Investigations

The severity and duration of

ischemia at the time of
presentation provides a narrow
margin of time for investigations
 general investigations  CK
 [Patients with a
suspected
hypercoagulable state
will need additional
studies seeking:]
 Anticardiolipin
antibodies
 Elevated homocysteine
concentration
 Antibodies to platelet
factor IV
Doppler US

to assess the level of obstruction & severity of ischemia

 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
0.7 to 0.9 is mild disease,
0.5 to 0.69 is moderate disease,
< 0.5 is severe disease.
 Arteriography
 If the differentiation between embolic &
thrombotic ischemia is not clear clinically, and if
the limb condition permits,
 DO ANGIOGRAPHY
 Value of angiography
 Localizes the obstruction
 Visualize the arterial tree & distal run-
 off Can diagnose an embolus:
 Sharp cutoff, reversed meniscus or clot
silhouette
 Thrombosis:
No obvious cardiac source. history
Embolism: of cluadication.
obvious cardiac source No hx 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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TREATMENT

Goals of therapy include

restoration of blood flow,
preservation of limb and life, and
prevention of recurrent
thrombosis
 THROMBOLYTICS

IMMEDIATE CARE SURGERY

A. Immediate care

 Anticoagulation Analgesia
 measures to improve existing perfusion
 treatment of associated cardiac
 conditions
B Catheter directed thrombolysis
•Agents used:
Streptokinase,
Urokinase, tissue
plasminogen
activator

•Indications:
1.Viable or marginally
threatened limb (class I,
IIa)
Contraindications:

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:
1.Cardio-pulmonary resuscitation within previous 10 days
2.Major surgery or trauma within previous 10 days
3.Uncontrolled hypertension
 SURGERY

OPERATIVE
REVASCULARISATION AMPUTATION
 Fogarty
balloon
catheter
(with post-op
anti
coagulants)
 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]

 Amputation

for irreversible
ischemia with
permanent tissue
damage
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)
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
Algorithm to be followed…
Patient with
suspected ischemia

History Examination investigations

Acute limb ischemia confirmed and staged

 Heparin

I IIA IIb III

EMERGENCY
EARLY OPERATIVE RE-
AMPUTATION
INTERVENTION VASCULARISATI
ON

NO YES

TREAT FOR
SAME AS
CHRONIC
FOR IIa
ISCHEMIA
Management of IIa

ARTERIOGRAPHY

No lesion

Discrete localized lesions

Multiple extensive lesions