Acute Limb Ischemia. Management of Common Peripheral Vascular Disease. Etiology. Peripheral Vascular disease 11/10/2014

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1 Acute Limb Ischemia Management of Common Peripheral Vascular Disease October 7, 2014 นพ.ณรงช ย ว องกลก จศ ลป Diplomate, Thai Board of Surgery. Diplomate, Thai Subspecialty Board of Vascular Surgery. Diplomate, Thai Subspecialty Board of Trauma Surgery. Any sudden decrease in limb perfusion causing a potential threat to limb viability. Presentation is normally up to 2 weeks following the acute event. Trans-Atlantic inter-society Consensus for management of peripheral arterial disease Etiology ประว ต การผ าต ดหลอดเล อด โรงพยาบาลศร นคร นทร คณะแพทยศาสตร มหาว ทยาล ยขอนแก น 2517 ศ.นพ.ทองอวบ อ ตรว เช ยร ได ทำผ ำต ด repair AAA (Hut Hospital ) 22 ม ถ นำยน 2526 รศ.นพ.เช ดช ย ต นต ศ ร นทร ได ทำผ ำต ด Repair AAA หญ ง อำย 63 ป 2527 CVT unit AE unit General unit 2551 Vascular surgeon Peripheral Vascular disease Time to presentation in relation to etiology Peripheral arterial disease (PAD), atherosclerosis obliterans Degenerative process Arterial occlusion (acute, chronic) Aneurysms 1

2 History Present illness abruptness and time of onset of the pain, location and intensity, change in severity over time Past history history of claudication, heart disease (e.g. atrial fibrillation) or aneurysms (i.e. possible embolic sources), concurrent disease or atherosclerotic risk factors (hypertension, diabetes, tobacco abuse, hyperlipidemia, family history of cardiovascular disease, strokes, blood clots or amputations) Incidence of location of peripheral emboli Haimovici's vascular surgery, 5th ed, P s (6 P s) Pain Pulselessness Pallor Paresthesia Paralysis Poikilothermia Physical examination Clinical categories Clinical Manifestations Assessment of acute limb ischemia (ALI) Recommendation 29 Assessment of acute limb ischemia (ALI) Due to inaccuracy of pulse palpation and the physical examination, all patients with suspected ALI should have Doppler assessment of peripheral pulses immediately at presentation to determine if a flow signal is present. O Connell JB, Semin Vasc Surg

3 Investigation Routine laboratory studies. electrocardiogram, standard chemistry, complete blood count, prothrombin time, partial thromboplastin time and creatinine phosphokinase level. Patients with a suspected hypercoagulable state will need additional studies seeking anticardiolipin antibodies, elevated homocysteine concentration and antibody to platelet factor IV Investigation Other imaging techniques Computed tomographic angiography (CTA) Advantages: speed, convenience and ability for crosssectional imaging of the vessel Disadvantage : iodinated contrast media increase the risk of renal injury to the patient Magnetic resonance (MR) angiography Cumbersome and time-consuming which may delay treatment. Investigation Imaging arteriography major value in localizing an obstruction and visualizing the distal arterial tree assists in distinguishing patients who will benefit more from percutaneous treatment than from embolectomy or open revascularization procedures. catheter-based treatment CTA MRA CT and MR Angiography of the Peripheral Circulation, 2007 Arteriography Duplex ultrasound used in some centers to define the anatomic extent of peripheral arterial disease Haimovici's vascular surgery, 5th ed, 2004 Rutherford Vascular Surgery, 6th ed, 2005 Peripheral vascular ultrasound, 2 nd ed,

4 Treatment The initial goal of treatment for ALI is to prevent thrombus propagation and worsening ischemia. The standard therapy (except in cases of heparin antibodies) is unfractionated heparin intravenously Older, more sedentary patients with significant co-morbidities Category I Viable should be treated with heparin and observation, being watched closely while attention is given to treating associated comorbidities Rutherford RB, Semin Vasc Surg 2009 Algorithm for management of acute limb ischemia Active patients without significant comorbidities. Category I Viable Endovascular revascularization (CDT and, possibly, percutaneous mechanical thrombectomy) CDT = catheter-directed thrombolysis Rutherford RB, Semin Vasc Surg 2009 Category IIa Marginal threatened Endovascular revascularization (CDT and, possibly, percutaneous mechanical thrombectomy) Rutherford RB, Semin Vasc Surg 2009 Rutherford RB, Semin Vasc Surg

5 Category IIb Immediate threatened Completion angiography Aim: restoring flow within 3 to 6 hours Open revascularization Intraoperative assessment of the adequacy of clot removal Vascular surgeons are competent in both endovascular and open techniques Rutherford RB, Semin Vasc Surg 2009 Amputation Category III Irreversible Bypass Patients presenting very soon after the onset of ischemia (within an hour or 2), a functional limb may actually be salvaged if revascularization is accomplished immediately Ao-Bi-Fem Fem-Fem Ax-Bi-Fem Rutherford RB, Semin Vasc Surg 2009 Surgical revascularization Indications profoundly ischemic limb (class IIb) suprainguinal occlusion: preferred choice Thrombo-embolectomy Bypass Femoral tibial bypass Aboveknee femoral popliteal bypass 5

6 Endovascular procedures Catheter-directed thrombolytic therapy r-tpa, urokinase, streptokinase Advantages: reduced risk of endothelial trauma, clot lysis in branch vessels too small for embolectomy balloons and gradual low-pressure reperfusion Other endovascular techniques Percutaneous aspiration thrombectomy (PAT) thin-wall, large-lumen catheters and suction with a 50-mL syringe to remove embolus or thrombus Percutaneous mechanical thrombectomy (PMT) basis of hydrodynamic recirculation dissolution of thrombus CDT PAT Rutherford Vascular Surgery, 6th ed, 2005 Haimovici's vascular surgery, 5th ed, 2004 Contraindications to thrombolysis Absolute contraindications 1. Established cerebrovascular event (excluding TIA within previous 2 months) 2. Active bleeding diathesis 3. Recent gastrointestinal bleeding (within previous 10 days) 4. Neurosurgery (intracranial, spinal) within previous 3 months 5. Intracranial trauma within previous 3 months AngioJet System Relative contraindications 1. Cardiopulmonary resuscitation within previous 10 days 2. Major nonvascular surgery or trauma within previous 10 days 3. Uncontrolled hypertension (systolic 180 mmhg or diastolic 110 mmhg) 4. Puncture of noncompressible vessel 5. Intracranial tumor 6. Recent eye surgery Minor contraindications 1. Hepatic failure, particularly those with coagulopathy 2. Bacterial endocarditis 3. Pregnancy 4. Active diabetic proliferative retinopathy Rutherford Vascular Surgery, 6th ed,

7 Trellis System Compartment syndrome Reperfusion increased capillary permeability local edema and compartment hypertension regional venule obstruction and nerve dysfunction capillary and arteriolar obstruction and muscle and nerve infarction Rutherford Vascular Surgery, 6th ed, 2005 Complication Bleeding Reperfusion injury Compartment syndrome Rhabdomyolysis Pain out of proportion to physical signs, paresthesia and edema Compartment pressures of > 20 mmhg Fasciotomy Postreperfusion syndrome Result of ischemia/reperfusion injury in skeletal muscle Massive edema Myoglobin, potassium, lactate, and microthrombi from the damaged skeletal muscle into the systemic circulation Can cause renal failure, arrhythmias, and eventually death Beyersdorf F, Semin Vasc Surg 2009 Rhabdomyolysis Myoglobinuria Acute tubular necrosis: myoglobin precipitates, lipid peroxidation and renal vasoconstriction Clinical features: tea colored urine, elevated serum creatine kinase and positive urine myoglobin assay Treatments: hydration, alkalinizing the urine and eliminating the source of myoglobin 7

8 CLINICAL OUTCOMES Mortality rates for ALI: 15% 20%. Major morbidities major bleeding: 10% 15% major amputation: up to 25% fasciotomy: 5% 25% renal insufficiency : up to 20% Classification of peripheral arterial disease Follow-up care Immediate postoperative period: heparin Warfarin often for 3 6 months or longer Causes of chronic arterial occlusion Seek the source of embolism Bleeding risk factors: platelet inhibition therapy Chronic Limb Ischemia Intermittent claudication Critical limb ischemia (CLI) chronic ischemic rest pain patients with ischemic skin lesions, either ulcers or gangrene. Presence of symptoms for more than 2 weeks Co-existing Vascular Disease 8

9 Risk factor INTERMITTENT CLAUDICATION Muscle discomfort in the lower limb reproducibly produced by exercise and relieved by rest within 10 minutes. Muscle fatigue, aching or cramping on exertion that is relieved by rest. The symptoms are most commonly localized to the calf, but may also affect the thigh or buttocks. Critical Limb Ischemia (CLI) Ischemic rest pain: an ankle pressure less than 50 mmhg or a toe pressure less than 30 mmhg. Patients with ulcers or gangrene: an ankle pressure less than 70 mmhg or a toe systolic pressure less than 50 mmhg Patients with ankle-brachial index (ABI) less than 0.3 (0.4). Physical examination Blood pressure in both arms, Cardiac murmurs, gallops or arrhythmias Palpation for an abdominal aortic aneurysm Color and temperature of the skin of the feet, Muscle atrophy, Decreased hair growth and Hypertrophied, slow-growing nails. Bruit: carotid, aorta or femoral arteries 9

10 Specific peripheral vascular examination Palpation of the radial, ulnar, brachial, carotid, femoral, popliteal, dorsalis pedis and posterior tibial artery pulses. Pulses grading: from 0 (absent), 1 (diminished) and 2 (normal). INTERMITTENT CLAUDICATION The treatment goals: to relieve symptoms, improve exercise performance and daily functional abilities Life style and risk factor modification Exercise rehabilitation Pharmacotherapy Cilostazol Naftidrofuryl Measurement of ABI Critical Limb Ischemia (CLI) Primary goals of the treatment: Relieve ischemic pain, Heal (neuro)ischemic ulcers, Prevent limb loss, Improve patient function and quality of life and prolong survival. 10

11 Strategy Aggressive modification of cardiovascular risk factors and should be prescribed antiplatelet drugs Pain control Anti-biotics Revascularization or/and amputation Revascularization Critical Limb Ischemia Severe intermittent claudication Which? Open repair / bypass Endovascular techniques TASC classification of aorto-iliac lesion 11

12 Aorto-bi-femoral arterial bypass TASC classification of femoral popliteal lesion Axillo-bi-femoral arterial bypass Femoro-femoral arterial bypass 12

13 Femoropopliteal arterial bypass Femorotibial arterial bypass Endovascular procedure Endovascular surgery, 4 th Ed,

14 Survival 14

15 Aneurysm Ultrasound Dilatations of localised segments of the arterial system Symptoms: expansion, thrombosis, rupture or the release of emboli Abdominal aortic aneurysm commonest type 2% of the population at autopsy 95% have associated atheromatous degeneration 95% occur below the renal arteries Asymptomatic Symptomatic: back and abdominal discomfort, sudden, severe back and/or abdominal pain (rupture) Investigations General CT scan Angiography Magnetic resonance angiogram (MRI) 15

16 Endoluminal procedure EndoVascular Aortic Repair (EVAR) Open surgical procedure Q&A 16