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Acute limb ischemia

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Acute limb ischemia

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Acute limb ischemia

  1. 1. Case capsule
  2. 2. History • 44 year old Mr. X • Acute onset pain in the left leg • Progressive numbness of the left leg and • Weakness at the ankle • What else would you like to know? 12 hours
  3. 3. • No history of IHD, RHD, TIA, stroke, claudication. • No history of diabetes/hypertension. • Smoking history of 20 pack years.
  4. 4. Examination • BP- 120 / 70 mm Hg. • Pulse- 110 per minute. • Bilateral femoral, popliteal , posterior tibial and dorsalis pedis pulses were not palpable. • No bruits heard. What else would you like to examine?
  5. 5. • Left lower limb was pale, cold and pulseless. • Reduced sensations over the limb. • Ankle power- grade 3 • DIAGNOSIS?
  6. 6. ACUTE LIMB ISCHEMIA • Acute limb ischemia is defined as a sudden decrease in limb perfusion that threatens the viability of the limb. • incidence -1.5 cases per 10,000 persons per year • Classification of acute limb ischemia? • Which grade was our patient?
  7. 7. Classification of acute limb ischemia from the Society of Vascular Surgery/International Society of Cardiovascular Surgery (Rutherford et al, 1997)
  8. 8. • Etiology of acute limb ischemia?
  9. 9. Etiology • Acute thrombotic occlusion • Embolus -30% • trauma • iatrogenic injury • popliteal aneurysm • aortic dissection.
  10. 10. • How will you differentiate between embolus and thrombus?
  11. 11. EMBOLUS THROMBOSIS Severity Complete- no collaterals Incomplete- collaterals Onset Seconds or minutes Hours or days Multiple sites Upto 15% cases Rare Embolic source Present (usually AF) Absent Bruits Absent Present Contralateral pulses Present Absent Claudication Absent Present
  12. 12. • What are the 6 Ps of acute limb ischemia?
  13. 13. Clinical features • Pain • Parasthesia • Paralysis • Pulselessness • Pallor • Perishing cold
  14. 14. • Stat dose of IV Heparin 5000 IU (80 IU/kg) • What is the role of heparin? • What are the contraindications for heparin
  15. 15. Contraindications for heparin • Active bleeding • Recent neurosurgical and spine operations(within 3 months) • Recent GI bleed(less than 10 days) • Recent eye surgery • Established CVA within 2 months. • What next?
  16. 16. Imaging • Urgency for revascularization vs. Time for imaging. • Category I, IIA – CT angiogram • Category IIB – Immediate surgery • Category III – imaging not indicated. • Best approach –Hybrid theatre with Catheter directed angiography with endovascular Thromboembolectomy
  17. 17. In our patient • Suspected acute on chronic limb ischemia. • Contralateral pulses absent.
  18. 18. CT angiogram for Mr. X • Thrombus in the infrarenal aorta >90% occlusion. • Occlusion of Left distal CFA and proximal SFA. • Reformation of distal SFA and popliteal with poor distal run off. • What next?
  19. 19. • Aortic endartrectomy, femoral embolectomy and patch plasty and fasciotomy.
  20. 20. Endovascular • Patients presenting early – less than 12 hours. • Limb should be viable. • No contraindication to thrombolysis.(recent major surgery, IC bleed or active bleeding). • Diagnostic angiography performed prior to it.
  21. 21. • Direct administration of thrombolytic agent into thrombus with a multi side hole catheter. • Clinical and angiographic examinations during administration. • Once flow established  angiography to look for stenotic /inciting lesions management of which can be catheter based or open. • WHAT ARE THE COMMON THROMBOLYTIC AGENTS? • HOW DO THEY ACT?
  22. 22. • Common thrombolytic agents – alteplase, reteplase, rTPA, urokinase. • Act by converting plasminogen to plasmin which degrades fibrin.
  23. 23. Open surgical technique • Surgical strategy guided by anatomical lesion and type of occlusion. • Thromboembolectomy with forgarty catheter/ bypass surgery • Adjuncts – Endarterectomy / patch plasty/intra-operative thrombolysis/ fasciotomy.
  24. 24. •POST OPERATIVE MONITORING? Post operative care
  25. 25. • Adequate hydration. • Monitor urine output. • Examine the limb for viability. • Creat, K+, CPK, HCO3-
  26. 26. Reperfusion injuries • Myocardial injury: – Release of myocardial depressant factors: C3a, TxA2, LTD4, PAF • Remote lung injury: – pulmonary edema, ARDS • Renal injury: – Myoglobin deposition in renal tubules – Acute tubular necrosis • Gastrointestinal – Mucosal edema • Compartment syndrome
  27. 27. Compartment syndrome • severe pain, hypoesthesia, and weakness of the affected limb; • myoglobinuria and elevated CPK. • anterior compartment of the leg - most susceptible. • assessment of peroneal-nerve function • Compartment pressure >30 mm Hg
  28. 28. • Long term anticoagulation • Ecospirin • Clopidogrel if stenting done.
  29. 29. Prognosis
  30. 30. • THANK YOU
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Acute limb ischemia

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