LIMB ISCHEMIA

DIAGNOSIS AND MANAGEMENT

PRESENTERS :
FARRAH AIN
SUHAILA
NURUL ‘IZZATI
 OVERVIEW
Acute Limb Ischemia:
• Definition, Causes, Sign & Symptoms
• History & physical examination
• Differentiation between thrombotic or embolitic causes
• Viability of the limb
• Investigation
• Management
• Complication

Chronic Limb Ischemia:

• Critical vs non- critical
• Risk factor
• Clinical features
• Treatment
• Management

Other causes of Chronic Limb Ischemia

• Buerger’s disease
• Raynaud’s disease
• Takayasu’s Arteritis
 CLASSIFICATION OF PERIPHERAL ARTERIAL
DISEASE

Acute Limb Ischemia Chronic Limb Ischemia

• Onset: < 14 days • Onset: > 14 days

occlusion occlusion
ACUTE LIMB ISCHEMIA
 DEFINITION

• Sudden obstruction in the arterial flow to the extremity due to an embolism or

thrombosis (Medscape, 2019)
• Occurs when there is a sudden lack of blood to a limb.

THIS IS AN EMERGENCY !

• Complete arterial occlusion will lead to irreversible limb damage within 6 hours.
 REMEMBER THE 6PS!

1. PAIN
2. PALLOR
3. PULSELESSNESS
4. PERISHING COLD (POIKILOTHERMIA)
5. PARASTHESIAS
6. PARALYSIS
 CAUSES

• TRAUMATIC :

Blunt Injury – bone fracture

Penetrating – Stab wound , gun shot

•NON TRAUMATIC

Embolism
Thrombosis
 CHRONIC LIMB ISCHEMIA

• Decreased limb perfusion for >2 weeks

• Chronic limb ischemia is divided into Critical Limb and non-critical limb ischemia and
further subdivided into which causes symptoms (claudication) and asymptomatic.
• Most common cause is artherosclerosis with gradually developing diffuse stenosis of
peripheral arteries resulting in diminished blood supply to lower limb
• Less common causes includes : buerger’s disease @ thromboangitis obliterans,
vasculitis ( example Takayasu arteritis)
 CRITICAL LIMB ISCHEMIA

• Patients with chronic ischemia rest pain > 2 weeks , ulcers or gangrene attributable to objectively
proven arterial occlusive disease
• Features :

Rest pain requires opioid analgesia lasting > 2 weeks

Gangrene or ulcers over toes or feet
Objective indication of poor vascular supply to lower
limbs
(a) Ankle brachial pressure index < 0.5
(b) Toe pressure index < 0.3
(c) Toe pressure < 30mmHg , Ankle pressure <
50mmHg
Risk Factors:

The risk factors for critical limb ischemia include:

•Age (Men over 60 and women after menopause)

•Smoking
•Diabetes
•Overweight or obesity
•Sedentary lifestyle
•High cholesterol
•High blood pressure
•Family history of vascular disease

(UCSF Department of Surgery)

►

•
 INVESTIGATIONS

DIAGNOSTIC TOOLS

NON
INVASIV
INVASIV
E E

Doppler’s
ABSI PPG DUPLEX ANGIOGRAM
USG
 1. USG DOPPLER
• Used to identify an arterial waveform
• Normal sound is triphasic
• ARTERY: loud and sharp, rhythmic and synchronised with heartbeat
• VEIN: Low pitched, almost harsh tone (windstorm)
 2. ANKLE BRACHIAL SYSTOLIC INDEX

• ABSI = HIGHEST ANKLE PRESSURE

HIGHEST ARM PRESSURE

RATIO RESULT
S
≥ 1.3 • Raised due to calcification
• May be incompressible
• Toe pressure required

≥ 0.96 - < 1.3 Normal

< 0.96 – 0.6 Intermittent claudication
≤ 0.5 Critical Limb
Ischaemia;
• May present with
rest pain or
gangrene
 3. PPG Toe Pressures & Toe Brachial Index
(TBI)
 To assess the vascular condition of the foot by obtaining systolic pressures at the toe

 Toe pressures use an infrared PPG sensor to determine the small vessel vascular
condition distal to the ankle.

 Toe pressures may be useful in cases of unsuspected vascular disease and in baseline
diabetic foot assessment where falsely high ankle pressures can occur due to
calcification.
Interpreting the Results of a Toe Brachial Index (TBI)

 The TBI is calculated by dividing the toe pressure by the highest arm pressure.

 When calculating the TBI ratio use the highest arm pressure to rule out subclavean steal
syndrome.

 Greater than 0.7 = Normal

 Less than or equal to 0.7 = Abnormal

 A toe pressure of greater than 30 mmHg may be an indicator of healing potential in foot ulcer.

 A PPG waveform that does not have swift recovery may indicate poor perfusion
 4. SKIN PERFUSION PRESSURE

 Non-invasive test.

 Proved useful in the assessment of peripheral arterial disease (PAD) for both critical limb
ischaemia (CLI)

 For the determination of optimal levels for amputation.

 Useful indicators for wound healing potential

 Useful in situations where toe blood pressure measurements are not possible, due to toe
amputation, ulceration or gangrene.

 Normal value lower limb : > 50 mmHg

 Diagnostic value of PAD : 30 - 50 mmHg

 CLI or severe PAD : <30 mmHg

 5. DUPLEX SCAN

• Evaluation of blood flow

• Combines
• Traditional USG: uses sound waves that bounce off vessels to create pictures
• Doppler: record sound waves to measure speed an assess flow
 6. CT- ANGIOGRAPHY

• CT scan + contrast
• Less invasive compared to DSA
• Use of contrast: Renal damage
 7. DIGITAL SUBSTRACTION ANGIOGRAM

• Gold standard
• Invasive
• Only done if there’s potential therapeutic intervention
HOW TO CLASSIFY WHETHER IT IS VIABLE/
THREATENED/ NON-VIABLE?
 INITIAL MANAGEMENT

1. HEPARIN THERAPY
• Initial bolus: 5000 unit
• Then continue with IVI heparin
• Adjust dose according to APTT ratio
• Aim: 2-3

2. Analgesics
 DEFINITIVE MANAGEMENT
EMBOLISM
• Conservative Mx: Anti- coagulation only
THROMBOSIS • Thrombolytic therapy: Streptokinase, urokinase
•Conservative Mx:procedure:
Endovascular Anti- coagulation
Balloononly
catheter • Endovascular procedure: Thrombectomy,
embolectomy Angioplasty/ stents
• Arterial bypass • Arterial bypass
• Amputation • Amputation
 EMBOLECTOMY
• Fogarty balloon catheter
• Insert catheter through
arteriotomy
• Clamp proximal and distal to
clot
• Catheter inserted till distal part
of clot, balloon inflated to
trawl clot out
STENTING
 ARTERIAL BYPASS
• Considered when cannot be treated by
angioplasty
• Long lesion/ complete occlusion

• Need a good landing zone distally

• Eg: aortofemoral, femoropopliteal,
poplitealtibial
 COMPLICATIONS POST REVASCULARISATION

1. REPERFUSION INJURY
• Formation of oxygen free radicals  directly damage tissue & impairs adequate nutrient flow,
 pr ol on gs ischaemic interval

2. RHABDOMYOLYSIS
• Release by-products of ischaemic muscles
• Electrolytes and pH change  arrythmia
• Myogobulin  A K I

3. COMPARTMENT SYNDROME
• Cell mb damaage and leakage of fluid into interstitium
• Four compartment fasciotomy should be performed
Risk Factor Modification:
- Cessation of Smoking
- Well control of diabetes and hypertension
- Statin therapy for hyperlipidemia
- Encourage exercise / rehabilitation
programme
DIFFERENTIAL DIAGNOSIS