Acute Limb Ischemia - Emergency Case presentation

2. A 70 year old female came to casuality with
c/o of sudden onset of pain in left leg from
one hour @3.30 pm on 30th july 2014

3. O/E there were absent popliteal and lower
pulsations and decreased sensations of left leg
and it was cold and pale compared to right leg.
Patient had history of Heart disease and k/c/o
Hypertension and DM type 2.
No Recent history of Trauma/Claudication/Fever/
intravascular procedures / drugs of abuse.
Contralateral leg pulses are felt

5. Patient is sent for urgent Doppler
Ultrasonography @3.35pm

6. • Ultrasonography revealed Large Clot in Left
common iliac artery

7. Patient is shifted to Operation theatre under
care of vascular surgeon @ 3.45pm

8. Acute Limb Ischemia
Etiology

9. Clinical Evaluation of Acute Ischemia (Clinical Picture)
Signs of acute ischemia
5Ps
Pain: symptom
+
Pulseless
Pale
Parasthesia
Paralysis
Inspection
COLOR:
Early: pale
Later: cyanosed mottling fixed
mottling & cyanosis
Pallor
Reversible
mottling
An area of fixed
cyanosis surrounded
by reversible
mottling
Fixed
mottling &
cyanosis

10. Clinical Evaluation of Acute Ischemia (Clinical Picture)
Signs of acute ischemia
5Ps
Pain: symptom
+
Pulseless
Pale
Parasthesia
Paralysis
Palpation
Femoral Popliteal
Posterior tibial Dorsalis pedis
Palpate peripheral pulses, compare with the other
side & write it down on a sketch
Slow capillary refilling of the skin after finger pressure

11. Clinical Evaluation of Acute Ischemia (Clinical Picture)
Signs of acute ischemia
5Ps
Pain: symptom
+
Pulseless
Pale
Parasthesia
Paralysis
Palpation
Loss of sensory function
Numbness will progress to anesthesia
Progress of Sensory loss
Light touch
Vibration sense
Proprioreception
Deep pain
Pressure sense
Late

12. Clinical Evaluation of Acute Ischemia (Clinical Picture)
Signs of acute ischemia
5Ps
Pain: symptom
+
Pulseless
Pale
Parasthesia
Paralysis
Palpation
Loss of motor function:
Indicates advanced limb threatening
ischemia
Late irreversible ischemia: Muscle turgidity
Intrinsic foot muscles are affected first,
followed by the leg muscles
Detecting early muscle weakness is
difficult because toes movements are
produced mainly by leg muscles

13. Investigations

14. Doppler US
to assess the level of obstruction & severity of ischemia

15. • What are we
• looking for?
• NORMAL
• • Multiphasic
• • Pulsatile
• • Regular amplitude
• An audible Doppler signal assures some blood flow. No Doppler
signals, then a vascular surgeon should be immediately consult

16. If a pulse is detected, then the ankle-brachial index (ABI)
and segmental leg pressures should be checked..

17. 0.7 to 0.9 is mild disease,
0.5 to 0.69 is moderate disease,
< 0.5 is severe disease.

18. Management of Acute Limb Ischemia
The severity and duration
of ischemia at the time of
presentation provides a
narrow margin of time for
investigations and
treatment.

19. Rutherford Classification
Category Description Cap. refill Paralysis Sensory
loss
A V
I Viable Not immediately
threatened
Intact - - Aud Aud
IIa Marginally
Threatened
Salvagable if
treated
Intact/slow - Partial _ Aud
IIb Immediately
Threatened
Salvagable if
treated
emergently
Slow/absent Partial Partial _ Aud
III Irreversible Primary
amputation req.
Absent Complete Complete _ _
Doppler

20. IMMEDIATE CARE
THROMBOLYTICS
SURGERY

21. Immediate Care
1.Anticoagulation
2.Analgesia
3.measures to improve existing perfusion
4.treatment of associated cardiac
conditions

22. B Catheter directed thrombolysis
Agents used: Streptokinase,
Urokinase, tissue plasminogen
activator
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

23. Contraindications:
Absolute:
1. Cerebro-vascular stroke within previous 2 months
2. Active bleeding or recent GI bleeding within previous 10 days
3. Intracranial trauma or neurosurgery within previous 3 months
Relative:
1. Cardio-pulmonary resuscitation within previous 10 days
2. Major surgery or trauma within previous 10 days
3. Uncontrolled hypertension

24. Embolectomy
Fogarty balloon catheter
(with post-op anti coagulants)

26. for irreversible
ischemia with
permanent tissue
damage

27. Clinical Outcomes
• Mortality -15–20%.
• Major morbidities include:
1. Due to major bleeding 10–15% of patients
require transfusion/and or operative
intervention
2. Amputation (25–30% of patients)
3. Fasciotomy (5–25% of patients)
4. Renal insufficiency (up to 20% of patients)

29. Conclusions and Recommendations
• Heparin should be administered as soon as
possible.
• In Patient with viable and marginally threatened
limb imaging studies can be obtained to guide
therapeutic decision.
• In patient with Immediate threatened limb
Emergency angiography followed by catheter
based thrombolysis or thrombectomy or open
surgical vascularization is indicated to restore or
preserve limb viability.