acute limb ischemia - ESVS 2020 guideline

must know for surgical residents
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2. Acute limb ischemia – 2020 esvs guidelines definition: Sudden decrease in arterial perfusion of the limb Potential threat to the survival of the limb Requiring urgent evaluation and management Duration : < 2 weeks Common causes Embolism Thrombosis of native arteries or reconstructions Peripheral arterial aneurysm Dissection Traumatic arterial injury Diagnosis Medical emergency 6Ps: late signs  pain, pallor, pulselessness , poikilothermia , paresthesia, paralysis ABI < 0.7 is critical Look for signs of visceral ischemia, neurosigns , and DVT Cardiac exam to look for cardiac cause: AF Imaging: DSA, duplex US, CE-MRA, and CTA (first line, most often used Classification for severity: Rutherford  Facebook: happy Friday knight

3. Treatment Initial Oxygen therapy UFH: 5000 U or 70-100 U/kg IV and monitor + adjust APTT ratio (aim: to reduce further embolism or clot propagation and provide anti-inflammatory effect Adequate analgesia Rehydration Decision making Open revascularization VS thrombolysis VS hybrid Acute limb ischemia – 2020 esvs guidelines Open revascularization techniques Thrombo -embolectomy Using fogarty balloon Under LA Transverse arteriotomy if no plan to bypass Surgical bypass Used if intravascular recanalization not achieved Used in acute on chronic ischemia Vein graft VS prosthetic graft Completion angiogram after surgery or embolectomy: recommend If residual is found, intraarterial rtPA 4 – 10 mg directly into artery downstream Facebook: happy Friday knight

4. Thrombolysis Systemic: not recommend Catheter directed thrombolysis (CDT) Equivalent results to surgery Initially used in IIA Systematic review showed it may be used in Rutherford IIB Access: femoral artery under US guide Drugs: urokinase and rtPA (0.02 – 0.1 mg/kg/h) Complications: bleeding and access site Distal embolization Other endovascular techniques Thrombus aspiration Endovascular mechanical thrombectomy Ultrasound accelerated thrombolysis Acute limb ischemia – 2020 esvs guidelines Facebook: happy Friday knight

5. Complications of restoration to ischemic tissue: compartment syndrome and reperfusion injury Tissue swelling in fascial compartment Late diagnosis results in irreversible muscle necrosis and ischemic nerve damage Dx : based on clinical symptoms and signs  severely pain but can be minimal if nerve injury Results: muscle damage  myoglobin and CK leakage into circulation  AKI Compartment pressure: little consensus on threshold Risk factors: duration > 6h, young, previous Hx of ALI, hypotension, high CK, severity, inadequate intraop backflow, positive fluid balance Treatment: fasciotomy Prevention: prophylactic fasciotomy after revascularisation Postoperative treatment and follow up Most common cause is AF and intracardiac thrombus  prevention of recurrent embolization  echo and CTA whole aorta if no cardiac source For native arterial thrombosis Look for concomitant malignancy or thrombophilia Smoking cessation Antithrombotic and statin  recommend to decrease cardiac complication and to prevent atherosclerotic disease progression Imaging: duplex US is modality of choice during follow up Acute limb ischemia – 2020 esvs guidelines Facebook: happy Friday knight