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Acute limb

ischemia
PRADITA DIAH PERMATASARI

Etiology of acute limb


ischemia
Acute arterial embolism:
Acute arterial thrombosis:

Acute traumatic ischemia:

Of a relatively health arterial tree

Of a previously diseased arterial tree

Etiology

Patho-pysiology

Acute Embolic Ischemia


An embolus
suddenly
occludes a
relatively
healthy arterial
tree
It usually
arrest at
arterial
bifurcation
Aortic bifurcation
Iliac bifurcation
Femoral bifurcation
Popliteal trifurcation

An embolus can originate from


the heart (MS with atrial
fibrillation, MI with mural
thrombus) or dilated diseased
arteries (aortic aneurism)

Example of
acute
arterial
embolus
Saddle
Embolus of
right iliac
artery

Acute
Thrombotic
Ischemia

Atherosclerosis
causes
progressive
narrowing of the
arterial tree
Stimulates
development of
collaterals
Sluggish flow &
rough surface
will favor acute
thrombosis

Clinical Picture

Clinical Evaluation of Acute Ischemia (Clinical Picture)


Signs of acute ischemia

5Ps
Pain:
Pain symptom

Pale
Pulseless
Parasthesia
Paralysis

Inspection
COLOR:

Fixed
mottling &
cyanosis

Early:
Early pale
Later:
mottling
Later cyanosed
mottling & cyanosis

fixed

An area of fixed
cyanosis
surrounded by
reversible mottling
Pallor
Reversible
mottling

Empty veins:
compare the Rt.
(ischemic) & Lt.
(normal)

Clinical Evaluation of Acute Ischemia (Clinical Picture)


Signs of acute ischemia

Palpation

5Ps
Pain:
Pain symptom

Femoral

Popliteal

Posterior tibial

Dorsalis pedis

Pale
Pulseless
Parasthesia

Palpate peripheral pulses,


pulses compare with the
other side & write it down on a sketch

Paralysis

Temperature:
Temperature the limb is cold with a level of
temperature change (compare the two limbs)
Slow capillary refilling of the skin after finger
pressure

Clinical Evaluation of Acute Ischemia (Clinical Picture)


Signs of acute ischemia

5Ps
Pain:
Pain symptom

Pale
Pulseless
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

Clinical Evaluation of Acute Ischemia (Clinical Picture)


Signs of acute ischemia

5Ps
Pain:
Pain symptom

Palpation
Loss of motor function:

Indicates advanced limb threatening


ischemia
Late irreversible ischemia: Muscle
turgidity

Pale
Pulseless

Intrinsic

Parasthesia

Detecting

Paralysis

foot muscles are affected


first, followed by the leg muscles
early muscle weakness is
difficult because toes movements are
produced mainly by leg muscles

Management of Acute Limb


Ischemia

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

general
investigations

[Patients

with a

suspected
hypercoagulable state
will need additional
studies seeking:]
Anticardiolipin
antibodies
Elevated homocysteine
concentration
Antibodies to platelet
factor IV

Doppler US

to assess the level of obstruction & severity of ischemia

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..

0.7 to 0.9 is mild disease,


0.5 to 0.69 is moderate disease,
< 0.5 is severe disease.

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

Clinical differentiation between


thrombosis & embolism
Thrombosis:

Embolism:

No obvious cardiac source.

obvious cardiac source

history of cluadication.

No hx of cluadication
Normal pulses in contralateral limb
Angiogram: minimal atherosclerotic
Few collateral

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abnormal pulses in contralateral limb.


Angiogram: diffuse atherosclerotic
Well developed collateral

Stage of Acute Limb Ischemia

Doppler
Category

Description

Cap. refill

Paralysis

Sensory
loss

I
IIa
IIb

Viable

Not immediately
threatened

Intact

Aud

Aud

Threatened

Salvagable if
treated

Intact/slow

Partial

Aud

Threatened

Salvagable if
treated
emergently

Slow/absen
t

Partial

Partial

Aud

III

Irreversible

Primary
amputation req.

Absent

Complete

Complete

TREATMENT
Goals of therapy include restoration of
blood flow, preservation of limb and life,
and prevention of recurrent thrombosis

THROMBOLYTICS

IMMEDIATE CARE

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:
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:
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:
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)

Diffuse intense disease of the superficial


femoral artery resolved
by implanting a coated stent.

SURGICAL AORTIC GRAFT

Surgery

[Surgery may be considered in trauma, where there are


contraindications to CDT, or where CDT is not available.

The method of revascularization (open surgicalor endovascular)


may differ depending on:

Anatomic location of occlusion

Etiology of ALI

Contraindications to open or endovascular treatment

Local practice patterns]

Amputation

for irreversible
ischemia with
permanent tissue
damage

Clinical outcomes

1.
2.
3.
4.

Mortality -1520%.
Major morbidities include:
Due to major bleeding 1015% of patients require
transfusion/and or operative intervention
Amputation (2530% of patients)
Fasciotomy (525% of patients)
Renal insufficiency (up to 20% of patients)

Follow-up care

warfarin,

longer.

often for 36 months or

Patients with thromboembolism will


need long-term anticoagulation,
possibly lifelong.

If

contraindicated due to bleeding


risk factors>> platelet inhibition
therapy

Algorithm to be followed
Patient with
suspected ischemia

History

Examination

investigations

Acute limb ischemia confirmed and staged

Heparin

IIA

EARLY
INTERVENTION

NO

TREAT FOR
CHRONIC
ISCHEMIA

YES

SAME AS
FOR IIa

IIb

III

EMERGENCY
OPERATIVE
REVASCULARISATION

AMPUTATION

Management of IIa
ARTERIOGRAPHY

No lesion

Discrete localized lesions

Multiple extensive lesions

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