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Management of Acute Limb Ischemia Steven Hanish, MD Thursday Resident Conference September 29, 2005 Outline Review of lower extremity arterial anatomy Clinical Presentation Surgical vs. non-surgical interventions Compartment Syndrome Anatomy Anatomy Anatomy Anatomy

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Management of Acute Limb Ischemia

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Management of acute limb ischemia l.jpg

Management of Acute Limb Ischemia

Steven Hanish, MD

Thursday Resident Conference

September 29, 2005


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Outline

  • Review of lower extremity arterial anatomy

  • Clinical Presentation

  • Surgical vs. non-surgical interventions

  • Compartment Syndrome


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Anatomy


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Anatomy


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Anatomy


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Anatomy


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Rutherford Classification

Doppler


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Historical Perspective

  • Blaisdell, et. al. - 1st study to look at outcomes of patients with ALI

    • 52 patients

      • 17 thrombectomy

        • 4 amputations

        • 2 deaths

      • 29 Heparin

        • 1 death

        • 5 amputations

      • 6 amputation

        • 1 death

  • M&M: 25%


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Historical Perspective

  • Jivegard, et. al. corroborated prior findings

    • 1995

  • 234 patients

    • 61 treated with heparin at 1 center

    • 173 early revascularization at 10 centres

    • Gangrene and Death were endpoints

  • Findings:

    • 20% mortality

    • Loss of motor function or cyanosis predictive of gangrene


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ER Consult

  • You get a text page from the ER stating - “Lady in 3b has a cold leg and no pulses….”

    What now?


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ER Consult

  • H and P

    • Focus on comorbidities

    • Tobacco, Diabetes, Afib,

    • H/O vascular diseases

    • H/O hypercoag. state


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ER Consult

Physical Exam:

  • Pain

  • Pallor

  • Pulselessness

  • Paresthesias

  • Paralysis

  • Poikilothermia


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ER Consult

66 yo AA female

36 hours of cool, painful RLE

On coumadin for afib and stopped 10 days ago for colonoscopy

PMH: ESRD, DM, Afib, CHF (30% EF)

+ Tob +HL


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Case Presentation

  • PE:

    • Irregularly, irregular pulse

    • Palp. Femoral pulses, no distal pulses, RLE very cool

    • No evidence of tissue necrosis


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Etiology of Arterial Occlusion

Thrombotic vs. Embolic

  • Embolic Sources

    • Cardiac: 75%

      • Atrial Fibrillation: 51%

      • Acute MI: 24%

    • Non-Cardiac: 10%

      • Atheromatous Debris: 5%

      • Aneurysmal Origin: 5%

    • Post CV Surgery: 7%


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Etiology of Arterial Occlusion

  • Embolization Sites

    • Distal Aorta: 16%

    • Iliac: 17%

    • Common Femoral: 44%

    • Popliteal: 15%

    • Upper Extremity: 8%

    • (Visceral: 6% in separate series)

  • Outcome

    • Perioperative Heparin + Fogarty Thromboembolectomy: 10% Mortality and 92% Limb Salvage

  • Recurrence

    • Threefold Increase Without Anticoagulation (7% vs. 21%)

      Mills, Porter, Ann Vasc Surg, 1994


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Case Presentation

  • NOW WHAT?

Operating Room vs. Interventional Radiology


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TPA vs. Surgery

  • 3 randomized, clinical trials

    • Rochester series

    • STILE trial

    • TOPAS trial


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TPA


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Rochester Series

  • Ouriel K, Shortell CK, DeWeese JA, et. al. A comparison of Thrombolytic Therapy with operative revascularization in the initial treatment of acute peripheral ischemia. J Vasc Surg 1994; 19: 1021-1030

    • Compared Urokinase to primary operation in 114 patients

    • Rutherford IIb

    • Mean symptoms 48 hours

  • Outcome @ 12 months:

    • 84% receiving UK alive vs. 58% in surgery arm

    • 80% limb salvage in both groups

    • Cardiovascular complications = worse outcome


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Surgery or Thrombolysis for the Ischemic Lower Extremity

  • Sponsored by Genetech (Activase)

  • 393 patients randomized

    • rt-PA

    • UK

    • Primary operation

  • Death and Amputation rates similar in both groups, though, lysis patients had more frequent interventions


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Surgery or Thrombolysis for the Ischemic Lower Extremity

  • 30 day outcomes better with surgery (p<0.001)

    • Reduction in ongoing/recurrent ischemia

  • Stratification by duration of ischemia

    • 0-14days, lysis had lower amputation rates (p=0.052)

    • >14 days, surgery trended toward lower morbidity and less recurrent ischemia

    • 55.8% of lytic patients had a reduction in their operative plan when referred for surgery


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Surgery or Thrombolysis for the Ischemic Lower Extremity

  • Subgroup analysis:

    • Native artery vs. graft occlusion

      • 10% amputation rate in native artery treated with lysis vs. 0% treated with surgery, P=0.0024

      • Amputation rate lower in graft occlusions treated with lysis vs. surgery, p= 0.026

    • Conclusion: lysis is more beneficial in acute graft occlusion < 14 days


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Thrombolysis Or Peripheral Arterial Surgery

  • Funded by Abbott Labs - rUK

  • 544 patients randomized to rUK vs. primary surgery

  • 1 year follow-up

    • Amputation free survival equivalent between groups (68.2% v. 68.8%)

    • 31.5% of lysis patients alive without further intervention at 6 month f/u ( 26% at 1 yr)


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Thrombolysis Or Peripheral Arterial Surgery

  • Predictive factors for amputation-free survival

    • White (RR=1.75; p=0.003)

    • Younger age (RR=1.015; p=0.046)

    • CNS disease (RR=1.726; p=0.006)

    • H/O Malignancy (RR=1.615; p=0.024)

    • CHF (RR=2.202; p<0.001)

    • Low Body Weight (RR=1.007/lb; p=0.006)

    • Skin Changes (RR=1.585; p=0.007)

    • Rest pain (RR=0.503; p=0.003)

  • Longer occlusions fare better with lysis (30cm)


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Thrombolysis Or Peripheral Arterial Surgery

  • Cost analysis: Operative intervention for ALI extended life and was less costly than lysis

  • Life expectancy: 5.04 vs. 4.75 yrs

  • Lifetime cost : $57,429 vs. $76, 326


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Thrombolysis Or Peripheral Arterial Surgery

  • Thrombolysis becomes cost effective if:

    • 1 yr mortality drops from 20% to 10.7%

    • Amputation rate falls from 15% to 3.9%

    • 1 yr cost drops below $13,000 ($49,000 now)

  • Conclusion: Surgery provides most cost effective utilization of resources


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Lysis vs. Surgery

  • Discussion


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Case Presentation

  • To OR:

    • Arteriogram showed no profunda flow and popliteal occlusion

    • Fogarty thromboembolectomy of CFA, PFA, SFA, popliteal, peroneal

    • Foot warm at completion of case

? Fasciotomy


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Compartment Syndrome

“increased pressure within a limited space compromises the circulation and function of the tissues within that space” - Matsen, 1980

First described by Malgaigne and first medical reference by Volkmann, 1881


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Compartment Syndrome

  • Orthopedic, vascular, soft tissue and iatrogenic

  • Vascular - 0 -21% incidence

    • Incidence rises to 50% in patients with both popliteal and venous injuries


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Compartment Syndrome

  • Increased pressure within a fascial compartment

    • Edema, blood

    • Decreased capillary perfusion

    • Peripheral Nerves at risk, Sensorimotor deficit on exam

    • Loss of sensation to light touch as first sign

      • Web space between Great Toe and Second Toe

      • Sensory portion of Deep Peroneal N.

  • Infrageniculate Compartments:

    • Anterior: Anatomy dictates vulnerability

    • Lateral: Affected in conjunction with Anterior

    • Deep posterior and Superficial posterior


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Etiology

  • Normal pressure 10-12 mmHg

  • Compartment Perfusion Pressure = CPP=MAP - Comp. pressure

  • Critical pressure = 30-50 mmHg

  • More accurate measure is :

    • Delta p = diastolic pressure - Comp. press


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Treatment

  • Recommended in patients with delta p < 30 and/or clinical signs

  • Prophylatic in patients with vascular injuries with warm ischemia >4-6 hrs, ligation of major veins or crush injuries


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Fasciotomy


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Case Presentation

  • POD 1 Right calf was tense

  • Compartment pressure 22mm Hg

  • No sensory deficit

  • Discharged home on coumadin on POD 8


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Summary

  • Acute arterial occlusion is associated with high morbidity and mortality

  • Embolic and Thrombotic sources

  • Emergent intervention is necessary

  • Surgery vs. TPA

  • Be aware of compartment pressures


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