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ACUTE LIMB ISCHAEMIA
Dr Sumer Yadav
MCh --PlasticAnd Reconstructive Surgeon
sumeryadav2004@gmail.com
Acute limb Ischaemia
 Sudden interruption of blood supply to
limb resulting in threat to the limb
viability.
sumeryadav20...
Acute limb Ischaemia
sumeryadav2004@gmail.com
Etiology
sumeryadav2004@gmail.com
Sources of emboli
 Heart – recent MI, Atrial fibrillation,Valvular
heart disease.
 Blood vessels – aneurysms
 An embolu...
sumeryadav2004@gmail.com
Clinical Evaluation of Acute Ischemia (Clinical Picture)
Signs of acute ischemia
5Ps
Pain: symptom
+
Pulseless
Pale
Parast...
Clinical Evaluation of Acute Ischemia (Clinical Picture)
Signs of acute ischemia
5Ps
Pain: symptom
+
Pulseless
Pale
Parast...
Clinical Evaluation of Acute Ischemia (Clinical Picture)
Signs of acute ischemia
5Ps
Pain: symptom
+
Pulseless
Pale
Parast...
Clinical Evaluation of Acute Ischemia (Clinical Picture)
Signs of acute ischemia
5Ps
Pain: symptom
+
Pulseless
Pale
Parast...
INVESTIGATIONS
The severity and duration of ischemia at the time of presentation
provides a narrow margin of time for inve...
What are we
looking for?
NORMAL
• Multiphasic
• Pulsatile
• Regular amplitude
An audible Doppler signal assures some blood...
If a pulse is detected, then the ankle-brachial index (ABI)
and segmental leg pressures should be checked..
sumeryadav2004...
If time permits, do a duplex
ultrasound
sumeryadav2004@gmail.com
Arteriography
 If the differentiation between embolic & thrombotic
ischemia is not clear clinically, and if the limb cond...
 Value of angiography
 Localizes the obstruction
 Visualize the arterial tree & distal run-off
 Can diagnose an embolu...
WWW.SMSO.NET
Embolism:
obvious cardiac source
No hx of cluadication
Normal pulses in contralateral limb
Angiogram: minimal...
Rutherford Classification
Category Description Cap. refill Paralysis Sensory
loss
A V
I Viable Not immediately
threatened
...
Management
sumeryadav2004@gmail.com
IMMEDIATECARE
THROMBOLYTICS
SURGERY
sumeryadav2004@gmail.com
A. Immediate care
 Anticoagulation
 Analgesia
 measures to improve existing perfusion
 treatment of associated cardiac...
B Catheter directed
thrombolysis
Agents used: Streptokinase,
Urokinase, tissue plasminogen
activator
Indications:
1. Viabl...
Contraindications:
Absolute:
1. Cerebro-vascular stroke within previous 2 months
2. Active bleeding or recent GI bleeding ...
SURGERY
OPERATIVE
REVASCULARISATION AMPUTATION
sumeryadav2004@gmail.com
Embolectomy
Fogarty balloon catheter
(with post-op anti coagulants)
sumeryadav2004@gmail.com
Embolectomy
SurgicalTherapy
• Iliac and femoral embolectomy
– Common femoral approach
–Transverse arteriotomy proximal pro...
Embolectomy
• Popliteal embolectomy
– 49% success rate from femoral approach
– Blind passage selects peroneal 90%
– may ex...
Embolectomy
• Completion angiography
– 35% incdence of retained thrombus
• Failure requires
–Thrombolytic thearpy
– revasc...
Thrombolytic Therapy
 Advantages
• Opens collaterals & microcirculation
• Avoids sudden reperfusion
• Reveals underlying ...
Indications for Thrombolysis
 Category 1-2a limbs should be considered
– Class 2b :Two schools of thought
1)“Delay in def...
Technique of Thrombolysis
• Catheter directed delivery
1) Lace clot via catheter with side holes
2) Pulse-Spray technique ...
Mechanical Thrombectomy
• Percutaneous aspiration embolectomy
–Viable alternative in selected patents
–Varity of devises
–...
Algorithm to be followed…
Patient with
suspected ischemia
History Examination investigations
Acute limb ischemia confirmed...
Heparin
I IIA IIb III
AMPUTATION
EMERGENCY
OPERATIVE
RE-
VASCULARISATION
EARLY
INTERVENTION
NO YES
TREAT FOR
CHRONIC
ISCHE...
Management of IIa
ARTERIOGRAPHY
No lesion
Discrete localized lesions
Multiple extensive lesions
sumeryadav2004@gmail.com
Post operative management
 Monitor distal pulse
 Keep foot elevated
 Monitor movements and sensation
 Continue Heparin...
Clinical outcomes /
complications
• Mortality -15–20%.
• Major morbidities include:
1. Due to major bleeding 10–15% of pat...
Reperfusion effects
 Local
 Reperfusion injury – paradoxical death of already
dying muscles after reperfusion
 Systemic...
DURING ISCHAEMIA
sumeryadav2004@gmail.com
DURING ISCHAEMIA
sumeryadav2004@gmail.com
AFTER REPERFUSION
sumeryadav2004@gmail.com
MANAGEMENT OF REPERFUSION EFFECTS
sumeryadav2004@gmail.com
MANAGEMENT OF REPERFUSION EFFECTS
sumeryadav2004@gmail.com
Reperfusion effects
 Systemic
 Substances Released
 Lactic Acid
 K+
 Inflammatory Mediators
 Myoglobin
 Activated L...
Reperfusion effects
 Systemic
 Reperfusion syndrome
 Hypotension
 ARDS
 Lactic acidosis
 Hyperkalemia
 Renal failur...
Management and prevention of
Reperfusion syndrome
 Cardiac – IV fluids and inotropes
 Respiratory – KeepO2
 Renal – hyd...
Reperfusion effects
 Mangement
 Ligation of vessel if not
responding to other supportive
measures
sumeryadav2004@gmail.c...
Compartment syndrome
Reduced organ perfusion due to increased
intra compartment pressure.
 Compartment Perfusion Pressure...
Compartment syndrome
Causes
 Trauma (muscle contusion)
 Haematoma
 Reperfusion
 Intracompartmental extravasation of fl...
Compartment syndrome
Clinical features
 Excessive pain - pain on passive movements
 Numbness -e.g. anterior compt. first...
Compartment syndrome
Treatment
 Recognize
 Reduce intracomparmental pressure
 Remove bandages and cast
 Keep limb elev...
Compartment syndrome
Treatment
sumeryadav2004@gmail.com
Compartment Syndrome
Fasciotomy
sumeryadav2004@gmail.com
Thank You
sumeryadav2004@gmail.com
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Acute limb ischaemia

  1. 1. ACUTE LIMB ISCHAEMIA Dr Sumer Yadav MCh --PlasticAnd Reconstructive Surgeon sumeryadav2004@gmail.com
  2. 2. Acute limb Ischaemia  Sudden interruption of blood supply to limb resulting in threat to the limb viability. sumeryadav2004@gmail.com
  3. 3. Acute limb Ischaemia sumeryadav2004@gmail.com
  4. 4. Etiology sumeryadav2004@gmail.com
  5. 5. 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. sumeryadav2004@gmail.com
  6. 6. sumeryadav2004@gmail.com
  7. 7. Clinical Evaluation of Acute Ischemia (Clinical Picture) Signs of acute ischemia 5Ps Pain: symptom + Pulseless Pale Parasthesia Paralysis Inspection COLOR: Early: pale Later: cyanosed mottling fixed mottling & cyanosis Pallor Reversible mottling An area of fixed cyanosis surrounded by reversible mottling Empty veins: compare the Rt. (ischemic) & Lt. (normal) Fixed mottling & cyanosis sumeryadav2004@gmail.com
  8. 8. Clinical Evaluation of Acute Ischemia (Clinical Picture) Signs of acute ischemia 5Ps Pain: symptom + Pulseless Pale Parasthesia Paralysis Palpation Femoral Popliteal Posterior tibial Dorsalis pedis Palpate peripheral pulses, compare with the other side & write it down on a sketch Temperature: the limb is cold with a level of temperature change (compare the two limbs) Slow capillary refilling of the skin after finger pressure sumeryadav2004@gmail.com
  9. 9. Clinical Evaluation of Acute Ischemia (Clinical Picture) Signs of acute ischemia 5Ps Pain: symptom + Pulseless Pale Parasthesia Paralysis Palpation Loss of sensory function Numbness will progress to anesthesia Progress of Sensory loss Light touch Vibration sense Proprioreception Deep pain Pressure sense Late sumeryadav2004@gmail.com
  10. 10. Clinical Evaluation of Acute Ischemia (Clinical Picture) Signs of acute ischemia 5Ps Pain: symptom + Pulseless Pale Parasthesia Paralysis Palpation Loss of motor function: Indicates advanced limb threatening ischemia Late irreversible ischemia: Muscle turgidity Intrinsic foot muscles are affected first, followed by the leg muscles Detecting early muscle weakness is difficult because toes movements are produced mainly by leg muscles sumeryadav2004@gmail.com
  11. 11. INVESTIGATIONS The severity and duration of ischemia at the time of presentation provides a narrow margin of time for investigations sumeryadav2004@gmail.com
  12. 12. What are we looking for? NORMAL • Multiphasic • Pulsatile • Regular amplitude An audible Doppler signal assures some blood flow No Doppler signals, a vascular surgeon should be immediately consulted sumeryadav2004@gmail.com
  13. 13. If a pulse is detected, then the ankle-brachial index (ABI) and segmental leg pressures should be checked.. sumeryadav2004@gmail.com
  14. 14. If time permits, do a duplex ultrasound sumeryadav2004@gmail.com
  15. 15. Arteriography  If the differentiation between embolic & thrombotic ischemia is not clear clinically, and if the limb condition permits,  DO ANGIOGRAPHY sumeryadav2004@gmail.com
  16. 16.  Value of angiography  Localizes the obstruction  Visualize the arterial tree & distal run-off  Can diagnose an embolus:  Sharp cutoff, reversed meniscus or clot silhouette sumeryadav2004@gmail.com
  17. 17. WWW.SMSO.NET Embolism: obvious cardiac source No hx of cluadication Normal pulses in contralateral limb Angiogram: minimal atherosclerotic Few collateral Clinical differentiation between thrombosis & embolism Thrombosis: No obvious cardiac source. history of cluadication. abnormal pulses in contralateral limb. Angiogram: diffuse atherosclerotic Well developed collateral sumeryadav2004@gmail.com
  18. 18. Rutherford Classification Category Description Cap. refill Paralysis Sensory loss A V I Viable Not immediately threatened Intact - - Aud Aud IIa Threatened Salvagable if treated Intact/slow - Partial _ Aud IIb Threatened Salvagable if treated emergently Slow/absent Partial Partial _ Aud III Irreversible Primary amputation req. Absent Complete Complete _ _ Doppler sumeryadav2004@gmail.com
  19. 19. Management sumeryadav2004@gmail.com
  20. 20. IMMEDIATECARE THROMBOLYTICS SURGERY sumeryadav2004@gmail.com
  21. 21. A. Immediate care  Anticoagulation  Analgesia  measures to improve existing perfusion  treatment of associated cardiac conditions sumeryadav2004@gmail.com
  22. 22. B Catheter directed thrombolysis Agents used: Streptokinase, Urokinase, tissue plasminogen activator 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 sumeryadav2004@gmail.com
  23. 23. Contraindications: 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: 1. Cardio-pulmonary resuscitation within previous 10 days 2. Major surgery or trauma within previous 10 days 3. Uncontrolled hypertension sumeryadav2004@gmail.com
  24. 24. SURGERY OPERATIVE REVASCULARISATION AMPUTATION sumeryadav2004@gmail.com
  25. 25. Embolectomy Fogarty balloon catheter (with post-op anti coagulants) sumeryadav2004@gmail.com
  26. 26. Embolectomy SurgicalTherapy • Iliac and femoral embolectomy – Common femoral approach –Transverse arteriotomy proximal profunda origin – Collateral circulation may increase backbleeding – Examine thrombus sumeryadav2004@gmail.com
  27. 27. Embolectomy • Popliteal embolectomy – 49% success rate from femoral approach – Blind passage selects peroneal 90% – may expose tibialperoneal trunk & guide catheter – Idrectly cannulate distal vessels • Distal embolectomy – Retrograde/antegrade via ankle incisions – Frequent Rethrombosis –ThrombolyticTx viable alternative sumeryadav2004@gmail.com
  28. 28. Embolectomy • Completion angiography – 35% incdence of retained thrombus • Failure requires –Thrombolytic thearpy – revascularization sumeryadav2004@gmail.com
  29. 29. Thrombolytic Therapy  Advantages • Opens collaterals & microcirculation • Avoids sudden reperfusion • Reveals underlying stenosis • Prevent endothelial damage from balloons Risks • Hemmorhage • Stroke • Renal failure • Distal emboli transiently worsen ischemia sumeryadav2004@gmail.com
  30. 30. Indications for Thrombolysis  Category 1-2a limbs should be considered – Class 2b :Two schools of thought 1)“Delay in definitiveTx” 2)“Thrombolytics extend window of opportunity” • Clots <14days most responsive – But even chronic thrombus can be lysed • Large clot burden – Requires longer duration of thrombolytics sumeryadav2004@gmail.com
  31. 31. Technique of Thrombolysis • Catheter directed delivery 1) Lace clot via catheter with side holes 2) Pulse-Spray technique (mechanical component) • Urokinase andTPA equally effective • 4 hr treatment followed by angiogram – 4000IU/min x4hr, 2000Iu/M=min x 48h – r-UK (TOPASTrial) – no improvement after 4hr >> surgery – Continue Heparin tt – Fibrinogen levels sumeryadav2004@gmail.com
  32. 32. Mechanical Thrombectomy • Percutaneous aspiration embolectomy –Viable alternative in selected patents –Varity of devises – Combines diagnostic and therapeutic procedure – Removes non-lysable debris – Effective in distal vessels – Risk distal embolization • Combine with lyticT x sumeryadav2004@gmail.com
  33. 33. Algorithm to be followed… Patient with suspected ischemia History Examination investigations Acute limb ischemia confirmed and staged sumeryadav2004@gmail.com
  34. 34. Heparin I IIA IIb III AMPUTATION EMERGENCY OPERATIVE RE- VASCULARISATION EARLY INTERVENTION NO YES TREAT FOR CHRONIC ISCHEMIA SAME AS FOR IIa sumeryadav2004@gmail.com
  35. 35. Management of IIa ARTERIOGRAPHY No lesion Discrete localized lesions Multiple extensive lesions sumeryadav2004@gmail.com
  36. 36. 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 sumeryadav2004@gmail.com
  37. 37. Clinical outcomes / complications • Mortality -15–20%. • Major morbidities include: 1. Due to major bleeding 10–15% of patients require transfusion/and or operative intervention 2. Amputation (25–30% of patients) 3. Fasciotomy (5–25% of patients) 4. Renal insufficiency (up to 20% of patients) sumeryadav2004@gmail.com
  38. 38. Reperfusion effects  Local  Reperfusion injury – paradoxical death of already dying muscles after reperfusion  Systemic  Reperfusion syndrome  Hypotension  ARDS  Lactic acidosis  Hyperkalemia  Renal failure sumeryadav2004@gmail.com
  39. 39. DURING ISCHAEMIA sumeryadav2004@gmail.com
  40. 40. DURING ISCHAEMIA sumeryadav2004@gmail.com
  41. 41. AFTER REPERFUSION sumeryadav2004@gmail.com
  42. 42. MANAGEMENT OF REPERFUSION EFFECTS sumeryadav2004@gmail.com
  43. 43. MANAGEMENT OF REPERFUSION EFFECTS sumeryadav2004@gmail.com
  44. 44. Reperfusion effects  Systemic  Substances Released  Lactic Acid  K+  Inflammatory Mediators  Myoglobin  Activated Leucocytes  Etc. sumeryadav2004@gmail.com
  45. 45. Reperfusion effects  Systemic  Reperfusion syndrome  Hypotension  ARDS  Lactic acidosis  Hyperkalemia  Renal failure  Ect sumeryadav2004@gmail.com
  46. 46. Management and prevention of Reperfusion syndrome  Cardiac – IV fluids and inotropes  Respiratory – KeepO2  Renal – hydration, Monitor IP/ OP, dialysis  Correct electrolyte abnormalities – K+  Continue mannitol for 48 hours sumeryadav2004@gmail.com
  47. 47. Reperfusion effects  Mangement  Ligation of vessel if not responding to other supportive measures sumeryadav2004@gmail.com
  48. 48. 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 sumeryadav2004@gmail.com
  49. 49. Compartment syndrome Causes  Trauma (muscle contusion)  Haematoma  Reperfusion  Intracompartmental extravasation of fluids  Tight bandage, cast sumeryadav2004@gmail.com
  50. 50. Compartment syndrome Clinical features  Excessive pain - pain on passive movements  Numbness -e.g. anterior compt. first toe web (deep peroneal N )  Tense swollen leg  Do not look for absent distal pulse – late sumeryadav2004@gmail.com
  51. 51. Compartment syndrome Treatment  Recognize  Reduce intracomparmental pressure  Remove bandages and cast  Keep limb elevated Fasciotomy sumeryadav2004@gmail.com
  52. 52. Compartment syndrome Treatment sumeryadav2004@gmail.com
  53. 53. Compartment Syndrome Fasciotomy sumeryadav2004@gmail.com
  54. 54. Thank You sumeryadav2004@gmail.com
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Acute limb ischaemia

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