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Vascular > Acute Limb Ischemia > Flashcards

Acute Limb Ischemia Flashcards

1
Q

Classic signs of ALI

A

6 P’s:
Pain
Pallor
Pulselessness
Paralysis
Paraesthesia
Perishingly cold

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2
Q

Rutherford classification

A

I: viable
II: threatened
a (marginal): minimal sensory
b (immediate): sensory + motor deficit
III: irreversible

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3
Q

Parameters of Rutherford classification

A

Capillary refill
Sensory Loss
Muscle paralysis
Doppler sign

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4
Q

Embolic causes of ALI

A

Cardiac:
-AF
-post MI mural thrombus
-CRHD
Atherosclerotic plaque
Proximal aneurysms

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5
Q

Thrombotic causes of ALI

A

Atherosclerosis
Popliteal aneurysm
Bypass graft occlusion
Stent occlusion
Thrombotic conditions

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6
Q

Other (non-embolic/thrombotic) causes of ALI

A

Trauma/Iatrogenic
Aortic dissection
Drug use
Popliteal entrapment
Cystic adventitial disease
External compression
Compartment syndrome

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7
Q

TOPAS trial

A

Multicenter RCT comparing Surgery vs intra-arterial thrombolysis in acute lower limb ischemia

NO difference in amputation free survival (6m, 1y) and overall survival

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8
Q

Evidence of surgery vs intra-arterial thrombolysis

A

New York study
TOPAS
STILE

Conclusion: both effective

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9
Q

Indications for intra-arterial thrombolysis

A

Acute lower limb ischemia
Bypass graft thrombosis
Endovascular complications

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10
Q

Contraindications for IAT

A

Active bleeding (absolute)
Known pregnancy
Stroke/TIA within 2 months
Craniotomy within 2months
Vas/abd surgery within 2 weeks
Puncture of non-compressible vessel/bx within 10 days
Previous GIB
Trauma within 10 days

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11
Q

Agents for IAT

A

Urokinase
r-TPA (tissue plasminogen activator)
Streptokinase (rarely used due to anaphylaxis)

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12
Q

Predictors of failure for IAT

A

Multilevel disease
DM
Age
Female
Failure of guide wire traversal

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13
Q

Management for compartment syndrome

A

Emergency double incision fasciotomy

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14
Q

Landmarks for double incision lower limb fasciotomy

A

Anterolateral incision: 2cm anterior to fibular shaft
Posteromedial: 2cm posterior to medial border of tibia

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15
Q

Ischemic-reperfusion injury

1) pathophysiology
2) toxic metabolites
3) manifestation

A

1) bloodstream carries toxic metabolites to the parts of body
2) K, PO4, Lactic acid, Myoglobin, CK
3) AKI, DCI, SIRS

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16
Q

Treatment of myoglobinuria in ischemic repercussion injury

A

NaHCO3 for alkalinization of urine
Emergency hemodialysis

17
Q

Modifiable risks for atherosclerosis

A

Smoking
DM/Glycemic control
HT
HL
Renal disease
High homocysteine levels
Hypercoagulability

18
Q

Non-modifiable risks for atherosclerosis

A

Age
Gender
Ethnicity

19
Q

Definition of Peripheral arterial disease (PAD)

A

atherosclerosis leads to arterial stenosis and occlusion of major vessels supplying the lower extremities

20
Q

Intermittent claudication

A

Reproducible ischemic muscle discomfort in lower limb by exercise, and relieved by rest within 10 minutes

21
Q

Pre-operative preparation for embolectomy

A
  • Rehydration
  • O2 therapy
  • Heparin injection
    • 5000 units or 80 units/ kg
  • LA under MAC
  • Prep:
    • Heparin saline
    • Fogarty catheter (Fr3,4,5)
    • Radiolucent XR table
    • Doppler USG
22
Q

What is the incision for embolectomy?

A

Vertical incision directly over femoral pulse at midpoint between pubic symphysis and ASIS

23
Q

How to perform a femoral embolectomy?

A
  • Vertical incision over groin centered over CFA
  • Double sling CFA, SFA, PFA
  • Transverse arteriotomy in origin of CFA just above PFA
  • Fogarty ballon Fr 4/5 for proximal trawl, Fr 3 / 4 for distal trawl until good flow and back bleeding
24
Q

What are potential problems with just femoral approach?

A
  • Anterior tibial artery clots missed
  • May need popliteal exploration for three lower limb vessels
25
Q

What type of sutures are used for vascular repair?

A

Monofilament

Synthetic (Non-absorbable)

Double-armed

Vascular (6 decks)

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