VASCULAR SESSION

Vito A. Damay MD
ACUTE LIMB ISCHEMIA
BE FAST AND CURIOUS
 LOOSING SENSE
• 65 y o diabetic man
with CAD old MI
AKI dd CKD
• 2nd day
hospitalization
 MANAGEMENT
• Antiplatelet
• Statin
• Diuretics
• Hydration balance
• Symptoms? Getting Better, Difficulties for
mobilization
 PLAN AND ORDER
• Electrocardiography
• Laboratorium Tests
– Hb, Ht, Leukocyte, random blood glucose, electrolyte,
ureum, creatinine, HbsAg, clotting factor

– Ready for discharge, but…

 INSIDE THE BLANKET
DIFF DIAGNOSIS
• SHOCK
• PHLEGMACIA CERULEA
DOLANS
• NEUROPATHY
• AORTIC DISSECTION
 INSIDE THE BLANKET
• PAIN
• PARESTHESIA
• PULSELESSNESS
• PARALYSIS
• PALLOR
• PERISHING COLD
ACUTE LIMB ISCHEMIA

Ram BL, George RK. Non traumatic acute limb ischemia – presentation, evaluation and management.
Indian J Vasc Endovasc Surg. 2017;4(4):192-197
SPECTRUM OF LEAD

CLAUDICATIO VS ACUTE ICHEMIA

 ACUTE LIMB ISCHEMIA
• PAIN
• PARESTHESIA
• PULSELESSNESS
• PARALYSIS
• PALLOR
• PERISHING COLD
 • Is about clinical diagnosis, you have to be FAST and
ALI Curious
• Uncover the Blanket and Palpate
ESC 2017/ ASVS 2020
 ACUTE LIMB ISCHEMIA
Once the clinical diagnosis is established,
treatment with unfractionated heparin should be
given, along with appropriate analgesia A.S.A.P. –ESC, 2017

•Initial IV bolus of 60-80 units/kg (max: 5000

units), THEN initial IV infusion of 12-15
units/kg/hr (max: 1000 units/hr)
•Dose should be adjusted to maintain aPTT of 50-
70 sec
• In the case of neurological deficit, urgent
revascularization is mandatory; imaging should not
delay intervention.
• If no neurological deficit, revascularization have to
be done within hours after imaging exam, in case
by case decision.
Stadium I, IIA/B : Revascularization à fibrinolytic,
mechanical thrombectomy, surgical embolectomy
Stadium III : amputation
CASE BY CASE DECISION
CASE MANAGEMENT BY COLLABORATION
 Point to Remember

• Management of acute limb ischaemia. CTA =

computed tomography angiography; DSA = digital
subtraction ultrasound; DUS = duplex ultrasound.
• Imaging should not delay revascularization.
• Specific etiological work-up is necessary (cardiac,
aorta).
• The Modern Concept of IntraArterial Thrombolysis and
Catheter Based Thrombus removal, lead to Amputation rates
w 6 mths < 10%
• There is no clearsuperiority up to date about Local
Thrombolysis VS Open Surgery for 30 day mortality and limb
salvage
• Endovascular Therapy or Open after Thrombus Removal if
Pre-existing Lesion still exist
• Consider Fasciotomy in long lasting ischemia
THINGS TO
CONSIDER
1. Clinical Condition
2. Comorbidities
3. Bleeding risk
4. Center
Capabilities
5. Non Medical Issue
 PREMEDICATION COCKTAIL
• Pharmacologic treatment
– Oral: Natrium Bicarbonate 3 x 500 mg, Alupurinol 3
x 500 mg, Mefenamic Acid 3 x 500 mg
– Intravenous: Pentoxyphylin 1200 mg/24 hours, NacL 0.9%
500ml/24 hours
– Pethidine 12 – 25 mg loading dose or morphine 2 mg
loading dose (can be repeated).
 WHO IS AT RISK
• Pts with Cardiovascular Disease ?
• CAD
• CHF
• STROKE
• VALVULAR HEART DISEASE
• DM
• CKD
• Seniors
• “That Virus” Infection…?

This Photo by Unknown Author is licensed under CC BY-NC

• For the period from January to March, the incidence rate of patients presenting with ALI
in 2020 was significantly greater than that for the same months in 2019 (23 of 141
[16.3%] vs 3 of 163 [1.8%]; P < .001)].
• Successful revascularization was lower than expected, which we believed was due to a
virus-related hypercoagulable state.
• The use of continuous postoperative systemic heparin infusion was
significantly associated with survival (0% vs 57.1%; P = .042).
 Changes in blood
coagulation during
SARS-CoV-2) infection

• INCREASED D-dimer, fibrin or

fibrinogen degradation products, and
fibrinogen
• DECREASED antithrombin values,
prothrombin time activity, and
thrombin time have been described
by Han et al
• Systemic proinflammatory cytokine
response inducing the expression of
procoagulant factors, local
inflammation.
• Receptor for SARS-CoV-2 (ACE 2) is
expressed on the membrane of
vascular muscle and endothelial cells.
WHERE ARE THEY?
All the high risk ALI
patients
Have YOU UNCOVER THE BLANKET?
 Thorough clinical history and physical
examination are key steps in PADs
management.-ESC,2017-
It Means Focused CARDIOVASCULAR EXAM from Head to Toe
It Means Focused • If treated promptly, restoration of
perfusion may lead to limb salvage.
CARDIOVASCULAR However, delay is likely to result in limb
EXAM loss and possibly death. ALI is associated
with limb loss rates of 5–30% and
from Head to Toe mortality rates of 11–18%.
PREVENT AND EARLY DETECTION
IN CHRONIC STABLE PHASE
• ABI ≤0.90 is associated 2-3 x increased risk of total
and CV death.
• ABI >1.40 represents arterial stiffening, also associated
with a higher risk of CV events & mortality.It is more
prevalent in elderly patients, mostly in those with DM
or CKD.
• ABI is a strong marker of generalized atherosclerosis
and CV risk
 HOW to REFER
• ASSES the LIMB, with 5 +1 P
• CV RISK FACTOR and COMORBIDITES
• ASSESS Cardio Status, HEMODINAMIC and
CLINICAL HF or CVD.
• ECG , RELEVANT LAB
• PREMEDICATION
• ANTI COAGULATION
 CASE 2
• 63 y.o male with angina
pectoris radiated to the left
arm. The pain was intense
with crescendo type
• Referred with ACS
CASE 2
POST INTRA ARTERIAL THROMBOLYSIS
BE FAST, CURIOUS AND
UNCOVER THE
BLANKET…