STASE ILMU BEDAH

RSUD SEKARWANGI SUKABUMI

FAKULTAS KEDOKTERAN UMJ
2021

ACUTE
L I M B
ISCHEMIA
SHERLY ASTUTI -
2016730099
Dokter Pembimbing : dr. Danny Pratama, SpB.SubBVE
 DEFINISI

Acute Limb Ischemia (ALI) adalah kondisi darurat yang

disebabkan oleh oklusi mendadak arteri sehingga terjadi
penurunan perfusi jaringan yang mengancam kelangsungan
hidup ekstremitas.

Acute limb ischemia  < 2 minggu

Martin B, Jonathan J, Stefan A, et al. European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the
Management of Acute Limb Ischaemia. Eur J Vasc Endovasc Surg (2020) 59, 173-218
EPIDEMIOLOGI
.
• the incidence is around
140/million/year.
• Even with the extensive use of newer
endovascular techniques including
thrombolysis, most published series
report a 10% to 30% 30-day
amputation rate.

Lars N,William H, et al. Inter-Society Consensus for the Management of PAD. TASC II(2007)
EPIDEMIOLOGI
• Prevalensinya
. < 0,1% pada populasi umum dan sekitar 5-10%
pada pasien dengan faktor risiko penyakit kardiovaskular lain
• Ekstremitas bawah lebih sering terkena, disebabkan oleh
trombosis arteri akut pada sebagian besar kasus.
• Iskemia akut ekstremitas atas hanya 1/5 dari semua kejadian
ALI, dengan insiden 2,4 kasus per 100.000 orang per tahun.
Embolisasi dari jantung adalah etiologi yang paling umum
(80% kasus).

Carlo S, Gianmarco D, Giuseppe G, et al. Diagnostic Approach to Acute Limb Ischaemia. Springer International
Publishing Switzerland (2017)
EPIDEMIOLOGI
.
• Amputation in ALI may be complicated by bleeding due to
an increased prevalence of concomitant anticoagulation.
• In addition, the site of amputation is more often proximal,
as the calf muscle is usually compromised.
• The ratio of above-knee to below-knee amputation is 4:1
compared to the usual 1:1 for critical limb ischemia.
• The incidence of major amputation is up to 25%. When
further evaluated, 10%– 15% of patients thought to be
salvageable undergo therapy and ultimately require major
amputation, and 10% of patients with ALI present
unsalvageable.
Lars N,William H, et al. Inter-Society Consensus for the Management of PAD. TASC II(2007)
ETIOLOGI

Penyebab paling umum dari ALI adalah emboli,

trombosis arteri asli atau rekonstruksi, aneurisma arteri
perifer, diseksi, dan cedera arteri traumatis.

tiga kategori ALI yang berbeda:

i. tromboemboli arteri ekstremitas bawah;
ii. eksaserbasi akut dari iskemia tungkai kronis; dan
iii. ALI iatrogenik setelah prosedur revaskularisasi

Martin B, Jonathan J, Stefan A, et al. European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the
Management of Acute Limb Ischaemia. Eur J Vasc Endovasc Surg (2020) 59, 173-218
Lars N,William H, et al. Inter-Society Consensus for the Management of PAD. TASC II(2007)
Bhavin L Ram, Robbie K George. Nontraumatic Acute Limb Ischemia –
Presentation, Evaluation, and Management. Indian Journal of Vascular and
Endovascular Surgery (2017)
FAKTOR RISIKO

Martin B, Jonathan J, Stefan A, et al. European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the
Management of Acute Limb Ischaemia. Eur J Vasc Endovasc Surg (2020) 59, 173-218
KLASIFIKASI BERDASARKAN ONSET DAN
KEPARAHAN
TERMINOLOGI DEFINISI

Onset
• Acute Iskemi<14 hari
• Acute on Chronic Perburukan keluhan dan tanda (<14hari)
• Chronic Iskemi stabil >14 hari
Keparahan
• Incomplete Tungkai tidak terancam
• Complete Mengancam tungkai
• Irreversibele Tungkai tidak viable
KLASIFIKASI SIGN AND SYMPTOM ALI
RUTHERFORD
TEMUAN SINYAL DOPPLER
DESKRIPSI/
KATEGORI Hilangnya Lemah
PROGNOSIS` Arteria Vena
Sensoris otot
I. Viabel Tidak Mengancam Tidak Tidak Terdengar Terdengar

II. Mengancam Terselamatkan jika Minimal (jari) Sering

diobati dengan Tidak tidak
a. Marginally atau tidak ada. Terdengar
tepat. terdengar
Lebih luas dari
Tertangani jika Ringan, Biasanya
b. Immediately jari, nyeri saat Terdengar
cepat dilakukan moderat tidak
istirahat,
revaskularisasi. terdengar
Kehilangan jaringan Ada,
utama atau Tidak Tidak
III. Irreversibel Ada, anestesi paralisis
kerusakan saraf terdengar terdengar
(rigor)
permanen
 ALUR DIAGNOSIS
PEM.FISIK

Selalu mulai 6P’s

dengan general • Pain (nyeri)
appearance dan • Pallor (Pucat)
vital sign. • Pulselessness (Tidak terasa
denyut nadi)
Selalu
bandingkan
• Paresthesia (tidak ada sensori)
dengan tungkai • Paralysis (tidak bisa bergerak)
kontralateral • Poikilothermia

Bandingkan pulse of arteries di kedua tungkai

ABI in ALI is also a predictor of outcome and an index
< 0.7 is critical.
 Either constant or elicited by
passive movement of the
PAIN involved extremity.

PALLOR Embolic occlusions are usually

PULSELESSNESS very sudden and of great
intensity, such that patients
PARESTHESIA often present within a few
hours of onset.
PARALYSIS
POIKILOTHERMIA
 COLOR Early: Pale Later: Cyanosed →
Mottling → fixed mottling & cyanosis
PAIN

PALLOR Pallor
An area of fixed
PULSELESSNESS cyanosis
surrounded by
PARESTHESIA reversible mottling

PARALYSIS Empty veins:

compare with
POIKILOTHERMIA normal limb
 sudden loss of previously
PAIN palpable pulse implies embolic
cause. compare with the other
PALLOR side

PULSELESSNESS Slow capillary refilling of the

skin after finger pressure
PARESTHESIA
PARALYSIS The limb is cold

POIKILOTHERMIA
 Loss of sensory function
Numbness will progress to
PAIN anesthesia

PALLOR Progress of Sensory loss

Light touch
PULSELESSNESS Vibration sense
Deep pain
Pressure sense
PARESTHESIA

PARALYSIS
POIKILOTHERMIA
 Loss of motor function:
Indicates advanced limb
threatening ischemia
PAIN
Intrinsic foot muscles are affected
PALLOR first, followed by the leg muscles

PULSELESSNESS Detecting early muscle weakness is

difficult because toes movements
PARESTHESIA are produced mainly by leg muscles

PARALYSIS
POIKILOTHERMIA
 ALUR DIAGNOSIS
IMAGING MODALITIES

TIME
TIME IS
IS TISSUE!!
TISSUE!!
The time needed to obtain any type
• Digital Substraction
of imaging should be wighed
against the urgency of Angiography (DSA)
revascularization
• Duplex Ultrasound
If non invasive imaging is chosen, it • Computed Tomography
is important that this doesn’t delay
subsequent treatment Angiography (CTA)
Martin B, Jonathan J, Stefan A, et al. European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the
Management of Acute Limb Ischaemia. Eur J Vasc Endovasc Surg (2020) 59, 173-218
 ALUR DIAGNOSIS
IMAGING MODALITIES

DIGITAL
DIGITAL SUBSTRACTION
SUBSTRACTION
ANGIOGRAPHY
ANGIOGRAPHY (DSA)
(DSA)

In terms of diagnostic accuracy, DSA is

still considered the standard
investigation for ALI.

DSA can deligneate etology and offers

the advantage of allowing treatment in
the same setting in modern practice.
This should be considered in
association with endovascular surgery
Martin B, Jonathan J, Stefan A, et al. European Society for Vascular Surgery (ESVS)
2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia.
Eur J Vasc Endovasc Surg (2020) 59, 173-218
 ALUR DIAGNOSIS
PEM.PENUNJANG

DUPLEX
DUPLEX ULTRASOUND
ULTRASOUND

able to obtain the necessary information

in 90% of cases where revascularization is
considered including patient with ALI.

An accurate modality with which to

detect complete or incomplete
obstruction in the common femoral,
superficial femoral, and popliteal arteries,
and bypass graft.
 ALUR DIAGNOSIS
PEM.PENUNJANG

COMPUTED
COMPUTED TOMOGRAPHY
TOMOGRAPHY
ANGIOGRAPHY
ANGIOGRAPHY (CTA)
(CTA)

An advantage of CTA is that it allows

evaluation of the thoracic and abdominal
aorta to seek a potential embolic source,
and also the mesenteric vessels to look
for other emboli. Extravascular findings
may be seen that are related to the
aetology of ALI (e.g., in some types of
popliteal artery entrapment) or are of
clinical importance
• Catat kedalaman ulkus, jaringan
dasar ulkus, jika tulang teraba
• Lihat tanda infeksi disekitar luka
(eritema, purulen)
• Inspeksi lesi preulcerative lainya
(blister, calluses, corns)

Martin B, Jonathan J, Stefan A, et al. European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the
Management of Acute Limb Ischaemia. Eur J Vasc Endovasc Surg (2020) 59, 173-218
ALGORITMA Initial Management:
• Antikoagulan (IV Calcium Heparin)
Treatment:
• Antikoagulan (Heparin & warfarin, selama
beberapa minggu)
• Endovascular
– Mechanical thrombectomy
– Percutaneus thrombolysis
• Grade I: Konservatif  antikoagulan,
Endovaskular (Jangan thrombolisis too
risky)
• Grade II a: (acute Subcritical ischemia)
thrombolisis, Embolectomy
• Grade II b: (Acute critical ischemia)) 
Thrombolisis, Percutaneus Thrombectomy
• Grade III: Irreversibel, tidak ada gunanya lagi
revaskularisasi (menjadi rhabdomyolisis) 
Martin B, Jonathan J, Stefan A, et al. European Society for Vascular
Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management
Amputasi
of Acute Limb Ischaemia. Eur J Vasc Endovasc Surg (2020) 59, 173-218
TREATMENT

• OPEN SURGERY
• ENDOVASCULAR TECHNIQUE
• HYBRID APPROACH
• Catat kedalaman ulkus, jaringan
dasar ulkus, jika tulang teraba
• Lihat tanda infeksi disekitar luka
(eritema, purulen)
• Inspeksi lesi preulcerative lainya
(blister, calluses, corns)

Martin B, Jonathan J, Stefan A, et al. European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the
Management of Acute Limb Ischaemia. Eur J Vasc Endovasc Surg (2020) 59, 173-218
OPEN REVASCULARIZATION

• THROMBO-EMBOLECTOMY
• SURGICAL BYPASS
o COMPLETION IMAGING AFTER
• Catat kedalaman ulkus, jaringan
EMBOLECTOMY
dasar
• HYBRID ulkus, jika tulang teraba
TREATMENT
• Lihat tanda infeksi disekitar luka
(eritema, purulen)
• Inspeksi lesi preulcerative lainya
(blister, calluses, corns)

Martin B, Jonathan J, Stefan A, et al. European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the
Management of Acute Limb Ischaemia. Eur J Vasc Endovasc Surg (2020) 59, 173-218
CATHETER DIRECTED
THROMBOLYSIS

• Urokinasie
• rtPA

• Recommended dose :
o Weight related doses of rtPA (alteplase) for CDT : 0.002-0.1
mg/kg/hour
o Non weight related dose : 0.25-1.0 per hour for low dose infusions

Martin B, Jonathan J, Stefan A, et al. European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the
Management of Acute Limb Ischaemia. Eur J Vasc Endovasc Surg (2020) 59, 173-218
AMPUTATION

• Catat kedalaman ulkus, jaringan

dasar ulkus, jika tulang teraba
• Lihat tanda infeksi disekitar luka
(eritema, purulen)
• Inspeksi lesi preulcerative lainya
(blister, calluses, corns)
COMPLICATION OF AMPUTATION

• Catat kedalaman ulkus, jaringan

dasar ulkus, jika tulang teraba
• Lihat tanda infeksi disekitar luka
(eritema, purulen)
• Inspeksi lesi preulcerative lainya
(blister, calluses, corns)
COMPARTMENT SYNDROME

• Compartment syndrome (CS) is

a serious complication
following ALI
revascularisation.The tissue
• Catat kedalaman ulkus, jaringan
swelling as a result of IRI raises
dasar ulkus, jika tulang teraba
pressure in the limb muscles
• Lihat tanda infeksi disekitar luka
which are constrained by fascial
(eritema, purulen)
compartments.
• Inspeksi lesi preulcerative lainya
• Thus, intracompartment
(blister, calluses, corns)
pressure rises as a result of
swelling and may be sufficiently
high to reduce perfusion of
already damaged tissues Martin B, Jonathan J, Stefan A, et al. European Society for Vascular
Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management
of Acute Limb Ischaemia. Eur J Vasc Endovasc Surg (2020) 59, 173-
218
Thank You!