Dr. Rajdeep Agrawal

Acute Ischemia Of Lower Limb(AILL)

AetiologyAetiology 1. Embolisation most common cause1. Embolisation most common cause heart as a source - 70 %, heart as a source - 70 %, Atrial Fibrillation, Atrial Fibrillation, AMI with mural thrombusAMI with mural thrombus 2. Acute thrombosis superimposed upon2. Acute thrombosis superimposed upon stenosisstenosis 3. Popliteal Aneurysm3. Popliteal Aneurysm

Dr. Rajdeep Agrawal

Acute Ischemia Of Lower Limb

The extent of ischemia & The extent of ischemia & final outcome depends uponfinal outcome depends upon

1. Size & location of clot1. Size & location of clot 2. Extent of collateral 2. Extent of collateral

circulationcirculation 3. Time between onset of 3. Time between onset of

occlusion & treatmentocclusion & treatment

Dr. Rajdeep Agrawal

Clinical Features Characterized by 5 “P”sCharacterized by 5 “P”s

1. Pain - sudden onset1. Pain - sudden onset 2. Pallor- waxy2. Pallor- waxy 3. Parasthesia – numbness3. Parasthesia – numbness 4. Pulselessness4. Pulselessness 5. Paralysis5. Paralysis

Dr. Rajdeep Agrawal

Therapeutic Strategies in Acute Ischemia

Most common vascular emergencyMost common vascular emergency 1. Intra arterial thrombolysis1. Intra arterial thrombolysis 2. Thrombo-aspiration with 2. Thrombo-aspiration with

cathetercatheter 3. Mechanical thrombolysis3. Mechanical thrombolysis 4. Surgical embolectomy – Fogarty4. Surgical embolectomy – Fogarty catheter catheter

Dr. Rajdeep Agrawal

Peripheral Intra-arterial Thrombolysis (PIAT)

Rapidly restores blood flow to ischemic Rapidly restores blood flow to ischemic limb & identifies underlying lesions for limb & identifies underlying lesions for percutaneous or surgical interventionpercutaneous or surgical intervention

Catheter directed local delivery of Catheter directed local delivery of thrombolytic agents directly at the site thrombolytic agents directly at the site of thrombosis is significantly more of thrombosis is significantly more effective than systemic thrombolysis & effective than systemic thrombolysis & is associated with lower bleeding is associated with lower bleeding complicationscomplications

Dr. Rajdeep Agrawal

Thrombolytic Agents StreptokinaseStreptokinase UrokinaseUrokinase Recombinant human tissue Recombinant human tissue

type plasminogen activator type plasminogen activator (rtpA, alteplase)(rtpA, alteplase)

In recent years UK & rtpA have In recent years UK & rtpA have largely superceded & replaced SK largely superceded & replaced SK as preferred agent as preferred agent

Dr. Rajdeep Agrawal

Peripheral Intra-arterial Thrombolysis (PIAT)

PIAT – Common procedurePIAT – Common procedure Angiography is doneAngiography is done Thrombus is locatedThrombus is located Multiple end hole catheter is advanced Multiple end hole catheter is advanced

to the upper limit of the thrombusto the upper limit of the thrombus One of the infusion methods shown next One of the infusion methods shown next

is then used is then used

Dr. Rajdeep Agrawal

PIAT– Infusion Methods Stepwise infusionStepwise infusion Done by stepwise advancement of infusionDone by stepwise advancement of infusion catheter as thrombus dissolvescatheter as thrombus dissolves Graded infusionGraded infusion ( McNamara’s( McNamara’s

protocolprotocol)) gradual tapering of infusion rate gradual tapering of infusion rate Continuous infusionContinuous infusion Pulse spray techniquePulse spray technique

Dr. Rajdeep Agrawal

PIAT--McNamara’s Protocol UK 4000 units/min x 2hrsUK 4000 units/min x 2hrs 2000 units/min x next 2hrs2000 units/min x next 2hrs 1000 units/min x next 4-24 hrs or1000 units/min x next 4-24 hrs or until the lysis is completeduntil the lysis is completed

Systemic heparin continued during PIAT Systemic heparin continued during PIAT And till definite endovascular or surgical And till definite endovascular or surgical Rx of underlying lesion is doneRx of underlying lesion is done

Dr. Rajdeep Agrawal

PIAT--McNamara’s Protocol

Complete lysis is considered if > 75%Complete lysis is considered if > 75% of the clot dissolves of the clot dissolves Initial reestablishment of flow Initial reestablishment of flow takes on an 3.3 hrs avg. takes on an 3.3 hrs avg. complete clot lysis up to 13hrs avg complete clot lysis up to 13hrs avg Systemic Heparin is continued through Systemic Heparin is continued through

this periodthis period

Dr. Rajdeep Agrawal

Predictors Of Successful Thrombolysis

Easy traversability of clot with Easy traversability of clot with non-hydrophilic guide wire non-hydrophilic guide wire 0.035”0.035”

Significant lysis within 2hrsSignificant lysis within 2hrs

Dr. Rajdeep Agrawal

Thrombolysis-Contraindications

AbsoluteAbsolute 1. Recent Cerebro Vascular 1. Recent Cerebro Vascular

Accident,Accident, neurosurgery, intracranial neurosurgery, intracranial

trauma,trauma, within the last 3 monthswithin the last 3 months 2. Active bleeding diathesis2. Active bleeding diathesis 3. Recent GI bleed (< 10days)3. Recent GI bleed (< 10days) 4. Irreversible ischemia 4. Irreversible ischemia

Dr. Rajdeep Agrawal

Thrombolysis-Contraindications

RelativeRelative 1. Cardiopulmonary resuscitation, 1. Cardiopulmonary resuscitation, major nonvascular surgery, traumamajor nonvascular surgery, trauma within last 10 dayswithin last 10 days 2. Uncontrolled HT systolic > 1802. Uncontrolled HT systolic > 180 diastolic >110 diastolic >110

3. Puncture of non compressible vessel 3. Puncture of non compressible vessel 4. Intracranial tumor, diabetic proliferative 4. Intracranial tumor, diabetic proliferative

retinopathy, bacterial endocarditis, retinopathy, bacterial endocarditis, pregnancypregnancy

Dr. Rajdeep Agrawal

PIAT -- Complications

Significant hemorrhage Significant hemorrhage 1%1%

Distal EmbolisationDistal Embolisation

Dr. Rajdeep Agrawal

Post PIAT Management Underlying flow limiting lesion is Underlying flow limiting lesion is

present in more than 70% cases & present in more than 70% cases & surgery or PTA can be performed surgery or PTA can be performed immediately after thrombolysis with immediately after thrombolysis with no additional risk of hemorrhageno additional risk of hemorrhage

No underlying lesion -- No underlying lesion -- anticoagulationanticoagulation

Dr. Rajdeep Agrawal

Treatment of Acute Occlusion

Embolectomy - Using Fogarty’s catheter -> Embolectomy - Using Fogarty’s catheter -> Catheter passed beyond emblous, balloon Catheter passed beyond emblous, balloon inflated & pulled back till blood comesinflated & pulled back till blood comes

Direct Embolectomy - Artery exposed, Direct Embolectomy - Artery exposed, transverse incision, clot removed.transverse incision, clot removed.

Intra-arterial Thrombolysis - TPA preferred. Intra-arterial Thrombolysis - TPA preferred. Arteriography done and a catheter Arteriography done and a catheter embedded in clot - Thrombolytic agent embedded in clot - Thrombolytic agent infused over several hrsinfused over several hrs

Dr. Rajdeep Agrawal

Surgical Embolectomy Relatively simple procedureRelatively simple procedure Done under LA, small incision in the Done under LA, small incision in the

groin, using Fogarty’s cath.groin, using Fogarty’s cath. ProblemsProblems 1. Blind procedure, can be traumatic1. Blind procedure, can be traumatic 2. Not successful in 10 – 30% cases2. Not successful in 10 – 30% cases 3. Inefficient in multistenosed artery3. Inefficient in multistenosed artery 4. Complete removal of thrombus 4. Complete removal of thrombus

difficult in leg arteries difficult in leg arteries

Dr. Rajdeep Agrawal

Post PTA MX Antiplatelet agentsAntiplatelet agents LMW Heparin X 7 – 10 DLMW Heparin X 7 – 10 D IV / oral TrentalIV / oral Trental StatinsStatins Aggressive control of risk Aggressive control of risk

factorsfactors

Dr. Rajdeep Agrawal

Newer Techniques Of Angioplasty

AtherectomyAtherectomy DirectionalDirectional Percutaneous Rotational Percutaneous Rotational TEC TEC

LASERLASER StentStent

Dr. Rajdeep Agrawal

Directional Atherectomy

It excises the atheromatous It excises the atheromatous plaque material into very plaque material into very fine slices which can be fine slices which can be retrieved outside bodyretrieved outside body

Dr. Rajdeep Agrawal

Percutaneous Rotational Atherectomy (Rotablator)

Dr. Rajdeep Agrawal

LASER A LASER produces an intense A LASER produces an intense

beam of light in uniform beam of light in uniform wavelength that can be wavelength that can be precisely focused to deliver high precisely focused to deliver high energy levels to a small areaenergy levels to a small area

It converts solid plaque to gas It converts solid plaque to gas which is soluble in bloodwhich is soluble in blood

Dr. Rajdeep Agrawal

Stent An expandable metallic helical An expandable metallic helical

device which is permanently device which is permanently implanted in the arteryimplanted in the artery. .

MechanismMechanism The prosthesis acts as a The prosthesis acts as a

scaffold to hold the artery openscaffold to hold the artery open Prevents recoil of the vesselPrevents recoil of the vessel Reduces Restenosis Reduces Restenosis

Dr. Rajdeep Agrawal

Lower Limb Ischemia - Approach to therapy

Risk factor managementRisk factor management

* * Abstinence from smokingAbstinence from smoking

* * Control of diabetesControl of diabetes

* * Control of hyperlipidemiaControl of hyperlipidemia

Dr. Rajdeep Agrawal

Lower Limb Ischemia - Approach to therapy

Risk factor managementRisk factor management** Weight reductionWeight reduction

• Control of hypertension, CHF, CRFControl of hypertension, CHF, CRF• Chronic anticoagulation oral Chronic anticoagulation oral

with judicious use of PT PI with judicious use of PT PI measurementsmeasurements

Dr. Rajdeep Agrawal

Lower Limb Ischemia - Role of Drugs

Pentoxyfylline – not usefulPentoxyfylline – not useful

Antiplatelet AgentsAntiplatelet Agents

ProstaglandinsProstaglandins

VasodilatorsVasodilators