Case capsule

History

• 44 year old Mr. X• Acute onset pain in the left leg• Progressive numbness of the left leg

and • Weakness at the ankle

• What else would you like to know?

12 hours

• No history of IHD, RHD, TIA, stroke, claudication.

• No history of diabetes/hypertension.• Smoking history of 20 pack years.

Examination

• BP- 120 / 70 mm Hg.• Pulse- 110 per minute.• Bilateral femoral, popliteal , posterior tibial

and dorsalis pedis pulses were not palpable.• No bruits heard.

What else would you like to examine?

• Left lower limb was pale, cold and pulseless.• Reduced sensations over the limb.• Ankle power- grade 3

• DIAGNOSIS?

ACUTE LIMB ISCHEMIA

• Acute limb ischemia is defined as a sudden decrease in limb perfusion that threatens the viability of the limb.

• incidence -1.5 cases per 10,000 persons per year

• Classification of acute limb ischemia?• Which grade was our patient?

Classification of acute limb ischemia

from the Society of Vascular Surgery/International Society of Cardiovascular Surgery (Rutherford et al, 1997)

• Etiology of acute limb ischemia?

Etiology• Acute thrombotic occlusion

• Embolus -30%

• trauma

• iatrogenic injury

• popliteal aneurysm

• aortic dissection.

• How will you differentiate between embolus and thrombus?

EMBOLUS THROMBOSIS

Severity Complete- no collaterals Incomplete- collaterals

Onset Seconds or minutes Hours or days

Multiple sites Upto 15% cases Rare

Embolic source Present (usually AF) Absent

Bruits Absent Present

Contralateral pulses Present Absent

Claudication Absent Present

• What are the 6 Ps of acute limb ischemia?

Clinical features

• Pain• Parasthesia• Paralysis• Pulselessness• Pallor• Perishing cold

• Stat dose of IV Heparin 5000 IU (80 IU/kg)• What is the role of heparin?• What are the contraindications for heparin

Contraindications for heparin

• Active bleeding• Recent neurosurgical and spine

operations(within 3 months)• Recent GI bleed(less than 10 days)• Recent eye surgery• Established CVA within 2 months.

• What next?

Imaging

• Urgency for revascularization vs. Time for imaging.

• Category I, IIA – CT angiogram• Category IIB – Immediate surgery• Category III – imaging not indicated.

• Best approach –Hybrid theatre with Catheter directed angiography with endovascular Thromboembolectomy

In our patient

• Suspected acute on chronic limb ischemia.• Contralateral pulses absent.

CT angiogram for Mr. X

• Thrombus in the infrarenal aorta >90% occlusion.

• Occlusion of Left distal CFA and proximal SFA.• Reformation of distal SFA and popliteal with

poor distal run off.

• What next?

• Aortic endartrectomy, femoral embolectomy and patch plasty and fasciotomy.

Endovascular

• Patients presenting early – less than 12 hours.• Limb should be viable.• No contraindication to thrombolysis.(recent

major surgery, IC bleed or active bleeding).• Diagnostic angiography performed prior to it.

• Direct administration of thrombolytic agent into thrombus with a multi side hole catheter.

• Clinical and angiographic examinations during administration.

• Once flow established angiography to look for stenotic /inciting lesions management of which can be catheter based or open.

• WHAT ARE THE COMMON THROMBOLYTIC AGENTS?

• HOW DO THEY ACT?

• Common thrombolytic agents – alteplase, reteplase, rTPA, urokinase.

• Act by converting plasminogen to plasmin which degrades fibrin.

Open surgical technique

• Surgical strategy guided by anatomical lesion and type of occlusion.

• Thromboembolectomy with forgarty catheter/ bypass surgery

• Adjuncts – Endarterectomy / patch plasty/intra-operative thrombolysis/ fasciotomy.

•POST OPERATIVE MONITORING?

Post operative care

• Adequate hydration.• Monitor urine output.• Examine the limb for viability.• Creat, K+, CPK, HCO3-

Reperfusion injuries• Myocardial injury:– Release of myocardial depressant factors: C3a, TxA2, LTD4,

PAF

• Remote lung injury:– pulmonary edema, ARDS

• Renal injury:– Myoglobin deposition in renal tubules– Acute tubular necrosis

• Gastrointestinal– Mucosal edema

• Compartment syndrome

Compartment syndrome

• severe pain, hypoesthesia, and weakness of the affected limb;

• myoglobinuria and elevated CPK.• anterior compartment of the leg - most

susceptible.• assessment of peroneal-nerve function• Compartment pressure >30 mm Hg

• Long term anticoagulation• Ecospirin • Clopidogrel if stenting done.

Prognosis

• THANK YOU