Acute Limb Ischemia

Definition, Etiology & Patophysiology Clinical Evaluation & Classes

Ali SABBOUR
Management

Prof. of Vascular Surgery, Ain Shams University

Definition of Acute Limb Ischemia

Sudden decrease of arterial limb perfusion causing threat to limb viability

Etiology of acute limb ischemia

Acute arterial embolism:

Of a relatively health arterial tree

Acute arterial thrombosis:

Of a previously diseased arterial tree

Acute traumatic ischemia:

Acute Embolic Ischemia

Patho-pysiology

Acute Thrombotic Ischemia

An embolus can originate from the heart (MS with atrial fibrillation, MI with mural thrombus) or dilated diseased arteries (aortic aneurism)

An embolus suddenly occludes a relatively healthy arterial tree It usually arrest at arterial bifurcation
Aortic bifurcation
Iliac bifurcation Femoral bifurcation Popliteal trifurcation

Atherosclerosis causes progressive narrowing of the arterial tree Stimulates development of collaterals Sluggish flow & rough surface will favor acute thrombosis

It is important to differentiate between embolic & thrombotic ischemia: Because the

management is different Clinical Features Suggestive of acute Embolism:
Sudden onset of symptoms

Known embolic source

Absence of previous claudication Normal pulse in the other limb

Postgraduates

The severity of acute ischemia depends on:

a) Capability of existing collaterals to carry blood around the acute obstruction
(collaterals are more developed b) The location of obstruction in relation to the in patients with preexisting number of axial arteries chronic ischemia) Accordingly, arterial embolism is c) The extent of obstruction more likely to produce sudden One axial a. with limited collateral pathways Aorta & common iliac The larger the obstruction, the& severe ischemia symptoms more collaterals are d) The duration lost then arterial thrombosis
Internal & external iliac

Superficial & deep femoral

Flow distal to the obstruction is sluggish. If collaterals cannot For Example: increase the flow above a critical point, a stagnation clot will Popliteal a occlusion (a develop in axial distal arterial collateral potentials single axial a.) results in Two the aa. With better tee. This the reason why heparin should be given as early as possible severe ischemia, while
One axial a. with limited collateral pathways posterior tibial occlusion may be asymptomatic if other leg arteries are patent

Two axial aa. With better collateral potentials

Popliteal artery

Tibial arteries

Three axial aa. with better collateral potentials

Definition: Sudden decrease of arterial limb perfusion causing threat to limb viability Etiology: 1-Embolic (Rh.heart w mitral stenosis & AF or Ischemic heart w acute myocardial
infarction & mural thrombus or extra-cardiac embolism from aneurismal arteries)
2-Thrombotic

acute ischemia on top of atherosclerotic arterial stenosis

Pathology: onset of symptoms is more acute in embolic ischemia (absent collaterals) Other factors determine the severity of acute ischemia Clinical Picture

Management

Clinical Evaluation of Acute Ischemia (Clinical Picture)

Symptoms of acute ischemia:
Pain: Diffuse foot & leg severe aching pain of acute onset (more acute in
embolic ischemia) Pain may diminish in intensity by time if collaterals open improving circulation, or if ischemia progresses causing ischemic sensory loss

Coldness is an early symptom Numbness followed by sensory loss (late) Muscle weakness (heavy limb) followed by paralysis (late)

Clinical Evaluation of Acute Ischemia (Clinical Picture)

History
Aim of your questions 1- To know whether these symptoms are of acute ischemia or not
(DD of acute ischemia : acute DVT [phlegmasia] , hypo-perfusion states [e.g. heart failure specially if associated with chronic ischemia]

2- To know the severity of acute ischemia

(ask about symptoms of different classes of acute ischemia see later)

3- To look for the underlying etiology

(ask about Rh. Heart Ds, claudication, recent arterial intervention e.g. cardiac cath., risk factors for atherosclerosis: hypertension, diabetes, smoking, hyperlipedemia, family history of cardio-vascular disease)

Clinical Evaluation of Acute Ischemia (Clinical Picture)

Signs of acute ischemia
Inspection COLOR: Fixed mottling & cyanosis Early: pale

5Ps
Pain: symptom

+
Pale Pulseless Parathesia Paralysis

Later: cyanosed mottling mottling & cyanosis

fixed

An area of Pallor fixed cyanosis surrounded by reversible Reversible mottling mottling

Empty veins: compare the Rt. (ischemic) & Lt. (normal)

Clinical Evaluation of Acute Ischemia (Clinical Picture)

Signs of acute ischemia Palpation

5Ps
Pain: symptom

+
Pale Pulseless Parathesia Paralysis

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

Clinical Evaluation of Acute Ischemia (Clinical Picture)

Signs of acute ischemia Palpation Loss of sensory function
Numbness will progress to anesthesia Progress of Sensory loss Light touch Vibration sense Proprioreception

5Ps
Pain: symptom

+
Pale Pulseless Parathesia Paralysis

Deep pain
Pressure sense

Late

Clinical Evaluation of Acute Ischemia (Clinical Picture)

Signs of acute ischemia Palpation Loss of motor function:
Indicates advanced limb threatening ischemia Late irreversible ischemia: Muscle turgidity

5Ps
Pain: symptom

+
Pale Pulseless Parathesia Paralysis

Postgraduates

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

Postgraduates

Classes of Acute Ischemia

Clinical Findings Class
I. Viable II.a Marginal threat II.b Immediate threat III.Irreversible

Doppler
Arterial Venous signals Signals
audible
Often not audible Usually not audible

Prognosis

Sensory loss
-ve
Minimal sensory loss Rest pain w sensory loss
more than toes

Motor
weakness
-ve
No muscle weakness Mild to moderate

audible
audible

Not immediately threatened

Salvageable if prompt ttt (there is time for
angiography)

audible

Salvageable with immediate ttt (no time

for angiography)

Severe anesthesia

Paralysis w Inaudible Inaudible

muscle rigor

Not salvageable,
permanent N. & muscle damage , needs amputation

Definition: Sudden decrease of arterial limb perfusion causing threat to limb viability Etiology: 1-Embolic (Rh.heart w mitral stenosis & AF or Ischemic heart w acute myocardial
infarction & mural thrombus or extra-cardiac embolism from aneurismal arteries)
2-Thrombotic

acute ischemia on top of atherosclerotic arterial stenosis

Pathology: onset of symptoms is more acute in embolic ischemia (absent collaterals) Other factors determine the severity of acute ischemia

Clinical Picture

The limb is described as having 5 Ps :

Pain, Pale, Pulseless, Parathesia, Paralysis

Management

Investigations of acute limb ischemia

The severity and duration of ischemia at the time of presentation provides a narrow margin of time for investigations
Postgraduates

Doppler US
It is important to look for arterial Doppler signals to assess the level of obstruction & severity of ischemia

The presence of pedal signals usually indicates that there is time for conventional arteriography & proper patient preparation The ABI is not of value in acute ischemia. If it can be measured, the limb is not threatened

Investigations of acute limb ischemia

Arteriography
Patients with high clinical probability of embolic ischemia do NOT need angiography If the differentiation between embolic & thrombotic ischemia is not clear clinically, and if the limb condition permits,

DO ANGIOGRAPHY
Value of angiography Localizes the obstruction Visualize the arterial tree & distal run-off Can diagnose an embolus:
Sharp cutoff, reversed meniscus or clot silhouette

Popliteal embolism
Reversed meniscus sign

Lt. iliac embolism

Clot silhouette

Treatment of acute limb ischemia

A Once you diagnose Immediate anticoagulation with heparin to avoid clot propagation
Appropriate analgesia Simple measures to improve existing perfusion:

Keep the foot dependant

Avoid pressure over the heal Avoid extremes of temperature (cold induces vasospasm, heal raises the
metabolic rate)

Maximum tissue oxygenation (oxygen inhalation) Correct hypotension Start treatment of other associated cardiac conditions (CHF, AF)

Treatment of acute limb ischemia

B Catheter directed thrombolysis
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 Agents used: Streptokinase, Urokinase, tissue plasminogen activator

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

Treatment of acute limb ischemia

C Surgery
1- Acute embolism: Catheter embolectomy under local anesthesia

2- Immediate surgical revascularization is indicated in class IIb, or class I, IIa when thrombolysis is not possible or contraindicated

A combination of different procedures can be done: Arterial exploration at different sites Arterial thrombectomy

Bypass surgery based on pre-operative angiography if available or intra-operative angiography

Following revascularization:
The sudden return of oxygenated blood to the acutely ischemic muscles generates & releases oxygen free radicals that causes cellular injury and severe edema

Compartment syndrome
& muscle necrosis

ttt Fasciotomy
Longitudinal incision of the skin & deep fascia to release pressure over swollen muscles

Amputation:
Done for irreversible ischemia with permanent tissue damage (turgid muscles, fixed cyanosis) The level of amputation is decided according to the level of palpable pulse.

Palpable popliteal pulse -------------- Below knee amputation

Absent popliteal pulse ---------------- Above knee amputation

Definition: Sudden decrease of arterial limb perfusion causing threat to limb viability Etiology: 1-Embolic (Rh.heart w mitral stenosis & AF or Ischemic heart w acute myocardial
infarction & mural thrombus or extra-cardiac embolism from aneurismal arteries)
2-Thrombotic

acute ischemia on top of atherosclerotic arterial stenosis

Pathology: onset of symptoms is more acute in embolic ischemia (absent collaterals) Other factors determine the severity of acute ischemia Clinical Picture

The limb is described as having 5 Ps : Pain, Pale, Pulseless, Parathesia, Paralysis Investigations Doppler to evaluate level & degree of ischemia Conventional angiography in class I & IIa Intraoperative angiography in class IIb Heparin Catheter directed thrombolysis Operative revascularization Amputation in irreversible ischemia

Treatment