ACUTE LIMB ISCHEMIA

2. A thrombus is a blood clot that forms
in a vessel and remains there.
An embolism is a clot that travels
from the site where it formed to
another location in the body.
Thrombi or emboli can lodge in a blood vessel and
block the flow of blood in that location depriving
tissues of normal blood flow and oxygen.
This can result in damage, destruction (infarction), or
even death of the tissues (necrosis) in that area.

3. • An embolus suddenly
occludes a relatively
healthy arterial tree
• An embolus can originate
from the heart (MS with
atrial fibrillation, MI with
mural thrombus) or
dilated diseased arteries
(aortic aneurism)
• It usually arrests at
arterial bifurcation
Acute embolic ischemia
• Atherosclerosis causes
progressive narrowing of
the arterial tree
• Stimulates development of
collaterals
• Sluggish flow & rough
surface will favor acute
thrombosis
Acute thrombotic ischemia

4. Causes

5. Signs of acute ischemia
6Ps
Pain: symptom
+
Pulseless
Pale
Parasthesia
Paralysis
COLOR:
Early: pale
Later: cyanosed mottling fixed
mottling & cyanosis
Pallor
Reversible
mottling
An area of fixed
cyanosis
surrounded by
reversible mottling
Empty veins:
compare the Rt.
(ischemic) & Lt.
(normal)
Fixed
mottling &
cyanosis

6. Signs of acute ischemia
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
Temperature: the limb is cold with a level of
temperature change (compare the two limbs)
Slow capillary refilling of the skin after finger
pressure
5Ps

7. 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

8. 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

9. DOPPLER
ULTRASOUND
to assess the level of
obstruction & severity
of ischemia
WHAT ARE WE
LOOKING FOR?
NORMAL
• Multiphasic
• Pulsatile
• Regular amplitude
An audible Doppler signal assures some blood flow
No Doppler signals, a vascular surgeon should be immediately consulted

10.  If the differentiation between embolic & thrombotic ischemia
is not clear clinically, and if the limb condition permits,
 DO ANGIOGRAPHY
• Value of angiography
• Localizes the obstruction
• Visualize the arterial tree & distal run-off
• Can diagnose an embolus:
• Sharp cutoff, reversed meniscus or clot silhouette
Arteriography

11. Goals of therapy include restoration of blood flow,
preservation of limb and life, and prevention of
recurrent thrombosis
• Resuscitation
• Anticoagulation
• Analgesia
• measures to improve existing perfusion
• treatment of associated cardiac conditions

12. Agents used: Streptokinase, Urokinase(used in our setup), tissue plasminogen activator(Best but
expensive)
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
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
Catheter directed thrombolysis

13. Fogarty balloon
catheter
(with post-op anti
coagulants)
Embolectomy

14. for irreversible
ischemia with
permanent tissue
damage
Amputations: