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: .

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 .Acute Embolic Ischemia Patho-pysiology Acute Thrombotic Ischemia An embolus can originate from the heart (MS with atrial fibrillation.

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 .

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

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 .Definition: Sudden decrease of arterial limb perfusion causing threat to limb viability Etiology: 1-Embolic (Rh.

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) 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.

g. family history of cardio-vascular disease) . hypo-perfusion states [e.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. recent arterial intervention e. heart failure specially if associated with chronic ischemia] 2. cardiac cath. Heart Ds. risk factors for atherosclerosis: hypertension.. hyperlipedemia.To know whether these symptoms are of acute ischemia or not (DD of acute ischemia : acute DVT [phlegmasia] . smoking. diabetes. claudication.Clinical Evaluation of Acute Ischemia (Clinical Picture) History Aim of your questions 1.g.

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. (normal) . (ischemic) & Lt.

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 5Ps Pain: symptom + Pale Pulseless Parathesia Paralysis Femoral Popliteal Posterior tibial Dorsalis pedis Palpate peripheral pulses.

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 .

followed by the leg muscles Detecting early muscle weakness is difficult because toes movements are produced mainly by leg muscles .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.

a Marginal threat II. needs amputation . & muscle damage .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.Postgraduates Classes of Acute Ischemia Clinical Findings Class I.b Immediate threat III. Viable II.

Pulseless. Paralysis Management .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.Definition: Sudden decrease of arterial limb perfusion causing threat to limb viability Etiology: 1-Embolic (Rh. Parathesia. Pale.

the limb is not threatened . If it can be measured.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.

iliac embolism Clot silhouette . and if the limb condition permits. reversed meniscus or clot silhouette Popliteal embolism Reversed meniscus sign Lt.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. DO ANGIOGRAPHY Value of angiography Localizes the obstruction Visualize the arterial tree & distal run-off Can diagnose an embolus: Sharp cutoff.

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) .

Intracranial trauma or neurosurgery within previous 3 months Relative: 1. Urokinase. IIa) 2. Recent acute thrombosis (not suitable for embolism or old thrombi) 3. Avoid patients with contraindications Agents used: Streptokinase. Uncontrolled hypertension . Active bleeding or recent GI bleeding within previous 10 days 3.Treatment of acute limb ischemia B Catheter directed thrombolysis Indications: 1. Viable or marginally threatened limb (class I. Cerebro-vascular stroke within previous 2 months 2. tissue plasminogen activator Contraindications: Absolute: 1. Major surgery or trauma within previous 10 days 3. Cardio-pulmonary resuscitation within previous 10 days 2.

Immediate surgical revascularization is indicated in class IIb.Acute embolism: Catheter embolectomy under local anesthesia 2. 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 .Treatment of acute limb ischemia C Surgery 1. or class I.

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 .

fixed cyanosis) The level of amputation is decided according to the level of palpable pulse.Below knee amputation Absent popliteal pulse ---------------.Above knee amputation .Amputation: Done for irreversible ischemia with permanent tissue damage (turgid muscles. Palpable popliteal pulse -------------.

Definition: Sudden decrease of arterial limb perfusion causing threat to limb viability Etiology: 1-Embolic (Rh. Pulseless. 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 . Pale. Parathesia.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.