Acute Ischemia of The Lower Limb (LL)

Acute LL ischemia
Sudden occlusion of a previously patent artery supplying a limb.
Embolic ischemia “Commonest” Thrombotic ischemia
sudden occlusion of artery by embolism Sudden occlusion of an artery by thrombus
The embolism: Predisposing factors for Thrombosis:
circulating foreign body (FB) mass Virchow’s triad:
circulates in the blood stream & becomes 1. Roughening of the - Astherosclerosis,
arrested in the vessel. Usually become intima: - Thromboangitis
lodged at the bifurcation of the artery. obliterance,
Sources of arterial emboli: - PAN….
The Cardiac (90%) - Trauma: arterial
• Valvular heart disease. (MS) catheterization, intra-
• Arrhythmia (Atrial fibrillation) arterial drug injection,
• Prosthetic heart valves. 2. Slowing in the compression by fracture
• Mural thrombus of MI. blood stream: or dislocation
• Atrial myxoma. 3. Increase of the blood coagulable state
Arterial source (9%) 1. Occasionally thrombosis occurs on relatively
 Atherosclerotic aorta. normal artery
 Aneurysm. 2. In patients with hypercoagulable states ex:
Other (1%) Paradoxical.
- Pt with malignancy, polycythemia
- pt taking high doses of oestrogen
Site of impaction of the emboli: Types of acute thrombotic ischemia
usually impact at branching points in Primary type: Secondary type:
arterial tree, particularly at - Rare - Very common
1. the bifurcation of the aorta, - Occurs in healthy - Occurs on top of an
2. the common femoral bifurcation. artery organic arterial lesion
3. popliteal trifurcation. - Causes: - Causes:
• dehydration, atherosclerosis, burger’s
• fever, dis., on top of aneurysm
• repeated trauma
Clinical differentiation between thrombosis & embolism
1. Obvious cardiac source. 1. No obvious cardiac source.
2. No history of claudication. 2. History of claudication.
3. Normal pulses in Contralateral 3. Abnormal pulses in contralateral limb.
limb. 4. Angiogram:
4. Angiogram: • Diffuse atherosclerotic
• Minimal atherosclerotic • Well-developed collateral
• Little collateral
Diagnosis:
History:
- Cardiac disease - Claudication pain - Trauma

Clinical Features of acute limb ischemia: 6 p’s

- Pain. - Pulselessness. - Paresthesia.
- Pallor. - Perishing cold. - Paralysis.
!‫يشتك لك من ألم يف أحد أطرافه الزم تحط يدك عىل نبض الطرف المصاحب لأللم‬ ‫ي‬ ‫ أي عيان‬:‫يوىص به األطباء‬
pulse‫كل الناس بتسلم عادي دكتور الفاسكوالر بيسلم وإيده عىل الـ ـ ـ ـ ـ‬
Investigations:
- Doppler. - Duplex. - Angiography.
Management:
• Urgent management: IV heparin.
• Following, resuscitation & appropriate imaging… pt. considered for:
A- If the limb viable golden 1st 6 hours:
1. Embolectomy.
2. Thrombolysis.
3. Surgical reconstruction (thromboend artrectomy or grafting).
B- If the limb not viable mottled cyanosis = fixed color changes
Amputation

‫جدول توضيح‬
Lecture notes ‫شكر خاص لزميلنا صاحب التفري غ‬
- Ischemia in clinical means absent distal pulsations (pulseless)
- Acute ischemia means sudden cessation of perfusion that may affect tissue viability
- Causes
- thromboembolic agent (The most important) 90%
- intraarterial injection
- Aortic dissection
- low cardiac output
…The rest causes
Acute embolic Ischemia
• Embolus is a circulating plug or mass or foreign body of non-blood element
(air embolism or fat embolism)
• Thrombus is a circulating mass of blood element
(fibrin network + platelets + coagulation factors)
- the Main source of Emboli is the heart like valvular heart diseases (dislodgement of
vegetation)
- AF
- but the source may be showers like detached atheroma from showers ‫ ينتشر؟‬like detached
atheroma from Aortic atherosclerosis
- Site of impaction is the bifurcation of arteries
- C/P is the 6Ps but the most important are Pulseless - Perishing Coldness - Pain
- for clinical assessment we must know (6Ps ‫)تطبيق الـ‬
1. the level of occlusion, 4. Limb viable or not,
2. site of last distal pulse, 5. Limb ischemia partial or complete.
3. There's paralysis or paresis,
because the golden 6 hour for intervention start from complete limb ischemia
- In Acute neglected ischemia there will be skin mottling, cyanosis and fixed color
change and the limb will be amputated
- AVOID time consuming investigations like angiography
- BUT angiography may be used in partial ischemia.
- The main investigations are duplex and Doppler
Treatment
- Heparin bolus (make sure no contraindications like hypertension) to avoid
propagating thrombus
- clinical assessment
• If viable get rid of the thrombus by removing it surgically (thrombectomy) by fogarty
catheter or by thrombolytic (catheter directed) like streptokinase or urokinase
- D.D of Acute limb pain ‫اهتم بإجابات الفاسكوالر‬
1. Acute ischemia 4. Thrombosed varicose veins
2. Chronic ischemia 5. Thrombophlebitis
3. DVT
Then non-vascular causes as you want
6. Fracture limb 7. Osteomyelitis and osteoarthritis 8. cellulitis 11. Gout
9. Tenosynovitis 10. Diabetic neuropathy
Write brief about every cause especially vascular causes
 IV heparin

embolectomy sudden occlusion of an artery

thrombectomy 1st 6 hours (viable) urgent management

at bifurcation
reconstruction
valvular
amputation not viable (mottled cyanosis)
AF

doppler cardiac source prosthetic valves

duplex investigations MI

angioraphy atrial myxoma

atherosclerosis
pain acute ischemia embolic
Arterial source aneurism
pulselessness
paradoxical
perishing cold
C/P obvious cardiac source
pallor

parasthesia history & examination no claudication pain

paralysis normal pulse in other limb

minimal collateral
cardiac disease
angiogram meniscus shape
claudication pain history
multiple
trauma
classification atherosclerosis
vessel
trauma

predisposing factors Virchow's triad

velocity compression

viscosity malignancy, polycythemia, estrogen

‫ﺷﻜﺮ ﺧﺎص ﻟﺰﻣ�ﻠﻨﻨﺎ ﻣﺼﻤﻢ اﻟﺨﺮاﺋﻂ اﻟﺬﻫﻨ�ﺔ‬

rare

1ry in healthy artery

due to dehydration / fever / repeated trauma

types
very common

thrombotic
2ry on top of organic arterial lesion

due to atherosclerosis / burger / aneurysm

no obvious cardiac source

history & examination claudication pain

absent pulse in contralateral limb

collaterals

angiogram conical shape

calcification