Neo innovation in Limb Ischemia Management diagnosis treatment clinical investigation follow up

1. Neo innovation in Limb
Ischemia Management
KHALID AL-RAJHI, MD
Consultant of General Surgery, Vascular and Endovascular surgery
Lead of Vascular Surgery - Ministry of Health - Jazan Province – Saudi Arabia
TOT General Surgery Residency Program – King Fahad Central Hospital, Jazan – Saudi Arabia

2. Limb Ischemia
“A decrease in limb perfusion causing a potential threat to limb viability”
• Acute : patients presenting with symptoms for less than 2 weeks. patient with
a few hours history of a painful cold white limb.
• Chronic : patient with a few days history of short distance claudication > 2
weeks.
• Acute thrombosis superimposed upon stenosis Acute on Chronic : patient with
a sudden increase in ischemic symptoms on a background of peripheral arterial
disease.

4. Acute Limb
Ischemia
Rapid evaluation + Appropriate treatment strategy
revascularization is essential in determining successful clinical
outcome in both limb salvage and reduction of patient morbidity
and mortality.
Surgical revascularization has long been the standard approach to restoration
of limb perfusion, however with advancements in thrombolytic therapy and
catheter-based techniques, endovascular approaches have emerged as first
line therapy in the treatment of ALI1.
Despite vast therapeutic modalities : major amputation rates of
15% to 50%.2
The risk of mortality remains high : approximately 15% to 20%
die within the 1st year after presenting ALI3.

5. Clinical Features
Characterized by
6 “P”s
1. Pain - sudden onset.
2. Pallor.
3. Poikilothermia ( coldness).
4. Paresthesia – numbness.
5. Pulselessness.
6. Paralysis.

6. Rutherford ALI classification
Rutherford R: Clinical staging of acute limb ischemia as the basis for choice of revascularization method:
when and how to intervene. Semin Vasc Surg. 2009.

7. Acute limb ischemia
Common etiologies
1. Embolic – Causes 15% of ALI cases
• Cardiac source 80%
- valve, mural thrombus, arrythmia
• Non-cardiac source 20%
- aneurysm thrombus, ulcerated atherosclerotic plaque, arterial
dissection
- Blue Toe Syndrome
- manipulation of devices during EVAR.

8. 2. Thrombotic – Causes 85% of ALI cases
• Of native or aneurysmal artery
• Most commonly located at: Bypass grant, common femoral artery,
popliteal artery
• Of indwelling bypass graft

9. Less common etiologies
1. Extrinsic compression of arterial lumen
• Aortic or vascular dissection, creating pseudo lumen which
compromises true lumen
• Compartment syndrome
• Thoracic outlet syndrome
• Massive DVT

10. 2. Vasospasm
• Raynaud’s disease
- Vasospastic condition causing well-demarcated ischemia to fingers
and toes
- Three stages: Pallor (hypoperfusion), then cyanotic (hypoxemia), then
hyperemia (reperfusion) - Usually bilateral limb involvement

11. 3. Vasculitis
• Buerger’s disease (Thromboangiitis obliterans)
- Segmental, inflammatory vaso-occlusive disease of small and medium
arteries
-Heavy tobacco use is a significant risk factor –
• Temporal arteritis (Giant cell arteritis) - Inflammatory condition of
medium and large arteries
• Takayasu’s arteritis - Chronic, inflammatory, large-vessel disease of
aorta and its large branches -Predominantly found in young women
(age 20-30).
4. Low intravascular volume +/- mild peripheral vascular disease (PVD)
• Congestive heart failure, dehydration, sepsis
5. Trauma

12. IVUS

13. Traditional Fogarty Balloon Assisted Thrombectomy
• indicated to removal of
fresh, soft emboli from
the peripheral arterial
system.
• single and double lumen
available in size 2F to 8F,
and 80 cm, 60 or 40 cm
long for some sizes.

14. Endovascular
Therapy
• Advantages of endovascular therapies :
 Minimal invasive option in the acutely frail patient.
 Suboptimal revascularization common with surgical
strategies for ALI.
 Residual thrombus has been demonstrated in a large
fraction of vessels after open surgical thrombectomies.

15. Catheter directed thrombolysis
• thrombolytic medication (tissue plasminogen activator, t-PA) is infused over time that
span hours to days, in the region of thrombus using a multi side-hole catheter. Either
retrograde ‘up and over’ or antegrade, and at times combination antegrade and
retrograde infusion systems are employed for infusion after crossing the occluded
segment.
• (Alteplase) is the agent of choice for CDT. Infusion rates ranging from 0.5 to 1 mg/h are
used along with concurrent infusion of 200-500 units of heparin through the side port of
the vascular sheath to prevent access vessel thrombosis during treatment.
• Repeat angiograms are performed periodically (typically 24 hour intervals at our
institution) to assess therapy progress.
• relative and absolute contraindications of thrombolytic therapy for appropriate risk
stratification for bleeding events. Physicians must inquire about recent trauma or major
surgery, recent cardiopulmonary resuscitation, cranial or spinal surgery, active malignancy,
intracranial tumor burden and aneurysms, stroke, recent vascular interventions, known
active bleeding conditions, severe and uncontrolled hypertension, and lastly pregnancy.
• Severe, underlying renal disease may also preclude CDT and other image based
percutaneous modalities given contrast requirements.

16. • Angiographic images of a
patient presenting with
left lower extremity acute
limb ischemia. An acute
occlusion at the level of
the left adductor canal
superficial femoral artery
is (A) visualized with (B)
absent infrapopliteal
runoff vessels. (C)
Following successful
catheter directed
thrombolysis, a caus-
ative, irregular
atherosclerotic lesion is
identified. (D) Further-
more, restoration of
preserved outflow tibial
vessels is demon- strated
following thrombolysis.

17. Percutaneous Thrombus aspiration

19. Endovascular treatment of BTK ALI

22. Chronic Limb-
Threatening
Ischemia (CLTI)
• the presence of peripheral artery disease
(PAD) in combination with rest pain,
gangrene, or a lower limb ulceration >2
weeks duration.
• All patients with CLTI should be afforded
best medical therapy including the use of :
- Antithrombotic.
- Lipid-lowering.
- Antihypertensive.
- Glycemic control agents.
- Counseling on smoking cessation, diet,
exercise, and preventive foot care.

23. Chronic Limb Ischemia

25. Reversed Homograft vein – Allograft – In situ bypass

26. Endovascular
Therapy

29. CERAB

30. Eiffel Tower vs CERAB

31. SAFARI
Technique

32. pDVA

33. EVAR
• Elective AAA.
• rAAA.
• Infra-renal aortic/aortoiliac injury.

38. Laparoscopic infra-renal AAA Repair

39. REBOA

40. The Beauty of Vascular Surgery:
Multiple techniques / Tools to fix a given problem.

41. 1. Endovascular Treatment Strategy Using Catheter-Directed Thrombolysis, Percutaneous Aspiration
Thromboembolectomy, and Angioplasty for Acute Upper Limb Ischemia.Ueda T, Murata S, Miki I, Yasui
D, Sugihara F, Tajima H, Morota T, Kumita SI. Cardiovasc Intervent Radiol. 2017 Jul; 40(7):978-986.
2. Analysis of the results of endovascular and open surgical treatment of acute limb ischemia.de Athayde
Soares R, Matielo MF, Brochado Neto FC, Cury MVM, Duque de Almeida R, de Jesus Martins M, Pereira
de Carvalho BV, Sacilotto R. J Vasc Surg. 2019 Mar; 69(3):843-849.
3. Enezate TH, Omran J, Mahmud E, Patel M, Abu-Fadel MS, White CJ, Al-Dadah AS. Endovascular versus
surgical treatment for acute limb ischemia: a systematic review and meta-analysis of clinical trials.
Cardiovasc Diagn Ther. 2017 Jun;7(3):264-271.