Acute Limb Ischemia - Emergency Case presentation
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A 70-year-old female presented with sudden onset of left leg pain and was found to have absent pulses and decreased sensation in the left leg. Doppler ultrasound revealed a large blood clot in the left iliac artery. She was taken immediately to the operating room for emergency surgery. Acute limb ischemia requires rapid diagnosis and treatment to save threatened limbs. Options include catheter-directed thrombolysis, surgical embolectomy, or amputation if ischemia has caused irreversible damage. Prompt treatment is needed to prevent major complications like amputation or death.
Acute Limb Ischemia - Emergency Case presentation
- 2. A 70 year old female came to casuality with c/o of sudden onset of pain in left leg from one hour @3.30 pm on 30th july 2014
- 3. O/E there were absent popliteal and lower pulsations and decreased sensations of left leg and it was cold and pale compared to right leg. Patient had history of Heart disease and k/c/o Hypertension and DM type 2. No Recent history of Trauma/Claudication/Fever/ intravascular procedures / drugs of abuse. Contralateral leg pulses are felt
- 5. Patient is sent for urgent Doppler Ultrasonography @3.35pm
- 6. • Ultrasonography revealed Large Clot in Left common iliac artery
- 7. Patient is shifted to Operation theatre under care of vascular surgeon @ 3.45pm
- 9. Clinical Evaluation of Acute Ischemia (Clinical Picture) Signs of acute ischemia 5Ps Pain: symptom + Pulseless Pale Parasthesia Paralysis Inspection COLOR: Early: pale Later: cyanosed mottling fixed mottling & cyanosis Pallor Reversible mottling An area of fixed cyanosis surrounded by reversible mottling Fixed mottling & cyanosis
- 10. Clinical Evaluation of Acute Ischemia (Clinical Picture) Signs of acute ischemia 5Ps Pain: symptom + Pulseless Pale Parasthesia Paralysis Palpation Femoral Popliteal Posterior tibial Dorsalis pedis Palpate peripheral pulses, compare with the other side & write it down on a sketch Slow capillary refilling of the skin after finger pressure
- 11. Clinical Evaluation of Acute Ischemia (Clinical Picture) Signs of acute ischemia 5Ps Pain: symptom + Pulseless Pale Parasthesia Paralysis Palpation Loss of sensory function Numbness will progress to anesthesia Progress of Sensory loss Light touch Vibration sense Proprioreception Deep pain Pressure sense Late
- 12. Clinical Evaluation of Acute Ischemia (Clinical Picture) Signs of acute ischemia 5Ps Pain: symptom + Pulseless Pale Parasthesia Paralysis Palpation Loss of motor function: Indicates advanced limb threatening ischemia Late irreversible ischemia: Muscle turgidity Intrinsic foot muscles are affected first, followed by the leg muscles Detecting early muscle weakness is difficult because toes movements are produced mainly by leg muscles
- 13. Investigations
- 14. Doppler US to assess the level of obstruction & severity of ischemia
- 15. • What are we • looking for? • NORMAL • • Multiphasic • • Pulsatile • • Regular amplitude • An audible Doppler signal assures some blood flow. No Doppler signals, then a vascular surgeon should be immediately consult
- 16. If a pulse is detected, then the ankle-brachial index (ABI) and segmental leg pressures should be checked..
- 17. 0.7 to 0.9 is mild disease, 0.5 to 0.69 is moderate disease, < 0.5 is severe disease.
- 18. Management of Acute Limb Ischemia The severity and duration of ischemia at the time of presentation provides a narrow margin of time for investigations and treatment.
- 19. Rutherford Classification Category Description Cap. refill Paralysis Sensory loss A V I Viable Not immediately threatened Intact - - Aud Aud IIa Marginally Threatened Salvagable if treated Intact/slow - Partial _ Aud IIb Immediately Threatened Salvagable if treated emergently Slow/absent Partial Partial _ Aud III Irreversible Primary amputation req. Absent Complete Complete _ _ Doppler
- 21. Immediate Care 1.Anticoagulation 2.Analgesia 3.measures to improve existing perfusion 4.treatment of associated cardiac conditions
- 22. B Catheter directed thrombolysis Agents used: Streptokinase, Urokinase, tissue plasminogen activator Indications: 1. Viable or marginally threatened limb (class I, IIa) 2. Recent acute thrombosis (not suitable for embolism or old thrombi) 3. Avoid patients with contraindications
- 23. Contraindications: Absolute: 1. Cerebro-vascular stroke within previous 2 months 2. Active bleeding or recent GI bleeding within previous 10 days 3. Intracranial trauma or neurosurgery within previous 3 months Relative: 1. Cardio-pulmonary resuscitation within previous 10 days 2. Major surgery or trauma within previous 10 days 3. Uncontrolled hypertension
- 24. Embolectomy Fogarty balloon catheter (with post-op anti coagulants)
- 26. for irreversible ischemia with permanent tissue damage
- 27. Clinical Outcomes • Mortality -15–20%. • Major morbidities include: 1. Due to major bleeding 10–15% of patients require transfusion/and or operative intervention 2. Amputation (25–30% of patients) 3. Fasciotomy (5–25% of patients) 4. Renal insufficiency (up to 20% of patients)
- 29. Conclusions and Recommendations • Heparin should be administered as soon as possible. • In Patient with viable and marginally threatened limb imaging studies can be obtained to guide therapeutic decision. • In patient with Immediate threatened limb Emergency angiography followed by catheter based thrombolysis or thrombectomy or open surgical vascularization is indicated to restore or preserve limb viability.