LIMB ISCHEMIA

Dr Qaaneta Bint-e-Najaf
 ACUTE LOWER LIMB ISCHEMIA

• This is a surgical emergency.

• Sudden
• Greater than 6 hrs
• Thromoembolic pathology
Symptoms of acute limb ischaemia

• Pain (possibly related to anoxia, acidosis, and metabolite and

substance P accumulation).
• Pallor
• Paraesthesia
• Perishingly cold
• Paralysis
• Pulseless
INVESTIGATIONS
(Narrow margin of time)
• General (CK, Anti cardiolipin Ab, elevated homocysteine conct,
Antibodies to plt factor IV, add std for hypercoagulable states)
• Doppler US
• ABI and segmental leg pressures
• Duplex US
• Angiography ( if unable to diff between thrombosis or embolism and
if time permits )
• DSA
• US Doppler ( to Assess level of obstruction and
severity of ischaemia)
• If no doppler signals  consult a vascular surgeon
immed

• If some flow / pulse  ABPI and segmental leg

pressures to look for severity and level of occlusion.
ABPI of 0.9 – 0.7  mild disease
0.69 – 0.5  moderate disease
<0.5  severe disease
MANAGEMENT
Acute limb ischaemia is a surgical emergency and must be resolved within 4–6
hours to prevent complications from tissue ischaemia. In acute-on-chronic
ischaemia the limb may remain viable forlonger, depending on collateral supply.
Note: nerve conduction disappears after 15–30 min of acute ischaemia;
permanent muscle damage occurs after few hours, with the EHL being the last
muscle to recover on revascularisation. Skin will tolerate ischaemia for up to 48
hours.
• Principles of management of acute limb ischaemia • Resuscitation (oxygen
and intravenous fluids) • Immediate anticoagulation (5000 units heparin
intravenously) • Analgesia • Restore arterial continuity • Identify and correct
any underlying source of embolus
THROMBOLYSIS
• performed if the limb is not too acutely ischaemic.
• It is the preferred choice for acute-on-chronic ischaemia.
• Tissue plasminogen activator (tPA), urokinase or streptokinase is
introduced through a catheter inserted under fluoroscopic control, directly
into the clot. Clot dispersal can be monitored by serial arteriography.
• Complications: • Puncture site haemorrhage/false aneurysm •
Retroperitoneal haemorrhage • Stroke • Gastrointestinal bleeding •
Anaphylaxis
• Contraindications: • Extreme old age • Recent surgery • Peptic ulceration
• Recent stroke • Bleeding tendencies
EMBOLECTOMY
Indications: treating embolus (usually after urgent angiography or duplex US). For acutely
ischaemic upper limbs diagnostically.

Incision:
Femoral: longitudinal incision in groin below Ing lig.
Brachial: transverse incision below the skin crease at the elbow.
Procedure :Artery is identified and dissected free.
Vascular slings are placed proximally and distally.
Patient is heparinised (eg 5000 units intravenous bolus).
Vascular clamp applied proximally and distally and a transverse arteriotomy is performed.
Fogarty catheter is passed distally balloon inflated  catheter withdrawn (drawing
embolus out of the artery) – this is repeated proximally and distally until flow is restored.
Arteriotomy is closed with non-absorbable sutures (eg fine Prolene) .
Intraoperative hazards: Over-inflation of the Fogarty catheter inside
the artery can cause damage to sections of artery and intimal stripping
– this causes a very prothrombotic state and the artery is likely to
thrombose postoperatively.
Postop: Continue formal anticoagulation; regular observations of limb
perfusion must be performed (pulses, capillary refill, temperature,
colour); re-exploration may be indicated if thrombosis occurs; always
look for the source of the underlying embolus for definitive
management.
Complications: Haemorrhage, postoperative thrombosis, limb loss.
Complications of acute limb ischaemia
Reperfusion injury: the body’s response after restoration of arterial continuity,
due to release of high concentrations of products of metabolism (eg potassium,
lactate, myoglobin) back into the general circulation. This can cause local and
systemic effects.
After reperfusion, local tissue swelling occurs. If unrelieved this swelling can
cause further ischaemia and ultimately contractures (eg Volkmann’s ischaemic
contracture following upper limb ischaemia). This can be prevented by timely
fasciotomy.
Systemically, reperfusion can cause rhabdomyolysis and renal failure. It may also
cause pulmonary oedema/ARDS, myocardial dysfunction and clotting disorders.
• Compartment syndrome
Long-term management of acute limb
ischaemia
• Following the restoration, investigations are performed to identify the
underlying cause of embolism:
• Echocardiography to assess left ventricular and heart valves
• Ultrasonography (especially abdominal aorta and popliteal arteries)
• Arteriography to look for other sources of emboli
• Long-term anticoagulation is also required, initially with heparin and
later with warfarin.
CHRONIC LIMB ISCHAEMIA
Buerger’s disease (thromboangiitis obliterans): in young men who smoke heavily ,
usually bilateral, Starts in lower limbs.
• Management includes smoking cessation, sympathectomy , antibiotics, foot care
and analgesia. Prostaglandin infusions, Serial amputations are often required.

• Takayasu’s arteritis (pulseless disease) • Inflammatory infiltrate affecting

branches of the aortic arch • Young or middle-aged women• Associated with
pain, malaise and elevated ESR • Presents with hypertension or ischaemic
symptoms of the upper limb.
• Management includes steroids and immunosuppression

• Raynaud’s: Usually females, bilateral, ass with abnormal sensitivity to cold, can
cause gangrene.
Classification of Limb Ischemia

•• Functional limb ischemia : Blood flow is normal in resting extremity

but cannot be increased in response to exercise. Manifest as
claudication.

•• Critical limb ischemia: Reduction of peripheral perfusion to the

extent that basal metabolic needs are not adequately met. Manifest as
rest pain.
HISTORY
• Age : TAO (young males)
• Gender : Raynaud’s (females young age).
• CHIEF COMPLAINT: Pain, Ulceration, Blackish discoloration
• PAIN: Site, character, radiation ,Intermediate claudication, Rest pain-relieving factors,
Claudication distance.
• Boyd’s classification
• Grade I: Pt exp pain after walking some distance and pain disappears and patient
continues to walk.
• Grade II – Pain persists and still the patient continues to walk with limp.
• Grade III – Pain compels the patient to take rest.
Etiological History : History of pain following exposure to cold
(Raynaud’s), History of cardiac problems (atrial fibrillation with
embolism) ,History of diabetics, smoking (atherosclerosis).
• History of Involvement of Other Vessels: Chest pain (MI), Black
outs /LOC (CVA), Abdominal pain (mesenteric ischemia), Impotence
(bilateral internal iliac occlusion), Blurred visions (ophthalmic vessels).
• Past history: History of Diabetes, hypertension and
hypercholesterolemia
• Personal history: History of smoking
• Family history: Atherosclerotic diseases in family
• Treatment history: History of surgery before (amputation,
sympathectomy).
INVESTIGATIONS
• Routine blood investig: sugar , urea, creatinine
• Serum cholesterol and triglycerides
• Urine sugar
• X-ray of lower limbs for any calcification of vessels, bone problems
• ABPI and segmental leg pressures
• Ultrasound duplex
• Arteriography
• RECENT ADV: Xenon isotope scanning and transcutaneous oximetry
• Others: CT and MR angiography, intravascular ultrasound
CONSERVATIVE MANAGEMENT OF
IC
Intermittent claudication is usually managed by correction of risk factors.
Patients should: Stop smoking, Exercise, improve their diet (low-fat) ,
Lose weight
• Management includes:
• Antiplatelet agents (aspirin, clopidogre, dipyridamole l)
• Aggressive BP management in patients with hypertension.
• Aggressive blood sugar control in patients with diabetes.
• Management of hypercholesterolaemia/hyperlipidaemia with lipid-
lowering drugs (statins)
Conservative management of chronic
critical ischaemia
• Requires active limb revascularisation to prevent limb loss.

• However, concurrent conservative strategies for improving blood flow

are also required:
• Stop smoking
• Optimise cardiac output
• Treat infections
• Anticoagulation (aspirin)
Non-surgical interventions for PVD
Angioplasty: a balloon catheter is introduced, then inflated across the sten:osis or
occlusion to dilate this section of the artery. This technique is good for short
occlusions and works better for proximal than for distal disease
Stenting: arterial stents are expandable metal prostheses.They are usually balloon-
expandable and introduced under fluoroscopic control, combined with angioplasty.
Primary arterial stenting is now the mainstay of treatment for most symptomatic
arterial stenoses and short occlusions that fail to respond to medical management.
Stenting is also indicated for failed angioplasty, and for correction of intimal arterial
defects
Lumbar sympathectomy: used if arterial reconstruction is not feasible. This is
usually chemical (phenol, translumbar injection with radiographic control), but it
can be surgical.
• Drug therapy: vasodilators in combination with antiplatelet therapy (aspirin),
nifedipine, iloprost and pentoxifylline
SURGERY FOR PVD
Anatomical procedures (eg femoropopliteal bypass, femorodistal
bypass)
Extra-anatomical procedures eg axillo-bifemoral and femorofemoral
crossover grafts
Vascular grafts:
• Autologous: long saphenous vein (LSV), Composite vein grafts
• Prosthetic: Dacron or PTFE grafts are tubes of prosthetic material.
They have a much lower patency rate than autologous grafts
• Early complications
• Haemorrhage , Graft thrombosis ,Wound infection , Swollen leg
(reperfusion or DVT) , Lymphatic fistula

• Late complications
• Graft thrombosis , False aneurysm, Graft infection
Amputations of isch lower limbs
• Indications ( three Ds):
• Dying (eg vascular disease,
gangrene)
• Dangerous (eg tumour,
severe infection)
• Damned nuisance (eg
useless, painful limb after
trauma, neurological
damage)
THANK YOU