Mahmoud Amlatar

Components

What is limb ischemia? Why does it occur? What is ALI? How is it diagnosed? How is it treated? How is it prevented?

Limb ischemia
Ischemia: deficient supply of blood to a body part that is due to obstruction of the inflow of arterial blood. (M-W dictionary)
Classifcation of limb ischemia
Terminology Onset: Acute Acute on chronic Chronic Severity: Incomplete Complete Irreversible Limb not threatened Limb threatened Limb non-viable Ischaemia <14 days Worsening symptoms and signs (<14 days) Ischaemia stable for >14 days Definition or comment

Causes of Limb Ischemia

thrombosis

trauma

ischemia

embolism

vascular

Acute Limb Ischemia

Defined as: a sudden decrease in limb perfusion that could 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

Acute Limb Ischemia

Time of presentation:
Early (hours): embolism, trauma, peripheral aneurisms w/emboli. Late (days): thrombosis, reconstruction occlusion Conclusion:
ALI may be the first manifestation of arterial disease in a previously asymptomatic patient. or may occur as an acute event that causes symptomatic deterioration in a patient with lower extremity PAD and intermittent claudication.

Diagnosing ALI: Hx
HISTORY:
HPI: primarily on
pain function (paralysis), numbness (paraesthesia) focus on time course of the condition, its location, and intensity / change in severity.

PH:
RF of atherosclerosis; HTN, DM, dyslipidemia, smoking. Hx of leg pain / claudication, vascular intervensions, heart disease, other vascular diseases.

FH: Hx CVD, strokes, amputations

Diagnosing ALI: P/E

Inspection:
Pallor >> blue limb >> marbled Empty veins Hair loss Muscle wasting Ulcers gangrene

Diagnosing ALI: P/E

Palpation:
Temp. changes Prolonged capillary refill Pulselessness Neurological deficits Muscle tenderness

Clinical Classification of ALI

Diagnosing ALI: Invx

Basic workup:
CBC PT, PTT Lipid profile ECG CPK

Imaging:
duplex CTA / MRA angiography

Treatment of ALI

Treatment of ALI
REVASCULARIZATION

Treatment of ALI
Endovascular procedures:
CDT: Catheter-directed thrombolytic therapy PAT: percutaneous aspiration thrombectomy PMT: percutaneous mechanical thrombectomy

Treatment of ALI
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
Surgery
Open surgery Amputation (30%)
15% of patients limbs thought to be salvageable ultimately require major amputation, and 10% of patients with ALI present as unsalvageable

Treatment of ALI
Post-surgical Complications:
Bleeding (anticoagulation)
Reperfusion injury: compartment syndrome
increased vascular permeability, resulting in local edema and compartment hypertension. Resulting in blood vessels, nerve, muscle compression; leading to hypoxia and tissue death. Most common clinical symptoms include disproportional pain, paresthesia and edema.

Treatment of ALI
Acute renal failure: in patients with:
CK levels >5000U/L Urine myoglobin >20mg/dl

Mortality rates:

MORTALITY
major bleeding amputation fasciotomy renal insufficiency

Treatment of ALI
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

Thank You