A 44-year-old man presented with acute onset left leg pain, numbness, and weakness. On examination, his left lower limb was pale, cold, pulseless with reduced sensation. Imaging showed a thrombus in his aorta and left iliac and femoral arteries. He was diagnosed with acute limb ischemia and underwent aortic endarterectomy, femoral embolectomy and patch angioplasty, and fasciotomy to restore blood flow and prevent compartment syndrome. Post-operatively, he required monitoring for reperfusion injuries and long-term anticoagulation to prevent recurrence.

1. Case capsule

2. History
• 44 year old Mr. X
• Acute onset pain in the left leg
• Progressive numbness of the left leg
and
• Weakness at the ankle
• What else would you like to know?
12 hours

3. • No history of IHD, RHD, TIA, stroke,
claudication.
• No history of diabetes/hypertension.
• Smoking history of 20 pack years.

4. Examination
• BP- 120 / 70 mm Hg.
• Pulse- 110 per minute.
• Bilateral femoral, popliteal , posterior tibial
and dorsalis pedis pulses were not palpable.
• No bruits heard.
What else would you like to examine?

5. • Left lower limb was pale, cold and pulseless.
• Reduced sensations over the limb.
• Ankle power- grade 3
• DIAGNOSIS?

6. ACUTE LIMB ISCHEMIA
• Acute limb ischemia is defined as a sudden
decrease in limb perfusion that threatens the
viability of the limb.
• incidence -1.5 cases per 10,000 persons per
year
• Classification of acute limb ischemia?
• Which grade was our patient?

7. Classification of acute limb
ischemia
from the Society of Vascular Surgery/International Society of Cardiovascular Surgery
(Rutherford et al, 1997)

8. • Etiology of acute limb ischemia?

9. Etiology
• Acute thrombotic occlusion
• Embolus -30%
• trauma
• iatrogenic injury
• popliteal aneurysm
• aortic dissection.

10. • How will you differentiate between embolus and
thrombus?

11. EMBOLUS THROMBOSIS
Severity Complete- no collaterals Incomplete- collaterals
Onset Seconds or minutes Hours or days
Multiple sites Upto 15% cases Rare
Embolic source Present (usually AF) Absent
Bruits Absent Present
Contralateral pulses Present Absent
Claudication Absent Present

12. • What are the 6 Ps of acute limb ischemia?

13. Clinical features
• Pain
• Parasthesia
• Paralysis
• Pulselessness
• Pallor
• Perishing cold

14. • Stat dose of IV Heparin 5000 IU (80 IU/kg)
• What is the role of heparin?
• What are the contraindications for heparin

15. Contraindications for heparin
• Active bleeding
• Recent neurosurgical and spine
operations(within 3 months)
• Recent GI bleed(less than 10 days)
• Recent eye surgery
• Established CVA within 2 months.
• What next?

16. Imaging
• Urgency for revascularization vs. Time for
imaging.
• Category I, IIA – CT angiogram
• Category IIB – Immediate surgery
• Category III – imaging not indicated.
• Best approach –Hybrid theatre with Catheter
directed angiography with endovascular
Thromboembolectomy

17. In our patient
• Suspected acute on chronic limb ischemia.
• Contralateral pulses absent.

31. CT angiogram for Mr. X
• Thrombus in the infrarenal aorta >90%
occlusion.
• Occlusion of Left distal CFA and proximal SFA.
• Reformation of distal SFA and popliteal with
poor distal run off.
• What next?

32. • Aortic endartrectomy, femoral embolectomy
and patch plasty and fasciotomy.

33. Endovascular
• Patients presenting early – less than 12 hours.
• Limb should be viable.
• No contraindication to thrombolysis.(recent
major surgery, IC bleed or active bleeding).
• Diagnostic angiography performed prior to it.

34. • Direct administration of thrombolytic agent
into thrombus with a multi side hole catheter.
• Clinical and angiographic examinations during
administration.
• Once flow established  angiography to look
for stenotic /inciting lesions management of
which can be catheter based or open.
• WHAT ARE THE COMMON THROMBOLYTIC
AGENTS?
• HOW DO THEY ACT?

35. • Common thrombolytic agents – alteplase,
reteplase, rTPA, urokinase.
• Act by converting plasminogen to plasmin
which degrades fibrin.

36. Open surgical technique
• Surgical strategy guided by anatomical lesion
and type of occlusion.
• Thromboembolectomy with forgarty catheter/
bypass surgery
• Adjuncts – Endarterectomy / patch
plasty/intra-operative thrombolysis/
fasciotomy.

37. •POST OPERATIVE MONITORING?
Post operative care

38. • Adequate hydration.
• Monitor urine output.
• Examine the limb for viability.
• Creat, K+, CPK, HCO3-

39. Reperfusion injuries
• Myocardial injury:
– Release of myocardial depressant factors: C3a, TxA2, LTD4,
PAF
• Remote lung injury:
– pulmonary edema, ARDS
• Renal injury:
– Myoglobin deposition in renal tubules
– Acute tubular necrosis
• Gastrointestinal
– Mucosal edema
• Compartment syndrome

40. Compartment syndrome
• severe pain, hypoesthesia, and weakness of
the affected limb;
• myoglobinuria and elevated CPK.
• anterior compartment of the leg - most
susceptible.
• assessment of peroneal-nerve function
• Compartment pressure >30 mm Hg

41. • Long term anticoagulation
• Ecospirin
• Clopidogrel if stenting done.

42. Prognosis

43. • THANK YOU