Download - Acute limb ischemia
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Case capsule
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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
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• No history of IHD, RHD, TIA, stroke, claudication.
• No history of diabetes/hypertension.• Smoking history of 20 pack years.
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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?
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• Left lower limb was pale, cold and pulseless.• Reduced sensations over the limb.• Ankle power- grade 3
• DIAGNOSIS?
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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?
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Classification of acute limb ischemia
from the Society of Vascular Surgery/International Society of Cardiovascular Surgery (Rutherford et al, 1997)
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• Etiology of acute limb ischemia?
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Etiology• Acute thrombotic occlusion
• Embolus -30%
• trauma
• iatrogenic injury
• popliteal aneurysm
• aortic dissection.
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• How will you differentiate between embolus and thrombus?
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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
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• What are the 6 Ps of acute limb ischemia?
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Clinical features
• Pain• Parasthesia• Paralysis• Pulselessness• Pallor• Perishing cold
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• Stat dose of IV Heparin 5000 IU (80 IU/kg)• What is the role of heparin?• What are the contraindications for heparin
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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?
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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
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In our patient
• Suspected acute on chronic limb ischemia.• Contralateral pulses absent.
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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?
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• Aortic endartrectomy, femoral embolectomy and patch plasty and fasciotomy.
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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.
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• 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?
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• Common thrombolytic agents – alteplase, reteplase, rTPA, urokinase.
• Act by converting plasminogen to plasmin which degrades fibrin.
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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.
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•POST OPERATIVE MONITORING?
Post operative care
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• Adequate hydration.• Monitor urine output.• Examine the limb for viability.• Creat, K+, CPK, HCO3-
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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
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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
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• Long term anticoagulation• Ecospirin • Clopidogrel if stenting done.
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Prognosis
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• THANK YOU