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Management of Acute Limb Ischemia

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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  1. Management of Acute Limb Ischemia Steven Hanish, MD Thursday Resident Conference September 29, 2005

  2. Outline • Review of lower extremity arterial anatomy • Clinical Presentation • Surgical vs. non-surgical interventions • Compartment Syndrome

  3. Anatomy

  4. Anatomy

  5. Anatomy

  6. Anatomy

  7. Rutherford Classification Doppler

  8. 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%

  9. 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

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

  11. ER Consult • H and P • Focus on comorbidities • Tobacco, Diabetes, Afib, • H/O vascular diseases • H/O hypercoag. state

  12. ER Consult Physical Exam: • Pain • Pallor • Pulselessness • Paresthesias • Paralysis • Poikilothermia

  13. 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

  14. Case Presentation • PE: • Irregularly, irregular pulse • Palp. Femoral pulses, no distal pulses, RLE very cool • No evidence of tissue necrosis

  15. 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%

  16. 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

  17. Case Presentation • NOW WHAT? Operating Room vs. Interventional Radiology

  18. TPA vs. Surgery • 3 randomized, clinical trials • Rochester series • STILE trial • TOPAS trial

  19. TPA

  20. 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

  21. 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

  22. 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

  23. 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

  24. 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)

  25. 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)

  26. 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

  27. 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

  28. Lysis vs. Surgery • Discussion

  29. 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

  30. 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

  31. Compartment Syndrome • Orthopedic, vascular, soft tissue and iatrogenic • Vascular - 0 -21% incidence • Incidence rises to 50% in patients with both popliteal and venous injuries

  32. 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

  33. 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

  34. 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

  35. Fasciotomy

  36. Case Presentation • POD 1 Right calf was tense • Compartment pressure 22mm Hg • No sensory deficit • Discharged home on coumadin on POD 8

  37. 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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