1. Teguh Marfen Djajakusumah
Division of Vascular and Endovascular Surgery –
Department of Surgery
Universitas Padjadjaran – Hasan Sadikin Hospital
ACUTE LIMB ISCHEMIA
AND
THROMBECTOMY
2.
3. DEFINITION
• Acute Limb Ischemia (ALI) is the result of a sudden
deterioration in the arterial supply to the limb.
• AHA 2016: Acute (<2 week), severe hypoperfusion of
the limb characterized by these features: pain, pallor,
pulselessness, poikilothermia (cold), paresthesias, and
paralysis.
• Presentation is normally up to 2 weeks following the
acute event
• Two causes: Arterial embolism and Thrombosis
• Earnshaw JJ. Acute Ischemia: Evaluation and Decision Making. In: Rutherford’s Vascular Surgery, 8th edition. Elsevier-Saunders, 2014:161;2518
Inter-Society Consensus for the Management of PAD (TASC-II). J vasc surg 2007:45;1;40-47
• Gerhard-Herman MD, Gornik HL, Barret C, Corriere MA. et al. 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity
Peripheral Artery Disease. Journal of the American College of Cardiology
4. DEFINITION
Critical Limb Ischemia (CLI)
A condition characterized by chronic (≥2 week) ischemic
rest pain, non-healing wound/ulcers, or gangrene in 1 or
both legs attributable to objectively proven arterial
occlusive disease.
• Gerhard-Herman MD, Gornik HL, Barret C, Corriere MA. et al. 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity
Peripheral Artery Disease. Journal of the American College of Cardiology
5. EMBOLISM
• Mostly cardiac origin
• Atrial and Ventricular
• Most common cause: atrial
fibrilation (left atrial appendage
– stasis due to incoordinate
contractions of atrium and
ventricle)
• Mural thrombus: Acute Myocardial
Injury
• Left ventricular aneurysm
• Cardiac valve disease
6. THROMBOSIS
Atherosclerotic obstruction
• Progressive atherosclerotic narrowing of the
peripheral arteries: development of platelet thrombus
• Clinical manifestations are less dramatic than emboli
due to collateralization
Hypercoagulable states
• Low arterial flow and hyperviscosity
• Associated with venous thrombosis
Aortic or arterial dissection
7.
8. INCIDENCE
There is little information about the incidence of
acute ischemia in general population, but it is
estimated around 14 in every 100,000 population
9. CLINICAL PRESENTATION
• Depend on the size of the artery occluded and whether
collaterals have developed
• Symptoms (sudden onset)
1. Loss sensation
2. Motor nerve (weakness)
3. Skin (pallor)
4. Muscles (muscle tenderness)
10. CLINICAL PRESENTATION
• Skin: White (pallor) at the beginning, then Dusky blue
as capillary venous-dilatation occurs.
• Terminal stage of skin ischemia is caused by
extravasation of blood due to capillary disruption: NON-
VIABLE SKIN Dangerous for Revascularization
11. CLINICAL ASSESMENT
• History
• Acute white leg: urgent intervention
• Severe ischemia: irreversible muscle necrosis
occurs within 6 – 8 hours
• Risk factors (heart disease, diabetes, smoking)
• Physical findings
• 6 P’s; pain, pallor, paresis, pulse deficit, paresthesia,
poikilothermia
• ABI (if possible)
12. CLINICAL ASSESMENT
• Late Signs:
• Muscle rigor
• Tenderness
• Pain on passive movement
• Paresis limb
• Absence of doppler signal
14. • Look normal skin
appearance
• Anesthetic, paralyzed
• Note for RIGOR (foot)
• Collapse of saphenous
vein?
15.
16. INVESTIGATION
• Patients with ALI should be evaluated in the same
fashion as those with chronic symptoms, but the
severity and duration of ischemia at the time of
presentation rarely allow this to be done at the onset
• Lab studies: ECG, CBC, and hypercoagulability test
• Arteriography
• CTA
• MRA
17. TREATMENT
The standard therapy is:
UNFRACTIONATED HEPARIN Intravenously
Recommendation I (Strong – Effective)
Level of Evidence: Consensus of Expert Opinion based on clinical experience
20. TIMING FOR REVASCULARIZATION
• Category I (viable limb): within 6-24 hours
• Category IIa & IIb (marginally or immediate
threatened limb): within 6 hours
• Revascularization technique are depend on
facilities available
Recommendation I (Strong – Effective)
Level of Evidence: randomized and non-randomized, meta analysis, limited data
21. TREATMENT – CD - THROMBOLYSIS
• RCT: No clear superiority for thrombolysis versus surgery on
30 days limb salvage
• Surgery is 3 to 5 fold more performed than thrombolysis
• Initial treatment of choice in level I or IIa
• Advantage: less endothelial trauma, lysis clot in small vessel
• Systemic thrombolysis: no role!
• Berridge D, Kessel D, Robertson I. Surgery versus thrombolysis for initial management of acute limb ischaemia. Cochrane
Database Syst Rev 2002; CD002784(1)
• Kuukasjarvi P, Salenius J. Perioperative outcome of acute lower limb ischaemia on the basis of the national vascular registry.
The Finnvasc Study Group. Eur J Vasc Surg 1994;8:578-83.
• Eliason JL, Wainess RM, Proctor MC, Dimick JB, Cowan JA Jr, Upchurch GR Jr, et al. A national and single institutional
experience in the contemporary treatment of acute lower extremity ischemia. Ann Surg 2003;238(3):382-9. discussion 389–390.
23. FEMORAL EMBOLECTOMY - PROCEDURE
• Longitudinal groin incision,
look for CFA, SFA, and
DFA
• Pass rubber sling around
CFA, DFA, SFA
• Transverse arteriotomy for
emboli cases
• Longitudinal arteriotomy
for diseased artery
CFA
DFA
24. • Make sure the patient is adequately anticoagulated
before occluding the artery
• Heparin IV 75-100 IU/Kg, wait 3-5 min before clamping.
Effective for 3-4 hours. Can be repeated in 2 hours
25. CHOOSING THE CATHETER
Depend on vessels size:
• Size 2: Less than 2mm (Pedal, hand vessels)
• Size 3: 2-4mm (Tibial, infrapopliteal)
• Size 4: 4-10mm (Above knee, superficial femoral artery,
common femoral artery)
• Size 5: More than 10mm (iliac artery)
• Size 6,7: Aorta (saddle embolism)
26. FEMORAL EMBOLECTOMY - PROCEDURE
• Pass the embolectomy
catheter distally
• Extract the blood clot
• Repeat it until distal
backflow occurred
• Heparin flush
• Tighten up the sling or
bulldog clamp
• If there is a proximal clot,
repeat the procedure
proximally
27. FEMORAL EMBOLECTOMY - PROCEDURE
• The successful of proximal embolectomy is marked by strong
proximal flow; if the blood ooze, repeat the procedure. If the
flow remain ooze, it is possible that the occlusion cause by
stenosis / plaque.
Normal CFA flow: 314 mL/min
28.
29. FEMORAL EMBOLECTOMY - PROCEDURE
• Make sure the pulse present
• Running suture with 6.0 polypropylene
30. POST PROCEDURE
• Make sure the distal pulse present (might be delayed)
• Warm foot, return of capillary refill
• Observe the calf, check for any swelling
• Heparin 600-1000 unit hourly
• Proper hydration
• If swelling occurred, and patient started to feel pain, it is the
first sign of compartment syndrome: urgent FASCIOTOMY*
– Do NOT wait for 5Ps!
* Fasciotomy should be considered for patient with category IIb ischemia
for whom the time of revascularization is > 4hour
Recommendation I (Strong – Effective)
Level of Evidence: randomized and non-randomized, meta analysis, limited data
31. SUMMARY
• ALI: Heparinization
• ALI Class I, IIa, IIb: REVASCULARIZATION
• ALI Class III: Amputation
• Class III is: Blue, or Rigor, and anesthetic, paralysis
• Revascularization: Thrombectomy
• Compartment Syndrome: Fasciotomy
32. SUMMARY
• Ina CBGs: I-1-20-I,II,III
• Primary M62.26
• Secondary I74.3
• Treatment 38.18
• And 38.13 for fasciotomy
