HISTORY

HPI: 81 y.o. F presents (8/29) with R-foot pain and swelling since (8/27). Pt is s/p R-CFA
endartectomy with patch angioplasty repair & R-CFA-popliteal bypass w/ PTFE (6/10). She
visited her vascular doctor and was sent to the hospital for surgery after duplex at the office
revealed her bypass to be occluded.
ROS: Negative except whats mentioned above.
Allergy: Statins & Penicillin's
PMH: COPD, PAD, Cervical CA, skin CA, GERD, HTN, HLD
PSH: R Fem-pop bypass w PTFE (6/10), L Mastectomy, hysterectomy, cataract removal, ex lap w/
lysis of adhesions, and appendectomy.
FH: CAD
SH: 40 PPD (quite 20 yrs), Denies Alcohol & drugs
MEDs:ASA, Norco, Ventolin HFA, Albuterol, Rivastigmine, Diltiazem, Furosemide, Omeprazole.
 PE:
Vitals: P: 87, BP: 136/65, BMI: 23.05
General: NAD
HEENT: NC/AT, No icterus, PERRLA
CVS: Normal regular rate
Respiratory: Decreased breath sounds bilaterally
Abdomen: Soft, non-distended
Extremities: Femoral pulse- L-1+, R 2+. PT-R 0+,L-1+, DP-R 0+,L1+
A/P
Impression: 81 y.o F presented w/ R-foot pain since 8/27. Duplex was done
that showed her bypass to be occluded.
1. Aortogram with runoff, intent to treat.
TIMELINE
(8/29) Pt was found to have an occlusion of her Fem-pop graft
(8/29) Pt was admitted to the hospital and scheduled for Thrombolysis w/
transarterial/ transcatheter approach (8/30)
(8/30) Angiogram showed clot in bypass thus EKOS catheter was placed. t-PA &
Heparin drip started, and pt was admitted to the ICU w/ Q4 Neuro/motro/plasminogen
exam.
(8/31) Lysis check. R-limb ischemia persisted, & angiogram did not show
revascularization. EKOS catheter was removed.
(9/1) Amputation was discussed with the pt and pt agreed on R-AKA on 9/1.
ACUTE LIMB ISCHEMIA
Sudden decrease in limb perfusion.
Ischemic rest pain or development of tissue loss.
Clinical presentation depends upon the etiology and whether the patient has
underlying PVD.
Incidence 1.5 cases per 10,000 persons per year.
ETIOLOGY
Embolus from a proximal source lodging into a more distal vessel.
-Atrial fibrillation, Left ventricular thrombus formation following MI or LVD,
prosthetic valves, and infected cardiac valves.
-Common femoral, common iliac, and popliteal artery bifurcations.
Acute thrombosis of a previously patent artery.
-Symptoms less sever than embolus (collateral circulations)
-At sites of an atherosclerotic plaque.
Acute thrombosis of a stent, graft, arterial aneurysms.
Dissection of an artery or direct trauma to an artery.
CLINICAL PRESENTATION
Thrombosis Embolus
Onset Hours to days Minutes

Upper limb affected Rarely Commonly (25%)

Multiple sites affected No Sometimes (15%)
Embolic source No Yes (AF most common)
Previous claudication Yes No
Severity Incomplete Complete (No
(collaterals) collaterals)
Management Prompt Immediate embolectomy
heparinisation
followed by
angioplasty or bypass
PHYSICAL EXAMINATION
6 Ps of Acute limb ischemia
Pain
Parasthesia
Paralysis
Pulselessness
Pallor
Polar
DIAGNOSIS & CLASSIFICATION
History, PE, & ABI
bilaterally.
Whether or not to proceed
with additional diagnostic
testing depends upon the
severity.
Anticoagulation prior to
imaging and monitored
throughout for progression
of ischemia.
Digital subtraction
arteriography

Society of vascular surgery/International society of cardiovascular surgery

(Rutherford et al, 1997)
DIFFERENTIAL DIAGNOSIS
Chronic limb ischemia
Acute compartment syndrome
Phlegmasia cerulea dolens
Vasospasm (Reynaud syndrome, Ergotamine)
Non-ischemic limb pain
INITIAL MANAGEMENT
2012 American College of Chest Physicians
(ACCP) & 2007 Inter-Society Consensus
for the Management of PVD (TASC II)
Recommend Immediate IV heparin bolus
followed by continuous heparin infusion.
Prevents further propagation of thrombus
and inhibits thrombosis distally.
Time is Crucial!!!
Medical risk assessment- EKG and blood
test
THROMBOLYTIC THERAPY VS. SURGERY
Clinical features:
Embolus vs. thrombus
Location and length of the lesion
Duration of symptoms
Availability of autologous vein for bypass grafting
Suitability of patient for surgery
TOPAS TRIAL
Randomized, prospective, double-blinded
Comparing thrombolysis vs surgery in pt w. Acute lower extremity ischemia <14 days.
Phase 1 of trial compared 3 different doses of catheter-directed rUK vs surgery in 213 patients
Complete lysis of thrombus achieved in 71% of patients.
Phase 2 included 544 pts with acute arterial occlusion <14 days, who where randomly assigned to to
the above rUK vs. surgery.
No difference between the groups in amputation-free survival rates, 6 months ( 72 vs. 75% with
surgery).
Amputation survival rates better with thrombosis in bypass graft vs. native vessel.
No significant mortality rate between thrombolysis & surgical revascularization at 6 months (16 vs.
12% with surgery) and at 1 year (65 vs 70%).
Major hemorrhage more common with rUK than with surgery (12.5 vs 5.5%)
40% of pts with thrombolysis required subsequent surgery within 6 months. However, these pts still
required a lower number of open procedures when compared to immediate surgery (315 vs 551)
STILL TRIAL
Consisted of 393 pts with non-embolic arterial and graft occlusion who presented
with progressive symptoms of limb ischemia of up to 6 months duration.
Pts randomly assigned to treatment with surgery or intra-arterial catheter directed
thrombolysis.
Failure of catheter placement in 28% of pts assigned to thrombolytic therapy.
Post-hoc analysis showed that pts with ischemia of <14 days who were treated with
thrombolysis had significant lower rate of amputation (6 vs. 18%).
By contrast, pts with ischemia >14 days did better with surgical revascularization,
with significant reduction at one year in the rates of major amputation (35 vs. 65%).
For patients receiving thrombolysis who subsequently required surgery, the
magnitude of the surgical procedure was decreased by 56 percent.
Factors associated with poor outcome Fem-pop occlusion, diabetes, and critical
limb ischemia.
RECOMMENDATIONS
Based, in part, upon the observations in TOPAS and STILE the following
recommendations have been made:
1. The 2005 American College of Cardiology/American Heart Association (ACC/AHA)
concluded that there was general agreement that catheter-based thrombolytic therapy
is effective and beneficial and is indicated in patients with acute limb ischemia of
<14 days. Evidence was considered less well established for patients with acute limb
ischemia of > 14 days duration.
The guideline also concluded that the weight of evidence was in favor of
mechanical thromboembolectomy as adjunctive therapy.
2. The 2012 American College of Chest Physicians (ACCP) guideline on
antithrombotic therapy for peripheral vascular disease suggested catheter-based
thrombolytic therapy in patients with acute limb ischemia.
CONCLUSION
Threatened limb Should undergo emergent surgical revascularization.
Non-viable limbs Patients should go prompt amputation. Delays in amputation of
a nonviable extremity can result in infection, myoglubinuria, acute renal failure, and
hyperkalemia.
Difficult to compare published results
Once diagnosed with history and PE begin with bolus of heparin followed by
continuous IV heparin infusion. Anticoagulation prevents propagation of thrombus in
the arterial and venous systems due to low flow.
Catheter-based thrombolytic therapy indicated for patients with acute limb ischemia
of <14 days in those who have a low risk of developing myonecrosis and ischemic
nerve damage during the time period required to achieve revascularization.
REFERENCES
1) Norgren L, Hiatt WR, Dormandy JA, et al. Inter-Society Consensus for the
Management of Peripheral Arterial Disease (TASC II). J Vasc Surg 2007; 45 Suppl
S:S5.
2) Results of a prospective randomized trial evaluating surgery versus thrombolysis
for ischemia of the lower extremity. The STILE trial. Ann Surg 1994; 220:251.
3) Ouriel K, Veith FJ, Sasahara AA. A comparison of recombinant urokinase with
vascular surgery as initial treatment for acute arterial occlusion of the legs.
Thrombolysis or Peripheral Arterial Surgery (TOPAS) Investigators. N Engl J Med
1998; 338:1105.
4) Uptodate.com