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1.  64 yr old male with previous history of
heart attack came to casualty with c/o
sudden onset of pain in the right leg
below the knee.
 On examination….

4.  Absent popliteal and lower pulsations
 Decreased sensations
 Inability to move toes

5. Acute limb
ischemia

6. Etiology of acute limb ischemia
Acute arterial embolism: Of a relatively health arterial tree
Acute arterial thrombosis: Of a previously diseased arterial tree
Acute traumatic ischemia:

8. Patho-pysiology

9. Acute Embolic Ischemia
An embolus can originate from
An embolus the heart (MS with atrial
suddenly fibrillation, MI with mural
occludes a thrombus) or dilated diseased
relatively arteries (aortic aneurism)
healthy arterial
tree
It usually
arrest at
arterial
bifurcation
Aortic bifurcation
Iliac bifurcation
Femoral bifurcation
Popliteal trifurcation

10. Example of
acute
arterial
embolus
“Saddle”
Embolus of
right iliac
artery

11. Acute Thrombotic Ischemia
Atherosclerosis
causes
progressive
narrowing of the
arterial tree
Stimulates
development of
collaterals
Sluggish flow &
rough surface
will favor acute
thrombosis

12. Clinical Picture

13. Clinical Evaluation of Acute Ischemia (Clinical Picture)
Signs of acute ischemia
Inspection
5Ps COLOR:
Fixed Early: pale
Early
Pain: symptom
Pain
mottling &
+
Later: cyanosed
Later mottling fixed
cyanosis mottling & cyanosis
An area of fixed
cyanosis
Pale surrounded by
reversible mottling
Pulseless Pallor
Reversible
mottling
Parasthesia
Empty veins:
Paralysis compare the Rt.
(ischemic) & Lt.
(normal)

14. Clinical Evaluation of Acute Ischemia (Clinical Picture)
Signs of acute ischemia Palpation
5Ps
Pain: symptom
Pain
+ Femoral Popliteal
Pale
Pulseless Posterior tibial Dorsalis pedis
Palpate peripheral pulses, compare with the
pulses
Parasthesia other side & write it down on a sketch
Temperature: the limb is cold with a level of
Temperature
Paralysis temperature change (compare the two limbs)
Slow capillary refilling of the skin after finger
pressure

15. Clinical Evaluation of Acute Ischemia (Clinical Picture)
Signs of acute ischemia Palpation
5Ps Loss of sensory function
Pain: symptom
Pain Numbness will progress to anesthesia
+ Progress of Sensory loss
Pale Light touch
Vibration sense
Pulseless
Proprioreception
Parasthesia Deep pain
Late
Pressure sense
Paralysis

16. Clinical Evaluation of Acute Ischemia (Clinical Picture)
Signs of acute ischemia Palpation
5Ps Loss of motor function:
Pain: symptom
Pain Indicates advanced limb threatening
+
ischemia
Late irreversible ischemia: Muscle
turgidity
Pale
Intrinsic foot muscles are affected
Pulseless
first, followed by the leg muscles
Detecting early muscle weakness is
Parasthesia
difficult because toes movements are
produced mainly by leg muscles
Paralysis

18. Investigations
The severity and duration of
ischemia at the time of
presentation provides a narrow
margin of time for investigations

19.  general investigations  CK
 [Patients with a
suspected
hypercoagulable state
will need additional
studies seeking:]
 Anticardiolipin
antibodies
 Elevated homocysteine
concentration
 Antibodies to platelet
factor IV

20. Doppler US
to assess the level of obstruction & severity of ischemia

21. What are we
looking for?
NORMAL
• Multiphasic
• Pulsatile
• Regular amplitude
An audible Doppler signal assures some blood flow
No Doppler signals, a vascular surgeon should be
immediately consulted

23. 0.7 to 0.9 is mild disease,
0.5 to 0.69 is moderate disease,
< 0.5 is severe disease.

25. Arteriography
 If the differentiation between embolic &
thrombotic ischemia is not clear clinically, and if
the limb condition permits,
 DO ANGIOGRAPHY

26.  Value of angiography
 Localizes the obstruction
 Visualize the arterial tree & distal run-off
 Can diagnose an embolus:
 Sharp cutoff, reversed meniscus or clot
silhouette

27. Embolism: Thrombosis:
obvious cardiac source No obvious cardiac source.
No hx of cluadication history of cluadication.
Normal pulses in contralateral limb abnormal pulses in contralateral limb.
Angiogram: minimal atherosclerotic Angiogram: diffuse atherosclerotic
Few collateral Well developed collateral
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28. Doppler
Category Description Cap. refill Paralysis Sensory A V
loss
I Viable Not immediately
threatened
Intact - - Aud Aud
IIa Threatened Salvagable if
treated
Intact/slow - Partial _ Aud
IIb Threatened Salvagable if
treated
Slow/absen
t
Partial Partial _ Aud
emergently
III Irreversible Primary
amputation req.
Absent Complete Complete _ _

30. TREATMENT
Goals of therapy include
restoration of blood flow,
preservation of limb and life, and
prevention of recurrent thrombosis

31. THROMBOLYTICS
IMMEDIATE CARE SURGERY

32. A. Immediate care
 Anticoagulation
 Analgesia
 measures to improve existing perfusion
 treatment of associated cardiac
conditions

33. B Catheter directed thrombolysis
Agents used: Streptokinase,
Urokinase, tissue plasminogen
activator
Indications:
Indications
1. Viable or marginally threatened limb (class I, IIa)
2. Recent acute thrombosis (not suitable for embolism or
old thrombi)
3. Avoid patients with contraindications

34. Contraindications:
Absolute:
Absolute
1. Cerebro-vascular stroke within previous 2 months
2. Active bleeding or recent GI bleeding within previous 10
days
3. Intracranial trauma or neurosurgery within previous 3 months
Relative:
Relative
1. Cardio-pulmonary resuscitation within previous 10 days
2. Major surgery or trauma within previous 10 days
3. Uncontrolled hypertension

35. SURGERY
OPERATIVE
REVASCULARISATION AMPUTATION

36. Fogarty balloon catheter
(with post-op anti coagulants)

39.  Surgery
 [Surgery may be considered in trauma, where there are
contraindications to CDT, or where CDT is not available.
 The method of revascularization (open surgicalor
endovascular) may differ depending on:
 Anatomic location of occlusion
 Etiology of ALI
 Contraindications to open or endovascular treatment
 Local practice patterns]

40. Amputation
for irreversible
ischemia with
permanent tissue
damage

41. Clinical outcomes
• Mortality -15–20%.
• Major morbidities include:
1. Due to major bleeding 10–15% of patients require
transfusion/and or operative intervention
2. Amputation (25–30% of patients)
3. Fasciotomy (5–25% of patients)
4. Renal insufficiency (up to 20% of patients)

42. Follow-up care
 warfarin, often for 3–6 months or longer.
 Patients with thromboembolism will need
long-term anticoagulation, possibly lifelong.
 If contraindicated due to bleeding risk
factors>> platelet inhibition therapy

44. Algorithm to be followed…
Patient with
suspected ischemia
History Examination investigations
Acute limb ischemia confirmed and staged

45. Heparin
I IIA IIb III
EMERGENCY
EARLY OPERATIVE
AMPUTATION
INTERVENTION RE-
VASCULARISATION
NO YES
TREAT FOR
SAME AS
CHRONIC
FOR IIa
ISCHEMIA

46. Management of IIa
ARTERIOGRAPHY
No lesion
Discrete localized lesions
Multiple extensive lesions