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3: Surgery Y3 - Vascular [20] > [8] Acute Limb Ischaemia > Flashcards

[8] Acute Limb Ischaemia Flashcards

1
Q

What is acute limb ischaemia defined as?

A

A sudden decrease in limb perfusion that threatens the viability of the limb

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2
Q

What can complete or partial occlusion of the arterial supply to a limb lead to?

A

Rapid ischaemia and poor functional outcomes within hours

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3
Q

What can the causes of acute limb ischaemia be classified into?

A

Thrombosis in situ
Embolisation
Trauma

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4
Q

What % of cases of acute limb ischaemia are caused by thrombus in situ?

A

60%

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5
Q

How does a thrombosis in situ form?

A

An atheromatous plaque in the artery ruptures and a thrombus forms on the plaques cap

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6
Q

What kind of presentation can acute limb ischaemia caused by a thrombosis in situ?

A

Acute, or acute-on-chronic (on a background of peripheral arterial disease)

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7
Q

What % of cases of acute limb ischaemia are caused by embolisation?

A

30%

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8
Q

How does embolisation cause acute limb ischaemia?

A

A thrombus from a proximal source travels distally to occlude the artery

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9
Q

Where may the original thrombus result from in embolism causing acute limb ischaemia?

A

AF
Post-MI mural thrombus
Abdominal aortic aneurysm
Prosthetic heart valves

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10
Q

What % of cases of acute limb ischaemia are caused by trauma?

A

10%

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11
Q

Give an example of a traumatic cause of acute limb ischaemia

A

Compartment syndrome

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12
Q

What are the classical signs and symptoms of acute limb ischaemia?

A 
Pain
Pallor
Pulselessness
Paresthesia
Perishingly cold
Paralysis
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13
Q

What is acute limb ischaemia often characterised by?

A

The sudden onset of symptoms

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14
Q

What is a normal, pulsatile contralateral limb a sensitive sign of in acute limb ischaemia?

A

Embolic occlusion

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15
Q

What should be explored in the history of an acute limb ischaemia?

A

Causes of potential embolism

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16
Q

What are the potential causes of embolisation in acute limb ischaemia?

A 
Chronic limb ischaemia
Atrial fibrillation
Recent MI resulting in mural thrombus
Symptomatic AAA 
Peripheral aneurysms
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17
Q

What is the result of a later presentation to hospital with acute limb ischaemia?

A

The later a patient presents to hospital, the more likely that irreversible damage to the neuromuscular structures will have occurred, which will ultimately result in a paralysed limb

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18
Q

When does irreversible damage to neurovascular structures become more common in acute limb ischaemia?

A

> 6 hours post-symptom onset

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19
Q

What are the categories of acute limb ischaemia?

A

I - Viable
IIA - Marginally threatened
IIB - Immediately threatened
III - Irreversible

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20
Q

What is the prognosis of category I acute limb ischaemia?

A

No immediate threat

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21
Q

What degree of sensory loss is there in category I acute limb ischaemia?

A

None

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22
Q

What degree of motor deficit is there in category I acute limb ischaemia?

A

None

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23
Q

Is the arterial doppler audible in category I acute limb ischaemia?

A

Yes

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24
Q

Is the venous doppler audible in category I acute limb ischaemia?

A

Yes

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25
What is the prognosis in category II acute limb ischaemia?
Salvageable, if promptly treated
26
What degree of sensory loss is there in category II acute limb ischaemia?
Minimal (toes) or none
27
What degree of motor loss is there in category II acute limb ischaemia?
None
28
Is the arterial doppler audible in category II acute limb ischaemia?
No
29
Is the venous doppler audible in category II acute limb ischaemia?
Yes
30
What is the prognosis of category III acute limb ischaemia?
Salvageable if immediately revascularised
31
What degree of sensory loss is there in category III acute limb ischaemia?
More than toes | Rest pain
32
What degree of motor deficit is there in category IIb acute limb ischaemia?
Mild/moderate
33
Is the arterial doppler audible in category III acute limb ischaemia?
No
34
Is the venous doppler audible in category III acute limb ischaemia?
Yes
35
What is the prognosis of category III acute limb ischaemia?
Major tissue loss with permanent nerve damage inevitable
36
What degree of sensory loss is there in category III acute limb ischaemia?
Profound
37
What degree of motor loss is there in category III acute limb ischaemia?
Profound, paralysis
38
Is the arterial doppler audible in category IV acute limb ischaemia?
No
39
Is the venous doppler audible in category IV acute limb ischaemia?
No
40
What are the differential diagnoses of acute limb ischaemia?
Critical chronic limb ischaemia Acute DVT Spinal cord or peripheral nerve compresison
41
What forms of DVT can present like acute limb ischaemia?
Phlegmasia cerulea dolens and Phlegmasia alba dolens
42
What investigations into acute limb ischaemia should be done?
Routine bloods ECG Doppler ultrasound scan CT angiography
43
What should routine bloods include in acute limb ischaemia?
Serum lactate Thrombophilia screen Group and save
44
Why is serum lactate important in acute limb ischaemia?
Assess the level of ischaemia
45
When should a thrombophilia screen be done in acute limb ischaemia?
If <50 years old without known risk factors
46
What investigation can be done if the limb is considered to be salvageable?
CT arteriogram
47
Why is a CT arteriogram done when the limb is considered to be salvageable in acute limb ischaemia?
It can provide more information regarding the anatomical location of the occlusion, and can help decide the operative approach
48
How long will it take for acute limb ischaemia to cause irreversible tissue damage?
6 hours
49
What is the result of acute limb ischaemia causing irreversible tissue damage within 6 hours?
It is a surgical emergency, and early senior surgical support is vital
50
How should a patient with acute limb ischaemia be managed initially?
Start patient on high-flow oxygen and ensure adequate IV access A therapeutic dose of heparin or preferably a bolus dose then heparin infusion should be initiated as soon as practical
51
When can conservative management be considered in acute limb ischaemia?
In category I and IIa cases
52
What is the most effective non-operative management of acute limb ischaemia?
Prolonged course of heparin
53
What is required in any patient started on conservative management of acute limb ischaemia via heparin?
They will need regular assessment to determine its effectiveness through monitoring APPT and clinical review
54
What may be warranted in a patient recieving conservative management for acute limb ischaemia if no significant improvement is seen?
Surgical interventions
55
When is surgical intervention mandatory for acute limb ischaemia?
Category 2b cases and above
56
What are the options for surgical management of acute limb ischaemia when the cause is embolic?
Embolectomy Local intra-arterial thrombolysis Bypass surgery
57
How is an embolectomy performed in acute limb ischaemia?
Via a Fogarty catheter
58
What is the problem with the use of intra-arterial thrombolysis in acute limb ischaemia?
It is often difficult to conduct within 6 hours
59
What is intra-arterial thrombolysis often used for as a result of it being difficult to conduct within 6 hours?
Category 2a cases
60
When is bypass surgery used to treat embolic acute limb ischaemia?
When there is insufficient flow back
61
What are the options for surgical management of acute limb ischaemia when caused by thrombotic disease?
Local intra-arterial thrombosis Angioplasty Bypass surgery
62
What are the clinical signs of irreversible limb ischaemia?
Mottled, non-blanching appearance with hard woody muscles
63
What management does irreversible limb ischaemia require?
Urgent amputation or palliative approach
64
How are patients with acute limb ischaemia managed post-operatively?
Most require a high level of care, typically at the surgical high dependancey unit
65
Why do acute limb ischaemia patients need to be managed with a high level of care after acute limb ischaemia?
Due to the ischaemia reperfusion syndrome
66
What is involved in the long term management of acute limb ischaemia?
Reduction of the cardiovascular mortality risk Anti-platelet therapy Treatment of underlying predisposing conditions, e.g. uncontrolled AF Occupational therapy and physiotherapy
67
How is the cardiovascular mortality risk reduced following acute limb ischaemia?
Promotion of regular exercise Smoking cessation Weight loss
68
What anti-platelet therapy is given after acute limb ischaemia?
Low-dose aspirin or clopidogrel
69
What can be given as an alternative to anti-platelet therapy in acute limb ischaemia?
Anticoagulation with warfarin or a DOAC
70
When will occupational therapy and physiotherapy be required in the long-term management of acute limb ischaemia?
In cases resulting in amputation
71
How is rehabilitation conducted after amputation due to acute limb ischaemia?
A long term rehabilitation plan is discussed, with transfer to an intermediate rehabilitation centre
72
What is the mortality rate of acute limb ischaemia?
20%
73
What is the 30-day mortality rate following the surgical treatment of acute limb ischaemia?
15%
74
What is an important complication of acute limb ischaemia?
Reperfusion injury
75
What happens in reperfusion injury?
There is a sudden increase in capillary permeability
76
What can a sudden increase in capillary permeability result in?
Compartment syndrome | Release of substances from damaged muscle cells, such as potassium ions, hydrogen ions, and myoglobin
77
What can potassium ions released from damaged muscle cells lead to?
Hyperkalaemia
78
What can hydrogen ions released from damaged muscle cells lead to?
Acidosis
79
What can myoglobin released from damaged muscle cells lead to?
Significant AKI
80
What does electrolyte imbalance due to reperfusion injury require?
Close monitoring and potentially haemofiltration

3: Surgery Y3 - Vascular [20] (10 decks)

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