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Karthik Vamanan, MD
Asst. Prof. Dept. of Surgery
Vascular and Endovascular Surgery
Introduction
Vascular insufficiency
Acute
Chronic
Acute Ischemia
Etiology
Thrombosis
Embolism
Other causes
Causes of acute limb ischemia in
atherosclerotic patients
Other causes
Non atherosclerotic, non embolic causes of acute
limb ischemia
Epidemiology - Acute
Incidence = 14/100,000
units
May be silent
May reduce in intensity
H+P
Ask about onset
H+P
Pain
On passive extension of ischemic muscle
Paresthesias and paralysis
Diabetes?
Paresthesias first, then sensory, motor last.
Pallor
Level of demarcation
Cap refill
Venous filling
Poikilothermia
Pulseless
Differential
Conditions mimicking acute limb ischemia
Investigation
PE
DO NOT DELAY
Rx
Percutaneous
Thrombectomy
Thrombolysis
Open
Thrombectomy
Bypass
Fasciotomy?
Treatment
Treatment
Conclusions
Patients with acute limb ischemia face a 1-year
mortality of 10-20%
Treatment of occluded bypass grafts has a better
outcome than treatment of native arteries
Risk of major bleeding increases with thrombolysis
compared with surgical revascularization
Risk of a bleeding complication increases as
coagulopathy worsens (decreased fibrinogen,
prolonged PTT)
Risk of an intracranial bleed is approximately 1-2%
with thrombolysis
Lytic patients require fewer open surgical procedures
Treatment
Epidemiology- Chronic
Incidence between 500 and 1000 per million
Risk Factors
Age
Family history
Trauma
Smoking
Diabetes
Hypertension - shear forces
Hypercholesterolemia
Hypercoagulable syndromes
Homocysteinemia
PAOD
Spectrum of disease
Claudication
Intermittent claudication is lower extremity
Claudication
Natural History
Claudication
Pathogenesis
Claudication
Clinical Presentation
Claudication
History
Should be aimed at
Delineation of symptoms
Elimination of differential diagnoses
Presence of risk factors
Identification of other beds of atherosclerosis
Claudication
Specific History
Claudication
Specific History
Claudication
Differential Diagnosis
(TASC) definition:
CLI
Natural History
DM
Smoking
Occlusive Disease below the knee
CLI
History
Neuropathy
Venous disease
Infections
Physical Exam
Thorough physical
Wasting
Thin skin
Hair loss
Thick nails
Physical Exam
Pulse exam
Palpate
Presence
Strength
Character
Auscultate
Bruits
Physical Exam
Patterns of Disease
Inflow
Outflow
Combination
H+P
Ischemic ulcers
H+P
Other Ulcers
Neurotropic
Located at pressure points (under calluses, plantar
aspect of 1st/5th MP joints)
Painless
Punched out with deep sinus
Stasis
Located over medial malleolus or lower third of leg
May have mild pain relieved by elevation
Shallow, irregular shape, rounded edges, granulating
base
7% previous CVA
Investigation
NON-INVASIVE
Ankle-Brachial Index
Ankle-Brachial Index
Ankle SBP/Brachial SBP
normal is 0.9-1
single level occlusion > 0.5
multi level occlusion < 0.5
claudication 0.6 to 0.9
rest pain 0.3
Toe Pressures
Measured with cuff around digit and PPG
(photo-plethysmography) monitor
Not as likely affected by calcification of
arteries
Normal: 60 to 80% of ankle or brachial
Toe Photoplethysmographic
Waveforms
MRA
Angiogram
Angiogram
Angiogram
Treatment
Goals
Relieve symptoms
Pain
Infection
Tissue loss
Preserve function
Preserve limb
Risk factor modification
Improve quality of life
Treatment
Medical Management
Risk modification
Statins
Diabetes management
Control hypertension
Cessation of smoking
Exercise
Treatment
Drug therapy
Antiplatelet therapy
Aspirin
Clopidrogel
Ticlopidine
Oxypentifylline??
Pentoxyfylline
Treatment
Endovascular management
Treatment
Surgical