ACUTE LIMB ISCHEMIA

AND CHRONIC LIMB

ISCHAEMIA
CME ASSESSOR : MS ZARINA

PRESENTER:
MUHAMMAD FARHAN
SHARNYA
 ACUTE LIMB ISCHEMIA

Acute Limb Ischemia (ALI) defined as sudden decrease in

arterial blood flow to limb that threatens its viability, that is
present within 2 weeks.

It is a vascular emergency and can lead to extensive tissue

necrosis, which may ultimately result in limb amputation or
even death.
 ETIOLOGY
1) Thrombosis (80-85%)
Most commonly due to plaque rupture in an atherosclerotic segment (thrombosis in situ) in patients with PAD. Thrombus may
also form in context of thrombophilia, malignancy, hypovolaemia.

2) Embolism (10-15%)
• whereby a thrombus from a proximal source travels distally to occlude the artery. Eg: left atrium (in association with atrial
fibrillation) or mural thrombus (following myocardial infarction).
• Other sources include: Heart prostheses or bypass graft, and aneurysms

3) Trauma
• Can be result of iatrogenic injury during interventional procedures, such as percutaneous coronary intervention.

• Fracture or dislocation- cause intimal injury to vessels

EMBOLIC VS THROMBOTIC
RISK FACTORS
 HISTORY
Typical symptoms:
• Pain in affected limb usually at rest
• Discoloration
• Altered sensation (paraesthesia)
• Paralysis in affected limb (late sign)

Also important areas to cover in history include:

• Past medical history/comorbidities
• Predisposing risk factors
CLINICAL PRESENTATIONS (6PS)
 CLINICAL EXAMINATIONS
INSPECTION:
1. Colour of lower limb

2. Trophic changes :
-loss of hair, nail thickening, dry shiny skin,
small non- healing sores/ulcers.

3. Presence of ulcer

4. Presence of gangrene
wet gangrene - has ill defined spreading edge
dry gangrene - well defined edge - auto amputation may occur
PALPATION :
1. Temperature
2. Capillary Refill Time (<2s)
3. Palpate peripheral pulses
4. Sensation / paraesthesia

MOVEMENT
weakness / paralysis
Most common findings :
• Marble white appearance of skin
• Absent limb pulses on palpation
• Cold limb

Less common findings usually appear in later stages :

• Paraesthesia (with reduced or complete loss of light touch sensation in distal limb)
• Paralysis (inability to move toe or fingers)
• Muscle weakness
• Gangrene
RUTHERFORD CLASSIFICATION
 INVESTIGATIONS
Bedside investigations
• Duplex ultrasound/Doppler scan : to confirm absence of pulses
• ECG : to look for atrial fibrillation of ischemic changes

Laboratary investigations
• Baseline blood tests -FBC, RP, electrolytes , LFT, coagulation profile
• Serum lactate : to assess severity of ischemia.
• Thrombophilia screen (if no known risk factor)
• GSH/GXM if patient may require emergency surgical intervention.
Imaging
• CT/MR angiography: to guide
revascularisation if limb is viable. Provides
information regarding the anatomical location
of the occlusion and can help decide the
operative approach (femoral vs popliteal
incision)
• Echocardiography if an embolus of cardiac
origin is suspected
ESVS RECOMMENDATION

• - Diagnostic imaging is recommended to guide treatment, provided it does not delay treatment or if
the need for primary amputation is obvious

• - CTA is recommended as the first line modality for anatomical imaging

• - Duplex ultrasound or contrast-enhanced magnetic resonance angiography may be considered for

alternative imaging before starting treatment, depending on availability and clinical assessment

• - It is not recommended to use results of myoglobin and creatinine kinase on admission to base the
decision to offer revascularisation or primary amputation
 INITIAL MANAGEMENT OF ALI
• IV Heparin
- to prevent clot propagation + maintain collateral vessels
- bolus dose of 75 units/kg (max 10,000 units), followed by continuous infusion of 18 units/kg/hr
- 6 hourly coagulation profile and dose adjustment)
- keep aPTT ratio 2-3

• Adequate analgesia
MANAGEMENT OF ALI
REVASCULARISATION

• Open techniques
• Open thrombo-embolectomy
• Bypass Surgery
• Endovascular techniques
• Catheter Directed Thrombolysis (CDT)
• Percutaneous Aspiration Thrombectomy (PAT)
• Percutaneous Mechanical Thrombectomy (PMT)
• Hybrid Procedure
• Combination of open and endovascular techniques for multilevel occlusive
disease
 SURGICAL TREATMENT OF ALI
Surgical Embolectomy
• Rapid revascularization
• Can be done via low tech instrument
• Trasfemoral approach can be done via local
anaesthesia
SURGICAL BYPASS

• Indicated if intravascular recanalization cannot be achieved

• More for acute on chronic disease
• Ideally to use vein grafts for bypass but in urgent cases for Rutherford
IIb prosthetic graft may be considered
Catheter Directed Thrombolysis

- Direct delivery of the drug into existing thrombus

- Less thrombolytic drug dosage
- Less systemic bleeding complications
- Lyses clot in both large and small vessels
- Lower reperfusion syndrome than embolectomy
- Done via percutaneous approach with local
anaesthesia
CATHETER DIRECTED THROMBOLYSIS

-Indicated for Rutherford IIa but some studies show similar outcomes
to surgery for Rutherford IIb as well.
-Can be used in native artery occlusion, graft occlusions and embolic
occlusions
-urokinase or rtPA used commonly
-Major amputation free survival was 84% at 30 days and 75% at one
year.
-Risk of significant haemorrhage 13-30%
 Contraindications to thrombolytic agents

Absolute Relative contraindications

Contraindications
• Active bleeding disorder • Major surgery or trauma
• Gastrointestinal bleeding within 10 days
within 10 days • CPR within 1o days
• Cerebrovascular event • Pregnancy
within 6 months • Hepatuc failure
• Intracranial or spinal • Intracranial tumour
surgery within 3 months
• Head injury within 3
months
PERCUTANEOUS ASPIRATION THROMBECTOMY

• Initially described using large bore catheters and aspiration done

with a 50ml syringe
• Now newer devices with aspiration pumps and designed catheters
• Works better in acute <14 days duration
PERCUTANEOUS MECHANICAL THROMBECTOMY

• Rheolytic or microfragmentation catheters

• Better outcomes with shorter procedure and comparable limb
salvage as compared to thrombolysis
• Limitations
• Unable to use in small vessles of the leg
• Risk of distal embolisation
• Hemolysis results in hyperkalemia,hemoglobinuria and renal
damage
• Rotarex system has better primary and secondary patency rates than
thrombolysis and shorter hospital stay.
HYBRID TREATMENT

• Complex multilevel occlusive disease

• Combines open and endovascular techniques
• eg: incomplete thromboembolectomy followed by intra-arterial thrombolysis/
PAT/PMT
• Multicentre retrospective study of 1480 pts comparing open surgical,
endovascular or hybrid treatment for ALI showed
• Endovascular had reduced amputation rate vs open and hybrid in Rutherford
IIa and IIb
• No difference in 30 day mortality or freedom from intervention.
AMPUTATION

• Performed in a non-salvageable (class III) limb

ESVS ALGORITHM
 COMPLICATIONS
Surgical revascularisation causes sudden reperfusion of ischaemic tissue in the affected
limb, which can, in turn, lead to reperfusion injury. This can consist of:
• - Massive oedema: resulting in compartment syndrome and hypovolaemic shock.
The sudden release of built-up substances which can lead to various systemic
complications:
• - Hyperkalaemia due to the release of K+ ions: can cause cardiac arrhythmias.
• - Systemic acidosis from the release of H+ ions.
• - Acute kidney injury due to the release of myoglobin: patients may require
emergency renal replacement therapy.
Other important complications to remember include:

• Compartment syndrome due to oedema formation on reperfusion of the limb and

confinement of the muscles in their tight fascia: can ultimately lead to muscle
necrosis and is an emergency.
• Peripheral nerve injury, which can lead to chronic severe neuropathic pain in the
limb.
• The psychosocial impact of limb amputation on the patient and associated
physical morbidity (e.g. stump or phantom limb pain, immobility, etc).
LONG TERM MANAGEMENT
• Most common causes are AF an intracardiac thrombosis
• Source of embolus needs to be identified and treated
• Long term anticoagulation with warfarin/ direct oral anticoagulants
are indicated in patients with AF or intracardiac thrombus
• Long term Anticoagulation is no necessary but may be considered
• Clinic follow up with pulses and ABI and imaging only if there
is deterioration
• Antiplatelet and Statins maybe beneficial in ALI secondary to
thrombosis
CHRONIC LIMB ISCHAEMIA

• - A peripheral arterial disease that results in a symptomatic reduced blood

supply to the limbs.
• -It is typically caused by atherosclerosis (rarely vasculitis) and will commonly
affect the lower limbs (however the upper limbs and gluteals can also be affected).
ETIOLOGY

1. Atherosclerosis: (most common)

• Hypertension
• Hyperlipidemia
• Diabetes mellitus

2. Non-atherosclerosis:
• Buerger’s disease (aka thromboangitis obliterans)
• Vasculitis
• Vasospasm
RISK FACTORS
SYMPTOMS

One of the earlier symptoms is intermittent claudication, a cramping-type pain in the calf, thigh, or
buttock after walking a fixed distance (the ‘claudication distance’), relieved by rest within minutes.

• Muscular pain
• Not present at rest
• Comes on walking at a particular distance (claudication distance)
• Quickly relieved by resting
• Repetitive
CLASSIFICATION
CRITICAL LIMB ISCHAEMIA

• Critical limb ischaemia is the advanced form of chronic limb ischaemia.

• It can be clinically defined in three ways:

• 1. Ischaemic rest pain for greater than 2 weeks duration, requiring opiate
analgesia
• 2. Presence of ischaemic lesions or gangrene objectively attributable to the
arterial occlusive disease (Fig. 1)
• 3. ABPI less than 0.5
CLINICAL FEATURES
1) Rest pain requiring regular analgesia lasting >2 weeks AND/OR
2) Gangrene or ulcers over the toes or feet AND
3) Objective indication of poor vascular supply to the lower limbs
4) Ankle brachial pressure index <0.4
5) Toe pressure <30mmHg
6) Ankle pressure <50mmHg
 REST PAIN
• Severe pain in the distal portion of the lower limb
• (usually toes, foot but may involve more proximal areas if disease is severe) occurring at rest

• Aggravated or precipitated by lifting the limb

• Relieved by dependency of the limb
• many patients sleep with the leg hanging over the side of the bed to relieve the pain

• Disturb sleep at night

• Not easily controllable with analgesia
• requires opioids to control pain
• If persist more than 4-8 weeks, may require operative intervention
 ISCHAEMIC ULCERS
Ischaemic ulcers (most are neuroartheropathic ulcers)
• Usually arise from minor traumatic wounds with poor healing
• Often painful
• Most often occur on the tips of the toes, bunion area, over the metatarsal
heads (ball of the foot), lateral malleolus (as opposed to venous ulcers that
occur over the medial malleolus)
• Usually deep, dry, punctate
• (unlike venous ulcers that tend to be superficial, moist, diffuse)
• May become infected resulting in cellulitis, even abscess formation, and
spread to involve the underlying bone and joints - osteomyelitis, septic
arthritis
 INVESTIGATIONS
1. Laboratory : FBC, RP, PT/PTT, septic workup: blood c/s, wound c/s
2. Ankle-brachial pressure index
Interpreting the values :
- Normal ABPI is > 0.9 (can be more than 1.0 as ankle pressures tend to be higher than brachial; if >1.3,
suggests non-compressible calcified vessel)
- ABPI between 0.5 - 0.9 – occlusion, often associated with claudication
- ABPI < 0.5 : critical ischemia rest pain
3. Arterial Duplex ultrasound
- Duplex ultrasonography is a non-invasive and cost-effective procedure, which is used in screening, diagnosis,
and monitoring of patients with PAD. It accurately determines the location and degree of stenosis in arteries and
helps differentiate stenosis from an occlusion
4. Angiogram (arteriogram)
- Usually only done if planning intervention e.g. angioplasty, stenting
 INVESTIGATIONS
• Vascular lab
• ABI’s and Toe pressures
• Ankle-brachial index (ABI):

BP in ankle (DP and PT arteries)

___________________________________
BP in upper arm (brachial artery)
 MANAGEMENT
MANAGEMENT OF INTERMITTENT CLAUDICATION:
1. Best medical therapy (BMT)- risk factor modification
• Stop smoking
• Hypertension, hypecholestrolemia, obesity control
• Antiplatelet agent
• Exercise therapy
• Diabetes identification and active treatment
• Foot care

2. Surgical/ endovascular intervention

EXERCISE THERAPY

• Aim : Improves symptoms and quality of life and increases maximal walking
distance
• Did not improve ABI
• Supervised more effective than non-supervised
• Impossible in patient with CLI but can be considered after successful
revascularization
• Alternative exercise mode : cycling, strength training, upper-arm ergometry
PHARMACOTHERAPY

Aim : to decrease walking impairment

1. Cilostazol :
-Inhibitor of phosphodiesterase type III- for symptoms relief intermittent claudication
2. Pentoxifylline for symptoms relief in intermittent claudication
3. Statins,
4. Antiplatelet agents
 REVASCULARISATION

• Endovascular

• Open Surgery
 ENDOVASCULAR

• Angiography
• Angioplasty +/- stenting
• Bypass procedure
• Can use synthetic graft PTFE/dacron
• Vein graft (GSV)
• Example fem-pop bypass, fem distal bypass, aorto-bifem bypass, axillo-bifem bypass, fem-
fem crossover

• Amputation if non-viable limb

• Gangrenous
• Severe , persistent rest pain
EXTRA-ANATOMICAL BYPASS
THANK YOU