Management of Acute Limb Ischemia

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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

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Anatomy
4
Anatomy
5
Anatomy
6
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
• MM 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 _at_ 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 (plt0.001)
• Reduction in ongoing/recurrent ischemia
• Stratification by duration of ischemia
• 0-14days, lysis had lower amputation rates
  (p0.052)
• gt14 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, P0.0024
• Amputation rate lower in graft occlusions treated
  with lysis vs. surgery, p 0.026
• Conclusion lysis is more beneficial in acute
  graft occlusion lt 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 (RR1.75 p0.003)
• Younger age (RR1.015 p0.046)
• CNS disease (RR1.726 p0.006)
• H/O Malignancy (RR1.615 p0.024)
• CHF (RR2.202 plt0.001)
• Low Body Weight (RR1.007/lb p0.006)
• Skin Changes (RR1.585 p0.007)
• Rest pain (RR0.503 p0.003)
• 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 CPPMAP - 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 lt 30 and/or
  clinical signs
• Prophylatic in patients with vascular injuries
  with warm ischemia gt4-6 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