Acute Limb ISCHEMIA

Julien Sfeir MD
 70 y old F presents with an
acute painful left leg
• Presents at 1am
• Sudden leg pain since 2 hours
• Total paralysis
• No sensitivity
• Femoral pulse +++
• Normal pulses on RLL
• Hx of A Fib under sintrom
 What will you do now?
1. CALL THE VASCULAR surgeon

Simple measures to improve

existing perfusion:
2. ORDER INVESTIGATIONS • Keep the foot dependant
1-Coagulation Studies
a) Group and Hold • Avoid pressure over the heel
b) 12 Lead ECG
• Avoid extremes of temperature
c) Chest XR
(cold induces vasospasm)
• Maximum tissue oxygenation
(oxygen inhalation)
3. INITATE ACUTE MANAGEMENT:
• Correct hypotension
a) Analgesia
b) Commence IV heparin
Surgical embolectomy
Mr. X presents with an acutely
painful leg:
You have had a busy day in the ED and the next
patient to see is:

Mr. X – a 60 yr old gentleman with a very painful leg.

He tells you that he woke up this morning with an

excruciating pain in his right leg and has never felt
this pain before.

MUST RULE OUT ACUTE LIMB ISCHEMIA

 History & Exam Findings
Further Hx:
• Smokes 20cigs/day for 30 years
• 4 months of ‘leg cramps’ in BOTH legs
• 2-3 weeks of intermittent chest palpitations
• Has not seen a Dr. in the last month

Examination:
• Inspection:
o RLL: below the knee is pale/cool
• Palpation:
o Irregularly irregular pulse

o No pulses palpable below R femoral artery

o All pulses palpable in L leg but weak
o Normal Sensation + partial paralysis

Impression?
60yo male with a R Acute Ischemic limb on the background of heavy
smoking, untreated AF and symptomatic PVD.
 What will you do now?
1. CALL THE VASCULAR surgeon

Simple measures to improve

existing perfusion:
2. ORDER INVESTIGATIONS • Keep the foot dependant
1-Coagulation Studies
a) Group and Hold • Avoid pressure over the heel
b) 12 Lead ECG
• Avoid extremes of temperature
c) Chest XR
(cold induces vasospasm)
• Maximum tissue oxygenation
(oxygen inhalation)
3. INITATE ACUTE MANAGEMENT:
• Correct hypotension
a) Analgesia
b) Commence IV heparin
c) Call Radiology for Angiography if limb still viable
d) Discuss :
i) Thrombotic cause  ?cathetar induced thrombolysis
ii) Embolic cause  ?embolectomy
iii) All other measures not possible  Bypass/Amputation
 Mr. X’s Complication
…. 3-4 hours later

-Severe calf pain in the reperfused limb

-All pulses are present
-Leg is swollen, tense and +++ tender

REPERFUSION INJURY!
-Restored blood flow can lead to unwanted local + systemic effects

1) Washout = 2) Compartment Syndrome =

oMetabolic Acidosis oMay need fasciotomy
oHyperkalemia
oARF (myoglobinuria)
oNon-cardiac APO
 Acute ischemia
Definition:
Sudden occlusion of an artery is commonly
due to either emboli or trauma & it may also
happen when thrombosis occur on plaque pre-
existing atheroma.
What are the features of an
acute ischemic limb?
Fixed
mottling &
REMEMBER THE 6 P’S:
cyanosis
1. PAIN

1. PALLOR

1. PULSELESNESS

1. (POIKILOTHERMIA)

1. PARASTHESIAS

1. PARALYSIS
 Causes
Embolism, thrombosis & vascular injury are the causes of
acute lower limb ischemia.
Emboli:
• The Sources of arterial emboli are :
●Cardiac (90%) ●Arterial source (9%)
Arrhythmia (atrial fibrillation) Atherosclerotic aorta
Aneurysm
Valvular heart diseaes. ( MS)
Prosthetic heart valves. ●Other (1%)
Pardoxial.
Hx of myocardial infarction. Hx of medication (oral
Atrial myxoma. contraceptives)
Thrombosis:
• Thrombosis usually occur on a pre-existing atherosclerotic lesion.
• Occasionally thrombosis occur on relatively normal artery
In patients with hypercoagulabale states ex:
Pt with malignancy, polycythemia
or pt taking high doses of oestrogen.

Trauma
• It is important to determine a history of
arterial trauma, arterial catheterization,
intra-arterial drug induced injection,
aortic dissection, limb fractures.
• Emboli usually impact at branching points in arterial
tree, particularly at the bifurcation of the aorta, the
common femoral bifurcation & popliteal trifurcation.

Sites of occlusion embloi to the

lower limb:
Femoral artery 45%
Aorta & iliac artery 26%
popliteal artery 15%
tibial artery 1%
 Clinical differentiation between
thrombosis & embolism

Embolism: Thrombosis:

obvious cardiac source No obvious cardiac source.

No hx of claudication history of claudication.

Normal pulses in contralateral limb abnormal pulses in contralateral limb.

Angiogram: minimal atherosclerotic Angiogram: diffuse atherosclerotic

Few collateral Well developed collateral

 Investigation
• Clotting screen.
• Arteriography.
• ECG ( MI, Atrial fibrillation)
• Cardiac enzyme.
• Doppler US.
• Duplex imaging.

■ find source of embolism:

Holter monitring, Cardiac US,
US Aorta for AAA
 Management
• Immediately :
Anticoagulant with heparin to prevent propagation of
thrombus & distal thrombosis & this achieved by
giving a bolus of 50 U/Kg of heparin intravenously &
an infusion of about 1000 units of heparin per hour
after that.

• In pt thrombosis is thought to be the dx arteriography

should be considered to define the extant of problem
before revascularization.
 Management
• Embolectomy :
This operation usually performed
under local anaesthesia.
A groin incision is made & the
common femoral artery is
opened. often the clot is found
in the artery a Fogarty balloon
catheter is passed in turn into
the proximal & distal arteries
the balloon is inflated & the
catheter withdrawn removing
the clot.

Fogarty balloon catheter

 Management
• Thrombolytic therapy:
• Percutaneous intra-arterial thrombolytic therapy.
Takes approximately 12-72 hours to dissolve the clot.
• Agents used: streptokinase, urokinase & tissue
plasminogen activator.
• Mechanism:
The convert plasminogen to plasmin which the active
lytic agent.
Complications
Compartment syndrome
 THM
1. Risk factors for PVD

2. Recognise signs and symptoms of chronic ischemia of the lower limbs

3. Differential diagnosis for leg pain

4. Examine a chronic ischemic limb

5. Understand medical/surgical of management of PVD

6. Recognise an acute ischemic limb

7. Know it is important to call the vascular surgeon ASAP

8. Know what investigations to order in the ED

9. Be aware of the manifestations of reperfusion injury

Questions?