Evaluation of Acute Ischemia (Clinical Picture)Signs of acute ischemia Palpation 5PsPain: symptomPain + Femoral Popliteal Pale Pulseless Posterior tibial Dorsalis pedis Palpate peripheral pulses, compare with the pulses Parasthesia other side & write it down on a sketch Temperature: the limb is cold with a level of Temperature Paralysis temperature change (compare the two limbs) Slow capillary refilling of the skin after finger pressure
  • Clinical Evaluation of Acute Ischemia (Clinical Picture)Signs of acute ischemia Palpation 5Ps Loss of sensory functionPain: symptomPain Numbness will progress to anesthesia + Progress of Sensory loss Pale Light touch Vibration sense Pulseless Proprioreception Parasthesia Deep pain Late Pressure sense Paralysis
  • Clinical Evaluation of Acute Ischemia (Clinical Picture)Signs of acute ischemia Palpation 5Ps Loss of motor function:Pain: symptomPain Indicates advanced limb threatening + ischemia Late irreversible ischemia: Muscle turgidity Pale Intrinsic foot muscles are affected Pulseless first, followed by the leg muscles Detecting early muscle weakness is Parasthesia difficult because toes movements are produced mainly by leg muscles Paralysis
  • Investigations The severity and duration of ischemia at the time of presentation provides a narrow margin of time for investigations
  •  general investigations  CK  [Patients with a suspected hypercoagulable state will need additional studies seeking:]  Anticardiolipin antibodies  Elevated homocysteine concentration  Antibodies to platelet factor IV
  • Doppler USto assess the level of obstruction & severity of ischemia
  • What are we looking for? NORMAL • Multiphasic • Pulsatile • Regular amplitudeAn audible Doppler signal assures some blood flowNo Doppler signals, a vascular surgeon should beimmediately consulted
  • 0.7 to 0.9 is mild disease,0.5 to 0.69 is moderate disease,< 0.5 is severe disease.
  • Arteriography If the differentiation between embolic & thrombotic ischemia is not clear clinically, and if the limb condition permits, DO ANGIOGRAPHY
  •  Value of angiography Localizes the obstruction Visualize the arterial tree & distal run-off Can diagnose an embolus: Sharp cutoff, reversed meniscus or clot silhouette
  • Embolism: Thrombosis:obvious cardiac source No obvious cardiac source.No hx of cluadication history of cluadication.Normal pulses in contralateral limb abnormal pulses in contralateral limb.Angiogram: minimal atherosclerotic Angiogram: diffuse atheroscleroticFew collateral Well developed collateral WWW.SMSO.NET
  • Doppler Category Description Cap. refill Paralysis Sensory A V lossI Viable Not immediately threatened Intact - - Aud AudIIa Threatened Salvagable if treated Intact/slow - Partial _ AudIIb Threatened Salvagable if treated Slow/absen t Partial Partial _ Aud emergentlyIII Irreversible Primary amputation req. Absent Complete Complete _ _
  • TREATMENT Goals of therapy include restoration of blood flow, preservation of limb and life, and prevention of recurrent thrombosis
  • THROMBOLYTICSIMMEDIATE CARE SURGERY
  • A. Immediate care Anticoagulation Analgesia measures to improve existing perfusion treatment of associated cardiac conditions
  • B Catheter directed thrombolysis Agents used: Streptokinase, Urokinase, tissue plasminogen activator Indications: Indications 1. Viable or marginally threatened limb (class I, IIa) 2. Recent acute thrombosis (not suitable for embolism or old thrombi) 3. Avoid patients with contraindications
  • Contraindications:Absolute:Absolute1. Cerebro-vascular stroke within previous 2 months2. Active bleeding or recent GI bleeding within previous 10 days3. Intracranial trauma or neurosurgery within previous 3 monthsRelative:Relative1. Cardio-pulmonary resuscitation within previous 10 days2. Major surgery or trauma within previous 10 days3. Uncontrolled hypertension
  • SURGERY OPERATIVEREVASCULARISATION AMPUTATION
  • Fogarty balloon catheter(with post-op anti coagulants)
  •  Surgery [Surgery may be considered in trauma, where there are contraindications to CDT, or where CDT is not available. The method of revascularization (open surgicalor endovascular) may differ depending on: Anatomic location of occlusion Etiology of ALI Contraindications to open or endovascular treatment Local practice patterns]
  • Amputationfor irreversibleischemia withpermanent tissuedamage
  • Clinical outcomes• Mortality -15–20%.• Major morbidities include:1. Due to major bleeding 10–15% of patients require transfusion/and or operative intervention2. Amputation (25–30% of patients)3. Fasciotomy (5–25% of patients)4. Renal insufficiency (up to 20% of patients)
  • Follow-up care warfarin, often for 3–6 months or longer. Patients with thromboembolism will need long-term anticoagulation, possibly lifelong. If contraindicated due to bleeding risk factors>> platelet inhibition therapy
  • Algorithm to be followed… Patient with suspected ischemia History Examination investigations Acute limb ischemia confirmed and staged
  • Heparin I IIA IIb III EMERGENCY EARLY OPERATIVE AMPUTATION INTERVENTION RE- VASCULARISATION NO YESTREAT FOR SAME AS CHRONIC FOR IIa ISCHEMIA
  • Management of IIa ARTERIOGRAPHY No lesion Discrete localized lesions Multiple extensive lesions