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
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