Académique Documents
Professionnel Documents
Culture Documents
Sudden occlusion of an artery, decrease in limb perfusion that threatens limb viability and requires urgent evaluation and management , commonly due to acute thrombosis, embolic event, or trauma. It often will happen when thrombosis occur a pre-exiting atheroma (so-called acute on chronic deseas ) Incidence is 14/100,000 (12 % of operations performed in the average vascular unit)
Non-Cardiac source
Proximal AS plaque, Proximal Aneurysm, Paradoxical emboli
Cardiac emboli
Can occur spontaneously or iatrogenically The heart is by far the predominant source of spontaneous arterial emboli (80-90% cases) Presently , atherosclerotic heart disesase has been implicated as a causative factor in 60-70% of all cases of embolus with rheumatic mitral valve disease and associated atrial fibrillation in the remaining 30-40%.
Cardiac emboli
Next to atrial fibrillation, myocardial infarction is the second most frequent associated with peripheral arterial embolization ( 20%) Electrocardiographic changes were noted in 64% of all patients presenting with acute extremity ischemia requiring surgical intervention.
Cardiac emboli
Cardiac valvular prostheses are another common source of emboli (required permanent anticoagulant therapy) Intracardiac tumor such as atrial myxomas are a rare source of peripheral arterial emboli.
Noncardiac Emboli
Spontaneous emboli originating from non cardiac sources are noted in 5% to 10% of patients. Embolization of mural thrombus associated with aortoiliac, femoral or popliteal aneurysms has been reported.
Noncardiac tumors and may gain access to the arterial circulation and form arterial emboli such as primary or metastatic lung carcinoma. An additional 5-10% spontaneous emboli originate from a source that remains unidentified.
Sudden onset of diffuse and poorly localized leg pain 6 Ps Paresthesias Pain Poikilothermia (coolness) Pallor Pulselessness Paralysis
Pain : usually first symptom May be acute as in trauma or embolus: often with thrombosis the pain in insidious but become unrelenting Pain is usually present throughout the entire limb, compared with CLI in which it is most commonly described over the forefoot
Paresthesia :
Sign of progressive ischemia The myelinated fibers of prorioception and light sensation are lost early in acute ischemia Sensory changes occur as a result of ischemia of nerve tissue
Paralysis :
More often deficit/weakness begins to occur and is an ominous sign Absent dorsi and plantar flexion indicate loss of extensor and flexor muscle of lower leg After 8 hours of absolute ischemia skeletal muscle become rigid, contractet Complete motor paralysis is a late symptom signaling impending gangrene, representing a combination of both end-stage muscle and neural ischemia
Pallor :
Indicate major obstruction to the leg In the absence of collateral circulation, the limb will become waxy and marble white If untreated, the skin changes proceed to necrosis and desquamation.
Poikilothermia :
Rutherford Classification
for Limb Viability
Society of Vascular Surgery (SVS) / International Society of Cardiovascular Surgery (ISCVS) Doppler
Category
Description
Cap. refill
Paralysis
Sensory loss
I IIa IIb
Viable
Intact
_ _
Partial
_
Partial
Audible
Audible
Threatened
Intact/slow
_ _
Audible
Threatened
Slow/absent
Partial
Audible
III
Irreversible
Absent
Complete
Complete
Investigations
CLINICAL DIAGNOSIS
If time allows, especially if atherosclerotic thrombosis is suggested, preoperative angiography is often wise
Rapid restoration of adequate arterial perfusion without the development of morbid local or systemic complications
Treatment
Anticoagulation:
Systemic anticoagulation with intravenous unfractionated heparin is immediately instituted while preparations are made for surgery or angiography. An initial bolus of 5000 U is appropriate for most patients, followed by an intravenous infusion commencing at 1000 U/hr If urgent operation is not undertaken, the infusion should be monitored using the activated partial thromboplastin time, aiming for a ratio of 2 to 3
Surgical Revascularisasi
Surgical approaches to the treatment of acute limb ischemia include thromboembolectomy with ballon catheter, bypass surgery, and adjuncts such as endarterectomy, patch angioplasty, and intraoperative thrombolysis Thrombo-embolectomy : Fogarty catheter (4 F or 5 F)
Thrombolysis
Percutaneous thrombolysis is now an established intervention for all forms of acute arterial occlusion Thrombolytic agents are plasminogen activators that accelerate plasmin production with the degradation of fibrin
Thrombolysis
Endovascular Revascularization
The goal of catheter-based endovascular revascularization is to restore blood flow as rapidly as possible to a variable or threatened limb with the use drug, mechanical device, or both Patient in whom ischemia for 12 to 24 hour would not be safe and those with a nonviable limb, bypass graft with suspected infection or contraindication to thrombolysis (e.g recent intracranial hemorrahge, recent major surgery, vascular brain neoplasm, or active bleeding) should not undergo catheter-directed therapies
Reperfusion Injury
Local
Compartment Syndrome Systemic
Compartement syndrome
Following revascularization, significant limb swelling may occur. This situation has the potential to result in compartement syndrome, most frequently in the anterior compartement may elect to perform a fasciotomy Major risks fasciotomy include both infection and bleeding
Compartment Syndrome
Thank You