Acute limb ischaemia Joel Arudchelvam MBBS (Col), MD (Sur), MRCS (Eng) Consultant Vascular and Transplant Surgeon DEFINITION Causes Differentiating thrombosis and embolism Sources of emboli Presentation Acute on chronic ischemia Rutherford classification for acute limb ischaemia Management Embolectomy Management of acute on chronic ischaemia Complications of Acute limb Ischaemia

1. ACUTE LIMB ISCHAEMIA
Dr. Joel Arudchelvam
MBBS (Col), MD (Sur), MRCS (Eng)
ConsultantVascular andTransplant Surgeon
Teaching HospitalAnuradhapura

2. Q1
 A 30 year old male, who is a patient with
rheumatic valvular heart disease presented
with a history of sudden onset left upper
Limb pain for 5 hours duration. On
examination the brachial pulse was present,
but the radial and ulnar pulses were absent.
The hand was cold. the most likely cause for
the upper limb pain in this patient is;

3. a) Acute embolism
b) Vasculitis
c) Cervical radiculopathy
d) Neurogenic thoracic outlet syndrome
e) Thrombosis of the radial and ulnar arteries

4. Acute limb Ischaemia
 Sudden interruption of blood supply to
limb resulting in threat to the limb
viability.

5. Acute limb Ischaemia

6. Q4
A 70 year old male who is a patient with diabetes
mellitus for 20 years duration presented with a
history of right leg and foot pain for 5 days
duration. the pain was gradually worsening.The
pain was worse in the night. He also complained of
numbness on the foot. He gives a history of
bilateral calf claudication for 2 years duration. on
examination bilateral popliteal and distal pulses
were absent.The foot was cold. the most likely
cause for the above presentation is;

7. a) Bilateral popliteal artery embolisation
b) Bilateral knee joint osteoarthritis
c) Acute on chronic ischemia due to thrombosis
of the right popliteal artery
d) Myositis of the calf muscles
e) Stress fracture of the second metatarsal of
the foot

8. Acute on chronic ischemia
 occurs in patients with occlusive arterial
disease due to atherosclerosis
 thrombosis develops on the atherosclerotic
plaque
 ischemia is less severe

9. Differentiating thrombosis and embolism
Embolism Thrombosis
Sudden onset pain Sub acute onset
Young patient Elderly patient
Has a source of emboli No source of emboli
No history of occlusive
arterial disease
History of occlusive arterial
disease
Other pulses are present Other pulses may be absent

10. Sources of emboli
 Heart – recent MI, Atrial fibrillation,Valvular
heart disease.
 Blood vessels – aneurysms
 An embolus gets stuck at sites of bifurcation
as the diameter of the vessels reduces at
these places.

11. Acute limb Ischaemia
Presentation
“ P ”s
 Pain
 pallor
 Perishing cold
 Pulselessness
 Paresis / paralysis
 Paraesthesia / anaesthesia.
Beware
 Paralysed
 Unconcious

12. Q2
 A 60 year old male who was treated for acute
myocardial Infarction one week ago presented
with a history of sudden onset pain on the left
foot for 8 hours duration. He also complained
about difficulty in walking due to leg weakness.
On examination the left femoral pulse was
absent. the lower leg and the foot were cold. All
pulses were present on the opposite limb. an
acute thromboembolism was clinically
diagnosed. the most likely location of the
embolus is;

13. a) Descending thoracic aorta
b) Abdominal aorta
c) Bifurcation of the aorta
d) Bifurcation of the common iliac artery
e) Bifurcation of the common femoral artery

14. History
 Features of acute Limb ischemia and duration
 Sources of emboli
 Rheumatic valvular heart disease
 Recent myocardial infarction
 Atrial fibrillation
 Evidence of chronic occlusive arterial disease

15. Examination
 Pulse Status - both limbs, fibrillation
 Viability of the limb
 Evidence of aneurysms

16. Rutherford classification for
acute limb ischaemia
1. Viable: not immediately threatened, no
sensory loss, no muscle weakness
2. Threatened
A.Marginally: minimal sensory loss, no muscle
weakness
B. immediately: sensory loss, muscle weakness
3. Irreversible: anaesthesia ,paralysis

17. Q3
The above mentioned patient, on further
evaluation was found to have numbness of the
foot and weakness of the leg muscles. the most
appropriate next step in the management of
the above patient is;

18. a) Keep the patient fasting for 6 hours to
prepare for surgery
b) Urgent embolectomy under local
anaesthesia
c) Catheter directed thrombolysis of the
embolus
d) Systemic administration of the thrombolytic
agent
e) Aorto femoral bypass surgery

19. Acute limb Ischaemia
Management
 Recognize
 Start unfractionated heparin
 Loading dose 75 – 100 IU/Kg ( approximately 5000 IU )
 Followed Infusion of heparin -18U/kg (approximately -
1000U/hr)
 Refer to vascular surgeon
 Pain relief
 Keep fasting
 Inform theatre and anaesthetist
 Consent – for embolectomy and fasciotomy
 Check theViability of the limb - note.

20. Acute limb Ischaemia
 Surgery
 Embolectomy with fogarty
catheter
 Can be done under LA

21. Embolecctomy catheters
(Fogarty)

22. Embolectomy

23. Embolectomy

24. Closure of arteriotomy
 Transverse – Interrupted. 6/0 Prolene

25. Post operative management
 Monitor distal pulse
 Keep foot elevated
 Monitor movements and sensation
 Continue Heparin – 18U/kg per hour infusion
 Start warfarin when surgical bleeding is not a
concern
 Monitor for reperfusion effects

26. Management of acute on chronic
ischaemia
 If the Limb viability is threatened (Rutherford
2b)
 urgent thrombectomy anticoagulation and
subsequent imaging to plan further management.

 If the viability of the limb is not immediately
threatened( 1,2a)
 patient need urgent computed tomographic
angiogram (CTA) and the treatment is planned
accordingly.

27. Management of acute on chronic
ischaemia
Options ;
 Surgical or endovascular
 Surgery includes
 Thrombectomy
 Enarterectomy
 Bypass
 Endovascular
 Thrombolysis
 Thrombectomy
 Angioplasty / stenting
 For dead limb (3) the option is amputation

28. Complications of Acute limb
Ischaemia
 Limb loss
 Death
 Compartment syndrome
 Reperfusion effects
 Volkmann ischemic contracture

29. Reperfusion effects
 Local
 Reperfusion injury – paradoxical death of already
dying muscles after reperfusion
 Systemic
 Reperfusion syndrome
 Hypotension
 ARDS
 Lactic acidosis
 Hyperkalemia
 Renal failure

30. Q5
A 40 year old male with valvular heart disease and
atrial fibrillation presented with a history of
sudden onset pain on the right leg for 3 days
duration. At the onset he had mild weakness and
numbness. He sorted native treatment initially.
Gradually he developed paralysis of the leg. On
examination the popliteal and distal pulses were
absent.There was paralysis and anesthesia of the
leg. the foot was cold and mottled.The most
appropriate management of this patient is;

31. a) Urgent embolectomy
b) Femoral to popliteal artery bypass
c) Fasciotomy and confirmation of the viability
of the leg
d) Catheter directedThrombolysis
e) OpenThrombectomy

32. Compartment syndrome
Reduced organ perfusion due to increased
intra compartment pressure.
 Compartment Perfusion Pressure (CPP)
 MeanArterial Pressure (MAP)
 Intra Compartmental Pressure (ICP)
CPP = MAP – ICP

33. Compartment Syndrome
Fasciotomy

34. Thank You