Intended Learning Outcomes
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1 2011 Acute Limb Ischemia Definition, Etiology & Pathophysiology Clinical Evaluation Management Ali SABBOUR Prof. of Vascular Surgery, Ain Shams University
2 Acute Limb Ischemia
3 Intended Learning Outcomes Define acute ischemia List the possible causes of acute ischemia Differentiate between embolic and thrombotic ischemia based on a given clinical picture Diagnose acute ischemia from a given clinical picture List the possible D.D. Identify compartmental syndrome from a given clinical picture Distinguish irreversible ischemia from a given clinical picture State the indications of angiography in acute ischemia List the indications and contraindications of thrombolytic therapy Propose (choose) a suitable management plan for a patient with a given clinical picture of acute ischemia
4 Definition of Acute Limb Ischemia Sudden decrease in arterial limb perfusion causing threat to limb viability
5 Etiology of acute limb ischemia Acute arterial embolism: Acute arterial thrombosis: Of a relatively health arterial tree Of a previously diseased arterial tree Acute traumatic ischemia:
6 Acute Embolic Ischemia Patho-pysiology Acute Thrombotic Ischemia An embolus can originate from the heart (MS with atrial fibrillation, 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
7 Causes of Acute Embolic Ischemia
8 What are the sources of acute embolism? Cardiac: AF (atrial thrombus) MI (Mural thrombus) Extra-cardiac cardiac: e.g.: Aortic aneurysm
9 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 Normal pulse in the other limb What are the clinical features suggestive of Acute Embolism?
10 Definition: Sudden decrease of arterial limb perfusion causing threat to limb viability Etiology: 1-Embolic (Rh.heart w mitral stenosis & AF or 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 What are the symptoms & signs of acute ischemia? Management
11 Clinical Evaluation of Acute Ischemia (Clinical Picture) Symptoms of acute ischemia: Pain: Diffuse foot & leg (hand & f.arm) severe aching pain of acute onset (more acute in embolic ischemia) Pain may diminish in intensity by time if collaterals open improving circulation, or if ischemia progresses causing ischemic sensory loss Coldness is an early symptom Numbness followed by sensory loss (late) Muscle weakness Muscle weakness (heavy limb) followed by paralysis (late)
12 Clinical Evaluation of Acute Ischemia (Clinical Picture) History Aim of your questions 1- To know whether these symptoms are of acute ischemia or not (DD of acute ischemia : acute DVT [phlegmasia], hypo-perfusion states [e.g. heart failure specially if associated with chronic ischemia] 2- 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. Heart Ds, claudication, recent arterial intervention e.g. cardiac cath., risk factors for atherosclerosis: hypertension, diabetes, smoking, hyperlipedemia, family history of cardio-vascular disease)
13 Clinical Evaluation of Acute Ischemia (Clinical Picture) Signs of acute ischemia 5Ps Pain: symptom + COLOR: Early: pale Inspection Later: cyanosed mottling fixed mottling & cyanosis -- black Pale Pulseless Parathesia Paralysis Empty veins: compare the Rt. (ischemic) & Lt. (normal)
14 Clinical Evaluation of Acute Ischemia (Clinical Picture) Signs of acute ischemia 5Ps Pain: symptom + Palpation Pale Pulseless Parathesia Paralysis Palpate peripheral pulses, 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
15 Clinical Evaluation of Acute Ischemia (Clinical Picture) Signs of acute ischemia 5Ps Pain: symptom + Palpation Loss of sensory function Numbness will progress to anesthesia Progress of Sensory loss Pale Pulseless Parathesia Paralysis Light touch Vibration sense Proprioreception Deep pain Pressure sense Late
16 Clinical Evaluation of Acute Ischemia (Clinical Picture) Signs of acute ischemia 5Ps Pain: symptom + Pale Pulseless Parathesia Paralysis Palpation Loss of motor function: Indicates advanced limb threatening ischemia Late irreversible ischemia: Muscle turgidity
17 Case Scenario A 63 year old patient with past history of lower limb claudication presented with acute progressive pain of his Rt. Lower limb and inability to walk of 4 days duration On examination; the Rt. Foot and leg are cold, the foot showed fixed cyanosed with loss of sensation. Calf muscles are turgid. Pedal pulses are absent on both sides This patient has: a.reversible acute arterial thrombosis b.reversible acute arterial embolism c.irreversible acute arterial thrombosis d.irreversible acute arterial embolism
18 Which of the following presentations is suggestive of acute thrombosis? a.a patient with recent myocardial infarction reports that he suddenly developed limb pain and coldness at 3 am in the morning. He has no previous history of claudication. b.a diabetic patient with recent history of severe diarrhea developed limb coldness and pain that is progressing over the past 12 hours c. A 60y old pt. with known aortic aneurism suddenly develops right lower limb coldness. The right pedal pulse is absent while the left pedal pulse is intact d.a young patient with rheumatic heart and atrial fibrillation suddenly develops pain and coldness with inability to move his limb.
19 Definition: Sudden decrease of arterial limb perfusion causing threat to limb viability Etiology: 1-Embolic (Rh.heart w mitral stenosis & AF or 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, Pale, Pulseless, Parathesia, Paralysis Management
20 What are the immediate steps that you should do (as a primary care doctor) when you diagnose acute ischemia? Angiography is NOT a routine in acute ischemia. What are the indications of angiography in acute ischemia? What are the absolute contraindications for thrombolytic therapy? What is the treatment of acute embolic ischemia? What is compartmental syndrome & what is it s management?
21 Investigations of acute limb ischemia The severity and duration of ischemia at the time of presentation provides a narrow margin of time for investigations Doppler US Doppler US It is important to look for arterial Doppler signals to assess the level of obstruction & severity of ischemia
22 Investigations of acute limb ischemia High clinical probability of embolic ischemia do NOT need angiography If the differentiation is not clear clinically, and if the limb condition permits, DO ANGIOGRAPHY Value of angiography Localizes the obstruction Visualize the arterial tree & distal run-off Arteriography Can diagnose an embolus:sharp cutoff, reversed meniscus or clot silhouette
23 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, heat raises the metabolic rate) Maximum tissue oxygenation (oxygen inhalation) Correct hypotension Start treatment of other associated cardiac conditions (CHF, AF)
24 Treatment of acute limb ischemia B Catheter directed thrombolysis Agents used: Streptokinase Urokinase Tissue plasminogen activator
25 Treatment of acute limb ischemia B Catheter directed thrombolysis Indications: 1. Viable or marginally threatened limb 2. Recent acute thrombosis (not suitable for embolism or old thrombi) Agents used: Streptokinase, Urokinase, tissue plasminogen activator 3. Avoid patients with contraindications Contraindications: Absolute: 1. Cerebro-vascular stroke within previous 2 months 2. Active bleeding or recent GI bleeding within previous 10 days 3. Intracranial trauma or neurosurgery within previous 3 months Relative: 1. Cardio-pulmonary resuscitation within previous 10 days 2. Major surgery or trauma within previous 10 days 3. Uncontrolled hypertension
26 Treatment of acute limb ischemia C Surgery In acute embolism: Catheter embolectomy under local anesthesia
27 Treatment of acute limb ischemia C Surgery In acute embolism: Catheter embolectomy under local anesthesia In acute thrombosis, 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
28 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
29 Amputation: Done for irreversible ischemia with permanent tissue damage (turgid muscles, fixed cyanosis) The level of amputation is decided according to the level of palpable pulse. Palpable popliteal pulse Below knee amputation Absent popliteal pulse Above knee amputation
30 Definition: Sudden decrease of arterial limb perfusion causing threat to limb viability Etiology: 1-Embolic (Rh.heart w mitral stenosis & AF or 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, Pale, Pulseless, Parathesia, Paralysis Investigations Treatment 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
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