CV 2 MODULE

LEVEL 2
ACUTE LIMB ISCHEMIA

CLINICAL FEATURES
DEFINITION From Harrison
- Depend on location, duration & severity of obstruction.
o Occurs when arterial occlusion results in the sudden
o Severe pain
cessation of blood flow to an extremity. Develop in involved
o Paresthesia extremity within 1 hour
o Numbness
SEVERITY OF ISCHEMIA AND VIABILITY OF
o Coldness
EXTREMITY DEPEND ON:
(1) Location and extent of occlusion o Paralysis – occur with severe and persistent ischemia
(2) Presence and subsequent development of collateral blood
vessels Physical Findings:
o Loss if pulses distal to the occlusion
PRINCIPAL CAUSES OF ACUTE ARTERIAL o Cyanosis or pallor
OCCLUSION o Mottling
(1) Embolism o Decreased skin temperature
(2) Thrombus in situ o Muscle stiffening
(3) Arterial dissection o Loss of sensation
(4) Trauma o Weakness
o Absent deep tendon reflexes
MOST COMMON SOURCES OF ARTERIAL EMBOLI
(1) Heart From Schwartz:
(2) Aorta Six Ps:
(3) Large Arteries (1) Pain
(2) Pallor
CARDIAC DISORDERS THAT CAUSE (3) Paresthesias
THROMBOEMBOLISM (4) Paralysis
 Atrial fibrillation (5) Pulselessness
 Acute Myocardial Infarction (6) Poikilothermia or “perishing cold”
 Ventricular Aneurysm
 Cardiomyopathy Notes:
 Infectious and Marantic Endocarditis o Typical complain
 Thrombi associated with prosthetic heart valves - Foot and calf pain
 Atrial Myxoma - Absent pulses
- Diminution of sensation
o During evaluation of affected extremity, it is important to
Notes
Notes:
- Emboli to the distal vessels may also originate from compare findings with contralateral limb.
proximal sites of atherosclerosis and aneurysms of aorta o Patients with history of prior vascular procedures or history of
and large vessels lower extremity claudication suggest pre-existing vascular
- Arterial emboli tend to lodge at vessel bifurcations disease.
because the vessel calibre decreases at those sites o Patients with no history suggestive of prior vascular disease,
Sites of emboli lodging in lower extremities (descending order) Etiology most likely embolic.
(1) Femoral artery
(2) Iliac artery REMEMBER!!
(3) Aorta - ABSENT BILATERAL FEMORAL PULSES with bilateral lower
(4) Popliteal arteries extremity ischemia is most likely due to SADDLE EMBOLUS TO
(5) Tibioperoneal arteries AORTIC BIFURCATION.
- PALPABLE FEMORAL PULSE and ABSENT POPLITEAL &
DISTAL PULSES may be either due to DISTAL COMMON
FEMORAL EMBOLUS or EMBOLUS TO SUPERFICIAL FEMORAL
OR POPLITEAL ARTERIES.
- CALF ISCHEMIA AND ABSENT PEDAL PULSES POSSIBLY WITH
POPLITEAL PULSE PRESENT is due to POPLITEAL
TRIFURCATION EMBOLUS
- The finding of palpable contralateral pulses and absence of
ipsilateral pulses in acutely ischemic leg are suggestive of an
embolus, irrespective of Doppler signals
See Appendix for clearer picture o Thrombolytic therapy with recombinant tissue
plasminogen activator, reteplase, or tenecteplase is
CLASSIFICATION
most effective when acute arterial occlusion is recent (<2
o 2 major classifications based on clinical presentations:
weeks) and caused by a thrombus in an atherosclerotic
(1) FONTAINE CLASSIFICATION
vessel, arterial bypass graft, or occluded stent.
(2) RUTHERFORD CLASSIFICATION
o These clinical classifications help to establish uniform
ADVANTAGES:
standards in evaluating and reporting the results of o Reduced endothelial trauma
diagnostic measurements and therapeutic interventions
o Potential for more gradual and complete clot lysis in
branch vessels usually too small to access by
embolectomy balloons

MAJOR CONTRAINDICATIONS OF THROMBOLYSIS

- Recent stroke
- Intracranial Primary Malignancy
- Brain metastases
- Intracranial surgical intervention

RELATIVE CONTRAINDICATIONS
- Renal Insufficiency
See Appendix for clearer picture
- Allergy to contrast material
- Cardiac thrombus
DIAGNOSTIC EVALUATION - Diabetic retinopathy
- Coagulopathy
o Doppler assessment of peripheral blood flow - Recent arterial puncture
o Ultrasound duplex scans: use to identify site of lesion - Recent Surgery
by revealing flow disturbance and velocity changes.
o Contrast angiography: GOLD STANDARD imaging
study; can locate and size the anatomic significant
lesions and measure the pressure gradient across the
lesion, as well as plan for potential intervention.
However, it is SEMI-INVASIVE and should be confined
to patients for whom surgical or percutaneous
intervention is contemplated.

TREATMENT

 In patients with ALI, systemic anticoagulation with

heparin should be administered unless contraindicated.
 Heparin, generally intravenous unfractionated
heparin (IV UFH) is given emergently. Initially
5,000 IU or 70-100 IU/kg followed by infusion, dose
adjusted to patient response, and monitored activated
clotting time or activated partial thromboplastin time
(APTT)
 This can stop thrombus propagation and may provide
an anti-inflammatory effect that lessens ischemia.
 Intravenous fluid should be started and a Foley
catheter inserted to monitor urine output.
Endovascular Treatment (Thrombolytic Therapy)
o First-line treatment in patients with ALI because of the
potential to reduce mortality and morbidity while
achieving limb salvage
o Use for patients with small-vessel occlusion (these
patients are poor candidates for surgery because they
lack distal target vessels to use for bypass)
Surgical Revascularization
o Preferred when restoration of blood flow must occur
within 24 hours to prevent limb loss or when symptoms
of occlusion have been present for >2 weeks.
o Category IIa and IIb ALI: revascularization within 6
hours
o Category I ALI: revascularization within 6-24 hours
Amputation
o Performed when the limb is not viable, as characterized
by loss of sensation, paralysis, and absence of Doppler-
detected blood flow in both arteries and veins.
o For patients with Category III ALI
 COMPLICATIONS RELATED TO TREATMENT FOR ALI

Adverse events related to catheter-directed thrombolysis:

o Related to bleeding complications
o Hemorrhagic stroke ( 1% to 2.3%, with 50% occurring
during thrombolytic procedure)
o Hematoma at vascular puncture site (12-17%)
o GIT bleeding (5-10%)
o Hematuria (uncommon and should prompt a search for
urinary tumors)
o Hemorrhage requiring transfusion (25%)

Intracerebral hemorrhage – MOST FEARED complication;

older patients are more susceptible

2 MAJOR COMPLICATIONS FOLLOWING REVASCULARIZATION

(1) Reperfusion
(2) Compartment Syndromes

OTHER PROCEDUE-RELATED COMPLICATIONS

- Arterial rethrombosis
- Recurrent embolization
- Arterial injuries secondary to balloon catheter
manipulations

APPENDIX
REFERENCES
 Harrison’s Principles of Internal Medicine. 20th edition
 Schwartz’s Principles of Surgery 11th edition
 ESC Guidelines on Diagnosis and Treatment of PAD