Acute limb ischemia

Department of vascular surgery

Kasr Alaini hospital
Acute Limb Ischemia (ALI)
Sudden occlusion of an artery, commonly due to acute
thrombosis, embolic event, or trauma. It often will
happen when thrombosis occurs on a pre-existing
atheroma (so-called acute on chronic disease).
Incidence is 14/100,000 (12% of operations performed in
the average vascular unit).
Arm ischemia accounts for 1/5 of all extremity ischemia
cases and has a better prognosis than does LE ischemia
Iatrogenesis is becoming a more common cause of ALI
secondary to increased number of endovascular
interventions



Thrombosis: greater risk of limb loss;
Embolism: greater risk of death
2/3 of pts will require immediate amputation
in absence of intervention
Overall life expectancy for pts with LE ALI is
similar to many cancers: 17-44% are alive at 5
years

Embolism
Cardiac (80-90%)
Atrial Fibrillation
MI (mural thrombus)
RHD
Prosthetic valves
LA myxomas
Vegetations
Iatrogenic
Angio
Surgery
Non-cardiac (5-10%)
Proximal aneurysms (
aortic, popliteal, femoral)
Tumors invading
pulmonary artery
Atherosclerotic plaque
Bullets, FBs


Sites of Emboli
Emboli lodge at the site of bifurcation of the
Artery.
Femoral 36%
Aorto-iliac 22%
Popliteal 15%
Upper limb 14%
Visceral 7%
Others 6%
(1303 cases from two US hospitals)


Pathophysiology
Occlusion of artery:
Propagation of thrombus: proximally till origin of
a branch and distally up-to entry of collateral.


(a) Hypertrophy of collaterals, re-canalisation of
thrombus, chronic ischemia
OR
(b) Propagation of thrombus, occlusion of
branches and collaterals, Cellular ischemia,
leakage of proteins and fluid from capillary bed.
Pathophysiology
Increase in hydrodynamic pressure in extra-
vascular space
venous flow obstruction, aggravates
ischemia.
Edema of cells lead to narrowing of lumen
of small vessels : No reflow
phenomenon
Cellular death-Release of toxic products
:free radicals etc.
Reperfusion Injury
Lactic acid, K+, Myoglobin etc . accumulate
and are suddenly released in circulation:
cardiac arrhythmias (cardiodepressor
factors), sudden death, renal failure
Active oxygen metabolites : Superoxide (O2-)
and hydroxyl (OH-) radicals.
Embolism:
Obvious cardiac source
No hx of claudication
Normal pulses in contralateral limb
Few collaterals
Angiogram: minimal atherosclerosis

Clinical differentiation between thrombosis &
embolism
Thrombosis:
No obvious cardiac source
History of claudication
Decreased pulses in contralateral limb
Well developed collaterals
Angiogram: diffuse atherosclerosis

Diagnostic Criteria: Six Ps
Pain: usually first symptom
May be acute as in trauma or embolus; often
with thrombosis the pain is insidious but
becomes unrelenting
Pain is usually present throughout the entire
limb, compared with CLI in which it is most
commonly described over the forefoot

Diagnostic Criteria: Six Ps
Pain:
Paresthesia: sign of progressive ischemia
The myelinated fibers of proprioception and
light sensation are lost early in acute ischemia
Larger sensory nerves (temperature, pain,
pressure) are maintained unless prolonged
ischemic time ensues.
Diagnostic Criteria: Six Ps
Pain:
Paresthesia:
Paralysis: true paralysis rarely occurs; more
often motor deficit/weakness begins to occur and
is an ominous sign
Absent dorsi- and plantar flexion indicate loss of
extensor and flexor muscles of lower leg
After 8 hours of absolute ischemia skeletal
muscle becomes rigid, contracted, and
unsalvageble
Diagnostic Criteria: Six Ps
Pain:
Paresthesia:
Paralysis:
Pallor: Indicates major obstruction to the leg
Initial pallor may be followed by a gradual
improvement secondary to collateral filling
In the absence of collateral circulation, the
limb will become waxy and marble white
Diagnostic Criteria: Six Ps
Pain:
Paresthesia:
Paralysis:
Pallor:
Pulselessness: Absolute prerequisite of acute
ischemia; comparison to the other limb vital
The importance of an accurate and thorough
pulse examination cannot be overemphasized
Pt with pulses should lead the clinician to look for
other sources of pain
Diagnostic Criteria: Six Ps
Pain:
Paresthesia:
Paralysis:
Pallor:
Pulselessness:
Poikilothermia: cold limb, again comparison
to the contralateral limb very important


SVS Criteria for Limb Viability
Class I: Not immediately threatened; no sensory or motor
loss, audible arterial and venous signals/pulses
Class IIa: Marginally threatened; salvageable, needs urgent
treatment; min/no sensory loss; no motor deficit; +/- audible
arterial, audible venous signal
Class IIb: Immediately threatened; warrants urgent
intervention; +++ sensory loss, possible rest pain; mild muscle
weakness; usually inaudible signals, audible venous signal
Class III: Irreversible; major tissue loss and permanent nerve
damage probable; profound sensory and motor deficits
(possible paralysis); inaudible arterial and venous systems

Factors affecting outcome
Presence or absence of collaterals.
Occlusion of a diseased/ normal artery.
Occlusion of native artery/ graft.
Duration of ischemia
Co- morbidities.
Site of occlusion


Management
Heparin!!! Should be a reflex reaction
Prevents clot propagation and distal thrombosis
Aggressive resuscitation should be undertaken as
these pts tend to be old, malnourished and
dehydrated; often should be placed in ICU
Routine lab. Investigations.
Invasive monitoring: a-line, CVP, foley
Despite various charts and other discussions, the
remainder of the algorithm is not quite as easy.

Treatment.
Conservative alone
Thromboembolectomy
Thrombolysis alone
Thrombolysis followed by surgery
Percutaneous mechanical thrombectomy (PMT)
Primary amputation
Secondary amputation

Treatment.
For a viable limb, the options include:
Thromboembolectomy for pt with signs or sxs of
acute embolism (acute presentation, normal
contralateral limb, suspected source)
This is unlikely to treat a stenosed artery or
thrombosed graft
In such cases, treatment options lean toward a
surgical bypass vs. thrombolysis vs. observation
CTA vs. angio can be helpful; duplex also an
invaluable tool
Treatment.
For threatened limb, intervention is more
urgent:
There is debate upon whether preoperative
imaging wastes valuable time
In pts without muscle loss, there is value to an on-
table angio so as to perform thrombolysis if
warranted
Otherwise, LE bypass may need to be undertaken
Management
Pts with irreversible ischemia:
Complete neuro deficit, tense muscles, and a
mottled limb from capillary breakdown warrant
amputation
Attempts at revascularization usually prove futile
and risk renal and cardiac toxicity from
reperfusion syndrome
Overall prognosis very poor
Compartment Syndrome
Increased pressure within a fascial compartment
compromises the circulation and function of the tissues within
that space.
Skeletal muscle can tolerate ischemia for periods of up to 6
hours
Reperfusion syndrome occurs secondary to diffuse hyperemic
flow to the entire extremity
Increased microvascular permeability promotes local edema
and intra-fascial HTN venous obstruction
This leads to the development of superoxide and hydroxyl
free radicals, acidosis, hyperkalemia, ARF, arrhythmias,
respiratory distress
Compartment Syndrome
Low threshold to perform fasciotomy: You will never be
criticized for performing an unnecessary fasciotomy but
you will regret not performing one when warranted
Extremity compartment pressures >30 mandate opening
up all compartments
Pulse exam not a reliable indicator
Treat reperfusion injury: aggressive hydration, alkalinize
the urine (minimize toxic myoglobin)
Fasciotomy : Methods

Fasciotomy : Methods
Wound debridement
Thrombolysis (I&IIa)
Primarily useful in thrombotic occlusions
Advantages:
- Requires small puncture for per cutaneous
technique
- Unmasks lesion responsible for occlusive
event which can be tackled by surgery /
endovascular therapy.


Thrombolysis
Disadvantages:
Prolonged treatment time.
Repeated angiograms for follow-up.
Not suitable for embolic ischemia.
Generally fails if ischemia is of more than 72-
96 hrs.
Not to be used in severely ischemic limbs
(IIb&III)

Thrombolytic agents
Streptokinase
- less costly
- higher incidence of allergic reactions and
bleeding complications.
Urokinase- 4000 IU/min X 4hrs followed by 2000
IU/min
rt-PA
-Alteplase-0.9mg/kg < 90mg,10%bolus.


Contraindications (thrombolysis)
Absolute-
Active internal bleeding
Recent(<2 Mo) CVA
Intracranial pathology
Relative
Recent(<10 d) surgery
Left heart thrombus
Active peptic ulcer
Recent major trauma
Uncontrolled HT
Percut Mech Thrombectomy
Aspiration Catheters : Fragmentation of clot by
high-speed motor or by Venturi effect along with
clot trapping bags or expanding catheters.

Micro fragmentation only: Mechanical
fragmentation of thrombus.

Devices: Angiojet, Trellis etc.

No convincing proof of efficacy!
Take home message
Acute arterial occlusion is
associated with high morbidity and
mortality.
There is no absolute time limit for
revascularization, it is the
physiologic & clinical assessment of
the limb that dictates most
appropriate form of therapy.
Be aware of compartment pressures.
Amputation of the limb doesn't mean
treatment failure as it can be life
saving.