Limb ischemia

 Epidemiology:
 Incidence - 14 / 100,000 /year accounting for 12% of operations in the average vascular unit
 Iatrogenic causes are increasing due to the increasing use of endovascular therapy

Acute limb ischemia

 Definition:
Acute limb ischemia is a sudden decrease in limb perfusion that threatens limb viability and requires urgent evaluation and management (<2w.k)
 Etiology:

Thrombosis (50% of cases) Embolism (40% of cases) Iatrogenic (5% of cases)

❖ Atherosclerotic plaque
❖ Peripheral arterial disease (Popliteal
Artery Disease)
1. Popliteal artery aneurysms thrombosis
(10% of acute arterial occlusions).>>
see CT scan on the right
2. Popliteal artery entrapment syndrome
(popliteal artery compression caused
by an abnormal anatomical
relationship between the vessel and
nearby musculotendinous structures or
surrounding muscle hypertrophy.)
❖ Aortic Dissection (10% of pt)
❖ Accidental Intra-arterial Injection (inject
drug in artery rather than vein)
o Intense vasospasm.
o A significant source in young pts
(e.g drug abuser)
As emboli travel from other sources to
narrowing artery like atherosclerotic artery.
• Sources of emboli:
- Heart (75% of cases) during atrial fibrillation
or prosthetic valves and myocardial infraction.
- Emboli from aneurysm or atherosclerotic
lesion.
• 50-60% occurs in lower limb
❖ percutaneous endoluminal vascular
procedures
❖ Diagnostic angiography: (0.10% -
0.15%)
❖ Therapeutic intervention (1% - 2%)
➢ Intraaortic balloon pump 27%
(image below)
Trauma (5% of cases)
❖ MVC account for most blunt arterial injuries.
2/3 complete disruption and 1/3 intimal or medial
tear (assess perfusion)
Diagnosis and investigation
Diagnostic criteria (6P's mnemonic) Clinical classification of acute limb ischemia
Early stage:
❖ Pain: Sudden, severe and continue located distal in the extremity.
❖ Pallor: Cyanosis with fixed color change and might associated with
progression gangrene in late stage.
❖ Cold: Cold compare with other site of body.
❖ Pulselessness:
-Not feeling by hand.
- Present of pulse indicate no acute limb ischemia but if absent alone not
necessary rule in acute limb ischemia.
Late stage:
❖ Paraesthesia:
- In beginning, loss of touch in distal part. Pts with ALI & salvageable extremity should undergo an emergent evaluation that
- Then all sensation of distal with progression to proximal part. defines anatomic level of occlusion and that leads to prompt endovascular or
❖ Paralysis surgical revascularization.

Magnetic Resonance
Modality Duplex US CT Angiography Contrast angiography
Angiography
Useful to diagnose anatomic location and Diagnose anatomic location Useful to diagnose Gold standard modality
degree of stenosis of PAD and presence of significant anatomic location and
Advantage
stenosis in patients with lower degree of stenosis of PAD
extremity PAD.
Disadvantage/ Operator dependent and time consuming to Renal insufficiency Should be performed with Renal insufficiency
note! image both lower extremities Contrast allergy gadolinium enhancement Contrast allergy

Picture

 patient anticoagulated/sub-therapeutic INR

PT/INR, PTT
 screening for Thrombophilia (which could be the cause of hypercoagulable state)
Other investigation Echo  Identify wall motion abnormalities, intracardiac thrombus, valvular disease, aortic dissection
(transesophageal is (Type A)
preferable)  To locate the source of thromboemboli
Management (see the algorithm on the last page of the summary)
Overview General management Embolectomy
 Cardiac monitoring & pulse oximetry.
 Oxygen by face mask,
 Intravenous hyderation .
 Treatment of cardiac failure, arrhythmia.
 Morphine.
 Intravenous unfractionated heparin (very
important)

Thrombolysis
 Catheter-based thrombolysis is indicated for patients with ALI (Rutherford categories I and IIa) of less than 14 days.
 Mechanical thrombectomy devices can be used as adjunctive therapy.
Dosages Absolute contraindication Relative contraindication
 Reteplase  Cerebrovascular event within 3 months  Cardiopulmonary resuscitation within last 10
➢ Bolus, 2 to 5 U bolus, then continuous  Active bleeding diathesis days
infusion  Recent gastrointestinal bleeding within10  Major nonvascular surgery or trauma within
➢ Continuous, 0.25 to 0.5 U/h (20 units days last 10 days
maximum)  Neurosurgery (intracranial, spinal) within last  Uncontrolled hypertension: 180 mm Hg
 Alteplase 3 months systolic or 110 mm Hg diastolic
➢ Bolus 4 mg, infusion 0.5 mg-1 mg/hr  Intracranial trauma within last 3 months  Puncture of non-compressible vessel
 Tenecteplase  Intracranial tumor
 Recent eye surgery

Bypass surgery Primary amputation Fasciotomy

 Indication: acute thrombotic/embolic ischemia
Rutherford (I,IIa,IIb) after failed intervention
 The preferential use of autogenous vein,
specifically the great saphenous vein over
other conduits (alternative vein, prosthetic
graft), is based on randomized trials that
consistently demonstrate their improved
patency and limb salvage rates [2,24,49-54].
The benefits of autogenous vein are
accentuated for more distal bypass outflow
targets. (uptodate)
A nonviable extremity should not undergo an
evaluation to define vascular anatomy or efforts to
attempt revascularization.
-above/ below knee (above> below in ALI)
Post-operative medication
 continue heparin post-operatively
 start oral anticoagulant (warfarin) post-operatively when stable for 3 monts or longer depending on
underlying etiology and other comorbidities
 Indication: Compartment syndrome
-Pathophysiology: With extremity reperfusion,
there is increased capillary permeability,
resulting in local edema and compartment
hypertension.
- Compartment pressures of 20 mmHg are a
clear indication for fasciotomy.
 Chronic limb ischemia
Definition: is a peripheral arterial disease that results in a symptomatic reduced blood supply to the limbs

Clinical presentation Fontaine classification

Critical limb ischemia

Rest pain ABI< 0.3 Tissue loss
 Not controlled by is the systolic  Ischemic ulcer:
analgesics. pressure at the ankle, Found at the tip of
 Worse at night and by divided by the systolic toe and pressure
Ankle brachial index elevation of the lower pressure at the arm. It area.
extremity. has been shown to be  Deep ulcer ((may
 Relieved by hanging their a specific and penetrate down to
foot over the edge of the sensitive metric for deep fascia, tendon
bed or by walking. the diagnosis of & bone).
Peripheral Arterial  Cold surrounding
Disease (PAD). tissue
 See table on last
page to differentiate
b/w arterial and
venous ulcer
Intermittent claudication: Pain within a defined group of muscles that is induced by exercise and relieved with rest Investigations
Characteristic of pain The site of claudication gives a clue to the likely site of arterial  Lab investigation
 Not present at rest disease:  Radiological investigation
 Comes on walking a particular distance  Bilateral thigh and/or buttock: aortoiliac artery. (same as acute limb ischemia)
(claudication distance)  Unilateral thigh and or buttock: iliac artery.
 Quickly relieved by resting (usually 10min)  Calf: femoropopliteal artery
 Repetitive (recur after walking same o upper 2/3 due to superficial femoral artery
distance) o lower 1/3 to popliteal artery.
 Foot: infrapopliteal tibial artery.
Management of chronic limb ischemia
Best Medical treatment
 Indication: If mild not affecting patient Surgical
daily activity intervention
 Smoking cessation
 Control of hypercholesterolemia
Arterial
 Antiplatelet Endovascular
reconsutruction
Amputation
 Exercise program
 Control obesity
 Foot care Balloon
Stenting Endarterectomy Bypass surgery
angioplasty

Endovascular treatment Amputation Endarterectomy

 Balloon angioplasty  Last option  Limited use
 Stenting  Indications:
• Done under local anesthesia • Arterial reconstruction no feasible
• For short single level stenosis • Non salvageable limb
• Sepsis with spreading gangrene

Bypass surgery (Type of the bypass)

Anatomical Extra anatomical Synthetic Autogenous
For example: from femoral to -From R femoral to L femoral Using autogenous vein (great
popliteal or from aorta to femoral -From axillary to femoral saphenous or small saphenous)
 Management algorithm for acute limb ischemia

Tables and algorithm

Table: Gangrene: Ischemic dead tissue brown, dark blue or black

and gradually contract into crinkled hard mass.
TYPE DRY GANGRENE WET GANGRENE
Onset Slow and progressive Sudden
Character Dry & Black Edematous & grey
Margin Well demarcation Poor demarcation
Extent Minimal local sepsis Usually associated with
Restricted to gangrene site sepsis with proximal
progression

Prognosis Auto-amputation Life-threatening