acute ischaemia of lower limb

1. Dr. Rajdeep Agrawal
Acute Ischemia Of Lower Limb
(AILL)
 AetiologyAetiology
1. Embolisation most common cause1. Embolisation most common cause
heart as a source - 70 %,heart as a source - 70 %,
Atrial Fibrillation,Atrial Fibrillation,
AMI with mural thrombusAMI with mural thrombus
2. Acute thrombosis superimposed upon2. Acute thrombosis superimposed upon
stenosisstenosis
3. Popliteal Aneurysm3. Popliteal Aneurysm

2. Dr. Rajdeep Agrawal
Acute Ischemia Of Lower Limb
 The extent of ischemia & finalThe extent of ischemia & final
outcome depends uponoutcome depends upon
1. Size & location of clot1. Size & location of clot
2. Extent of collateral2. Extent of collateral
circulationcirculation
3. Time between onset of3. Time between onset of
occlusion & treatmentocclusion & treatment

3. Dr. Rajdeep Agrawal
Clinical Features
 Characterized by 5 “P”sCharacterized by 5 “P”s
1. Pain - sudden onset1. Pain - sudden onset
2. Pallor- waxy2. Pallor- waxy
3. Parasthesia – numbness3. Parasthesia – numbness
4. Pulselessness4. Pulselessness
5. Paralysis5. Paralysis

4. Dr. Rajdeep Agrawal
Therapeutic Strategies in
Acute Ischemia
 Most common vascular emergencyMost common vascular emergency
1. Intra arterial thrombolysis1. Intra arterial thrombolysis
2. Thrombo-aspiration with catheter2. Thrombo-aspiration with catheter
3. Mechanical thrombolysis3. Mechanical thrombolysis
4. Surgical embolectomy – Fogarty4. Surgical embolectomy – Fogarty
cathetercatheter

5. Dr. Rajdeep Agrawal
Peripheral Intra-arterial
Thrombolysis (PIAT)
 Rapidly restores blood flow to ischemicRapidly restores blood flow to ischemic
limb & identifies underlying lesions forlimb & identifies underlying lesions for
percutaneous or surgical interventionpercutaneous or surgical intervention
 Catheter directed local delivery ofCatheter directed local delivery of
thrombolytic agents directly at the sitethrombolytic agents directly at the site
of thrombosis is significantly moreof thrombosis is significantly more
effective than systemic thrombolysis &effective than systemic thrombolysis &
is associated with lower bleedingis associated with lower bleeding
complicationscomplications

6. Dr. Rajdeep Agrawal
Thrombolytic Agents
 StreptokinaseStreptokinase
 UrokinaseUrokinase
 Recombinant human tissue typeRecombinant human tissue type
plasminogen activator (rtpA,plasminogen activator (rtpA,
alteplase)alteplase)
In recent years UK & rtpA have largelyIn recent years UK & rtpA have largely
superceded & replaced SK assuperceded & replaced SK as
preferred agentpreferred agent

7. Dr. Rajdeep Agrawal
Peripheral Intra-arterial Thrombolysis
(PIAT)
PIAT – Common procedurePIAT – Common procedure
 Angiography is doneAngiography is done
 Thrombus is locatedThrombus is located
 Multiple end hole catheter is advanced to theMultiple end hole catheter is advanced to the
upper limit of the thrombusupper limit of the thrombus
 One of the infusion methods shown next isOne of the infusion methods shown next is
then usedthen used

8. Dr. Rajdeep Agrawal
PIAT– Infusion Methods
 Stepwise infusionStepwise infusion
Done by stepwise advancement of infusionDone by stepwise advancement of infusion
catheter as thrombus dissolvescatheter as thrombus dissolves
 Graded infusionGraded infusion ( McNamara’s( McNamara’s protocolprotocol))
gradual tapering of infusion rategradual tapering of infusion rate
 Continuous infusionContinuous infusion
 Pulse spray techniquePulse spray technique

9. Dr. Rajdeep Agrawal
PIAT--McNamara’s Protocol
 UK 4000 units/min x 2hrsUK 4000 units/min x 2hrs
2000 units/min x next 2hrs2000 units/min x next 2hrs
1000 units/min x next 4-24 hrs or1000 units/min x next 4-24 hrs or
until the lysis is completeduntil the lysis is completed
Systemic heparin continued during PIAT And tillSystemic heparin continued during PIAT And till
definite endovascular or surgical Rx ofdefinite endovascular or surgical Rx of
underlying lesion is doneunderlying lesion is done

10. Dr. Rajdeep Agrawal
PIAT--McNamara’s Protocol
 Complete lysis is considered if > 75%Complete lysis is considered if > 75%
of the clot dissolvesof the clot dissolves
 Initial reestablishment of flowInitial reestablishment of flow
takes on an 3.3 hrs avg.takes on an 3.3 hrs avg.
complete clot lysis up to 13hrs avgcomplete clot lysis up to 13hrs avg
Systemic Heparin is continued through thisSystemic Heparin is continued through this
periodperiod

11. Dr. Rajdeep Agrawal
Predictors Of Successful
Thrombolysis
 Easy traversability of clot withEasy traversability of clot with
non-hydrophilic guide wire 0.035”non-hydrophilic guide wire 0.035”
 Significant lysis within 2hrsSignificant lysis within 2hrs

12. Dr. Rajdeep Agrawal
Thrombolysis-Contraindications
 AbsoluteAbsolute
1. Recent Cerebro Vascular Accident,1. Recent Cerebro Vascular Accident,
neurosurgery, intracranial trauma,neurosurgery, intracranial trauma,
within the last 3 monthswithin the last 3 months
2. Active bleeding diathesis2. Active bleeding diathesis
3. Recent GI bleed (< 10days)3. Recent GI bleed (< 10days)
4. Irreversible ischemia4. Irreversible ischemia

13. Dr. Rajdeep Agrawal
Thrombolysis-Contraindications
 RelativeRelative
1. Cardiopulmonary resuscitation,1. Cardiopulmonary resuscitation,
major nonvascular surgery, traumamajor nonvascular surgery, trauma
within last 10 dayswithin last 10 days
2. Uncontrolled HT systolic > 1802. Uncontrolled HT systolic > 180
diastolic >110 3.diastolic >110 3.
Puncture of non compressible vesselPuncture of non compressible vessel
4. Intracranial tumor, diabetic proliferative4. Intracranial tumor, diabetic proliferative
retinopathy, bacterial endocarditis,retinopathy, bacterial endocarditis,
pregnancypregnancy

14. Dr. Rajdeep Agrawal
PIAT -- Complications
 Significant hemorrhage 1%Significant hemorrhage 1%
 Distal EmbolisationDistal Embolisation

15. Dr. Rajdeep Agrawal
Post PIAT Management
 Underlying flow limiting lesion is presentUnderlying flow limiting lesion is present
in more than 70% cases & surgery orin more than 70% cases & surgery or
PTA can be performed immediatelyPTA can be performed immediately
after thrombolysis with no additional riskafter thrombolysis with no additional risk
of hemorrhageof hemorrhage
 No underlying lesion -- anticoagulationNo underlying lesion -- anticoagulation

16. Dr. Rajdeep Agrawal
Treatment of Acute Occlusion
 Embolectomy - Using Fogarty’s catheter ->Embolectomy - Using Fogarty’s catheter ->
Catheter passed beyond emblous, balloonCatheter passed beyond emblous, balloon
inflated & pulled back till blood comesinflated & pulled back till blood comes
 Direct Embolectomy - Artery exposed,Direct Embolectomy - Artery exposed,
transverse incision, clot removed.transverse incision, clot removed.
 Intra-arterial Thrombolysis - TPA preferred.Intra-arterial Thrombolysis - TPA preferred.
Arteriography done and a catheter embeddedArteriography done and a catheter embedded
in clot - Thrombolytic agent infused overin clot - Thrombolytic agent infused over
several hrsseveral hrs

17. Dr. Rajdeep Agrawal
Surgical Embolectomy
 Relatively simple procedureRelatively simple procedure
 Done under LA, small incision in theDone under LA, small incision in the
groin, using Fogarty’s cath.groin, using Fogarty’s cath.
 ProblemsProblems
1. Blind procedure, can be traumatic1. Blind procedure, can be traumatic
2. Not successful in 10 – 30% cases2. Not successful in 10 – 30% cases
3. Inefficient in multistenosed artery3. Inefficient in multistenosed artery
4. Complete removal of thrombus4. Complete removal of thrombus
difficult in leg arteriesdifficult in leg arteries

18. Dr. Rajdeep Agrawal
Post PTA MX
 Antiplatelet agentsAntiplatelet agents
 LMW Heparin X 7 – 10 DLMW Heparin X 7 – 10 D
 IV / oral TrentalIV / oral Trental
 StatinsStatins
 Aggressive control of riskAggressive control of risk
factorsfactors

19. Dr. Rajdeep Agrawal
Newer Techniques Of
Angioplasty
 AtherectomyAtherectomy
 DirectionalDirectional
 Percutaneous RotationalPercutaneous Rotational
 TECTEC
 LASERLASER
 StentStent

20. Dr. Rajdeep Agrawal
Directional Atherectomy
 It excises the atheromatousIt excises the atheromatous
plaque material into very fineplaque material into very fine
slices which can be retrievedslices which can be retrieved
outside bodyoutside body

21. Dr. Rajdeep Agrawal
Percutaneous Rotational
Atherectomy (Rotablator)

22. Dr. Rajdeep Agrawal
LASER
 A LASER produces an intenseA LASER produces an intense
beam of light in uniformbeam of light in uniform
wavelength that can be preciselywavelength that can be precisely
focused to deliver high energyfocused to deliver high energy
levels to a small arealevels to a small area
 It converts solid plaque to gasIt converts solid plaque to gas
which is soluble in bloodwhich is soluble in blood

23. Dr. Rajdeep Agrawal
Stent
 An expandable metallic helicalAn expandable metallic helical
device which is permanentlydevice which is permanently
implanted in the arteryimplanted in the artery ..
 MechanismMechanism
 The prosthesis acts as aThe prosthesis acts as a
scaffold to hold the artery openscaffold to hold the artery open
 Prevents recoil of the vesselPrevents recoil of the vessel
 Reduces RestenosisReduces Restenosis

24. Dr. Rajdeep Agrawal
Lower Limb Ischemia -
Approach to therapy
 Risk factor managementRisk factor management
** Abstinence from smokingAbstinence from smoking
** Control of diabetesControl of diabetes
** Control of hyperlipidemiaControl of hyperlipidemia

25. Dr. Rajdeep Agrawal
Lower Limb Ischemia -
Approach to therapy
 Risk factor managementRisk factor management
** Weight reductionWeight reduction
• Control of hypertension, CHF, CRFControl of hypertension, CHF, CRF
• Chronic anticoagulation oral withChronic anticoagulation oral with
judicious use of PT PIjudicious use of PT PI
measurementsmeasurements

26. Dr. Rajdeep Agrawal
Lower Limb Ischemia -
Role of Drugs
 Pentoxyfylline – not usefulPentoxyfylline – not useful
 Antiplatelet AgentsAntiplatelet Agents
 ProstaglandinsProstaglandins
 VasodilatorsVasodilators