ACUTE LIMB ISCHEMIA VS

CRITICAL LIMB ISCHEMIA :

CLINICAL PRACTICE

By
F1 Parach Sirisriro
22 Feb 2018
 OUTLINE

• Definition
• Clinical presentation
• Diagnosis
• Management and recommendation for ALI
• Management and recommendation for CLI
 REFERENCE

- 2016 AHA/ACC Lower Extremity PAD Guideline

- 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral
Arterial Diseases, in collaboration with the European Society for Vascular
Surgery (ESVS)
- Cronenwett, Jack L.; Johnston, K. Wayne. Rutherford's Vascular
Surgery 8th edition , Chapter 161 - 162
- Creager, M. A., et al. (2012). "Acute limb ischemia." New England
Journal of Medicine 366(23): 2198-2206.
- Rutherford, R. B. (2009). Clinical staging of acute limb ischemia as the
basis for choice of revascularization method: when and how to
intervene. Seminars in vascular surgery, Elsevier.
- A.J. Comerota and R. Sidhu. (2009. Can Intraoperative Thrombolytic
Therapy assist with the Management of Acute Limb Ischemia? Seminars
in Vascular Surgery
DIFFERENTIATE BETWEEN ACUTE AND
CHRONIC ISCHEMIA
 DEFINITION

Acute Limb Ischemia (ALI) Critical limb ischemia

• Acute (<2 wk), severe A condition characterized by
hypoperfusion of the limb chronic (>2 wk) ischemic rest pain,
characterized by these nonhealing wound/ulcers, or
features gangrene in 1 or both legs
• Pain attributable to objectively proven
• Pallor arterial occlusive disease.
• Pulselessness
• Poikilothermia(cold)
• Paraesthesias, and
• Paralysis

Cronenwett, Jack L.; Johnston, K. Wayne. Rutherford's Vascular Surgery 8th edition , Chapter 161 - 162
 SIGN AND SYMPTOMS

ALI CLI
History History
- Leg symptoms in ALI relate to pain or - Claudication
function. - Other non–joint-related exertional
- Duration and intensity of the pain and lower extremity symptoms (not typical of
presence of motor or sensory changes. claudication)
- Previous Hx of claudication, heart - Impaired walking function
disease or aneurysm, and atherosclerotic - Ischemic rest pain
risk factor
Physical Examination Physical Examination
- Rule of Ps—pain, pallor, paresis, - Abnormal lower extremity pulse
pulse deficit,paresthesia, and examination
poikilothermia - Vascular bruit
- Nonhealing lower extremity wound
- Marblewhite skin
- Lower extremity gangrene
- Muscle tenderness, particularly in - Other suggestive lower extremity
the physical findings (e.g., elevation
calf pallor/dependent rubor)
- Proximity strong pulse (water-
hammer effect )

Cronenwett, Jack L.; Johnston, K. Wayne. Rutherford's Vascular Surgery 8th edition , Chapter 161 - 162
ALI : HOW WILL YOU DIFFERENTIATE BETWEEN
EMBOLUS AND THROMBUS?

Cronenwett, Jack L.; Johnston, K. Wayne. Rutherford's Vascular Surgery 8th edition , Chapter 161 - 162
MANAGEMENT OF ACUTE LIMB ISCHEMIA:
RECOMMENDATIONS

- 2 0 1 6 A H A / ACC LO W E R E X T R E M I T Y PA D G U I D E L I N E
- 2 0 1 7 E S C G U I D E L I N E S O N T H E D I AG N O S I S A N D
T R E AT M E N T O F P E R I P H E R A L A R T E R I A L D I S E A S E S ,
I N CO L L A B O R AT I O N W I T H T H E E U R O P E A N S O C I E T Y
F O R VA S C U L A R S U R G E R Y ( E S VS )
 SEVERITY OF ALI

2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery
 MANAGEMENT OF ACUTE LIMB ISCHEMIA:
RECOMMENDATIONS

2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery
 MANAGEMENT OF ACUTE LIMB ISCHEMIA:
RECOMMENDATIONS

 Oxygen delivered by facemask

 Correct dehydration  IV fluid resuscitation

 IV heparin
 Prevents clot propagation + maintains collateral
vessel
 Dose: bolus 80 mg/kg then drip 18 mg/kg/hr
 Keep aPTT ratio 2-3

 Adequate analgesia (PCA is a good alternative)

-Creager, M. A., et al. (2012). "Acute limb ischemia." New England Journal of Medicine 366(23): 2198-2206.
 MANAGEMENT OF ACUTE LIMB ISCHEMIA:
RECOMMENDATIONS

Nonviable limb : Condition of extremity (or portion of extremity) in

which loss of motor function, neurological function, and tissue integrity
cannot be restored with treatment.

Salvageable limb : Condition of extremity with potential to

secure viability and preserve motor function to the weight-bearing portion
of the foot if treated

2016 AHA/ACC Lower Extremity PAD Guideline

NON VIABLE LIMB

An area of fixed cyanosis

surrounded by reversible mottling

Major Tissue loss

And Rigor muscle
 REVASCULARIZATION FOR ALI:
RECOMMENDATIONS

1 local resources and patient factors (e.g., etiology

and degree of ischemia)
2. Emergently vs urgent depend on severity
3. Catheter-directed thrombolysis vs surgical
thromboembolectomy
Main target : RAPID RESTORATION of arterial flow with
least risk to patient

2016 AHA/ACC Lower Extremity PAD Guideline

 MANAGEMENT OF ACUTE LIMB ISCHEMIA:
RECOMMENDATIONS

1. For marginally or immediately threatened limbs

(Category IIa and IIb ALI), revascularization should be
performed emergently (within 6 hours).
2. For viable limbs (Category I ALI), revascularization
should be performed an on urgent basis (within 6 to 24
hours).

2016 AHA/ACC Lower Extremity PAD Guideline

TREATMENT ACUTE LIMB ISCHEMIA
 SURGICAL EMBOLECTOMY

Pros
 Rapid revascularization
 Can be done via low tech instrument
 Transfemoral approach can be done via local anesthesia

Cons
 Vessel injury
 Reperfusion syndrome
 Low success rate if ischemia >24 hour
 Adjunct by “Intraoperative thrombolysis”

Cronenwett, Jack L.; Johnston, K. Wayne. Rutherford's Vascular Surgery 8th edition , Chapter 161 - 162
 Embolectomy catheter / arterial /
balloon
7F Yellow
2.5 ml (fluid) 6F Blue
14 mm 2 ml (fluid) 5F White
13 mm 1.5 ml (fluid) 4F Red
11 mm 0.75 ml (fluid) 3F Green
9 mm 0.2 ml (fluid)
5 mm

Aortic femoral graft

Saddle aortic embolus CIA, EIA EIA, SFA, PA Tibial vessels

Cronenwett, Jack L.; Johnston, K. Wayne. Rutherford's Vascular Surgery 8th edition , Chapter 161 - 162
 SURGICAL
EMBOLECTOMY

Cronenwett, Jack L.; Johnston, K. Wayne. Rutherford's Vascular Surgery 8th edition , Chapter 161 - 162
 INTRA-OP THROMBOLYSIS

Pros
 Adjunct to surgical thromboembolectomy  Clear residual thrombus in
the small arteries and arteriole
 Minimal risk of bleeding

Cons
 May be inadequate in some patients with extensive distal and small
vessel thrombosis

A.J. Comerota and R. Sidhu. (2009. Can Intraoperative Thrombolytic Therapy assist with the Management of Acute Limb Ischemia?
Seminars in Vascular Surgery
 INTRA-OP THROMBOLYSIS

Operative thromboembolectomy

Incomplete thrombus
Complete/Near complete Extensive residual thrombus,
extraction with small volume
thrombus extraction Multi-vessel distal occlusion
residual thrombus

Bolus intra-arterial lytic Rx

during arterial occlusion
High dose isolated limb
Bolus intra-arterial lytic Rx (+repeat dose)
perfusion
into distal and proximal -or-
(Manual infusion or Partial
arterial segment during 20-30 minutes infusion
bypass with pump
arterial occlusion intra-arterial lytic Rx after
oxygenator)
arterial infusion is
restored

A.J. Comerota and R. Sidhu. (2009). Can Intraoperative Thrombolytic Therapy assist with the Management of Acute Limb Ischemia?
Seminars in Vascular Surgery
 INTRA-OP THROMBOLYSIS

High dose isolated limb perfusion

A.J. Comerota and R. Sidhu. (2009). Can Intraoperative Thrombolytic Therapy assist with the Management of Acute Limb Ischemia?
Seminars in Vascular Surgery
 CATHETER DIRECTED THROMBOLYSIS

Pros
 Direct delivery of the drug into existing thrombus
 ↓ Thrombolytic drug dosages
 ↓ Systemic bleeding complications
 Lyses clot in both large and small vessels
 Lower reperfusion syndrome than embolectomy
 Done via percutaneous approach with local anesthesia

Cons
 Usually takes 12 - 24 hours to be effective
 Still increased bleeding risk
 ICH: 0-2.5%
 Major bleeding: 1-20%

Cronenwett, Jack L.; Johnston, K. Wayne. Rutherford's Vascular Surgery 8th edition , Chapter 161 - 162
 MANAGEMENT OF ACUTE LIMB ISCHEMIA:
RECOMMENDATIONS

Catheter-based thrombolysis
effective for patients with ALI and a salvageable
(viable or marginally threatened) limb
Particularly in setting of
1. recent occlusion,
2. thrombosis of synthetic grafts
3. stent thrombosis

2016 AHA/ACC Lower Extremity PAD Guideline

 CATHETER DIRECTED THROMBOLYSIS

Contralateral approach Ipsilateral approach

Cronenwett, Jack L.; Johnston, K. Wayne. Rutherford's Vascular Surgery 8th edition , Chapter 161 - 162
Cronenwett, Jack L.; Johnston, K. Wayne. Rutherford's Vascular Surgery 8th edition , Chapter 161 - 162
 MECHANICAL THROMBECTOMY

Percutaneous mechanical thrombectomy (PMT)

as adjunctive therapy to thrombolysis (pharmacologic therapy)

Pros
 Disrupts the thrombus Allows better penetration of the clot by a
thrombolytic agent
 ↓ Thrombolytic dosing
 ↓ Therapy time  Increasingly being used in “class IIb”
 Done via percutaneous approach with local anesthesia
 Less vessel injury

Cons
 Can be used only large vessel
 Expensive device

Cronenwett, Jack L.; Johnston, K. Wayne. Rutherford's Vascular Surgery 8th edition , Chapter 161 - 162
 MECHANICAL THROMBECTOMY

Trellis device (Mechanical mixing AngioJet®

device)  Using a high-velocity saline
insert the wire for mechanical jet to extract the thrombus in
thrombus fragmentation an isovolumic manner
“Venturi effect”

Cronenwett, Jack L.; Johnston, K. Wayne. Rutherford's Vascular Surgery 8th edition , Chapter 161 - 162
 ARTERIAL BYPASS SURGERY

Pros
 Use in patient that…
 Failed other procedures  Our last resort!!!
 Severe tissue injury
 Peripheral vascular disease
 Main treatment for thrombosed popliteal artery aneurysm

Cons
 High surgical risk

Cronenwett, Jack L.; Johnston, K. Wayne. Rutherford's Vascular Surgery 8th edition , Chapter 161 - 162
 MANAGEMENT OF ACUTE LIMB ISCHEMIA:
RECOMMENDATIONS

• Amputation* :
• Performed as the first(index) procedure in
• A nonsalvageable (class III) limb
• Low potential of limb salvage
• Risk of reperfusion syndrome and associated MOF
*may be deferred if pain under control and no
infection and meets with patients goals

2016 AHA/ACC Lower Extremity PAD Guideline

 MANAGEMENT OF ACUTE LIMB ISCHEMIA:
RECOMMENDATIONS

• Monitored and treated (e.g., fasciotomy) for compartment

syndrome after revascularization (due to reperfusion causing
edema)

• Indications
1. Raised intra compartment pressure (> 30 mmHg) – not always
easily accessible
2. Clinical: increased pain, tense muscle, or nerve injury
3. Category IIb ischemia for whom time to revascularization is > 4
hours

2016 AHA/ACC Lower Extremity PAD Guideline

MANAGEMENT OF CRITICAL LIMB ISCHEMIA:
RECOMMENDATIONS

- 2 0 1 6 A H A / ACC LO W E R E X T R E M I T Y PA D G U I D E L I N E
- 2 0 1 7 E S C G U I D E L I N E S O N T H E D I AG N O S I S A N D
T R E AT M E N T O F P E R I P H E R A L A R T E R I A L D I S E A S E S ,
I N CO L L A B O R AT I O N W I T H T H E E U R O P E A N S O C I E T Y
F O R VA S C U L A R S U R G E R Y ( E S VS )
RECOMMENDATIONS FOR
PHYSIOLOGICAL TESTING

2016 AHA/ACC Lower Extremity PAD Guideline

BMT
 SEVERITY OF CLI

Cronenwett, Jack L.; Johnston, K. Wayne. Rutherford's Vascular Surgery 8th edition , Chapter 161 - 162
CLI RECOMMENDATIONS FOR
IMAGING

2016 AHA/ACC Lower Extremity PAD Guideline

MANAGEMENT OF CRITICAL LIMB ISCHEMIA:
RECOMMENDATIONS

2016 AHA/ACC Lower Extremity PAD Guideline

MANAGEMENT OF CRITICAL LIMB ISCHEMIA:
RECOMMENDATIONS

2016 AHA/ACC Lower Extremity PAD Guideline

 MANAGEMENT OF CRITICAL LIMB ISCHEMIA:
RECOMMENDATIONS REVASCULARIZATION
OPTIONS: GENERAL ASPECTS

2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery
 MANAGEMENT OF CRITICAL LIMB ISCHEMIA:
REVASCULARIZATION OPTIONS: GENERAL
ASPECTS

2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery
 REVASCULARIZATION OPTIONS:
AORTO-ILIAC LESION

2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery
 REVASCULARIZATION OPTIONS:
FEMORO-POPLITEAL LESION

2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery
 REVASCULARIZATION OPTIONS:
INFRA-POPLITEAL OCCLUSIVE LESION

2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery
 MANAGEMENT OF CRITICAL LIMB ISCHEMIA:
REVASCULARIZATION OPTIONS: GENERAL
ASPECTS

2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery
 THE WIFI CLASSIFICATION

The target population for

• Ischaemic rest pain with objectively confirmed
haemodynamic studies
ABI <0.40
Ankle pressure <50mmHg
Toe pressure <30mmHg
TcPO2 <30mmHg
• Diabetic foot ulcer,
• Non-healing lower limb or foot ulceration >_2 weeks
duration
• Gangrene involving any portion of the foot or lower limb.

2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery
 THE WIFI CLASSIFICATION

2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery
THE WIFI CLASSIFICATION
2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery
2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery
MANAGEMENT OF CRITICAL LIMB ISCHEMIA:
RECOMMENDATIONS

2016 AHA/ACC Lower Extremity PAD Guideline

 MANAGEMENT OF CRITICAL LIMB ISCHEMIA:
RECOMMENDATIONS

2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery
THANK YOU