ACUTE LIMB

ISCHEMIA
Arlinda Dehafsary,dr.
1302 2119 0503
 DEFINITIO
N
“Acute limb ischemia is Sudden decrease in limb
perfusion that threatens limb viability (within 2 weeks of
the onset of symptoms) and requires urgent evaluation and
management.”
 Introduction
■ Acute limb ischemia (ALI) is one of the most treatable and
potentially devastating presentations of Peripheral Artery Disease
(PAD)
■ Critical limb ischemia (CLI) is defined as limb pain that occurs at
rest or impending limb loss caused by severe compromise of blood
flow to the extremity.
■ Chronic ischemia induces the development of collateral blood vessels
and results in skin changes secondary to progressive ischemia.
 Burden of Acute Limb Ischemia
■ Acute limb ischemia is a surgical emergency with significant
morbidity and mortality.
■ The incidence of ALI is 9–16 cases per 100,000 persons
per year for the lower extremity and around 1–3 cases per
100,000 persons per year for the upper extremity.
■ Most published series report a 10% to 30% amputation
rate
■ The short-term mortality is 15% to 20% (3-year).
■ This is a time-sensitive condition, and the diagnosis is
primarily clinical.
Pathophysiology
■ Insufficient oxygenated blood to meet the metabolic demand
of the tissues.
■ Ischemia → shift aerobic to anaerobic metabolism → lactate
production → depletion of ATP → leakage of extracellular
calcium into muscle cells → cell death.
■ Severity Depends on
– Degree of obstruction
– Site of occlusion,
– Presence of collaterals
– Affected tissues
– systemic perfusion, such as cardiac output and
peripheral vascular resistance
Pathophysiology
■ The tissues most sensitive to ischemia are
– Peripheral nerves, (irreversible damage after 6 hours)
– Skin
– Subcutaneous tissues,
– Skeletal muscle (up to 10 hrs)
 Pathophysiology : Reperfusion
injury
■ Ischemic tissue → free radicals → trigger peroxidation of membrane lipids →
increased capillary permeability and filtration → swelling → compartment
syndrome.
■ Inflammation → leukocyte-activated platelet aggregation and complement system
activation → occlusion of the reperfused vessels (no-reflow phenomenon)
■ By products of cell death are released into the systemic circulation and include
potassium, phosphate, myoglobin, creatine kinase, and thromboplastin.
– and can lead to rhabdomyolysis, cardiac dysrhythmia, multiorgan
failure, disseminated intravascular coagulation, and death.
 Etiology
The etiology of lower extremity ALI is traditionally
either
■ Embolism,
■ In situ thrombosis with preexisting peripheral
arterial disease (PAD),
■ graft/stent thrombosis ,
■ trauma, or
■ peripheral aneurysm with embolism or
thrombosis .
 Embolism versus Thrombosis
Embolism Thrombosis

Sources Frequently detected Not specified

Onset Sudden Acute

Site Normal vessels On stenosis, calcified

Previous history a known embolic source, Symptoms of chronic

such as cardiac arrhythmias ischemia
Findings Normal pulses in uneffected Evidence of peripheral
limb arterial disease

Multiplicity Multiple sites Single site

Angiography multiple occlusions, no Diffuse atherosclerosis

collaterals Collaterals present

The timing of presentation depends on the severity of ischemia, which is linked to

the etiology. Patients with embolism, trauma, and popliteal aneurysms present
early (hours), compared to those with in situ thrombosis presenting later (days)
Clinical features of acute ischemia

Either constant or elicited by

Pain : symptom passive movement of the
involved extremity.
PALLOR
Embolic occlusions are
POIKILOTHERM usually very sudden and of
great intensity, such that
IA PULSELESS patients often present within
a few hours of onset.
PARASTHESIA

PARALYSIS
Clinical features of acute ischemia
COLOR
Early: Pale
Later: Cyanosed → Mottling → fixed mottling &
Pain : cyanosis
symptom
PALLO
R
Pallor
POIKILOTHERMIA
An area of fixed
cyanosis surrounded
PULSELESS by reversible mottling

PARASTHESIA Empty veins:

compare with normal
limb
PARALYSIS
 Clinical features of acute ischemia

The limb is cold

Pain : symptom

PALLOR sudden loss of previously

palpable pulse implies
embolic cause.
POIKILOTHERM compare with the
other side
IA PULSELESS
Slow capillary refilling of
the skin after finger
PARASTHESIA pressure

PARALYSIS
Clinical features of acute ischemia

Loss of sensory function

Pain : symptom
◦Numbness will progress to
PALLOR anesthesia

POIKILOTHERM Progress of Sensory loss

◦Light touch
IA PULSELESS
◦Vibration sense

PARASTHESIA Proprioreception Deep pain

Pressure sense
PARALYSIS
Clinical features of acute ischemia
Loss of motor function:

Pain : Indicates advanced limb threatening

symptom ischemia
PALLO fine movement affected first
R Late irreversible ischemia:
POIKILOTHERMI Muscle turgidity
A
PULSELES Intrinsic foot muscles are affected
S
first, followed by the leg muscles
PARASTHESI
A Detecting early muscle weakness is
difficult because toes movements are
PARALYSI produced mainly by leg muscles
S
Differential diagnosis
■ Low cardiac output (especially when superimposed on chronic
lower extremity PAD)
■ Acute deep vein thrombosis (DVT), (especially when
associated with features of phlegmasia cerulea dolens)
■ Chronic peripheral neuropathy (diabetic neuropathy), or
■ Acute compressive peripheral neuropathy (compartment
syndrome)
■ Potential causes of nonischemic limb pain include acute gout,
spontaneous venous hemorrhage, or traumatic soft tissue injury.
Klasifikasi Rutherford Acute Limb Ischemia

Rutherford’s Vascular Surgery and Endovascular

Therapy, Ed 9. 2018. Hal 4383
 Class II (salvageable)

Class III
(irreversible
)

Rutherford’s Vascular Surgery and Endovascular

Therapy, Ed 9. 2018. Hal 4383
 Diagnosis and Management
■ Diagnosis of ALI is primarily clinical.

■ In patients with suspected ALI, initial clinical evaluation

should rapidly assess limb viability and potential for
salvage and does not require imaging
■ The severity of the ischemia, according to the
classification presented above, will
dictate the extent of diagnostic tests performed for
systemic risk factor assessment.
 Management: Early heparinisation
■ Early heparinization is remains one of the mainstays in the treatment of ALI.
– Immediate full-dose heparinization can result in symptomatic
improvement in some patients, either from the anticoagulation effects of
heparin or volume expansion
– Prevents proximal and/or distal thrombus propagation and preserves
the microcirculation
– IV unfractionated heparin 80-150 U/kg bolus, followed by infusion of
18 U/kg/hour
– aPTT ratio 2-2.5
– If the patient has a known history of HIT or an anti-thrombin III deficiency,
alternative agents, such as direct thrombin inhibitors (lepirudin or
argatroban), can be used.
Management
■ Adequate analgesia
■ IV fluid resuscitication
■ Oxygen delivered by face mask
■ Correction of underlying electrolyte imbalances and
systemic anticoagulation
should proceed concomitantly.
■ Aspirin initiated.
■ Limb placed in dependent position and kept warm
Emergent imaging
Include:
■ Duplex
ultrasound,
■ CTA,
■ MRA and
■ invasive
angiogram
 Management of ALI
■ Main target: Rapid restoration of arterial flow with least risk to patient
■ For viable limbs (Category I ALI), revascularization should be performed
an on urgent basis (within 6–24 hours).
■ For marginally or immediately threatened limbs (Category IIa and IIb
ALI),
revascularization should be performed emergently (within 6 hours).
■ For nonsalvageable limb (Category III), Amputation should be performed as
the first procedure.
■ The revascularization strategy can range from catheter-directed thrombolysis
to surgical thromboembolectomy.
■ The technique that will provide the most rapid restoration of arterial flow
with the
least risk to the patient should be selected.
■ Prolonged duration of ischemia (> 6-8 hrs.) is the most common factor in
patients requiring amputation for treatment of ALI.
 Intervention options
■ Endovascular therapies
– Thrombolytics
– Mechanical
■ Surgical intervention
– Thrombo-embolectomy with
Fogarty balloon catheter
– Bypass surgery
– Intra-operative thrombolysis
(hybrid)
– Amputation
Intra-arterial thrombolysis
■ Catheter passed into occluded vessel, left embedded in clot and
thrombolytic agent infused over 24 to 48 hrs.
■ The method abandoned if no progression of dissolution of clot with time
(>24 hours)
■ Thrombolytic agents: tPA, alteplase, reteplase & tenecteplase.
■ Patients with profound ischemia who may not tolerate such a prolonged
procedure are not candidates for catheter-directed thrombolysis.
■ Percutaneous endovascular thrombolysis options are more effective in
patients with
– viable or marginally threatened limb and recent occlusion (<2
weeks),
– Arterial thrombosis,
– thrombosis of synthetic grafts, and stent thrombosis
Catheter directed thrombolysis
Pros:
■ Direct delivery of drug into existing thrombus
■ Reduces thrombolytic drug dosages
■ Lyses clot in both large and small vessels
■ Lower reperfusion syndrome than embolectomy
■ Done via percutaneous approach with local
anaesthesia

Cons: takes >24 hours to be effective, Risk of major

bleeding (6-9%),
Contraindications to thrombolytic therapy
Absolute contraindications
■ Established cerebrovascular events (including
transient ischemic attack) within last 2 months
■ Active bleeding diathesis
■ Recent (<10 days) gastrointestinal bleeding
■ Neurosurgery (intracranial or spinal) within last 3
months
■ Intracranial trauma within last 3 months
■ Intracranial malignancy or metastasis
Contraindications to thrombolytic therapy
Relative major contraindications Minor
■ Cardiopulmonary resuscitation within contraindications
last 10 days • Hepatic failure,
■ Major nonvascular surgery or trauma particularly
with
within
coagulopathy
last 10 days
• Bacterial
■ Uncontrolled hypertension (>180
endocarditis
mmHg systolic or >110 mmHg
diastolic) • Pregnancy
■ Puncture of noncompressible vessel • Diabetic
■ Recent eye surgery hemorrhagic
retinopathy
Mechanical thrombectomy
Percutaneous mechanical thrombectomy (PMT) with mechanical pulse spray/
suctioning with catheter as adjunctive therapy to thrombolysis (Angiojet
catheter)
■ Pros:
– Disrupts the thrombus- allows better penetration of the clot by a
thrombolytic agent
– Reduces thrombolytic dosing
– Reduces therapy time- increasingly being used in class IIb
– Done via percutaneous approach with local anaesthesia
– Less vessel injury
■ Cons:
– Can be used only large vessel
– Expensive device
Mechanical
thrombectomy
SURGICAL THROMBOEMBOLECTOMY
■ Local or general anesthesia
■ The artery (usually the larger proximal), exposed
and held in slings and longitudinal or
transverse incision given
■ Fogarty balloon catheter introduced past the
occlusion,
inflated and withdrawn with the clot.
■ Good back-bleeding and antegrade bleeding
suggest that the entire clot has been removed.
■ Completion angiography to ascertain adequacy.
Fogarty balloon embolectomy catheter
SURGICAL THROMBOEMBOLECTOMY
■ Pros:
– Rapid revascularization
– Transfemoral approach can be done via local
anaesthesia
– Adjunct by intraoperative thrombolysis
■ Cons:
– Risk of Vessel injury
– Reperfusion injury chances more and thus,
compartment syndrome
 Intra-operative
Thrombolysis
■ Pros:
– Adjunct to surgical
thromboembolectomy- clear
residual thrombus in small
arteries and arteriole
– Minimal risk of bleeding
■ Cons:
– Maybe inadequate in some
patients with extensive
distal and small vessel
thrombosis
 Arterial bypass surgery
■ Use in patient that
– failed other procedures- last
resort!
– Severe tissue injury
– Associated Peripheral
vascular disease
■ Main treatment for thrombosed
popliteal artery aneurysm
■ High surgical risk
■ Rarely used for ALI
Amputation
Performed as the first (index) procedure in
■ A non-salvageable (Class III limb)
■ Low potential of limb salvage
■ Risk of reperfusion syndrome
Complications of arterial revascularization
■ Reperfusion syndrome
– Hypotension
– Hyperkalemia
– Myoglobinuria
– Renal failure
■ Compartment
syndrome
■ Ischemic neuropathy
■ Muscle necrosis
■ Recurrent thrombosis
■ Lower leg swelling
 References
■ Schwartz’s Principles of Surgery, 10th edition
■ Critical Limb Ischemia: Acute and Chronic, (Robert S. Dieter •
Raymond A. Dieter, Jr Raymond A. Dieter, III • Aravinda
Nanjundappa), Springer, 2017
■ Acute Limb Ischemia: An Emergency Medicine Approach
(Jamie R. Santistevan, MD),
Emerg Med Clin N Am - (2017), Elsevier Inc.
■ 2016 AHA/ACC Guideline on the Management of Patients
With Lower Extremity Peripheral Artery Disease:
Executive Summary
THANK YOU