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ACUTE ISCHEMIA

Vascular Surgery
DEFINITION
• Acute ischemia is the result of a sudden deterioration in
the arterial supply to the limb
• Presentation is normally up to 2 weeks following the
acute event
• Two causes:
• Arterial embolism
• Thrombosis
Earnshaw JJ. Acute ischemia: Evaluation and Decision Making. In Rutherford’s Vascular Surgery,
7th edition. 2010:157;2389-2411
Inter-Society Consensus for the Management of PAD (TASC-II). J vasc surg 2007:45;1;40-47
EMBOLISM
• Embolism is the result of material passing through the
arterial tree and obstructing a peripheral artery
• Source:
• Heart (mural thrombus)
• Atherosclerotic debris from diseased proximal artery
CARDIAC EMBOLISM
• Atrial and Ventricular
• Most common cause: atrial fibrilation (left atrial
appendage – stasis due to incoordinate contractions
of atrium and ventricle)
• Mural thrombus: Acute Myocardial Injury
• Left ventricular aneurysm
• Cardiac valve disease
CARDIAC EMBOLISM
• Paradoxical
• Clot from DVT travel through a patent foramen ovale
into the arterial system
• Endocarditis
• Indwelling arterial lines, immnunocompromised
• Cardiac tumor
• Atrial myxoma: fragment as it enlarge
NON CARDIAC EMBOLISM
• Atheroembolism
• Patient with extensive atherosclerotic disease in
major arteries: aortic arch, descending thoracic
aorta, etc.
• Aortic mural thrombi
• Hypercoagulable condition
THROMBOSIS
• Atherosclerotic obstruction
• Progressive atherosclerotic narrowing of the
peripheral arteries: development of platelet
thrombus
• Clinical manifestations are less dramatic than emboli
due to collateralization
THROMBOSIS
• Hypercoagulable states
• Possible in absence of atherosclerotic disease, due
to low arterial flow and hyperviscosity
• Associated with venous thrombosis
• Aortic or arterial dissection
CLINICAL PRESENTATION
• Depend on the size of the artery occluded and whether
collaterals have developed
• Symptoms
1. Loss sensation
2. Motor nerve (weakness)
3. Skin (pallor)
4. Muscles (muscle tenderness)
CLINICAL PRESENTATION
• Skin: White (pallor) at the beginning, then Dusky blue
as capillary venodilatation occurs.
• Terminal stage of skin ischemia is caused by
extravasation of blood due to capillary disruption: NON-
VIABLE SKIN  Dangerous for Revascularization
CLINICAL ASSESMENT
• History
• Acute white leg: urgent intervention
• Severe ischemia: irreversible muscle necrosis
occurs within 6 – 8 hours
• Risk factors
• Physical findings
• 6 P’s; pain, pallor, paresis, pulse deficit, paresthesia,
poikilothermy
• ABI (if possible)
CLINICAL ASSESMENT
CLINICAL ASSESMENT
• Late Signs:
• Muscle rigor
• Tenderness
• Pain on passive movement
• Paretic limb
• Absence of doppler signal
CLASSIFICATION (TASC-II, 2007)

Inter-Society Consensus for the Management of PAD (TASC-II). J vasc surg 2007:45;1;40-47
INVESTIGATION
• Patients with ALI should be evaluated in the same
fashion as those with chronic symptoms, but the
severity and duration of ischemia at the time of
presentation rarely allow this to be done at the onset
• Lab studies: ECG, CBC, and hypercoagulability test
• Arteriography
• CTA
• MRA
TREATMENT

The standard therapy is:


UNFRACTIONATED HEPARIN Intravenously
TREATMENT - ALGORITHM
TREATMENT – CD - THROMBOLYSIS
• RCT: No clear superiority for thrombolysis versus surgery on
30 days limb salvage
• Surgery is 3 to 5 fold more than thrombolysis
• Initial treatment of choice in level I or IIa
• Advantage: less endothelial trauma, lysis clot in small vessel
• Systemic thrombolysis: no role!
• Berridge D, Kessel D, Robertson I. Surgery versus thrombolysis for initial management of acute limb ischaemia. Cochrane
Database Syst Rev 2002; CD002784(1)
• Kuukasjarvi P, Salenius J. Perioperative outcome of acute lower limb ischaemia on the basis of the national vascular registry.
The Finnvasc Study Group. Eur J Vasc Surg 1994;8:578-83.
• Eliason JL, Wainess RM, Proctor MC, Dimick JB, Cowan JA Jr, Upchurch GR Jr, et al. A national and single institutional
experience in the contemporary treatment of acute lower extremity ischemia. Ann Surg 2003;238(3):382-9. discussion 389–390.
TREATMENT - THROMBOLYSIS
Thrombolytic Primary Operation
Series Number of Period Amputatio Death Amputatio Death
Patients (Months) n (%) n (%)
(%) (%)
Rochester 114 12 18 16 18 42
STILE 393 6 12 6.5 11 8.5
TOPAS-II 544 12 15 20 13.1 17

STILE: Surgery vs Thrombolysis for Ischemia of the Lower Extremity


TOPAS: Thrombolysis or Peripheral Arterial Surgery
TREATMENT - THROMBOLYSIS
TREATMENT
• Percutaneous Aspiration Thrombectomy
• Percutaneous Mechanical Thrombectomy
• Hydrodynamic Devices (angiojet, oasis catheter,
hydrolyser)
• Rotational Devices
• Amplatz
TREATMENT - PMT
TREATMENT – POST PROCEDURE