This document discusses peripheral arterial disease and acute arterial occlusion. It describes the typical presentation of an acutely ischemic leg using the "5 or 6 P's" mnemonic of pain, pallor, pulselessness, paresthesias, paralysis, and poikilothermia. Acute limb ischemia can be caused by thromboembolism from the heart, aorta, or iliac arteries, or stent/graft failure in previously treated patients. Treatment depends on the severity and viability of the limb and may involve imaging, endovascular or open revascularization, or amputation. Risks of open thrombectomy include intimal damage and dissection while risks of thrombolysis include minor bleeding at access sites or

1. HRISTO RAHMAN 11/04/20
PERIPHERAL ARTERIAL DISEASE
ACUTE ARTERIAL OCCLUSION

2. ACUTE ARTERIAL OCCLUSION

5. PERIPHERAL ARTERIAL DISEASE
• POPULAR MNEMONIC FOR DESCRIBING THE PRESENTATION OF AN
ACUTELY ISCHAEMIC LEG IS REFERRED TO AS THE 5 OR 6 P’s:
• 1. PAIN;
• 2. PALLOR;
• 3. PULSELESSNESS;
• 4. PARESTHESIAS;
• 5. PARALYSIS;
• 6. POIKILOTHERMIA

6. • THESE SYMPTOMS AND
FINDINGS VARY IN DEGREE AND
ARE NOT NECESSARILY
PREDICTIVE OF THE EXTENT OF
DISEASE OR DEGREE OF
ISCHAEMIA
• SIMILAR PRESENTATION MAY
BE SEEN IN THE SETTING OF
BLUNT OR PENETRATING
VASCULAR TRAUMA, IN WHICH
NATIVE, NON DISEASED BLOOD
SUPPLY IS SUDDENLY
INTERRUPTED
• PATIENTS WITH ACUTE LIMB
ISCHAEMIA MAY HAVE LESS
DEVELOPED COLLATERAL
CIRCULATION AND LESS
TOLERANCE TO PROLONGED
ISCHAEMIA

7. PERIPHERAL ARTERIAL DISEASE
• CAUSE OF ACUTE LIMB ISCHAEMIA
• - THROMBOEMBOLISM IN INTERVENTION NAIVE PATIENT:
• -1. SOURCE OF THROMBEMBOLISM FROM THE HEART, IN WHICH CASE ATRIAL
FIBRILLATION IS A CO-MORBIDITY;
• -2. FROM VALVE LEAFLETS;
• -3. AORTA AND ILIAC ARTERIES WITH OR WITHOUT CONCURRENT ANEURYSMAL
DISEASE
• - THROMBOEMBOLISM IN PATIENTS WITH SURGICAL HISTORY OF PREVIOUS BYPASS
OR STENT PLACEMENT:
• -1. ACUTE OCCLUSION OF GRAFT AND STENT FAILURE;
• -2. DISEASE PROGRESSION

8. THERE ARE OPEN SURGICAL AND ENDOVASCULAR METHODS FOR ADDRESSING THE
PROBLEM

9. ACUTE LIMB ISCHAEMIA
TREATMENT ALGORITHM
DETAILED PATIENT HISTORY AND PHYSICAL EXAMINATION ARE
NEEDED FOR CLINICAL DIAGNOSIS OF THE SEVERITY OF
DISEASE
DOPPLER ULTRASOUND
CATEGORY I LIMBS ARE VIABLE AND NOT IMMEDIATELY THREATENED IMAGING
REVASCULARASATIO
N
CATEGORY IIA LIMBS ARE THREATENED BUT SALVAGEABLE IF TREATED IMAGING
REVASCULARASATIO
N
CATEGORY IIB LIMBS ARE SALVAGEABLE IF TREATED AS AN EMERGENCY
REVASCULARASATIO
N
CATEGORY III
LIMBS HAVE IRREVERSIBLE ISCHAEMIA AND ARE NOT
SALVAGEABLE
AMPUTATION

11. CONTRAINDICATIONS FOR INTRA-ARTERIAL THROMBOLYSIS
ABSOLUTE
RELATIVE
MINOR

12. ALTERNATIVE TO THROMBOLYSIS

13. TECHNIQUE
• PROXIMAL AND DISTAL CONTROL OF FEMORAL/POPLITEAL ARTERY
• LONGITUDINAL ARTERIOTOMY CREATED
• THROMBECTOMY BALLOON PASSED PROXIMALLY AND DISTALLY WITH CARE
UNTIL EXCELLENT FORWARD BLEEDING AND REASONABLE BACKBLEEDING ARE
SEEN
• ONCE THE CLOT IS SUCCESSFULLY REMOVED, THE ARTERY IS FLUSHED
PROXIMALLY AND DISTALLY WITH HEPARINIZED SALINE BEFORE CLAMPS ARE
REPLACED
• PATCH ANGIOPLASTY SHOULD BE CONCIDERED TO AVOID NARROWING OF THE
ARTERY
• FOUR-COMPARTMENT FASCIOTOMY MAY BE NECESSARY DEPENDING ON
DURATION OF ISCHAEMIC INSULT

16. • COMPLICATIONS OF
OPEN THROMBECTOMY:
• - 1. INTIMAL DAMAGE;
• - 2. DISSECTION
• COMPLICATIONS OF
THROMBOLYSIS:
• - 1. MINOR BLEEDING:
• - 1.1. ARTERIAL ACCESS;
• - 1.2. VENIPUNCTURE SITES;
• - 1.3. FOLEY CATHETER
• - 2. MAJOR BLEEDING:
• - 2.1. GI BLEEDING;
• - 2.2. SYMTOMATIC INTRACRANIAL
HAEMORRHAGE
• IF NO CULPRIT LESION IS FOUND:
• - 1. HYPERCOAGULABLE WORKUP;
• - 2. ORAL ANTICOAGULATION
CONSIDERED