Principal Management of Acute Limb Ischemia

QUICK REVIEW
 History & Exam Findings
Further Hx:
• 2 days ago pain on left LEA
• CVA 4 years ago
Examination:
• Inspection:
o LLL: below the knee is pale/cool
• Palpation:
o Irregularly irregular pulse
o LLL Capillary return is sluggish
o No pulses palpable below L femoral artery
o All pulses palpable but appear reduced in R leg

Impression?
60yo female with a L Acute Ischemic limb , untreated AF and
symptomatic PVD.
 ACUTE LIMB ISCHEMIA
⚫ Defined as a sudden decrease in limb
perfusion that threatens the viability of the
limb

⚫ less than 14 days’ duration

⚫ Symptoms develop over a period of hours to
days

⚫ Variable ischaemic clinical manifestations

⚫ Potential risk of limb loss
⚫ incidence 1.5 cases per 10,000 persons per
year. Shishehbor Mehdi H, 2014
 CAUSES
OF ACUTE LIMB ISCHEMIA
⚫ Thrombosis ( 50% of cases )
⚫ artherosclerosis (native or bypass)
⚫ Aneurysm
⚫ Trauma
⚫ Vasculitis
⚫ Hypercoagulable states

⚫ Embolism ( 30% of cases )

⚫ Uncommon causes : Arterial dissection

Naidoo et al, 2013

 What is the possible source for an
embolus?

Spontaneous (80%)
Cardiac source
arrhythmias, MI, prosthetic valve, endocarditis
Non-Cardiac source
Proximal Aneurysm, Paradoxical emboli

Iatrogenic (20%)
Angiographic manipulation
Surgical manipulation
What are the common sites for embolus
lodgment in the arterial tree?
 What are the features
of an acute ischemic limb?
Fixed
mottling &
REMEMBER THE 6 P’S:
cyanosis
1. PAIN

1. PALLOR

1. PULSELESNESS

1. PERISHING COLD (POIKILOTHERMIA)

1. PARASTHESIAS

1. PARALYSIS
 Investigations

⚫ Acute Limb Ischemia is a

CLINICAL DIAGNOSIS

⚫ If time allows, especially if atherosclerotic thrombosis is

suggested, preoperative angiography is often wise
 DIAGNOSTIC METHODS
⚫ Palpation arteries ( detect pulse,
temperature and pallor )

⚫ Presence of flow with a Doppler

instrument

⚫ Duplex Ultrasonography
⚫ Computed Tomographic Angiography
⚫ Magnetic Resonance Angiography
⚫ Contrast Angiography
Kovacs et al, 2013
CLINICAL CLASSIFICATION OF
ACUTE LIMB ISCHEMIA

Naidoo et al, 2013

 ALGORITHM FOR
THE DIAGNOSIS AND TREATMENT OF ACUTE LIMB
ISCHEMIA

Naidoo et al, 2013

 Acute Limb Ischemia (ALI)

I IIa IIb III Patients with ALI and a salvageable

extremity should undergo an emergent

evaluation that defines the anatomic level of

occlusion, and that leads to prompt

endovascular or surgical intervention.

I IIa IIb III

Patients with ALI and a non-viable extremity

should not undergo an evaluation to define

vascular anatomy or efforts to attempt

revascularization.
CT Angiography Digital Subtraction
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
 CTA has potential advantages over MRA

⚫ Pts with PPI or ICD may be imaged safely with CTA

⚫ Metal clips, stents, and prostheses usually do not cause
significant CTA artifacts

⚫ Has higher resolution

⚫ Can provide images of calcification in the vessel wall

⚫ Scan times are significantly faster with CTA than with

MRA

⚫ Claustrophobia not a problem

CTA also has potential disadvantages compared with

MRA

⚫ Requires iodinated contrast, which may be nephrotoxic

⚫ Requires ionizing radiation
ENDOVASCULAR REVASCULARISATION
⚫ Goal to restore blood flow as rapidly
⚫ With the use of drugs, mechanical devices, or both
⚫ Ischemia for 12 to 24 hours would not be safe
should not undergo catheter-directed therapies.
⚫ Two modalities exist:
⚫ CDT ( Catheter Directed Thrombolysis )
⚫ PMT ( Percutaneus Mechanical Thrombectomy )

Rooke TW et al, 2011

CATHETER-DIRECTED THROMBOLYSIS
⚫ Technique currently used to clear arteries, arterioles and
capillary beds
⚫ Thrombolytic agents or rt-PA use to enable clot
dissolution.
⚫ Deliver thrombolytic agent to thrombus
⚫ Success determined by the ability cross a thrombosed
⚫ Complications :
⚫ bleeding (12.5% )
⚫ distal embolisation
Rasavi, Hoffman, 2003
Thrombolysis
 PERCUTANEOUS MECHANICAL
THROMBECTOMY
⚫ Simple aspiration with or without thrombolytic
agent
⚫ best for high risk surgery and not suitable for CDT.
⚫ Complications
⚫ distal embolisation
⚫ haemolysis
⚫ fluid overload with select

Rasavi, Hoffman, 2003

SURGICAL REVASCULARISATION

⚫ balloon catheter embolectomy,

⚫ transluminal thrombectomy
⚫ vascular bypass procedures
⚫ Endarterectomy
⚫ patch-plasty
⚫ intraoperative thrombolysis
⚫ hybrid procedures (surgery and endovascular
procedures, viz. angioplasty/stenting).

Comerota ,Gravett , 2009

 SURGICAL REVASCULARISATION
⚫ Transfemoral Fogarty catheter-based techniques àbest suited for
embolic or thrombosed vascular graft

⚫ Iliac native vessel thrombectomy + stent à residual stenosis >

30%

⚫ Infra inguinal native vessel thrombosis à thrombectomy,

endarterectomy, patch angiography

⚫ Complication :
⚫ Amputation (10-30% )
⚫ Mortality ( 10-20 % )
⚫ Result :
⚫ degree ALI
⚫ Comorbidities Aliason et al, 2003
Surgical Thromboembolectomy Procedure
MRS T 73 yo Dx ALI
ENDOVASCULAR VERSUS SURGICAL
REVASCULARIZATION
⚫ Similar rates of limb salvage
⚫ Thrombolysis
⚫ higher rates of stroke and major hemorrhage within 30
days
⚫ 12 month rates of survival were higher
The Bypass Versus Angioplasty
in Severe Ischaemia of the Leg ( BASIL ) trial

⚫ No differences in amputation free survival, deaths, or

health relatec quality of life
⚫ Surgery à hospital costs one third higher
Comerota ,Gravett , 2009
 The surgery versus thrombolisis
for ischemia of the lower extremity ( STILE ) trial

⚫ Thrombolysis à higher rates of ischemia, amputation,

complications

⚫ Rate of amputation free survival higher sympton less than 14 days

In the thrombolysis or Pheriperal Arterial Surgery

( TOPAS ) trial

⚫ Rates limb salvage , survival did not differ

⚫ Thrombolysis à complication rate higher
Naidoo et al, 2013
 Catheter directed thrombolysis
⚫ Best result in viable or marginally threatened limb
⚫ Recent occlusion ( no more than 2 weeks )

Surgical revascularisation

⚫ Preferred for immediately threatened limb

⚫ Symptoms occlusion more than 2 weeks

Tendera et al, 2011

LONG TERM MANAGEMENT
⚫ Antithrombotic therapy, continued anticoagulation
⚫ Prostanoids
⚫ Antiplatelet à thrombosis superimposed atherosclerotic
plaque

⚫ Prevention measure same as for cardiovascular disease

⚫ Quitting smoking
⚫ Lowering LDL cholesterol
⚫ Reducing blood presure
⚫ Controlling diabetes
⚫ Managing heart failure

Anthonisen, 2005
 SUMMARY
ü ALI defined as a sudden decrease in limb perfusion
that cause acute thrombosis or embolism
ü less than 14 days’ duration
ü The features as parasthesia, pain, pollar, pulseless,
poikilothermia, paralysis
ü Prompt diagnosis and revascularization ( by
endovascular or by surgical ) reconstruction reduce
the risk of limb loss
ü Amputation is performed in patients with
irreversible damage
Thank You