Acute limb ischaemia

ACUTE LIMB ISCHAEMIA
Dr Sumer Yadav
MCh --PlasticAnd Reconstructive Surgeon
sumeryadav2004@gmail.com

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

Acute limb Ischaemia

Etiology

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.

Clinical Evaluation of Acute Ischemia (Clinical Picture)
Signs of acute ischemia
5Ps
Pain: symptom
+
Pulseless
Pale
Parasthesia
Paralysis
Inspection
COLOR:
Early: pale
Later: cyanosed mottling fixed
mottling & cyanosis
Pallor
Reversible
mottling
An area of fixed
cyanosis
surrounded by
reversible mottling
Empty veins:
compare the Rt.
(ischemic) & Lt.
(normal)
Fixed
mottling &
cyanosis

5Ps
Pain: symptom
+
Pulseless
Pale
Parasthesia
Paralysis
Palpation
Femoral Popliteal
Posterior tibial Dorsalis pedis
Palpate peripheral pulses, compare with the other
side & write it down on a sketch
Temperature: the limb is cold with a level of
temperature change (compare the two limbs)
Slow capillary refilling of the skin after finger
pressure

5Ps
Pain: symptom
+
Pulseless
Pale
Parasthesia
Paralysis
Palpation
Loss of sensory function
Numbness will progress to anesthesia
Progress of Sensory loss
Light touch
Vibration sense
Proprioreception
Deep pain
Pressure sense
Late

5Ps
Pain: symptom
+
Pulseless
Pale
Parasthesia
Paralysis
Palpation
Loss of motor function:
Indicates advanced limb threatening
ischemia
Late irreversible ischemia: Muscle turgidity
Intrinsic foot muscles are affected first,
followed by the leg muscles
Detecting early muscle weakness is
difficult because toes movements are
produced mainly by leg muscles

INVESTIGATIONS
The severity and duration of ischemia at the time of presentation
provides a narrow margin of time for investigations

What are we
looking for?
NORMAL
• Multiphasic
• Pulsatile
• Regular amplitude
An audible Doppler signal assures some blood flow
No Doppler signals, a vascular surgeon should be immediately consulted

If a pulse is detected, then the ankle-brachial index (ABI)
and segmental leg pressures should be checked..

If time permits, do a duplex
ultrasound

Arteriography
 If the differentiation between embolic & thrombotic
ischemia is not clear clinically, and if the limb condition
permits,
 DO ANGIOGRAPHY

 Value of angiography
 Localizes the obstruction
 Visualize the arterial tree & distal run-off
 Can diagnose an embolus:
 Sharp cutoff, reversed meniscus or clot
silhouette

WWW.SMSO.NET
Embolism:
obvious cardiac source
No hx of cluadication
Normal pulses in contralateral limb
Angiogram: minimal atherosclerotic
Few collateral
Clinical differentiation
between thrombosis & embolism
Thrombosis:
No obvious cardiac source.
history of cluadication.
abnormal pulses in contralateral limb.
Angiogram: diffuse atherosclerotic
Well developed collateral

Rutherford Classification
Category Description Cap. refill Paralysis Sensory
loss
A V
I Viable Not immediately
threatened
Intact - - Aud Aud
IIa Threatened Salvagable if
treated
Intact/slow - Partial _ Aud
IIb Threatened Salvagable if
treated
emergently
Slow/absent Partial Partial _ Aud
III Irreversible Primary
amputation req.
Absent Complete Complete _ _
Doppler

Management

IMMEDIATECARE
THROMBOLYTICS
SURGERY

A. Immediate care
 Anticoagulation
 Analgesia
 measures to improve existing perfusion
 treatment of associated cardiac conditions

B Catheter directed
thrombolysis
Agents used: Streptokinase,
Urokinase, tissue plasminogen
activator
Indications:
1. Viable or marginally threatened limb (class I, IIa)
2. Recent acute thrombosis (not suitable for embolism or old thrombi)
3. Avoid patients with contraindications

Contraindications:
Absolute:
1. Cerebro-vascular stroke within previous 2 months
2. Active bleeding or recent GI bleeding within previous 10 days
3. Intracranial trauma or neurosurgery within previous 3 months
Relative:
1. Cardio-pulmonary resuscitation within previous 10 days
2. Major surgery or trauma within previous 10 days
3. Uncontrolled hypertension

SURGERY
OPERATIVE
REVASCULARISATION AMPUTATION

Embolectomy
Fogarty balloon catheter
(with post-op anti coagulants)

Embolectomy
SurgicalTherapy
• Iliac and femoral embolectomy
– Common femoral approach
–Transverse arteriotomy proximal profunda origin
– Collateral circulation may increase backbleeding
– Examine thrombus

Embolectomy
• Popliteal embolectomy
– 49% success rate from femoral approach
– Blind passage selects peroneal 90%
– may expose tibialperoneal trunk & guide catheter
– Idrectly cannulate distal vessels
• Distal embolectomy
– Retrograde/antegrade via ankle incisions
– Frequent Rethrombosis
–ThrombolyticTx viable alternative

Embolectomy
• Completion angiography
– 35% incdence of retained thrombus
• Failure requires
–Thrombolytic thearpy
– revascularization

Thrombolytic Therapy
 Advantages
• Opens collaterals & microcirculation
• Avoids sudden reperfusion
• Reveals underlying stenosis
• Prevent endothelial damage from balloons
Risks
• Hemmorhage • Stroke • Renal failure • Distal emboli
transiently worsen ischemia

Indications for Thrombolysis
 Category 1-2a limbs should be considered
– Class 2b :Two schools of thought
1)“Delay in definitiveTx”
2)“Thrombolytics extend window of opportunity”
• Clots <14days most responsive
– But even chronic thrombus can be lysed
• Large clot burden
– Requires longer duration of thrombolytics

Technique of Thrombolysis
• Catheter directed delivery
1) Lace clot via catheter with side holes
2) Pulse-Spray technique (mechanical component)
• Urokinase andTPA equally effective
• 4 hr treatment followed by angiogram – 4000IU/min x4hr,
2000Iu/M=min x 48h – r-UK (TOPASTrial) – no
improvement after 4hr >> surgery
– Continue Heparin tt
– Fibrinogen levels

Mechanical Thrombectomy
• Percutaneous aspiration embolectomy
–Viable alternative in selected patents
–Varity of devises
– Combines diagnostic and therapeutic procedure
– Removes non-lysable debris
– Effective in distal vessels
– Risk distal embolization
• Combine with lyticT x

Algorithm to be followed…
Patient with
suspected ischemia
History Examination investigations
Acute limb ischemia confirmed and staged

Heparin
I IIA IIb III
AMPUTATION
EMERGENCY
OPERATIVE
RE-
VASCULARISATION
EARLY
INTERVENTION
NO YES
TREAT FOR
CHRONIC
ISCHEMIA
SAME AS
FOR IIa

Management of IIa
ARTERIOGRAPHY
No lesion
Discrete localized lesions
Multiple extensive lesions

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

Clinical outcomes /
complications
• Mortality -15–20%.
• Major morbidities include:
1. Due to major bleeding 10–15% of patients
require transfusion/and or operative
intervention
2. Amputation (25–30% of patients)
3. Fasciotomy (5–25% of patients)
4. Renal insufficiency (up to 20% of patients)

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

DURING ISCHAEMIA

AFTER REPERFUSION

MANAGEMENT OF REPERFUSION EFFECTS

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

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

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

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

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

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

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

Treatment
 Recognize
 Reduce intracomparmental pressure
 Remove bandages and cast
 Keep limb elevated
Fasciotomy

Treatment

Compartment Syndrome
Fasciotomy

Thank You

Acute limb ischaemia

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