Acute Ischemia

ETIOLOGY

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Embolism.
Thrombosis.
Bypass graft occlusion.

CLINICAL PRESENTATION
CLINICAL ASSESSMENT
CLASSIFICATION OF ACUTE LIMB ISCHEMIA
DIAGNOSIS
INVESTIGATION
MANAGEMENT
UPPER LIMB ISCHEMIA

Abdullah Mohammed Alamri

431019751

Definition
Acute ischemia is the result of a sudden

deterioration in the arterial supply to the limb.

Patients who present later than two weeks after
the onset of the acute event are considered to
have chronic limb ischemia.

Etiology
There are two main reasons for acute ischemia to

occur:
Arterial Embolism
Arterial Thrombosis.

Embolism
Usually the source of the embolus is the heart,

and the material is mural thrombus that has

accumulated and detached.
The other main cause is atherosclerotic debris
from a diseased proximal artery.
Once the embolus detaches, it passes easily
through large arteries and lodges peripherally,
usually at an arterial bifurcation, where vessels
naturally narrow.

Embolism
Cardiac origin.
Atrial and Ventricular.
Paradoxical.
Endocarditis.
Cardiac Tumor.

Non Cardiac origin.

Atheroembolism.
Aortic Mural Thrombi.

Embolism
Atrial and Ventricular:
The most common cause is atrial fibrillation.
Myocardial infarction lead to the formation Mural thrombus.

Paradoxical:

An emobli from deep venous thrombosis travels through a

patent foramen ovale into the arterial system.

Embolism
Endocarditis:
Bacterial endocarditis is an infrequent diagnosis

since the introduction of widespread

echocardiography and antibiotics.
IV drug users, patients with indwelling arterial or
venous lines, and immunocompromised.

Cardiac Tumor:
Atrial myxoma is a benign tumor of the left atrium

that may fragment as it enlarges.

Embolism
Atheroembolism:
Patients with extensive atherosclerotic disease

fragments of plaque or adherent thrombus may

detach and cause symptoms that mimic cardiac
embolism.
More sinister are fragments of atheromatous plaque
that detach.

Aortic Mural Thrombi:

Occasionally, patients with hypercoagulable

conditions develop an aortic mural thrombus in the

absence of aortic pathology, which then emboli to a
limb.

Thrombosis
Thrombosis results from blood clotting within an

artery, which can be caused by

Progressive atherosclerotic obstruction.
Hypercoagulability.
Aortic or arterial dissection.

Virchow's triad

Thrombosis
Atherosclerotic obstruction:
Thrombotic occlusion is most commonly the result of

progressive atherosclerotic narrowing in peripheral

arteries of the leg. Platelet thrombus develops on the
stenotic lesion, leading to an acute arterial occlusion.
The progressive process of atherosclerotic narrowing
results in the development of robust collateral
circulation.
The resulting symptoms of ischemia (usually the
acute onset of claudication) improve as collateral
vessels expand.
Critical ischemia is the end result when this process
occurs at multiple levels.

Thrombosis
Hypercoagulable States:
In situ vessel thrombosis can also occur in the

absence of atherosclerotic disease in states of

hypercoagulability, low arterial flow, or
hyperviscosity.
These hypercoagulable states are associated
predominantly with venous thrombosis, but
thrombocythemia in particular can cause arterial
occlusion, usually in small vessels.

Thrombosis
Aortic or Arterial Dissection:
Aortic dissection, which may involve the aortic

bifurcation and give the appearance of iliac artery

thrombosis. These patients typically have chest or
back pain and may be hypertensive.
Another clinical clue is renal failure if the dissection
involves the renal arteries.
Isolated arterial dissections of vessels supplying the
lower extremity are uncommon but can occur from
traumatic or fibrodysplastic causes.

Bypass Graft occlusion

Another significant cause of acute limb ischemia

is the occlusion of an existing patent bypass graft.

The diagnosis is usually easy, and the cause is
more likely to be thrombosis than embolism.
Assessment and treatment are similar to that for
native vessel ischemia, but decisions about
treatment can be much more difficult because of
the variety of options available.

Clinical Presentation
The symptoms caused by vascular occlusion

depend on:
The size of the artery occluded
Collaterals have developed.

 Acute ischemia
Affects sensory nerves first; therefore loss of

sensation is one of the earliest signs of acute leg

ischemia.
Motor nerves are affected next, causing muscle
weakness.
Then skin.
Finally muscles are affected by the reduction in
arterial perfusion. This is why muscle tenderness is
one of the end-stage signs of acute leg ischemia.

 Once ischemia is established, the skins initial

pallor becomes dusky blue as capillary

venodilatation occurs.
At this stage, pressure over the discolored skin
leaves it white because the vessels are still
empty.
The terminal stage of skin ischemia is caused by
extravasation of blood owing to capillary
disruption; digital pressure over the discolored
skin produces no blush. At this stage, the skin is
nonviable, and revascularization of necrotic tissue
risks compartment syndrome and renal failure
without salvaging the extremity.

Mohammed Waleed Bin Maneea

431019761

Objectives
CLINICAL ASSESSMENT.

CLASIFICATION OF ACUTE LIMB ISCHEMIA.

DIAGNOSIS.
INVESTIGATION.

CLINICAL ASSESSMENT

History
Present illness

primarily to pain or function.

The suddenness and time of onset of the pain
location and intensity
Past history
a history of claudication
heart disease (eg, atrial fibrillation)
aneurysms (ie, possible embolic sources).
concurrent disease or atherosclerotic risk factors
hypertension, diabetes, tobacco abuse,
hyperlipidemia,
family history of heart attacks, strokes, blood
clots, or amputations.

Physical Examination:
Examination:

What do to:

Inspection

Thick Shiny Skin

Hair Loss
Brittle Nails
Colour Changes (pallor)
Ulcers
Muscle Wasting

Palpation

Temperature (cool, bilateral/unilateral)

Pulses: ?Regular.
Capillary Refill
Sensation/Movement

Auscultation

Femoral Bruits

Ankle Brachial Index

(ABI)

= Systolic BP in ankle
Systolic BP in brachial artery

Buergers Test

Expose the skin and

look for:

Elevate the leg to 45 - and look for pallor

Place the leg in a dependent position 90& look for a
red flushed foot before returning to normal
Pallor at <20 = severe PAD.

6 P
Pain,

Pulseless,
Pallor,
Paresthesia,
Paralysis,
Poikilothermia (which means that the limbs

temperature equalizes with the surrounding

environment).

Diagnosis
Aortic Occlusion
The diagnosis of an aortic occlusion is usually
obvious:o - Paralysis of the legs is often the presenting feature.
o -patients are unwell, with mottled skin.
o - discoloration that often extends above the inguinal

ligament onto the lower abdomen.

o - no palpable extremity pulses.
o - The dissection or occlusion may already involve
the renal arteries, in which case the patient presents
in established renal failure.

 Iliac Occlusion:o -The findings are similar to those for aortic occlusion, but

unilateral.
o -femoral pulse is lost on the affected side, and mottling
usually extends to the inguinal level.
o - Aortic dissection should be excluded if there is time for
investigation or if symptoms are suggestive .

Femoropopliteal Occlusion:o-Femoropopliteal occlusion is the most common situation in those

with acute leg ischemia.

o-The severity of the ischemia depends on whether the profunda

femoris remains patent.

o- The symptoms are more severe if the profunda is involved.
o-Although the femoral pulse may be strongly palpable (owing to the

water-hammer effect), the artery may be occluded.

Popliteal and Infrapopliteal Occlusion:o -the calf muscles are ischemic with a palpable femoral
o

o
o

pulse.
-In young patients, rare diagnoses include popliteal
thrombosis due to muscular entrapment or cystic adventitial
disease.
-The most impo cause is popliteal aneurysm thrombosis or
embolization. This diagnosis should be suspected if a
generous popliteal pulse is palpable in either leg or there is
a nonpulsatile mass in the popliteal fossa of the affected
leg.
-The outcome of this condition is particularly poor, despite
aggressive treatment.
-Chronic embolization of thrombus from within the
aneurysm gradually occludes the distal vessels and arterial
outflow; the aneurysm then thromboses, leaving no distal
arterial targets for revascularization.
-Tibial embolism is an infrequent diagnosis, because most

Classification
used to be classified according to cause

thrombosis or embolism,because this had

implications for treatment and prognosis.
Not so useful..

New classification
The Society for Vascular Surgery and the

International Society for Cardiovascular Surgery

2007 the Trans-Atlantic Inter-Society Consensus.

based on clinical findings and

Doppler

Usually thrombotic occlusions are class I or IIA

and are treated with intra-arterial thrombolysis if
symptom duration <14 days (especially if bypass
graft occlusion) and if patient has significant comorbidities/high operative risk.
Usually embolic occlusions are class IIB or III.
They usually require surgery as thrombolytics
take effect too slowly.

INVESTIGATION
IN critical ischemia you may not have time for

investigation.
on-table angiography
But if you have time

Computed Tomographic
Angiography
CT angiography is the test of choice for urgent

investigation of acute arterial ischemia.

similar in quality to intra-arterial arteriography.
particularly good for aortoiliac occlusions.

Renal Function?

CT of lower extremity

the right popliteal artery is deviated medially and totally

occluded.

Ultrasound
Imaging with duplex ultrasonography is the

mainstay of investigation for chronic arterial

ischemia.
Portable ultrasound machines may permit rapid,
bedside imaging.

Transfemoral Arteriography
Arteriography was the mainstay of investigation for

acute leg ischemia.

The angiogram documents the level of occlusion and
sometimes its nature.
Thromboticcollateral arteries and evidence of

arterial atherosclerosis.
emboli can be seen in several vessels, establishing the

diagnosis

Angiography

 Angiography is the best choice when an

endovascular solution to the arterial occlusion.

thrombolysis, percutaneous thrombectomy,

angioplasty, or stenting can be performed during

the same operative session.

Magnetic Resonance
Angiography
Magnetic resonance angiography with gadolinium

enhancement is less useful than either CT or

ultrasound in the context of acute limb ischemia.

Echocardiography
Some surgeons, however, regard the

investigation as a vital part of the postoperative

management.
There are certainly some conditions that require

echocardiography to make a diagnosis, such as

valvular disease (including vegetations), septal
defect, and cardiac tumor.

Abdulmajeed Alharbi
431019768

Points to be covered :
Acute limb Ischemia:
Management of acute limb ischemia .
Ischemia of the upper limbs .

Management of acute limb

ischemia

Management
1. Patients presenting with the 6 Ps

and do not have a pulse or arterial

Doppler signal have a vascular
emergency until proven otherwise.

Management
2. Patients diagnosed with acute limb ischemia should

have full anticoagulation with an intravenous bolus of

heparin(100 units/kg) followed by a continuous IV drip
(10 units/kg).

Management
3. Arterial embolization should be suspected in a

patient with previous MI or atrial fibrillation with a

palpable contralateral pulse.
Patients with arterial embolization should
proceed to the operating room (OR) immediately
without further testing.
An embolectomy is performed if the limb is viable or
salvageable.
A bilateral femoral artery exposure is mandatory for
aortic saddle embolus for simultaneous balloon
embolectomy.

Management
4. Patients with irreversible ischemia (an

anesthetic and paralyzed extremity) should be

offered amputation.

Management
5. Patients suspected of having native

artery or bypass graft thrombosis should

undergo angiography immediately; this can
be performed in the OR if the interventional
radiologist is not available.
Arterial thrombosis secondary to

atherosclerotic occlusion should be treated

with arterial bypass.
An artificial conduit should be used for an

above the knee arterial bypass, while the

autologous vein should be used for bypass

Management
6. A completion arteriogram should be done in

the OR to assess technical problems of the

bypass conduit or the completeness of
embolectomy.
7. Consider four compartment (anterior,

medial, superficial posterior, and deep

posterior) fasciotomies if ischemia time is
greater than 4 h.

Management
8. Consider treatment for myoglobinuria

with IV hydration, mannitol, and

alkalization of urine, and maintain greater
than 100 cc/h urine output. Monitor for
hyperkalemia and other organ injuries.
9. Thrombolytic therapy plays no role in

emergency cases when the patient has

no pulse or Doppler signals. Thrombolytic
therapy generally takes more than 12 h,
as peripheral nerves and muscles
tolerate ischemia only for 6 h.

Management

Ischemia of the upper limbs

Upper limb ischemia

There are a number of significant

differences between acute ischemia

of the arm and leg.
Patients with acute arm ischemia

tend to be, on average, about 4

years older than those with acute leg
ischemia (mean age, 74).
Arm ischemia is seldom limb

threatening, and treatment decisions

are less urgent.

Upper limb ischemia

The main reason for treating arm ischemia is to

prevent late complications such as arm

claudication and pain.
Most arm ischemia is due to cardiac embolism.
Patients often present with a cold feeling and

numbness rather than pain in the arm.

The diagnosis is clinical and can be confirmed by

duplex imaging.

Upper limb ischemia

References