Acute Lower Extremity Ischaemia (ALEXI)

Nadraj G Naidoo

Head: Vascular Surgery and Endovascular Therapy

Department of Surgery

Groote Schuur Hospital

Cape Town
ACUTE LOWER EXTREMITY ISCHAEMIA (ALEXI)

Basic principles and concepts

• Pathology
• Clinical features
• Clinical severity grading system
• Vascular Imaging
Initial Treatment
• Anticoagulation
• Catheter-directed thrombolysis
• Pharmaco-mechanical thrombolysis
Revascularization strategies
• Endovascular treatment
• Operative treatment
• Hybrid procedures
Clinical outcomes
ALEXI: Definition and perspectives

Acute lower extremity ischaemia (ALEXI) is often defined as a sudden loss of perfusion to the lower
extremity/extremities, of less than 14 days duration, resulting in variable ischaemic clinical
manifestations and the potential risk of limb loss.

The incidence is ~ 150 cases per million per year.

Diagnostic errors and treatment delays are unforgiving, and may result in loss of limb or life.

Naidoo NG, Rautenbach PS, Kahn D. Acute lower extremity ischaemia. CME Journal. 2013;31(6); 201-2015
ALEXI: Clinical appraisal

• Does the patient have a significant cardiac history?

• Does the patient have features of established PAD?

• Does the patient have confounding features?

 Young age (Entrapment syndromes; HIV-related vasculopathy; Thrombophilia)
 Arterial aneurysms (Popliteal artery aneurysms)
 Substance abuse
 Trauma
ALEXI: Clinical appraisal

• Are the clinical features rapidly progressive (Presenting < 24 hours)?

• Are the clinical features slowly evolving (Presenting > 24 hours)?
 Paraesthesia
 Poikilothermia (“Perishing with the cold”)
 Pallor
 Paresis
 Pain (“ischaemia foot pain”; “painful calf compartments”; “pain out of proportion to clinical
features”)
 Pulselessness

Is the limb
viable?
Clinical severity grading

Findings Doppler signals

Category Sensory loss Muscle weakness Arterial Venous

I. Viable None None Audible Audible

II. Threatened
• IIa. Marginally threatened Minimal (toes) None Inaudible Audible
• IIb. Immediately threatened More than toes Mild-moderate Inaudible Audible
Severe rest pain

III. Irreversible Profound / Profound / Inaudible Inaudible

Anaesthetic Paralysis (rigor)
 Features Embolic Thrombotic

Severity marked, rapidly progressive less severe, slowly progressive

Onset minutes / hours generally days
Contralateral leg pulses present absent
PATHOLOGY Femoral arteries palpated soft, tender hard, calcified
Dystrophic limb features absent present
Cardiac abnormalities present generally absent
Iliac / femoral bruits absent may be present
• Cardio-embolism History of claudication absent present

• Atrial fibrillation
• Thrombo-embolism
• Aortic source
• Floating aortic thrombus
• Peripheral source
• Popliteal artery aneurysm
• Thrombosis
• Graft (Prosthetic)
• Native vessel
Diagnostic algorithm

• Doppler pressures (arterial and venous signals) Rapidly progressive / advanced

• Duplex arteriography (Duplex Ultrasound) ischaemia but limb
• CTA (Chest; abdomen; lower limbs) salvageable?
• For suspected non-cardiac pathology ….Fasciotomy / On-table
• Supporting tests (diagnostic and management –orientated) angiogram and proceed
• Urea, electrolytes and creatinine
• Blood gas
• Full blood count
• X-ray Chest
• ECG
• Young patients
 Thrombophilia screen (to be considered and performed before anti-coagulation)
 HIV status
• Cardiac ECHO when indicated
 Acute management

• Supportive (Oxygen therapy; pain control; medical optimization; etc.)

• Pre-empt reperfusion syndromes
• Adequate hydration
• Adequate urine output
• Anticoagulation
• Heparin
• Stat dose: 80-100 units intravenously (5000 units given in most centres)
• Heparin infusion:
• 25 000 units in 200mls N/Saline @ 8mls /hour
• aPTT 6 hourly
• Dose titrated to maintain an aPTT of 60 – 80 seconds
Non-operative treatment for lower limbs

Viable limb; no compelling indication for revascularization.

• Anti-coagulate
• Planning and treatment of offending, culprit pathology

Non-viable limb; significant medically-refractory co-morbidities; short-life

expectancy.
 Fasciotomy

Diagnostic
• 4-compartment fasciotomy

Therapeutic
• 4-compartment fasciotomy

Prophylactic
• 4-compartment fasciotomy
• Antero-lateral 2 compartment fasciotomy (limited skin incision)
 Major amputation

 Fixed skin staining

 Compartment rigidity (“rigor mortis”)
 Diagnostic fasciotomy:
• Non-viability of 2 or more calf compartments generally not compatible with limb salvage
 Following unsuccessful attempt at revascularization.
 Revascularization strategies

Trans-femoral embolectomy

 Vertical groin incision

 Transverse CF arteriotomy close to CFA bifurcation
 4;5;6 Fr catheters for iliac vessels
 3; 4 Fr catheters for infra-inguinal vessels
 Copious heparin-saline infusion
 Strategies for inadequate clearance of embolus (crural vessels)
• Endovascular techniques
• Trans-popliteal approach (trifurcation exploration)
 Revascularization strategies – native artery thrombosis

Thrombosed iliac vessels

 Surgical Thrombectomy

• Generally transfemoral approach for iliac thrombus

• Thrombectomy-catheters
• Residual iliac lesion:
• Iliac angioplasty
• Iliac stenting
• Generally combined with infra-inguinal embolectomy
Revascularization strategies – native artery thrombosis

Superficial Femoral Artery Thrombosis (with or without popliteal artery

thrombosis)

 Thrombolytic therapy (Catheter-directed)

 Bypass procedure (vein or prosthetic conduit)

Thrombosed Popliteal Artery Aneurysm (PAA)

Repair PAA

• Exclusion bypass grafting

• Open repair with interposition graft
• Endovascular aneurysm repair with covered stent (stentgraft)
• EVPAR
• Role of catheter-directed thrombolysis – controversial
• Intra-operative thrombolysis
Thrombosed prosthetic grafts

 Supra-inguinal grafts
• Graft thrombectomy
• Graft revision or redo surgery

 Infra-inguinal grafts
• Catheter-directed thrombolysis
• Graft thrombectomy and possible graft revision
• Redo surgery
 Thrombolytic therapy

Catheter-directed thrombolysis (CDT)

• Infra-inguinal native artery thrombosis
• Infra-inguinal prosthetic graft thrombosis
• Rutherford I and IIa only
• Current regimens use r-tPA (Alteplase; Alfimeprase)……..(less commonly Staphyllokinase / r-Urokinase)
• High-dose regimen (5000 units heparin & 1-2mg/hour r-tPA infusion for 4 hours at induction followed by
therapeutic heparin infusion and 0.5mg-1mg/hour r-tPA infusion)
• Low-dose regimen (5000 units heparin and 4mg r-tPA at induction followed by no heparin infusion but low dose
r-tPA infusion 0.5mg/hour)
• Streptokinase and urokinase no longer used!!!!
Pharmaco-mechanical catheter-directed thrombolysis (PMT / PM-CDT)
• Rotational devices
• Hydrodynamic devices
• Aspiration devices No role for systemic thrombolysis
 Catheter-directed thrombolysis

Contra-indications to CDT
 Generally access sheath in opposite groin
Absolute contra-indications:
 Check angiograms every 4-6 hours Active bleed
GI bleed within 2 weeks
 Duration of infusion should not exceed 48 hours
Stroke within 6 months
 Various infusion methods Intracranial or spinal surgery within 3 months
Head injury within 3 months
 Unmasked lesions can be treated simultaneously
• Balloon angioplasty Relative contra-indications:
• Stenting  Major surgery or trauma within 2 weeks
 Severe, poorly controlled hypertension
 Complications  Recent puncture of non-compressible vessel
• Bleeding  Pregnancy
• Distal embolization  Retinopathy
• Stroke  Recent eye surgery
• Limb loss  Liver failure
 Cardiopulmonary resuscitation in the last2 weeks
 Bacterial endocarditis
Catheter-directed thrombolysis VS. Surgery for ALEXI

Both are currently complimentary treatment strategies

Rochester study: (114 patients) comparing urokinase to surgery. The 1-year amputation
free survival in favour of CDT (higher 30-day mortality in surgical arm

Thrombolysis for Ischaemia of the Lower Extremity (STILE): (393 patients)

comparing surgery with alteplase or urokinase. For presentations less than 14 days the
results were in favour of thrombolysis (amputation rates at 6 months: 11% vs. 30% for
surgery). The results favoured surgery for presentations after 14 days.

Thrombolysis or Peripheral Arterial Surgery (TOPAS) study: similar amputation-free

survival at 30-days and 6 months (71.8% vs. 74.8%).
BJS 2014; 101: 1105–1112
Results
• Swedish study (High-dose regimen – Malmo vs. Low-dose regimen – Uppsala)
• 749 procedures in 644 patients
• Median age 73 years (47.1% women)
• Aetiology of ischaemia
• Graft occlusion - 38⋅8%
• Native arterial thrombosis - 32⋅2%
• Embolus in 22⋅3%
• Popliteal artery aneurysm - 6⋅7%
• 30-day mortality: 4.4%
• 30-day major amputation: 13.1%
• Bleeding complications: 30.3% (Major bleeds: 13.9%)
• Amputation-free survival at 1 year: 83.6% (similar in both groups)

Conclusion: Both treatment strategies were successful in achieving

revascularization with acceptable complication rates. “Continuous heparin
infusion during intra-arterial thrombolysis appeared to offer no advantage.”
 J Vasc Surg 2016;63:270-8.)

Surgical or endovascular revascularization for ALI is achievable with acceptable limb

salvage and amputation rates, which are not markedly different between the two modalities
in the short term. Endovascular therapy and surgery are complementary rather than
competing strategies for ALI.
 Cardiovasc Diagn Ther 2017;7(3):264-271

• 6 studys (5 RCTs)
• 1773 patients
• No difference in mortality at 1, 6 and 12 months
• No significant difference in amputation rates at 1, 6
and 12 months
• No difference in recurrence of ischaemia
 J Vasc Surg 2014;59:988-95

 Endovascular therapy with thrombolysis using tissue plasminogen activator remains an effective
treatment option for patients presenting with mild or moderate lower extremity ALI, with equal benefit
derived with CDT or PMT.
 Patients with end-stage renal disease or poor pedal outflow have an increased risk of limb loss and may
benefit from alternative revascularization strategies
 The use of PMT was a significant predictor of technical success (odds ratio, 2.67; P [ .046)