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Acute Limb Ischemia

Acute Limb Ischemia

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)

Causes of acute arterial occlusion


Embolus : greater risk of death Thrombosis : greater risk of death Others Trauma Iatrogenic Arterial dissection 2/3 of pts will require immediate amputation In absence of interventions

Clinical differentiation between thrombosis & embolism


Embolism : Thrombosis : Obvious cardiac source No obvious cardiac source No history of claudication History of claudication Normal pulse in contralaterals limb Decreased pulses in contralateral limb Few collaterals Well developed contralaterals Angiogram : minimal atherosclerosis Angiogram : diffuse atherosclerosis

Source for an embolus :


Spontaneous (80%)
Cardiac source
arrhythmias, MI, prosthetic valve, endocarditis

Non-Cardiac source
Proximal AS plaque, Proximal Aneurysm, Paradoxical emboli

Iatrogenic (20%) Angiographic manipulation Surgical manipulation

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.

Common sites for embolus lodgment in the arterial tree?

Diagnostic Criteria Six Ps


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 :

Cold Limb, again comparison to the contralateral limb very important

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

Not immediately threatened


Salvagable if promptly treated Salvagable if treated emergently/immediately

Intact

_ _
Partial

_
Partial

Audible

Audible

Threatened

Intact/slow

_ _

Audible

Threatened

Slow/absent

Partial

Audible

III

Irreversible

Primary amputation req.

Absent

Complete

Complete

Rutherford Vascular Surgery.2005.p.9761-2

Investigations

Acute Limb Ischemia is a

CLINICAL DIAGNOSIS

If time allows, especially if atherosclerotic thrombosis is suggested, preoperative angiography is often wise

Goal of treating patients with Acute Limb Ischemia

Rapid restoration of adequate arterial perfusion without the development of morbid local or systemic complications

Treatment

EMEGENCY (Golden time is 6 hours)


ABC IV Heparin (anticoagulation) Rapid surgical thromboembolectomy +/ - surgical bypass +/- thrombolytic therapy +/- primary amputation

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)

Surgical Thrmboemblectomy Procedure

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

Hyperkalemia Acidosis Myoglobulinuria

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

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