Andrei Castravet, Adrian Castravet, Victoria Stirbu

Vascular Surgeon, PMSI CRH “T. Mosneaga” Cardiovascular

Surgery Department
 API, leads to 14 out of 100.000, persons suffering, per year, in the USA.
 10 UP to 16 % of Performed Vascular Suregries, amputation rate between 10% and
30% , perioperative mortality - 15 %

Dormandy J, Heeck L, Vig S (June 1999). "Acute limb

ischemia". Semin Vasc Surg 12 (2): 148–53
 Acute peripheral ischemia is the condition that occurs when there is a sudden lack
of blood flow to a limb, which causes a GREAT danger for it’s viability.

Trans-Atlantic Intersociety Consensus (TASC II) Working

Group 2007

*Robert B. Rutherford,VASCULAR SURGERY, 6th edition

 Arterial Embolism
 Acute arterial thrombosis
 Arterial Trauma
 External arterial compression (compartment syndrome)
 Internal arterial compression (disecant aneurysm)
 Massive venous thrombosis (phlegmatia coerulea dolens)
 STRUCTURAL CAUSES IN THE UK (UNITED KINGDOM)

Davies B, Braithwaite BD, Birch PA, et al. Acute leg ischaemia

in Gloucestershire. Br J Surg 1997;84[4]:504-508
 STRUCTURAL CAUSE IN FINLANDA(LT)
AND SWEDEN (RGT)
 SU

Bergqvist D, Tröeng T, Elfstrom J, Luther M, Alback

et al. Auditing surgical outcome: ten years with the A. Acute leg ischemia: a case for the junior
Swedish vascular surgeon? Ann Chir Gynaecol
registry, 1995;84:373-378.)
Swedvasc. Eur J Surg 1998;164[S7]:3-32.
 Cardiac (macroembolism): left
atrium (atrial fibrilation), left
ventricle(post CMI), mitral/aortic
valve (vlavular prosthesis,
rheumatism, endocarditis), rare (left
ventricle aneurysm, atrial myxoma)
 Arterial (microembolism/arterio-
arterial embolism): atheroembolism
(atheromatouse plaque, involving
ulcers - Aorta, Iliac, Femoral arteries),
thrombembolism (birth from an
aneurysm)
 Rare: Paradoxal embolism(deep
venous system, through septal
cardiac defect), tumoral fragments,
foreign bodies,etc
 Degenerative
arteriopathies:
Aterosclerosis;
 Inflamatory arteriopathies
: obliterant thrombangiitis
(Bürger Disease);
 Arterial Aneurysms,
poplitea artery (dominant).
 Reconstructive vascular
surgeries: bypass/arterial
prosthetis,
thrombendarterectomy.
 Iatrogenic.
 Conditions of
hypercoagulability :
dehydration, hypotension,
stasis, haematological
conditions, etc.
 1854 Rudolf Wirchow – first mention about embolism and thrombosis
 1911 Georges Labey – first successful embolectomy
 1937 Connaught –heparine usage
 1950’ S. Sherry – streptokinase usage
 1963 Thomas J. Fogarty – Fogarty Catheter
Symptoms of acute limb ischaemia include (six “P”):
1. Pain
2. Pallor
3. Paresthesias
4. Perishingly cold
5. Pulselessness
6. Paralysis
 Clinically, palpation
and auscultation on
blood vessels, are a
MUST BE!
CriteriA Embolism Thrombosis
Identifiable source Frequently present Irrelevant
Past claudication Irrelevant Frequent

Appreciation of the pulse Proximal / contralateral - normal Ipsilateral and contralateral signs of
vascular disease

Past rhythm disturbances Frequent Irrelevant

Doppler Lack of pathological noises, high frequency of
the proximal occlusion flow signal and
prestenotic amplification.
The presence of pathological noises, the
gradual decrease of the frequency of the
flow signal and the lack of prestenotic
amplification of the proximal occlusion
signal.
SAVELIEV CLINICAL
CLASSIFICATION OF PAI
The degree of Classification criterion Prognosis

Paresthesia Pitch, Plegia, Subfascial Partial Total Necrotic of PAI

ischemia
, pain in decrease absence edema contracture contracture changes in evolution
rest or in motility of active tissues
effort movement

Viable
I +

Threatening
II A + +
ischemia

B + + +

Irreversible
III A + + + +
ischemia

B + + + + + +

C + + + + + + +
 Duplex
 Femoral TE
a
a
 BEFORE/AFTER SURGERY
a
 CT ANGIOGRAPHY
 PAI MANAGEMENT
Ischemia Embolism Thrombosis
degree
a
I Urgent embolectomy, or < 24 hours, due to Anticoagulant or thrombolytic treatment,
investigatin,and stabilysing the patient. investiigation (Duplex, Angiography).
Depending on the outcome - conservative
treatment, thrombolysis or revascularizationv

II A Urgent Surgery Anticoagulant, thrombolytic, Duplex,

angiography, revascularization in the first 24
hours

B Emergency revascularization

III A Emergency revascularization

+ fasciotomy

Emergency revascularization, delayed amputation

B
C Primary, high amputation
 Absolute:
Agony and extremely serious condition of the patient in PAI degree.I.

 Relative:
Associated, serious conditions (Recent Stroke, AMInfact,inoperable malign tumors)
PAI MANAGEMENT
a
PAI MANAGEMENT
a
PAI MANAGEMENT
a
PAI MANAGEMENT
A
 PAI MANAGEMENT
a
PAI MANAGEMENT
a
 PAI MANAGEMENT
a
PAI MANAGEMENT
PAI MANAGEMENT
a
PAI MANAGEMENT
a
 FEMORAL THROMBENDARTERECTOMY
AUTOVENOUS PATCH
a
 FEMORAL THROMBENDARTERECTOMY
PTFE PATCH
a
 AORTO-BIFEMURAL BYPASS
a
AORTO-FEMORAL BYPASS. AORTOTOMY,
PROXYMAL, DISTAL ANASTOMOSYS
a
a
FEMURO-POPLITEAL BYPASS
a
 FEMURO-INFRAPOPLITEAL
BYPASS
a
 FEMURO-TIBIAL/POPLITEO-
TIBIAL DISTAL BYPASS
a
EXTRAANATOMIC BY-PASSING
a
EXTRAANATOMIC BY-PASSING
a
EXTRAANATOMIC BY-PASSING
a
a

John W. Hallett „Comprehensive vascular and

endovascular surgery 2nd ed.”, Philadelphia, PA 19103-
2899, 2009
a
a
 PAI Diagnosis, is not hard to establish.
 It is necessary, for all Doctors, to know how to manage this Condition.
 Speaking to patiens, anamnesys – leads to 90% of success.