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Acute Limb Ischemia
Acute Limb Ischemia
Acute Limb Ischemia
ischemia
PRADITA DIAH PERMATASARI
Etiology
Patho-pysiology
Example of
acute
arterial
embolus
Saddle
Embolus of
right iliac
artery
Acute
Thrombotic
Ischemia
Atherosclerosis
causes
progressive
narrowing of the
arterial tree
Stimulates
development of
collaterals
Sluggish flow &
rough surface
will favor acute
thrombosis
Clinical Picture
5Ps
Pain:
Pain symptom
Pale
Pulseless
Parasthesia
Paralysis
Inspection
COLOR:
Fixed
mottling &
cyanosis
Early:
Early pale
Later:
mottling
Later cyanosed
mottling & cyanosis
fixed
An area of fixed
cyanosis
surrounded by
reversible mottling
Pallor
Reversible
mottling
Empty veins:
compare the Rt.
(ischemic) & Lt.
(normal)
Palpation
5Ps
Pain:
Pain symptom
Femoral
Popliteal
Posterior tibial
Dorsalis pedis
Pale
Pulseless
Parasthesia
Paralysis
Temperature:
Temperature the limb is cold with a level of
temperature change (compare the two limbs)
Slow capillary refilling of the skin after finger
pressure
5Ps
Pain:
Pain symptom
Pale
Pulseless
Parasthesia
Paralysis
Palpation
Loss of sensory function
Light touch
Vibration sense
Proprioreception
Deep pain
Pressure sense
Late
5Ps
Pain:
Pain symptom
Palpation
Loss of motor function:
Pale
Pulseless
Intrinsic
Parasthesia
Detecting
Paralysis
Investigations
The severity and duration of ischemia at the time of
presentation provides a narrow margin of time for
investigations
general
investigations
[Patients
with a
suspected
hypercoagulable state
will need additional
studies seeking:]
Anticardiolipin
antibodies
Elevated homocysteine
concentration
Antibodies to platelet
factor IV
Doppler US
What are we
looking for?
NORMAL
Multiphasic
Pulsatile
Regular amplitude
Arteriography
If the differentiation between embolic & thrombotic
ischemia is not clear clinically, and if the limb
condition permits,
DO ANGIOGRAPHY
Value of angiography
Embolism:
history of cluadication.
No hx of cluadication
Normal pulses in contralateral limb
Angiogram: minimal atherosclerotic
Few collateral
WWW.SMSO.NET
Doppler
Category
Description
Cap. refill
Paralysis
Sensory
loss
I
IIa
IIb
Viable
Not immediately
threatened
Intact
Aud
Aud
Threatened
Salvagable if
treated
Intact/slow
Partial
Aud
Threatened
Salvagable if
treated
emergently
Slow/absen
t
Partial
Partial
Aud
III
Irreversible
Primary
amputation req.
Absent
Complete
Complete
TREATMENT
Goals of therapy include restoration of
blood flow, preservation of limb and life,
and prevention of recurrent thrombosis
THROMBOLYTICS
IMMEDIATE CARE
SURGERY
A. Immediate care
Anticoagulation
Analgesia
Indications:
Indications
1. Viable or marginally threatened limb (class I, IIa)
2. Recent acute thrombosis (not suitable for embolism or
old thrombi)
3. Avoid patients with contraindications
Contraindications:
Absolute:
Absolute
1. Cerebro-vascular stroke within previous 2 months
2. Active bleeding or recent GI bleeding within previous 10
days
3. Intracranial trauma or neurosurgery within previous 3 months
Relative:
Relative
1. Cardio-pulmonary resuscitation within previous 10 days
2. Major surgery or trauma within previous 10 days
3. Uncontrolled hypertension
SURGERY
OPERATIVE
REVASCULARISATION
AMPUTATION
Embolectomy
Surgery
Etiology of ALI
Amputation
for irreversible
ischemia with
permanent tissue
damage
Clinical outcomes
1.
2.
3.
4.
Mortality -1520%.
Major morbidities include:
Due to major bleeding 1015% of patients require
transfusion/and or operative intervention
Amputation (2530% of patients)
Fasciotomy (525% of patients)
Renal insufficiency (up to 20% of patients)
Follow-up care
warfarin,
longer.
If
Algorithm to be followed
Patient with
suspected ischemia
History
Examination
investigations
Heparin
IIA
EARLY
INTERVENTION
NO
TREAT FOR
CHRONIC
ISCHEMIA
YES
SAME AS
FOR IIa
IIb
III
EMERGENCY
OPERATIVE
REVASCULARISATION
AMPUTATION
Management of IIa
ARTERIOGRAPHY
No lesion
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