Acute limb ischaemia
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Lecture on acute limb ischaemia for medical students. This is a surgical emergency that can be daunting even for experienced surgical doctors. Lecture encompasses classifications, basic sciences and principles of management.
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Acute limb ischaemia
- 1. Acute limb ischaemia Chea Chan Hooi Surgeon Sibu Hospital
- 2. Content • Introduction • Definition • Etiology • Clinical features • Classification • Investigations • Treatment options
- 3. Introduction • Vascular emergency • 14 of 100 000 population/year (USA)
- 4. Definition • Sudden interruption of blood supply leading to inadequacy to meet metabolic demands • ≤ 2 weeks
- 5. Etiology Traumatic • Blunt – Fracture – Dislocation • Penetrating Non-traumatic • Embolism • Thrombosis • Intimal flap – post bypass surgery
- 6. Embolus Thrombus Clinical feature Very sudden onset Existing claudication is uncommon Identifiable source (AF, previous MI, valvular heart disease, AAA) No signs of peripheral arterial disease, contralateral pulse present More gradual onset Commonly have claudication No identifiable source Signs of existing peripheral arterial disease, contralateral pulse weak/absent Definitive treatment Fogarty balloon catheter embolectomy Arterial by-pass/recon Amputation Thrombolysis (streptokinase, rTPA) Endovascular procedures (catheher thrombectomy or thrombus aspiration, balloon angioplasty, stenting) Arterial by-pass/recon Amputation
- 7. Clinical features • 6 Ps – Pulselessness – Pallor – Perishing cold – Paraesthesia – Pain – Paralysis
- 9. Rutherford Classification Category Description/Prog nosis Findings Doppler signal Sensory loss Motor loss Arterial Venous I Viable Not immediately threatened None None Audible Audible II Threatened A Marginally B Immediately Salvageable if promptly treated Salvageable if immediately revascularised Minimal (toes) More than toes, rest pain None Mild - moderate Inaudible Inaudible Audible Audible III Irreversible Major tissue loss or permanent nerve damage Profound, anaesthetic Paralysed Inaudible Inaudible
- 11. Systemic examination • Carotid bruit • Cardiac murmur • Lung bibasal creps • AAA • Full neurological examination
- 12. Investigations • CT angiography – Most cases due to embolism have typical presentation no investigation necessary especially if the limb viability is threatened – Only if early ischaemia or non-viable – MUST NOT SIGNIFICANTLY DELAY MANAGEMENT
- 13. • CK • Urine myoglobin • FBC • BUSEC • PT/PTT • GSH • ECG • CXR
- 14. Treatment options • Resuscitation • Symptomatic relief • Anticogulation – Unfractionated heparin – Bolus dose followed by infusion – Adjust for PTT ratio 2.0 – 2.5x – Might be omitted if definitive intervention possible <90 mins • Definitive intervention – Depends on the most likely cause of ischaemia
- 15. Thrombosis • Non-operative management • Thrombolysis – Kinases – rTPA • Thrombectomy using ultrasonic waves • Endovascular intervention – Angioplasty – Stenting • Bypass surgery • Fasciotomy • Amputation Embolism • Non-operative management • Embolectomy • Amputation
- 18. TQ! Q&A?