Acute limb ischaemia Joel Arudchelvam MBBS (COL), MD (SUR). MRCS (ENG) Consultant Vascular and Transplant Surgeon The National Hospital of Sri Lanka , Colombo Definition Causes Differentiating thrombosis and embolism

1. ACUTE LIMB ISCHAEMIA
Dr. Joel Arudchelvam
MBBS (COL), MD (SUR). MRCS (ENG)
ConsultantVascular andTransplant Surgeon
The National Hospital of Sri Lanka , Colombo

2. Acute limb Ischaemia -
Definition
 Sudden interruption of blood supply to
limb resulting in threat to the limb
viability.

3. Acute limb Ischaemia - Causes

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

5. Sources of emboli
 Heart – recent MI, Atrial fibrillation,Valvular
heart disease.
 Blood vessels – aneurysms
 An embolus gets stuck at sites of bifurcation
as the diameter of the vessels reduces at
these places.

6. Sites of embolus occlusion

7. Acute limb Ischaemia
Presentation
“ P ”s
 Pain
 pallor
 Perishing cold
 Pulselessness
 Paresis / paralysis
 Paraesthesia / anaesthesia.
Beware
 After trauma
 After anaesthesia
 Acute limb ischemia is a clinical diagnosis -there is no need of
imaging.

8. Embolus

9. Acute limb Ischaemia
Management
 Recognize
 Start unfractionated heparin
 Loading dose 75 – 100 IU/Kg ( approximately 5000 IU )
 Followed Infusion of heparin -18U/kg (approximately -
1000U/hr)
 Refer to vascular surgeon
 Pain relief
 Keep fasting
 Inform theatre and anaesthetist
 Consent – for embolectomy and fasciotomy
 Check theViability of the limb - note.

10. Acute limb Ischaemia
 Surgery
 Embolectomy with fogarty
catheter
 Can be done under LA

11. Embolectomy with fogarty
catheter

12. Embolectomy with fogarty
catheter

13. 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

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

15. Reperfusion effects
 Local
 Reperfusion injury – paradoxical death of already
dying muscles after reperfusion
 Systemic
 Reperfusion syndrome
 Hypotension
 ARDS
 Lactic acidosis
 Hyperkalemia
 Renal failure

16. Reperfusion effects
 Local
 Reperfusion injury – paradoxical death of already
dying muscles after reperfusion

17. DURING ISCHAEMIA

18. DURING ISCHAEMIA

19. AFTER REPERFUSION

20. AFTER REPERFUSION

21. MANAGEMENT OF REPERFUSION EFFECTS

22. MANAGEMENT OF REPERFUSION EFFECTS

23. Reperfusion effects
 Systemic
 Substances Released
 Lactic Acid
 K+
 Inflammatory Mediators
 Myoglobin
 Activated Leucocytes
 Etc.

24. Reperfusion effects
 Systemic
 Reperfusion syndrome
 Hypotension
 ARDS
 Lactic acidosis
 Hyperkalemia
 Renal failure
 Ect

25. Management and prevention of
Reperfusion syndrome
 Cardiac – IV fluids and inotropes
 Respiratory – KeepO2
 Renal – hydration, Monitor IP/ OP, dialysis
 Correct electrolyte abnormalities – K+
 Continue mannitol for 48 hours

26. Reperfusion effects
 Mangement
 Ligation of vessel if not
responding to other supportive
measures

27. Compartment syndrome
Reduced organ perfusion due to increased
intra compartment pressure.
 Compartment Perfusion Pressure (CPP)
 MeanArterial Pressure (MAP)
 Intra Compartmental Pressure (ICP)
CPP = MAP – ICP

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

29. Compartment syndrome
Clinical features
 Excessive pain - pain on passive movements
 Numbness -e.g. anterior compt. first toe web (deep peroneal N )
 Tense swollen leg
 Do not look for absent distal pulse – late

30. Compartment syndrome
Treatment
 Recognize
 Reduce intracomparmental pressure
 Remove bandages and cast
 Keep limb elevated
Fasciotomy

31. Compartment syndrome
Treatment

32. Compartment Syndrome
Fasciotomy

33. Volkmann ischaemic
contracture

34. Thank You