Jurnal Reading

Supervisor : Prof. Dr. dr. Djanggan Sargowo, SpPD, SpJP (K)

ACUTE LIMB ISCHEMIA

ACUTE ARTERIAL
OCCLUSION
PIOTR S. SOBIESZCZYK

Acute limb ischemia sudden limbthreatening decrease in arterial

perfusion of less than 14 days duration
Acute limb ischemia = acute arterial
occlusion
Acute limb ischemia vascular
emergency irreversible organ injury
within hours (lower limb artery), or
seconds (middle cerebral artery)

Epidemiology of
Acute Limb Ischemia

1990s 75 lower limb ischemia from

population of 500.000, mortality 18%,
amputation rate 13%.
Risk factor : men = women, middle aged
and older population, younger (with
paradoxical embolism, endocarditis, etc.)
Upper limb ischemia : only 16,6% of
acute limb ischemia

Upper limb ischemia population older

than lower limb ischemia (74 Vs 70 y.o)
Amputation-free survival rate delay
in diagnosis, non-Caucasian race, older
age, malignancy, CHF, low body weight
decrease.
75 yo patients, 30-day mortality rates :
42 %

Etiology of Acute
Limb Ischemia

Acute Upper-Extremity Ischemia

Iatrogenic Causes
Embolism
Thrombosis
Common sites : brachial, axillary,
subclavian artery

Iatrogenic Causes

Cardiac catheterization via a. brachialis

Cardiac catheterization via a. radialis

Embolism

(74 - 99% cases)

Cardioembolic (72%), prox vessel (12%),

others (16%)
AF and LV thrombus
Atrial myxoma
Atherosclerotic stenosis of a. subclavia
Primary aneurysm of a. subclavia
Thoracic outlet syndrome
Aortic arch atheroma
Intracardiac shunting (malignant emboli /
paradoxical embolism)

Thrombosis

Atherosclerotic disease
In situ thrombosis : arteritis, radiation
injury, hypercoagulable syndrome,
proximal artery lesions

Acute Lower-Extremity Ischemia

In Situ Thrombosis
Embolism
Iatrogenic Causes
Other Causes

In Situ Thrombosis

85% cases enrolled in the TOPAS

(Thrombolysis or Peripheral Arterial
Surgery)
30% native artery 70% after
intervention thrombosis (65% graft 5%
iliac/infrainguinal stent)
Most common site : popliteal artery

Embolism

Cardioembolic source :
AF,
rheumatic mitral stenosis + LAE,
LV dysfunction (apical thrombus formation),
endocarditis,
intracardiac myxoma,
paradoxical embolism (patent foramen ovale),
aortic aneurysm, and intramural thrombus (rare)

Common site of occlusions : aortoiliac

bifurcation, femoral bifurcation, popliteal
trifurcation

Iatrogenic cases

Arterial access in the common femoral

artery + injury
Catheter-associated thrombosis and
embolism of popliteal artery

Other causes

Intense vasospasm (ergotism or cocaine

ingestion)
Aortic dissection
DVT (+ massive swelling)
Phlegmasia cerulea dolens syndrome

Pathophysiology of
Acute Limb Ischemia

Emboli points : aortic, iliac, femoral,

popliteal, brachial bifurcation.
Thrombosis points : femoral, popliteal
artery, arterial bypass, ruptured
atherosclerotic plaque, low-output state.
Artery cessation aerobic anaerobic
lactate H+ acidosis
cell dysfunction & cell death
depletion of ATP NaK-ATPase
dysfunction intracellular Ca +
actin, myosin, protease muscle
fibers necrosis intracellular K, P,
Cr, myoglobin leak to systemic
circulation.

Window period : 6 hours (irreversible muscle

damage 3-6 hours)
Restoration of reperfusion injury activated
cytokines complex cascade + ROS + neutrophil
Neutrophil & xanthine oxidase ROS
Normal : xanthine dehidrogenase + NAD :
hypoxanthine xanthine
Ischemia (2hours) : xanthine dehidrogenase
xanthine oxidase, ATP hypoxanthine
Xanthine oxidase + O2 : Hypoxanthine xanthine
Ischemia O2 hypoxanthine
Reperfusion (O2 ) activated xanthine
dehydrogenase hypoxanthine conversion
ROS

Reperfussion impact : compartment

synd, ALI, AKI, acute pulmonary edema
Reperfussion syndrome : local response
+ systemic response
Local response : tissue swelling
Systemic response : MOFS till death

Diagnosis of Acute
Limb Ischemia

Physical examination, doppler evaluation, CTAngigraphy, MR-Angiography, duplex

ultrasonography.
6Ps pulselessness, pallor, pain, poikilothermia,
paralysis, & paresthesia
Determine the level of occlusion, search for potential
sources, & look for the systemic symptoms.
Thrombosis : signs of PAD, vague onset, less
striking examination findings, less distinct
demarcation of ischemic changes, cyanosis > pallor.
(Rutherford I - IIa)
Embolic : abrupt onset of onset, clearer demarcation
of ischemic temperature change, skin mottling,
pallor > cyanosis. (Rutherforf IIb - IIII)

Rutherford classification

Class I : viable & nonthreatened limb. Chronic

and noncritical ischemia.
Class II : directly threatened limb.
IIa : intact sensory and motoric, absent arterial

doppler. Marginally threatened.

IIb : sensory loss, mild motor impairment, absent
arterial doppler. Immediately threatened limb.

Class III : permanent nerve damage, sensory

loss, motor paralysis, absent arterial & venous
doppler, revascularization is harmful,
amputation is required.

Treatment of Acute
Limb Ischemia

Prompt recognition and rapid restoration is a

must
Revascularization vs primary amputation
viability of affected limb
Amputation-frees survival rate age, race,
diabetes, prompt initiation of anticoagulation
Endovascular therapy vs surgical embolectomy
the cause, Rutherford class, occlusion
location, patient characteristic
Complication : ischemic-reperfusion injury (mild
to systemic inflammatory response +
multiorgan failure)

Initial Medical
Management

Fluid resuscitation, analgesia, antithrombin and

antiplatelet therapy
Perioperative anticoagulation : heparin (UFH
100-150 U/kg) PTT 2-2.5 above baseline
Treat HIT (heparin-induced thrombocytopenia)
with DTI (direct thrombin inhibitors) lepirudin /
argatroban / bivalirudin
Correct the laboratory abnormalities (Cr +
neutrophil ) and stabilize the underlying acute
medical condition (MI + LV thrombus +
cardiogenic shock) life over limb

Endovascular Therapy of Acute

Limb Ischemia

To restore arterial flow : cross the entire

occluded segment, thrombolytic drug
infusion into the thrombus
Catheter-based delivery ia fibrinolytic
(Charles Dotter, 1974)
R-tPA enhancing the intrinsic fibrinolytic
process (plasminogenplasmin)
rtPA 0.5 1 mg/h, min 12 hours

Mechanical Thrombectomy
Device

AngioJet Xpeedior rheolytic thrombectomy catheter :

force saline / thrombolytic agents jets + aspiration
vacuum.
Best used to treat acute thrombus
Trellis device : multiple infusion holes catheter +
proximal & distal balloons + sinusoidal wire +
thrombolytic jets + aspiration vacuum
Rotarex device : over-the-wire catheter + rotating
catheter tip + aspiration vacuum
Hydrolyser catheter : 6F 0.18 inch guidewirecompatible catheter with Venturi effect + injectorr filled
with saline

Suction Embolectomy

For popliteal and tibial vessels

Large lumen catheter (6F-8F) + 60mL
syringe proximal from occlusion
aspirating syringe the thrombus is
aspirated and removed from artery
Combined with thrombolysis (success
rate 90%, limb salvage rate 86%)

Ultrasound-Assisted
Thrombolysis

High energy mechanically fragment

thrombus, low energy enzymatic
thrombolysis (dissociating fibrin,
exposing fibrin binding sites, thrombus
permeability and penetration by
thrombolytics)
Complication : distal embolization of
smaller fragments (sudden pain and
pulselessnes)

Surgical Therapy of Acute Limb

Ischemia

Fogarty catheter technique : appropriately

sized balloon tipped embolectomy catheter
occluded artery inflated distally
pulled back the thrombus removed
Intraoperative angiography + doppler exam
is needed
Modern surgical therapy : complex vascular
reconstruction + embolectomy +
angiography + hybrid endovascular
technique

Treatment of Upper-Extremity
Ischemia

Conservative : warming, vasodilataion,

anticoagulation
Surgical intervention : emblectomy
Fogarty balloon catheter embolectomy
(amputation and symptom free 85%,
amputation rates 2%, mortality rate
5.6%)
Catheter-directed thrombolytic therapy :
digital vessel thrombosis

Compartment Syndrome

Mostly occurs in class IIb and III.

Blood flow restoration oxygen free radicals +
inflammatory cells reperfusion injury tissue
swelling compartment synd.
Signs & symptoms : progressive pain, paresthesia,
hypoesthesia, pale, painfull swollen, pulseless.
Treat fast (fasciotomy), 6-8 hours irreversible
limb injury / limb loss
Prophylactic fasciotomy : > 6 hours ischemia,
young Px, incomplete reperfussion, tissue swelling.

Adjunctive Medical Therapy

Gradual reperfusion with modified

reperfusate
Hypothermia and low initial flow rates
Controlled reperfusion : 30 mins crystalloid
reperfusion solution + oxygenated blood,
directly into revascularized artery and muscle
bed
Free radical scavenger + antiinflammatory
agents
Iloprost (prostacyclin synthetic analog)

Thank You