Acute limb ischemia

January of vascular surgery 2000,

Part 2 • Volume 31 • Number 1

王雅珍
 Definition
• Acute limb ischemia is any sudden
decrease or worsening in limb perfusion
causing a potential threat to extremity
viability
 Etiology
• either an embolus, thrombosis, or a
combination of the two may produce the
obstruction
 clinical diagnosis of arterial
embolism in the leg
• may be suggested by the following features:
• (a) sudden onset of symptoms,
• (b) known embolic source,
• (c) absence of preceding claudication,
• (d) presence of normal pulses and Doppler
systolic blood pressures in the unaffected leg.
 Acute Arterial Occlusion

FIVE “P’s”
 Pallor
 Pulselessness or unequal pulses
 Paresthesias
 Pain
 Paralysis
 History
• Present illness
primarily to pain or function.
The suddenness and time of onset of the pain
location and intensity
• Past history
a history of claudication
heart disease (eg, atrial fibrillation)
aneurysms (ie, possible embolic sources).
concurrent disease or atherosclerotic risk factors
hypertension, diabetes, tobacco abuse,
hyperlipidemia,
family history of heart attacks, strokes, blood
clots, or amputations.
Differential diagnosis of acute
limb ischemia
 ARTERIAL EMBOLI

Source of Embolus in 300 Patients

Atrial Fibrillation 231
R.H.D. 48
Acute MI 50
Atherosclerotic plaque 7
Unknown
12
 Investigations for acute limb
ischemia
• 1 Arteriography
• 2 Doppler arterial study
• 3 MRA
Example of
acute
arterial
embolus

“Saddle”
Embolus of
right iliac
artery
 Imaging in acute limb ischemia
• Pre-intervention full imaging (usually by
angiography) should be performed, if
possible, to confirm the diagnosis and to
illustrate the distribution and localization of
the occlusion
• any imaging not unduly delay the
subsequent therapeutic intervention
 Levels of severity
• I. Viable:
• II. Threatened viability:
• III. Major, irreversible ischemic change:
Predicting outcome in acute limb
ischemia

• There is a need for objective measures

("markers") of the severity of acute
limb ischemia, and specifically for
definitive tests of tissue viability and
reversibility of ischemia, to predict
outcome more accurately, especially
between categories IIb and III.
Treatment
 Anticoagulant therapy in acute
limb ischemia

• Intravenous heparin at full

anticoagulant dosage should be given
as soon as the diagnosis of acute limb
ischemia has been made, provided that
heparin is not contraindicated
 Vasoactive drugs or
sympathectomy in acute limb
ischemia

• There is no evidence that "vasoactive"

drugs or sympathectomy are of benefit
in the treatment of acute limb ischemia.
 Factors for consideration in choosing
intervention for acute limb ischemia

• The choice as to which intervention should

be used for acute limb ischemia should be
based on
• ‧ location and anatomy of lesion
• ‧ duration of acute limb ischemia
• ‧ type of clot
• ‧ patient-related risks
• ‧ surgery-related risks
• ‧ contraindications to thrombolysis
Thrombolysis after arteriography in acute
limb ischemia

• If the decision is made to proceed with

thrombolysis after arteriography, then
the intrathrombus infusion method
should be used, which can be
performed successfully in most cases.
High-dose systemic thrombolysis in
arterial occlusion

• Intravenous administration of high

doses of currently available
thrombolytic agents should no longer
be used for the treatment of arterial
occlusion in the leg.
Other Endovascular Techniques

• Percutaneous aspiration thrombectomy

(PAT)
• Percutaneous mechanical
thrombectomy (PMT)
Surgery
Indications for surgery in acute
limb ischemia

• Immediately limb-threatening ischemia

(class IIb and early class III) is
preferentially treated surgically.
 Fasciotomy in acute limb
ischemia

• Fasciotomy should be performed at the

primary procedure if the acute severe
ischemia has been prolonged or if
signs of increased compartment
pressure develop.
 Predicting the requirement for
fasciotomy

• There is a need for an easy and

accurate test to predict which patients
require a fasciotomy.
 Long-term anticoagulation after
thromboembolectomy

• There is a need for further information

to determine whether long-term
anticoagulation is useful after
successful thromboembolectomy in the
absence of a proven source of emboli.