acute thrombotic limb ischemia

7/30/2019 Acute Thrombotic Limb Ischemia

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Mahmoud Amlatar


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What is limb ischemia?

Why does it occur?

What is ALI?

How is it diagnosed?

How is it treated?

How is it prevented?

Components


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Ischemia: deficient supply of blood to a body part

that is due to obstruction of the inflow of arterial

blood. (M-W dictionary)

Limb ischemia

Terminology Definition or comment

Onset:

Acute Ischaemia


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ischemia

thrombosis

embolism

vascular

trauma

Causes of Limb Ischemia


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Defined as: a sudden decrease in limb perfusion thatcould threaten its viability.

Serious medical condition

30-day mortality (15%)

Amputation rates (30%)

Rapid reduction in limb perfusion Produces new or worsening symptoms

Threatens limb viability

Multiple etiologies; thrombosis & embolism most

common

Acute Limb Ischemia


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Acute Limb Ischemia


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Time of presentation:

Early (hours): embolism, trauma, peripheral

aneurisms w/emboli. Late (days): thrombosis, reconstruction occlusion

Conclusion:

Acute Limb Ischemia

ALI may be the first manifestation of arterial disease in apreviously asymptomatic patient.

ormay occur as an acute event that causes symptomaticdeterioration in a patient with lower extremity PAD andintermittent claudication.


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HISTORY: HPI: primarily on

pain function (paralysis),

numbness (paraesthesia)

focus on time course of the condition, its location, andintensity / change in severity.

PH:

RF of atherosclerosis; HTN, DM, dyslipidemia, smoking.

Hx of leg pain / claudication, vascular intervensions, heartdisease, other vascular diseases.

FH: Hx CVD, strokes, amputations

Diagnosing ALI: Hx


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Inspection:

Pallor >> blue limb >> marbled

Empty veins

Hair loss

Muscle wasting

Ulcers

gangrene

Diagnosing ALI: P/E


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Palpation:

Temp. changes

Prolonged capillary refill

Pulselessness

Neurological deficits

Muscle tenderness

Diagnosing ALI: P/E


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Clinical Classification of ALI


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Basic workup: CBC

PT, PTT Lipid profile

ECG

CPK

Imaging: duplex

CTA / MRA

angiography

Diagnosing ALI: Invx


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Treatment of ALI


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REVASCULARIZATION

Treatment of ALI


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Endovascular procedures:

CDT: Catheter-directed thrombolytic therapy

PAT: percutaneous aspiration thrombectomy

PMT: percutaneous mechanical thrombectomy

Treatment of ALI


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CDT:

Reduced mortality rates

Reduced hospital stay Less complex surgical procedure in exchange for a

higher rate of failure

may reduce the risk of reperfusion injury

Treatment of ALI


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Surgery

Open surgery

Amputation (30%)

15% ofpatients limbs thought to be salvageable

ultimately require major amputation, and 10%

of patients with ALI present as unsalvageable

Treatment of ALI


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Post-surgical Complications:

Bleeding (anticoagulation)

Reperfusion injury: compartment syndrome

increased vascular permeability, resulting in local edemaand compartment hypertension.

Resulting in blood vessels, nerve, muscle compression;leading to hypoxia and tissue death.

Most common clinical symptoms includedisproportional pain, paresthesia and edema.

Treatment of ALI


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Acute renal failure: in patients with:

CK levels >5000U/L

Urine myoglobin >20mg/dl

Mortality rates:

Treatment of ALI

MORTALITY

majorbleeding

amputation

fasciotomy

renal

insufficiency


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Follow-up care:

Patients are discharged on warfarin (3-6 months)

Cases with thromboembolism (for life?) Many patients require lifelong anticoagulation due to

the high risk of recurrent limb ischemia

Treatment of ALI


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Thank You

acute thrombotic limb ischemia

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