Acute limb ischemia

Academic presentation of resident of Vascular Surgery at NICVD. Supervised by me (Dr Shantonu Kumar Ghosh).

1. Acute Limb Ischemia Presented by: Dr . Md. Jahir Uddin Molla Resident, Phase- B, MS (CVTS) BSMMU, Shahbag, Dhaka, Bangladesh Supervisor: Dr. Shantonu Kumar Ghosh Assistant Professor, Department of Vascular Surgery, National Institute of Cardio-vascular Diseases, Dhaka, Bangladesh

2. Acute Limb Ischemia “The Trans-Atlantic Inter-Society Consensus” defined acute ischemia as- “Acute limb ischemia is any sudden decrease in limb perfusion causing a potential threat to limb viability”

3. Acute Limb Ischemia: causes Embolism Cardiac Embolism Atrial and Ventricular Paradoxical embolism Endocarditis Cardiac Tumor Noncardiac Embolism Atheroembolism Aortic Mural Thrombi Angiogram Showing Aortic Plaque (A) Causing Distal Popliteal Thromboembolism (B).

4. Acute Limb Ischemia: causes Thrombosis Atherosclerotic Obstruction Hypercoagulable States Vasospasm Aortic Dissection Bypass Graft Occlusion

5. Acute Limb Ischemia: causes

6. Differentiating thrombosis and embolism Embolism Sudden onset pain Young patient Has a source of emboli No history of occlusive arterial disease Other pulses are present Thrombosis Sub acute onset Elderly patient No source of emboli History of occlusive arterial disease Other pulses may be absent

7. Presentation (symptoms and signs) The well-known rule of P ’s— Pain Pallor Perishing with cold Pulse deficit Paresis / paralysis Paraesthesia / anaesthesia. Beware After trauma After anaesthesia

8. CLASSIFICATION OF ACUTE LIMB ISCHEMIA From Rutherford RB, Baker JD, Ernst C, et al. Recommended standards for reports dealing with lower extremity ischemia: revised version. J Vasc Surg . 1997;26:517–538.

9. DIAGNOSIS Acute limb ischemia is a clinical diagnosis -there is no need of imaging. Aortic Occlusion Paralysis of the legs Patients are unwell with mottled skin discoloration (often extends above the inguinal ligament onto the lower abdomen) No palpable extremity pulses Iliac Occlusion The findings are similar to those for aortic occlusion, but unilateral.

10. Femoro-popliteal Occlusion The symptoms are more severe if the profunda is involved. Although the femoral pulse may be strongly palpable (owing to the water-hammer effect), the artery may be occluded . Popliteal and Infra-popliteal Occlusion The calf muscles are ischemic with a palpable femoral pulse .

11. Clinical Evaluation of Acute Ischemia (Clinical Picture) Fixed mottling & cyanosis An area of fixed cyanosis surrounded by reversible mottling Pallor

12. Femoral Popliteal Posterior tibial Dorsalis pedis

13. Loss of motor function: Indicates advanced limb threatening ischemia Muscle turgidity: Late irreversible ischemia

14. INVESTIGATION Computed Tomographic Angiography Ultrasound Transfemoral Arteriography Magnetic Resonance Angiography Echocardiography

15. Computed Tomographic Angiography Computed tomography angiogram demonstrating marked calcified atherosclerotic disease in the infrarenal abdominal aorta

16. Doppler US To assess the level of obstruction & severity of ischemia

17. Transfemoral Arteriography Catheter-based angiogram demonstrating a severely atherosclerotic aorta with a severe stenosis of the left renal artery and an occluded right renal artery. A selective angiogram of the left renal artery shows the severity of stenosis

18. Angiogram Showing Popliteal Embolus

19. INITIAL MANAGEMENT Goals of therapy include restoration of blood flow, preservation of limb and life, and prevention of recurrent thrombosis Diagnosis of acute ischemia  Severity classified  I mmediate interventions Anticoagulation Immediate anticoagulation with intravenous heparin L ow-molecular-weight heparin

20. Ancillary Supportive Measures Oxygen delivered by facemask Intravenous infusion of fluid and monitoring of urine output Full blood screen for blood urea nitrogen Full blood count Full thrombophilia screen Adequate analgesia (Intramuscular opiates are contraindicated/patient-controlled intravenous analgesia is a good alternative)

21. Contraindications to Pharmacologic Thrombolytic Agents

22. SPECIFIC TREATMENT Anticoagulation alone Operative intervention Endovascular intervention via mechanical thrombectomy or thrombolysis.

23. TREATMENT SELECTION Class I ALI - only medical therapy, such as anticoagulation . Revascularization can be performed electively (thrombolytic or open surgical intervention) Class II ALI requires a flexible approach to intervention. All patients with class II ALI require revascularization to preserve the functional integrity of the affected extremity. For patients with class IIa ischemia, immediate revascularization is not necessary

24. TREATMENT SELECTION More severe ALI (class IIb ) - manifested by both sensory and motor deficits, requires emergency revascularization . Class III ALI - manifests as a profound neurologic deficit (insensate, paretic limb), muscle rigidity, and the absence of arterial and venous Doppler ultrasound signals in the affected vascular bed . Revascularization is usually futile and may have adverse systemic effects such as cardiac arrest due to acidosis and hyperkalemia Primary amputation should be considered.

25. TREATMENT SELECTION ENDOVASCULAR TREATMENT Currently available percutaneous endovascular procedures include Catheter-directed thrombolysis (CDT ) Pharmacomechanical thrombolysis Catheter-directed thrombus aspiration Percutaneous Mechanical Thrombectomy (PMT)

26. TREATMENT SELECTION SURGICAL REVASCULARIZATION Techniques for salvage of an ischemic limb include : Balloon catheter thrombectomy or embolectomy Bypass procedures to direct blood flow beyond the occlusion Endarterectomy with or without patch angioplasty Hybrid procedures combining open and endovascular techniques

27. Embolectomy with fogarty catheter

28. PROGNOSIS The medical state of a patient is a good prognostic index of survival. Patients with acute myocardial infarction or poor cardiac output have a high mortality rate . Outcome can be predicted from pretreatment POSSUM (Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity) scores.

29. Despite active intervention, the outcome after treatment is often poor. In some patients, limb ischemia is a manifestation of the end of life such as in the very elderly with multiple comorbidities and palliative care is indicated rather than active intervention. Very high-risk group in whom palliation might be appropriate is patients with acute ischemia due to hypercoagulable blood as a consequence of advanced malignancy.

30. UPPER LIMB ISCHEMIA A number of significant differences exist between acute ischemia of the arm and leg. Arm ischemia seldom threatens the limb, and treatment decisions are less urgent. Most arm ischemia is due to cardiac embolism; atherosclerosis is rare in upper limb arteries.

31. The arm often improves after initial anticoagulation, and decisions about whether to perform embolectomy can be difficult. A small number of patients present with class IIb critical ischemia and should undergo urgent surgical intervention. Failed surgery in this situation risks ischemic contracture

32. The threat to the arm is generally low, but up to 20% of patients with acute arm ischemia do not survive the acute event, usually owing to cardiac complications. Rare causes of arm emboli include thoracic outlet syndrome and proximal subclavian artery aneurysm. Arteriovenous fistulae for dialysis may also cause a number of complications, including thrombosis and aneurysm formation .

33. Post operative management Monitor distal pulse Keep foot elevated Monitor movements and sensation Continue Heparin – 18U/kg per hour infusion Start warfarin when surgical bleeding is not a concern Monitor for reperfusion effects

34. Complications of Acute limb Ischaemia Reperfusion effects Compartment syndrome Volkmann ischemic contracture Limb loss Death

35. Reperfusion effects Local Reperfusion injury – paradoxical death of already dying muscles after reperfusion Systemic Reperfusion syndrome Hypotension ARDS Lactic acidosis Hyperkalemia Renal failure

36. DURING ISCHAEMIA

37. AFTER REPERFUSION

38. MANAGEMENT OF REPERFUSION EFFECTS

39. MANAGEMENT OF REPERFUSION EFFECTS

40. Compartment syndrome Reduced organ perfusion due to increased intra compartment pressure. CPP = MAP – ICP Compartment Perfusion Pressure (CPP) Mean Arterial Pressure (MAP) Intra Compartmental Pressure (ICP)

41. Compartment syndrome Causes Trauma (muscle contusion) Haematoma Reperfusion Intracompartmental extravasation of fluids Tight bandage, cast

42. Clinical features Excessive pain - pain on passive movements Numbness -e.g. anterior compt. first toe web (deep peroneal N ) Tense swollen leg

43. Treatment Recognize Reduce intracompartmental pressure Remove bandages and cast Keep limb elevated Fasciotomy

44. Ischemic contracture

45. Thank you