The document summarizes acute limb ischemia, including its causes, presentation, classification, diagnosis, and treatment. It defines acute limb ischemia as a sudden decrease in limb perfusion threatening limb viability. Common causes are embolism, thrombosis, and vasospasm. Diagnosis is clinical, and imaging such as CTA, ultrasound, and angiography can help determine the level and severity of obstruction. Treatment depends on the classification of ischemia severity and may include anticoagulation, endovascular interventions such as thrombectomy, or open surgical revascularization to restore blood flow and preserve the limb. Complications can include reperfusion effects, compartment syndrome, and ischemic contracture.

1. Acute Limb Ischemia

2. Acute Limb Ischemia
Presented by:
Dr. Md. Jahir Uddin Molla
Resident, Phase- B,
MS (CVTS)
BSMMU, Shahbag, Dhaka,
Bangladesh
Supervisor:
Dr. Shantonu Kumar Ghosh
Assistant Professor,
Department of Vascular Surgery,
National Institute of Cardio-vascular
Diseases, Dhaka, Bangladesh

3. Acute Limb Ischemia
“The Trans-Atlantic Inter-Society Consensus” defined acute ischemia
as-
“Acute limb ischemia is any sudden decrease in limb perfusion causing
a potential threat to limb viability”

4. Acute Limb Ischemia: causes
• Embolism
• Cardiac Embolism
• Atrial and Ventricular
• Paradoxical embolism
• Endocarditis
• Cardiac Tumor
• Noncardiac Embolism
• Atheroembolism
• Aortic Mural Thrombi
Angiogram Showing Aortic
Plaque (A) Causing Distal Popliteal
Thromboembolism (B).

5. Acute Limb Ischemia: causes
•Thrombosis
•Atherosclerotic Obstruction
•Hypercoagulable States
•Vasospasm
•Aortic Dissection
•Bypass Graft Occlusion

6. Acute Limb Ischemia: causes

7. Differentiating thrombosis and embolism
Embolism
• Sudden onset pain
• Young patient
• Has a source of emboli
• No history of occlusive arterial
disease
• Other pulses are present
• Thrombosis
• Sub acute onset
• Elderly patient
• No source of emboli
• History of occlusive arterial
disease
• Other pulses may be absent

8. Presentation
(symptoms and signs)
The well-known rule of P’s—
• Pain
• Pallor
• Perishing with cold
• Pulse deficit
• Paresis / paralysis
• Paraesthesia / anaesthesia.
• Beware
• After trauma
• After anaesthesia

9. CLASSIFICATION OF ACUTE
LIMB ISCHEMIA
• From Rutherford RB, Baker JD, Ernst C, et al. Recommended standards for reports
dealing with lower extremity ischemia: revised version. J Vasc Surg. 1997;26:517–
538.

10. DIAGNOSIS
Acute limb ischemia is a clinical diagnosis -there is no need of imaging.
• Aortic Occlusion
• Paralysis of the legs
• Patients are unwell with mottled skin discoloration (often extends
above the inguinal ligament onto the lower abdomen)
• No palpable extremity pulses
• Iliac Occlusion
The findings are similar to those for aortic occlusion, but unilateral.

11. • Femoro-popliteal Occlusion
• The symptoms are more severe if the profunda is involved.
Although the femoral pulse may be strongly palpable (owing to the
water-hammer effect), the artery may be occluded.
• Popliteal and Infra-popliteal Occlusion
• The calf muscles are ischemic with a palpable femoral pulse.

12. Clinical Evaluation of Acute Ischemia (Clinical
Picture)
Fixed
mottling &
cyanosis
An area of fixed
cyanosis
surrounded by
reversible
mottling
Pallor

13. Femoral Popliteal
Posterior tibial Dorsalis pedis

14. • Loss of motor function:
Indicates advanced limb threatening ischemia
• Muscle turgidity: Late irreversible ischemia

15. INVESTIGATION
• Computed Tomographic Angiography
• Ultrasound
• Transfemoral Arteriography
• Magnetic Resonance Angiography
• Echocardiography

16. Computed Tomographic Angiography
Computed tomography angiogram demonstrating marked
calcified atherosclerotic disease in the infrarenal
abdominal aorta

17. Doppler US
To assess the level
of obstruction &
severity of ischemia

18. Transfemoral Arteriography
Catheter-based angiogram demonstrating a severely atherosclerotic aorta with a
severe stenosis of the left renal artery and an occluded right renal artery. A selective
angiogram of the left renal artery shows the severity of stenosis

19. Angiogram Showing Popliteal Embolus

20. INITIAL MANAGEMENT
Goals of therapy include restoration of blood flow, preservation of limb
and life, and prevention of recurrent thrombosis
Diagnosis of acute ischemia Severity classified Immediate
interventions
• Anticoagulation
• Immediate anticoagulation with intravenous heparin
• Low-molecular-weight heparin

21. • Ancillary Supportive Measures
• Oxygen delivered by facemask
• Intravenous infusion of fluid and monitoring of urine output
• Full blood screen for blood urea nitrogen
• Full blood count
• Full thrombophilia screen
• Adequate analgesia
(Intramuscular opiates are contraindicated/patient-controlled
intravenous analgesia is a good alternative)

22. Contraindications to Pharmacologic
Thrombolytic Agents

23. SPECIFIC TREATMENT
• Anticoagulation alone
• Operative intervention
• Endovascular intervention via mechanical thrombectomy or
thrombolysis.

24. TREATMENT SELECTION
• Class I ALI - only medical therapy, such as anticoagulation.
Revascularization can be performed electively (thrombolytic or open
surgical intervention)
• Class II ALI requires a flexible approach to intervention.
All patients with class II ALI require revascularization to preserve the
functional integrity of the affected extremity.
For patients with class IIa ischemia, immediate revascularization is
not necessary

25. TREATMENT SELECTION
• More severe ALI (class IIb) - manifested by both sensory and motor
deficits, requires emergency revascularization.
• Class III ALI - manifests as a profound neurologic deficit (insensate,
paretic limb), muscle rigidity, and the absence of arterial and venous
Doppler ultrasound signals in the affected vascular bed.
• Revascularization is usually futile and may have adverse systemic
effects such as cardiac arrest due to acidosis and hyperkalemia
• Primary amputation should be considered.

26. TREATMENT SELECTION
• ENDOVASCULAR TREATMENT
• Currently available percutaneous endovascular procedures
include
• Catheter-directed thrombolysis (CDT)
• Pharmacomechanical thrombolysis
• Catheter-directed thrombus aspiration
• Percutaneous Mechanical Thrombectomy (PMT)

27. TREATMENT SELECTION
• SURGICAL REVASCULARIZATION
• Techniques for salvage of an ischemic limb include:
• Balloon catheter thrombectomy or embolectomy
• Bypass procedures to direct blood flow beyond the occlusion
• Endarterectomy with or without patch angioplasty
• Hybrid procedures combining open and endovascular techniques

28. Embolectomy with fogarty catheter

30. PROGNOSIS
• The medical state of a patient is a good prognostic index of survival.
• Patients with acute myocardial infarction or poor cardiac output have
a high mortality rate.
• Outcome can be predicted from pretreatment POSSUM
(Physiological and Operative Severity Score for the Enumeration of
Mortality and Morbidity) scores.

31. • Despite active intervention, the outcome after treatment is
often poor.
• In some patients, limb ischemia is a manifestation of the end
of life such as in the very elderly with multiple comorbidities
and palliative care is indicated rather than active
intervention.
• Very high-risk group in whom palliation might be appropriate
is patients with acute ischemia due to hypercoagulable blood
as a consequence of advanced malignancy.

32. UPPER LIMB ISCHEMIA
A number of significant differences exist
between acute ischemia of the arm and
leg.
• Arm ischemia seldom threatens the limb,
and treatment decisions are less urgent.
• Most arm ischemia is due to cardiac
embolism; atherosclerosis is rare in upper
limb arteries.

33. • The arm often improves after initial anticoagulation, and decisions
about whether to perform embolectomy can be difficult.
• A small number of patients present with class IIb critical ischemia and
should undergo urgent surgical intervention. Failed surgery in this
situation risks ischemic contracture

34. • The threat to the arm is generally low, but up to 20% of patients with
acute arm ischemia do not survive the acute event, usually owing to
cardiac complications.
• Rare causes of arm emboli include thoracic outlet syndrome and
proximal subclavian artery aneurysm.
• Arteriovenous fistulae for dialysis may also cause a number of
complications, including thrombosis and aneurysm formation.

35. Post operative management
• Monitor distal pulse
• Keep foot elevated
• Monitor movements and sensation
• Continue Heparin – 18U/kg per hour infusion
• Start warfarin when surgical bleeding is not a concern
• Monitor for reperfusion effects

36. Complications of Acute limb Ischaemia
• Reperfusion effects
• Compartment syndrome
• Volkmann ischemic contracture
• Limb loss
• Death

37. Reperfusion effects
• Local
• Reperfusion injury – paradoxical death of already dying muscles
after reperfusion
• Systemic
• Reperfusion syndrome
• Hypotension
• ARDS
• Lactic acidosis
• Hyperkalemia
• Renal failure

38. DURING ISCHAEMIA

39. AFTER REPERFUSION

40. MANAGEMENT OF REPERFUSION EFFECTS

41. MANAGEMENT OF REPERFUSION EFFECTS

42. Compartment syndrome
Reduced organ perfusion due to increased intra compartment
pressure.
CPP = MAP – ICP
• Compartment Perfusion Pressure (CPP)
• Mean Arterial Pressure (MAP)
• Intra Compartmental Pressure (ICP)

43. Compartment syndrome
Causes
• Trauma (muscle contusion)
• Haematoma
• Reperfusion
• Intracompartmental extravasation of fluids
• Tight bandage, cast

44. Clinical features
• Excessive pain - pain on passive movements
• Numbness -e.g. anterior compt. first toe web (deep peroneal N )
• Tense swollen leg

45. Treatment
• Recognize
• Reduce intracompartmental pressure
• Remove bandages and cast
• Keep limb elevated
• Fasciotomy

46. Ischemic contracture

47. Thank you