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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