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• 44 year old Mr. X
• Acute onset pain in the left leg
• Progressive numbness of the left leg
• Weakness at the ankle
• What else would you like to know?
• No history of IHD, RHD, TIA, stroke,
• No history of diabetes/hypertension.
• Smoking history of 20 pack years.
• 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?
• Left lower limb was pale, cold and pulseless.
• Reduced sensations over the limb.
• Ankle power- grade 3
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
• Classification of acute limb ischemia?
• Which grade was our patient?
Classification of acute limb
from the Society of Vascular Surgery/International Society of Cardiovascular Surgery
(Rutherford et al, 1997)
• Stat dose of IV Heparin 5000 IU (80 IU/kg)
• What is the role of heparin?
• What are the contraindications for heparin
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?
• Urgency for revascularization vs. Time for
• Category I, IIA – CT angiogram
• Category IIB – Immediate surgery
• Category III – imaging not indicated.
• Best approach –Hybrid theatre with Catheter
directed angiography with endovascular
In our patient
• Suspected acute on chronic limb ischemia.
• Contralateral pulses absent.
CT angiogram for Mr. X
• Thrombus in the infrarenal aorta >90%
• Occlusion of Left distal CFA and proximal SFA.
• Reformation of distal SFA and popliteal with
poor distal run off.
• What next?
• Aortic endartrectomy, femoral embolectomy
and patch plasty and fasciotomy.
• 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.
• Direct administration of thrombolytic agent
into thrombus with a multi side hole catheter.
• Clinical and angiographic examinations during
• Once flow established angiography to look
for stenotic /inciting lesions management of
which can be catheter based or open.
• WHAT ARE THE COMMON THROMBOLYTIC
• HOW DO THEY ACT?
• Common thrombolytic agents – alteplase,
reteplase, rTPA, urokinase.
• Act by converting plasminogen to plasmin
which degrades fibrin.
Open surgical technique
• Surgical strategy guided by anatomical lesion
and type of occlusion.
• Thromboembolectomy with forgarty catheter/
• Adjuncts – Endarterectomy / patch
•POST OPERATIVE MONITORING?
Post operative care
• Adequate hydration.
• Monitor urine output.
• Examine the limb for viability.
• Creat, K+, CPK, HCO3-
• severe pain, hypoesthesia, and weakness of
the affected limb;
• myoglobinuria and elevated CPK.
• anterior compartment of the leg - most
• assessment of peroneal-nerve function
• Compartment pressure >30 mm Hg
• Long term anticoagulation
• Clopidogrel if stenting done.