ACUTE LIMB ISCHEMIC

TITIEN BUNIYATI
ALI ASPAR MAPPAHYA

INTRODUCTI
ON

INTRODUCTI
ON
The major cause of lower extremity ALI is
atherosclerosis. Risk factor for atherosclerosis
such as cigarette smoking, diabetes,
dyslipidemia, hypertension, and
hyperhomocysteinemia.

The most important variables in producing

a good outcome are early diagnosis and
prompt initiation of therapy

CASE
REPORT

Physical Examination

Physical Examination

Labolatory Findings, 18 Ja

Wbc 24,4 x 103/ uL

RBC 6,26 x 106/ uL
HGB 12,2 gr/dl
HCT 34,9%
Plt 457 x 103/ uL
SGOT 53 u/L
SGPT 86 u/L
Ureum 59 mg/dl
Creatinin 1,5 mg/dl
GDS 175 mg/dl
GDS cito, 17 Jan 2014 40
mg/dl

Ck 1056 u/L
Ckmb 24,3 u/L
Troponin T 0,14 ng/ml
Na 124 mmol/L
K 4,86 mmol/L
Cl 99 mmol/L
PT 12,9 co 10,5
INR 1,09
APTT 73,1 co 24,6
HbA1c 11,7

ECG
Conclusion : Sinus Tachicardi, HR 125x/minutes,
normoaxis, iskemik whole anterior miokard

Thorax Foto
Normal lung, cardiomegaly with dilatatio
aortae, mediastinum wide (vena cava superior

Echodoppler lower extremitas dextra

Flow a. femoralis D decreased, flow vena
(+), CUS (+)
Mid distal femur, flow artery (-), colateral
minimal, flow vena (+)
Cruris-pedis : flow artery/vena (-)
Conclusion : PAD

DIAGNOSIS
HIPOGLIKEMIA
ACUTE LIMB ISCHEMIC STD II B

THERAPY

O2 4 lpm (NC)
Dextrose 40% 50 cc (2 flacon)
Maintenance dextrose 10% 12 tpm
Heparin, initial dose 3500 IU (bolus)
Heparin maintenance 700 IU/hour
Ciloztasol 2x100 mg
Aspilet 1x80 mg
Pethidin 1 amp in Nacl 0,9% 500 cc/24hour

Arteriography
Total oclusi in proximal truncus brachiocephalica dextra,
visualisasi a. femoralis dextra until distal not succesfull

Laboratory Control 21 Jan 2014

WBC 21.800/uL
HBG 9,6 g/dL
PLT 581.000/uL
HCT 26,9 %
Ur 53 mg/dL
Cr 0,90 mg/dL

Na 133
K 4,1
Cl 103
PT 12,5 co 13,2
INR 1,04
APTT 26,8 co 25,1

Monitoring During Hospi

17/01/2014
at ICU TD
110/80, N
90, P 20, S
36,5 C,
GDS 40

D-1

Delirium, demam TD 90/60, N

90, P 20, S 36,5 C, status
localis regio leg D, sianosis
10cm on patella, cold, not
papable a.femoralis D

D-2

Konsul ke EM dan
BTKV
Pasien delirium,
Na 124

D-3

Melena, gelisah, BP
132/65, P 116, P 30, S
37,5. therapy heparin
and aspilet stop. Get
pantoprazol, plan
consult GEH

D-4

Answer BTKV : diagnosis

PAD, plan trombektomi if
family agree

D-5

D-6

BP 105/65, P 122, R
28, S 36,5.Lab
wbc 21,8x103 hb
9,6, hct 26,9,plt
581x103,Na
133,K 4,1,Cl
103,PT 12,5 co

Discussion
Definition ALI : Any sudden decreased or
worsening in limb perfussion causing a
threat to extremity mobility.
ALI caused by atherosclerotic disease
(trombus, embolism) and nontherosclerotic
(arterial trauma, aortic or arterial disection,
etc). Most ALI seen in clinical practice is
caused by atherosclerotic disease.

RISK FACTOR

Older age (> 40 years)

Male gender
Smoking
Diabetes mellitus
Hyperlipidemia
Hypertension
Hyperhomocysteinemia

Clasification of Limb Ischemia

Clinical Finding

Pain
Pallor
Pulseless
Perishing cold
Parasthesia
paralysis

IMAGING OPTIONS
1.
2.
3.
4.

Digital Subtraction Angiography (DSA)

Duplex Ultrasonography
CT Angiography
MR Angiography (MRA)

TREATMENT
Initial ED Management :
1. Aspirin
2. Unfractionated Heparin
3. Positing Extremity in Dependent Position to
have gravity improve limb perfussion
pressure.
4. Avoid extremes of temperature to affected
extremity.
5. Pain control

INTERVENTION TREATMENT
1. Endovascular Intervention
a. Intra-arterial trombolysis
- Medication : urokinase, streptokinase
- Technique : An angiocatheter is inserted
into the contraleteral femoral artery.
b. Percutaneous Trombectomy
- mechanical versus aspiration technique

2. Surgery
a. Open Trombectomy
- local anesthesia and direct removal of clot
in the operating room.
b. Revascularization
- bypass revascularization of occluded
artery to reperfuse the distal extremity
c. Amputation
- in the ED, ice the extremity to decrease
metabolism and production of inflamatory
mediators.

Discussion

Treatment:

Acute Limb Ischemia

Heparin Therapy Immediately

Detail Examination

Clas I
Viable

Clas
II A

Clas
II B

Close Monitoring
Urgent Arteriography

Clas
III
Early

If Fail

PIAT

Late

If Fail

Urgent Embolectomy

Amputasi

UNIQUE MECHANISM OF ACTION

Cilostazol
cAMP

Platelets

Platelet
aggregation and
activation

Vascular smooth
muscle

Vasodilation
peripheral blood flow
Antiproliferative effect

Lipoprotein
lipase activity
TG synthesis
TG
HDL

Ideal lesion of Intervention Treatment

Type A - Angioplasty

<3cm
3-5cm

Type B - Angioplasty
Not distal poplitea

<3cm

<3cm

3-5cm

Type C - Surgical

<3cm

<3cm

Type D - Surgical
3-5cm