Acute limb

ischemia
by
PROF/ GOUDA ELLABBAN
EGYPT

Definition
Ischemia is
deficiency of blood supply in a part of the body.
It could be
acute
chronic
Acute limb ischemia
Sudden interruption of arterial blood supply the with
no time for collaterl to form .

Causes of acute arterial ischemia

An arterial embolus
Thrombosis on an atheromatous plaque
Thrombosis of an aneurysm
Arterial dissection
Traumatic disruption
External compression e.g cervical rib , popliteal
entrapment

Arterial embolus
Abnormal undissloved material carried in the blood
stream from one part of vascular system to impact in
distance part .
Types
1-Thrombus
It is the thrombus that dislodged from its source &
circulate in blood stream & impact in BV
2-Air
3-Fat
4-Neoplastic
Common source is mural thrombus that follow MI,
mitral stenosis & aneurysm
Emboli tend to lodge at bifurcation of vessles
Large emboli stradding in oartic bifurcation
Lower
limb ischemia

Trauma
Could be
1. Penterating
2. Blunt
3. Iatrogenic
Commonly in femoral or brachial artery
at arterial catheterization

Symptoms and Signs ( Ps )

Symptoms
Painless ( numbness )
Pain
Paraesthesiae
Paralysis
Signs
Pallor
Pulslessness
Perishingly cold to the touch
* Muscle tenderness is bad diagnostic especially in muscle of
anterior & posterior compartment of the calf

Physical Examination
Heart rhythm:
Presence of atrial fibrillation or other
arrhythmias
Apex beat (ventricular aneurysm)
Auscultation for evidence of valvular disease
Inspection of limbs:
Pallor of the skin
Tense, tender calf with impaired dorsiflexion
(compartment compression)

Physical Examination
Venous guttering:
Veins are so empty to appear as shallow grooves
or gutters
Buergers test: rapid pallor as arterial supply is
poor.
Delayed capillary refill.
Skin temperature: a difference of as small as 1C
can be ascertained.

Physical Examination
Absent peripheral pulses:
Important to delinate a blockage in the arteries
(e.g. presence of femoral pulse and absent distal
pulses indicate superficial femoral block.
Ankle brachial pressure index (ABPI)
It is the ratio of pressure at foot pulse to that at
the brachial artery. < 0.5 indicate significant
ischemia.

complication
Leg become mottled & marbled
Muscle hardness
Skin become blister
Gangrene which usually start in toes before
spreading distally

Differential Diagnosis
Arterial embolus
Acute arterial thrombosis
Thrombosed aneurysm
Aortic dissection
Traumatic arterial disruption
Cervial rib
Acute venous thrombosis
Spinal cord compression or infarction

Investigation
Critical ischemia needs investigating with great
urgency to relieve the patients pain and to prevent
irreversible damage.
They include:
Arteriography
Duplex ultrasonography: it is now replacing
angiography. It takes longer time to perform and is
more subjective but can give better information as
to the significance of stenoses and has the benefit
of being non-invasive.
ECG to exclude associated coronary diseases
Serum cholesterol: raised in atherosclerosis
Urine for sugar and blood glucose: to exclude DM

Management
Non-operative:
Arteriography and angioplasty: at the time of
arteriography, a stenosed segment of artery
may be dilated using a special balloon catheter.
Lumbar sympathectomy: palliationmay be
achieved by lumbar sympathectomy which
increases the blood supply to the skin, and
which may be performed percutaneously. The
small increase in blood supply may be sufficient
to allow an ulcer to heal but will not generally
improve rest pain.

Management
Operative treatment:
Reconstructive surgery: successful surgical
reconstruction demands 4 things:
Inflow: a good arterial supply up to the area of
blockage is necessary to ensure that blood can be
carried distally via the conduit to ischemic area
Outflow: there should be good vessels below the area
of disease on to which a conduit can be anastomosed.
The conduit: a graft of saphenous vein or an inert
prosthetic material may be used.
The patient: critical ischemia is often the first sign of
end-stage vascular disease which inevitably result in
death. Surgery for critical ischemia has a high
mortality reflecting this general deterioration.

Management
The conduit:
A graft of saphenous vein, reversed or used in
situ with valve destruction, or an inert prosthetic
material such as polytetrafluoroethylene (PTFE)
may be used for the conduit to take blood from
proximal to distal segment of the artery beyond
the blockage. In graft that start and finish above
the knee there is little to choose between PTFE
and vein in terms of long-term patency, but a
graft that crosses the knee is much more likely to
remain patent if it is saphenous vein rather than
PTFE. Infection is less likely with autologous vein.

Management
Operative treatment:
Amputation:
Pain that is not controlled by sympathectomy
or reconstructive surgery, and gangrene that
is associated with life-threatening infection
are indications for amputation of the limb or
part of the limb. The general principle is to
achieve a viable stump that heals primarily,
and a secondary goal is to make the stump as
distal as possible.