 64 yr old male with previous history of

heart attack came to casualty with c/o

sudden onset of pain in the right leg
below the knee.

 On examination….
 Absent popliteal and lower pulsations
 Decreased sensations
 Inability to move toes
Acute limb
ischemia
Etiology of acute limb ischemia

Acute arterial embolism: Of a relatively health arterial tree

Acute arterial thrombosis: Of a previously diseased arterial tree

Acute traumatic ischemia:

Patho-pysiology
Acute Embolic Ischemia
An embolus can originate from
An embolus the heart (MS with atrial
suddenly fibrillation, MI with mural
occludes a thrombus) or dilated diseased
relatively arteries (aortic aneurism)
healthy arterial
tree

It usually
arrest at
arterial
bifurcation
Aortic bifurcation
Iliac bifurcation
Femoral bifurcation
Popliteal trifurcation
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

Inspection
5Ps COLOR:
Fixed Early:
Early pale
Pain:
Pain symptom
mottling &

+
Later:
Later cyanosed mottling fixed
cyanosis mottling & cyanosis
An area of fixed
cyanosis
Pale surrounded by
reversible mottling
Pulseless Pallor

Reversible
mottling
Parasthesia
Empty veins:
Paralysis compare the Rt.
(ischemic) & Lt.
(normal)
 Clinical Evaluation of Acute Ischemia (Clinical Picture)

Signs of acute ischemia Palpation

5Ps
Pain:
Pain symptom

+ Femoral Popliteal

Pale

Pulseless Posterior tibial Dorsalis pedis

Palpate peripheral pulses,

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

Temperature:
Temperature the limb is cold with a level of
Paralysis 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 Palpation

5Ps Loss of sensory function

Pain:
Pain symptom Numbness will progress to anesthesia

+ Progress of Sensory loss

Pale Light touch

Vibration sense
Pulseless
Proprioreception
Parasthesia Deep pain
Late
Pressure sense
Paralysis
 Clinical Evaluation of Acute Ischemia (Clinical Picture)

Signs of acute ischemia Palpation

5Ps Loss of motor function:

Pain:
Pain symptom Indicates advanced limb threatening

+
ischemia
Late irreversible ischemia: Muscle
turgidity
Pale
Intrinsic foot muscles are affected
Pulseless
first, followed by the leg muscles
Detecting early muscle weakness is
Parasthesia
difficult because toes movements are
produced mainly by leg muscles
Paralysis
Investigations

The severity and duration of

ischemia at the time of
presentation provides a narrow
margin of time for investigations
 general investigations  CK
 [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
0.7 to 0.9 is mild disease,
0.5 to 0.69 is moderate disease,
< 0.5 is severe disease.
 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
Embolism: Thrombosis:

obvious cardiac source No obvious cardiac source.

No hx of cluadication history of cluadication.

Normal pulses in contralateral limb abnormal pulses in contralateral limb.

Angiogram: minimal atherosclerotic Angiogram: diffuse atherosclerotic

Few collateral Well developed collateral

WWW.SMSO.NET
 Doppler
Category Description Cap. refill Paralysis Sensory A V
loss

I Viable Not immediately

threatened
Intact - - Aud Aud

IIa Threatened Salvagable if

treated
Intact/slow - Partial _ Aud

IIb Threatened Salvagable if

treated
Slow/absen
t
Partial Partial _ Aud

emergently

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
 Fogarty balloon catheter
(with post-op anti coagulants)
 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
• Mortality -15–20%.

• Major morbidities include:

1. Due to major bleeding 10–15% of patients require

transfusion/and or operative intervention
2. Amputation (25–30% of patients)
3. Fasciotomy (5–25% of patients)
4. Renal insufficiency (up to 20% of patients)
Follow-up care

 warfarin, often for 3–6 months or longer.

 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

I IIA IIb III

EMERGENCY
EARLY OPERATIVE
AMPUTATION
INTERVENTION RE-
VASCULARISATION

NO YES

TREAT FOR
SAME AS
CHRONIC
FOR IIa
ISCHEMIA
Management of IIa

ARTERIOGRAPHY

No lesion

Discrete localized lesions

Multiple extensive lesions