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1362466100 acute ischaemia of lower limb


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acute ischaemia of lower limb

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1362466100 acute ischaemia of lower limb

  1. 1. Dr. Rajdeep Agrawal Acute Ischemia Of Lower Limb (AILL)  AetiologyAetiology 1. Embolisation most common cause1. Embolisation most common cause heart as a source - 70 %,heart as a source - 70 %, Atrial Fibrillation,Atrial Fibrillation, AMI with mural thrombusAMI with mural thrombus 2. Acute thrombosis superimposed upon2. Acute thrombosis superimposed upon stenosisstenosis 3. Popliteal Aneurysm3. Popliteal Aneurysm
  2. 2. Dr. Rajdeep Agrawal Acute Ischemia Of Lower Limb  The extent of ischemia & finalThe extent of ischemia & final outcome depends uponoutcome depends upon 1. Size & location of clot1. Size & location of clot 2. Extent of collateral2. Extent of collateral circulationcirculation 3. Time between onset of3. Time between onset of occlusion & treatmentocclusion & treatment
  3. 3. Dr. Rajdeep Agrawal Clinical Features  Characterized by 5 “P”sCharacterized by 5 “P”s 1. Pain - sudden onset1. Pain - sudden onset 2. Pallor- waxy2. Pallor- waxy 3. Parasthesia – numbness3. Parasthesia – numbness 4. Pulselessness4. Pulselessness 5. Paralysis5. Paralysis
  4. 4. Dr. Rajdeep Agrawal Therapeutic Strategies in Acute Ischemia  Most common vascular emergencyMost common vascular emergency 1. Intra arterial thrombolysis1. Intra arterial thrombolysis 2. Thrombo-aspiration with catheter2. Thrombo-aspiration with catheter 3. Mechanical thrombolysis3. Mechanical thrombolysis 4. Surgical embolectomy – Fogarty4. Surgical embolectomy – Fogarty cathetercatheter
  5. 5. Dr. Rajdeep Agrawal Peripheral Intra-arterial Thrombolysis (PIAT)  Rapidly restores blood flow to ischemicRapidly restores blood flow to ischemic limb & identifies underlying lesions forlimb & identifies underlying lesions for percutaneous or surgical interventionpercutaneous or surgical intervention  Catheter directed local delivery ofCatheter directed local delivery of thrombolytic agents directly at the sitethrombolytic agents directly at the site of thrombosis is significantly moreof thrombosis is significantly more effective than systemic thrombolysis &effective than systemic thrombolysis & is associated with lower bleedingis associated with lower bleeding complicationscomplications
  6. 6. Dr. Rajdeep Agrawal Thrombolytic Agents  StreptokinaseStreptokinase  UrokinaseUrokinase  Recombinant human tissue typeRecombinant human tissue type plasminogen activator (rtpA,plasminogen activator (rtpA, alteplase)alteplase) In recent years UK & rtpA have largelyIn recent years UK & rtpA have largely superceded & replaced SK assuperceded & replaced SK as preferred agentpreferred agent
  7. 7. Dr. Rajdeep Agrawal Peripheral Intra-arterial Thrombolysis (PIAT) PIAT – Common procedurePIAT – Common procedure  Angiography is doneAngiography is done  Thrombus is locatedThrombus is located  Multiple end hole catheter is advanced to theMultiple end hole catheter is advanced to the upper limit of the thrombusupper limit of the thrombus  One of the infusion methods shown next isOne of the infusion methods shown next is then usedthen used
  8. 8. Dr. Rajdeep Agrawal PIAT– Infusion Methods  Stepwise infusionStepwise infusion Done by stepwise advancement of infusionDone by stepwise advancement of infusion catheter as thrombus dissolvescatheter as thrombus dissolves  Graded infusionGraded infusion ( McNamara’s( McNamara’s protocolprotocol)) gradual tapering of infusion rategradual tapering of infusion rate  Continuous infusionContinuous infusion  Pulse spray techniquePulse spray technique
  9. 9. Dr. Rajdeep Agrawal PIAT--McNamara’s Protocol  UK 4000 units/min x 2hrsUK 4000 units/min x 2hrs 2000 units/min x next 2hrs2000 units/min x next 2hrs 1000 units/min x next 4-24 hrs or1000 units/min x next 4-24 hrs or until the lysis is completeduntil the lysis is completed Systemic heparin continued during PIAT And tillSystemic heparin continued during PIAT And till definite endovascular or surgical Rx ofdefinite endovascular or surgical Rx of underlying lesion is doneunderlying lesion is done
  10. 10. Dr. Rajdeep Agrawal PIAT--McNamara’s Protocol  Complete lysis is considered if > 75%Complete lysis is considered if > 75% of the clot dissolvesof the clot dissolves  Initial reestablishment of flowInitial reestablishment of flow takes on an 3.3 hrs avg.takes on an 3.3 hrs avg. complete clot lysis up to 13hrs avgcomplete clot lysis up to 13hrs avg Systemic Heparin is continued through thisSystemic Heparin is continued through this periodperiod
  11. 11. Dr. Rajdeep Agrawal Predictors Of Successful Thrombolysis  Easy traversability of clot withEasy traversability of clot with non-hydrophilic guide wire 0.035”non-hydrophilic guide wire 0.035”  Significant lysis within 2hrsSignificant lysis within 2hrs
  12. 12. Dr. Rajdeep Agrawal Thrombolysis-Contraindications  AbsoluteAbsolute 1. Recent Cerebro Vascular Accident,1. Recent Cerebro Vascular Accident, neurosurgery, intracranial trauma,neurosurgery, intracranial trauma, within the last 3 monthswithin the last 3 months 2. Active bleeding diathesis2. Active bleeding diathesis 3. Recent GI bleed (< 10days)3. Recent GI bleed (< 10days) 4. Irreversible ischemia4. Irreversible ischemia
  13. 13. Dr. Rajdeep Agrawal Thrombolysis-Contraindications  RelativeRelative 1. Cardiopulmonary resuscitation,1. Cardiopulmonary resuscitation, major nonvascular surgery, traumamajor nonvascular surgery, trauma within last 10 dayswithin last 10 days 2. Uncontrolled HT systolic > 1802. Uncontrolled HT systolic > 180 diastolic >110 3.diastolic >110 3. Puncture of non compressible vesselPuncture of non compressible vessel 4. Intracranial tumor, diabetic proliferative4. Intracranial tumor, diabetic proliferative retinopathy, bacterial endocarditis,retinopathy, bacterial endocarditis, pregnancypregnancy
  14. 14. Dr. Rajdeep Agrawal PIAT -- Complications  Significant hemorrhage 1%Significant hemorrhage 1%  Distal EmbolisationDistal Embolisation
  15. 15. Dr. Rajdeep Agrawal Post PIAT Management  Underlying flow limiting lesion is presentUnderlying flow limiting lesion is present in more than 70% cases & surgery orin more than 70% cases & surgery or PTA can be performed immediatelyPTA can be performed immediately after thrombolysis with no additional riskafter thrombolysis with no additional risk of hemorrhageof hemorrhage  No underlying lesion -- anticoagulationNo underlying lesion -- anticoagulation
  16. 16. Dr. Rajdeep Agrawal Treatment of Acute Occlusion  Embolectomy - Using Fogarty’s catheter ->Embolectomy - Using Fogarty’s catheter -> Catheter passed beyond emblous, balloonCatheter passed beyond emblous, balloon inflated & pulled back till blood comesinflated & pulled back till blood comes  Direct Embolectomy - Artery exposed,Direct Embolectomy - Artery exposed, transverse incision, clot removed.transverse incision, clot removed.  Intra-arterial Thrombolysis - TPA preferred.Intra-arterial Thrombolysis - TPA preferred. Arteriography done and a catheter embeddedArteriography done and a catheter embedded in clot - Thrombolytic agent infused overin clot - Thrombolytic agent infused over several hrsseveral hrs
  17. 17. Dr. Rajdeep Agrawal Surgical Embolectomy  Relatively simple procedureRelatively simple procedure  Done under LA, small incision in theDone under LA, small incision in the groin, using Fogarty’s cath.groin, using Fogarty’s cath.  ProblemsProblems 1. Blind procedure, can be traumatic1. Blind procedure, can be traumatic 2. Not successful in 10 – 30% cases2. Not successful in 10 – 30% cases 3. Inefficient in multistenosed artery3. Inefficient in multistenosed artery 4. Complete removal of thrombus4. Complete removal of thrombus difficult in leg arteriesdifficult in leg arteries
  18. 18. Dr. Rajdeep Agrawal Post PTA MX  Antiplatelet agentsAntiplatelet agents  LMW Heparin X 7 – 10 DLMW Heparin X 7 – 10 D  IV / oral TrentalIV / oral Trental  StatinsStatins  Aggressive control of riskAggressive control of risk factorsfactors
  19. 19. Dr. Rajdeep Agrawal Newer Techniques Of Angioplasty  AtherectomyAtherectomy  DirectionalDirectional  Percutaneous RotationalPercutaneous Rotational  TECTEC  LASERLASER  StentStent
  20. 20. Dr. Rajdeep Agrawal Directional Atherectomy  It excises the atheromatousIt excises the atheromatous plaque material into very fineplaque material into very fine slices which can be retrievedslices which can be retrieved outside bodyoutside body
  21. 21. Dr. Rajdeep Agrawal Percutaneous Rotational Atherectomy (Rotablator)
  22. 22. Dr. Rajdeep Agrawal LASER  A LASER produces an intenseA LASER produces an intense beam of light in uniformbeam of light in uniform wavelength that can be preciselywavelength that can be precisely focused to deliver high energyfocused to deliver high energy levels to a small arealevels to a small area  It converts solid plaque to gasIt converts solid plaque to gas which is soluble in bloodwhich is soluble in blood
  23. 23. Dr. Rajdeep Agrawal Stent  An expandable metallic helicalAn expandable metallic helical device which is permanentlydevice which is permanently implanted in the arteryimplanted in the artery ..  MechanismMechanism  The prosthesis acts as aThe prosthesis acts as a scaffold to hold the artery openscaffold to hold the artery open  Prevents recoil of the vesselPrevents recoil of the vessel  Reduces RestenosisReduces Restenosis
  24. 24. Dr. Rajdeep Agrawal Lower Limb Ischemia - Approach to therapy  Risk factor managementRisk factor management ** Abstinence from smokingAbstinence from smoking ** Control of diabetesControl of diabetes ** Control of hyperlipidemiaControl of hyperlipidemia
  25. 25. Dr. Rajdeep Agrawal Lower Limb Ischemia - Approach to therapy  Risk factor managementRisk factor management ** Weight reductionWeight reduction • Control of hypertension, CHF, CRFControl of hypertension, CHF, CRF • Chronic anticoagulation oral withChronic anticoagulation oral with judicious use of PT PIjudicious use of PT PI measurementsmeasurements
  26. 26. Dr. Rajdeep Agrawal Lower Limb Ischemia - Role of Drugs  Pentoxyfylline – not usefulPentoxyfylline – not useful  Antiplatelet AgentsAntiplatelet Agents  ProstaglandinsProstaglandins  VasodilatorsVasodilators