This document discusses arterial insufficiency, defined as sudden or gradual loss of arterial blood flow to the limbs. Acute limb ischemia occurs within 2 weeks of onset, while chronic limb ischemia lasts over 2 weeks with objectively proven arterial disease. The pathophysiology involves ischemia-reperfusion injury damaging cell membranes and increasing free radicals. Clinical evaluation looks for the five Ps: pain, pallor, paresthesia, paralysis, and pulselessness. Diagnosis involves physical exam, imaging like Doppler ultrasound, and laboratory tests like ankle-brachial pressure indexes. Treatment depends on severity, ranging from medical management with anticoagulation to endovascular or open surgical revascularization procedures like bypass grafts or amputation in severe cases

1. INSUFICIENCIA ARTERIAL
Jorge E. ReyesTovilla
MIP
Cirugía Cardiovascular
Internado Rotatorio de Pregrado

2. Antecedentes históricos

3. Definición
 La insuficiencia arterial aguda y crónica es
resultado de las alteraciones hemodinámicas
producto e la obstrucción arterial brusca o
paulatina en cualquier territorio e la
economía.

4. Acute Limb Ischemia
 Is defined as sudden loss of limb perfusion and
the term is applicable up to 2 weeks after an
initiating event

5. Chronic Limb Ischemia
 Is reserved for patients with objectively
proven arterial occlusive disease and
symptoms lasting for more than 2 weeks.

6. Fisiopatología
 The lower extremity may be salvaged after up to 5 to
6 hours of profound ischemia.
 Skin and bone are relatively resistant to the effects
of ischemia
 Nervous tissue is generally the most sensitive
component of the extremity to the effects of
ischemia
 Skeletal muscle plays a pivotal role in the numerous
local and systemic manifestations of extremity
ischemia-reperfusion injury.
 Alteración del flujo laminar se ocasiona turbulencia y
como consecuencia lesión enotelial.

7. Síndrome de reperfusión
 Daño a la membrana celular
 Fallo de la bomba ATPasa
 Edema intersticial debido a permeabilidad de
la membrana a iones proteínas y agua.
 Radicales libres que atacan a los ácidos
grasos de la membrana fosfolipídica celular
causando daño mecánico y funcional.

8. Anatomía patológica

10. Cuadro clínico
 “Five Ps”: pain, pallor, paresthesias, paralysis,
and pulselessness, to which some add a sixth
"P"—poikilothermia or "perishing cold.
 Clinical evaluation is extremely important in
determining the etiology and location of the
obstruction. One of the most important
pieces of information to obtain is whether the
patient has had prior vascular procedures or if
there is a history of LE claudication.

11. Exploración física
 Hipotermia
 Llenado capilar prolongado o ausente
 Alteraciones sensoriales o motoras
 Cambios irreversibles en músculo o piel
 Patients with acute arterial embolism generally
have normal palpable pulses above the occlusion
with a complete absence below.The pulse
immediately above the occlusion may be
particularly prominent with a “water-hammer”
quality that results from limited arterial outflow.

12. Cuadro clínico de la CLI
 Patients have such long-standing and severe
ischemia that irreversible ischemic injury to the
extremity (manifesting as rigor of the muscles or
frank gangrenous changes to the foot) has
occurred.
 Dolor en ciertos grupos musculares producto de
la actividad que ceden al descanso.
 Clauicación incapacitante
 Dolor en reposo
 Úlceras isquémicas

13. Diagnóstico clínico
 The diagnosis of LE occlusive disease often is
made based upon a focused history and
physical examination, and confirmed by the
imaging studies. A well-performed physical
examination often reveals the site of lesions
by detecting changes in pulses, temperature,
and appearances.

14. Diagnóstico por laboratorio
y gabinete
 No invasores:
- cuantificación de presiones sistólicas
segmentarias en reposo y con prueba de
esfuerzo
- Doppler y ultrasonofrafía duplex
- morfología e la onda de volumen del pulso
- La presión parcial de O2 transcutáneo
 Invasores :
- arteriografía ordinaria o
- la de sustracción digital

15. Tratamiento médico
 IV heparin bolus (5000-10,000 units) and
begun on a continuous infusion at 1000
units/hour.

16. Tratamiento quirurgico (ALI)
 Amputación: patients have such long-
standing and severe ischemia that irreversible
ischemic injury to the extremity (manifesting
as rigor of the muscles or frank gangrenous
changes to the foot) has occurred.
 Trombectomía

17. Tratamientoquirúrgico (CLI)
 Puentes arteriales: aortofemorales,
femorfemorales o axilofemorales
 Angioplastías intraluminales percutáneas

18. Bibliografía
 Townsend: SabistonTextbook of Surgery,
18th ed.
 Schwartz's Principles of Surgery, Ninth
Edition.
 Patología estructural y funcional 7 ed
 Tratado de cirugía general, CMCG, 2 ed