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Acute limb ischemia

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Acute limb ischemia

  1. 1.  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….
  2. 2.  Absent popliteal and lower pulsations Decreased sensations Inability to move toes
  3. 3. Acute limb ischemia
  4. 4. Etiology of acute limb ischemiaAcute arterial embolism: Of a relatively health arterial treeAcute arterial thrombosis: Of a previously diseased arterial treeAcute traumatic ischemia:
  5. 5. Patho-pysiology
  6. 6. 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
  7. 7. Example ofacutearterialembolus“Saddle”Embolus ofright iliacartery
  8. 8. Acute Thrombotic Ischemia Atherosclerosis causes progressive narrowing of the arterial tree Stimulates development of collaterals Sluggish flow & rough surface will favor acute thrombosis
  9. 9. Clinical Picture
  10. 10. 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)
  11. 11. 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
  12. 12. 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
  13. 13. 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
  14. 14. Investigations The severity and duration of ischemia at the time of presentation provides a narrow margin of time for investigations
  15. 15.  general investigations  CK  [Patients with a suspected hypercoagulable state will need additional studies seeking:]  Anticardiolipin antibodies  Elevated homocysteine concentration  Antibodies to platelet factor IV
  16. 16. Doppler USto assess the level of obstruction & severity of ischemia
  17. 17. 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
  18. 18. 0.7 to 0.9 is mild disease,0.5 to 0.69 is moderate disease,< 0.5 is severe disease.
  19. 19. Arteriography If the differentiation between embolic & thrombotic ischemia is not clear clinically, and if the limb condition permits, DO ANGIOGRAPHY
  20. 20.  Value of angiography Localizes the obstruction Visualize the arterial tree & distal run-off Can diagnose an embolus: Sharp cutoff, reversed meniscus or clot silhouette
  21. 21. 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
  22. 22. 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 _ _
  23. 23. TREATMENT Goals of therapy include restoration of blood flow, preservation of limb and life, and prevention of recurrent thrombosis
  24. 24. THROMBOLYTICSIMMEDIATE CARE SURGERY
  25. 25. A. Immediate care Anticoagulation Analgesia measures to improve existing perfusion treatment of associated cardiac conditions
  26. 26. 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
  27. 27. 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
  28. 28. SURGERY OPERATIVEREVASCULARISATION AMPUTATION
  29. 29. Fogarty balloon catheter(with post-op anti coagulants)
  30. 30.  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]
  31. 31. Amputationfor irreversibleischemia withpermanent tissuedamage
  32. 32. 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)
  33. 33. 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
  34. 34. Algorithm to be followed… Patient with suspected ischemia History Examination investigations Acute limb ischemia confirmed and staged
  35. 35. Heparin I IIA IIb III EMERGENCY EARLY OPERATIVE AMPUTATION INTERVENTION RE- VASCULARISATION NO YESTREAT FOR SAME AS CHRONIC FOR IIa ISCHEMIA
  36. 36. Management of IIa ARTERIOGRAPHY No lesion Discrete localized lesions Multiple extensive lesions
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