FN: Acute Limb Ischaemia Flashcards
Acute definition
Acute definition
Acute on chronic
Worsening symptoms and signs
Chronic
Ischaemia stable for >14d
Severity
Incomplete: limb not threatened
Complete: lib threatened - loss of limb unless intervention w/i/6hrs
Irreversible: requires amputation
Causes
Thrombosis in situ Embolism Graft/stent occlusion Trauma Aortic dissection
Thrombosis in situ (60%)
A previously stenosed vessel with plaque rupture
Usually incomplete ischaemia
Embolism (30%)
- 80% form LA to AF
- Valve disease
- iatrogenic form angioplasty/surgery
- Cholesterol in long bone fracture
- Paradoxical (venous via PFO)
- typically lodge at femoral bifurcation
- Often complete ischaemia
Presentation:6Ps
Pale Pulseless Perishingly cold Painful Parasthesia Paralysis
Emobolus Onset Severity Embolic source Caludication Hx Contralat pulses Dx Rx
Sudden Profound ischaemia Present - often AF Absent Present Clinical Embolectomy + Warfarin
Chronic
Ischaemia stable for >14d
Severity
Incomplete: limb not threatened
Complete: lib threatened - loss of limb unless intervention w/i/6hrs
Irreversible: requires amputation
Causes
Thrombosis in situ Embolism Graft/stent occlusion Trauma Aortic dissection
Thrombosis in situ (60%)
A previously stenosed vessel with plaque rupture
Usually incomplete ischaemia
Embolism (30%)
- 80% form LA to AF
- Valve disease
- iatrogenic form angioplasty/surgery
- Cholesterol in long bone fracture
- Paradoxical (venous via PFO)
- typically lodge at femoral bifurcation
- Often complete ischaemia
Presentation:6Ps
Pale Pulseless Perishingly cold Painful Parasthesia Paralysis
Thombosis Onset Severity Embolic source Caludication Hx Contralat pulses dx Rx
- Hrs-days
- Less severe - collaterals
- Present
- Absent
- Angiography
- Thrombolysis
Bypass surgery
OTher options
Emergency reconstruction
Amputation
Investigations
Bloods: FBC, U+E, INR, G+S, CK
ECG
Imaging: CXR, Duplex doppler
General Mx
In an acutely ischaemic limb discuss immediately with a senior as tim eis crucial
NBM
Rehydration: IV fluids
analgesia: morphine + metoclopramide
Abx: e.g. augmentin if sgns of infection
Unfractionated heparin IVI: prevent extension
Complete occlusion Mx
Yes: uregent surgery: embolectomy or bypass
No: agiogram + observe for deterioration
Angiography
Not performed if there is complete occlusion as it introduces delay: take straight to theatre
If incomplete occlusion, pre-op angio wil guide any distal bypass
Embolus management
Embolectomy
thrombolysis
Other otpions
Embolectomy
LA or GA
Wire fed through embolus
Fogarty catheter fed ocer the top
Balloon inflated and caether withdraw, reomving the embolsim
Send embolis for histo (exclude atrial myxoma)
Adequacy confirmed by on-table angiography
thrombolysis
Consider if embolectomy unsuccessful
e.g. local injectino of TPA
OTher options
Emergency reconstruction
Amputation
Post-embolectomy
- Anticoagulate: heparin IVI - warfarin
ID embolic source: ECG, echo, US aorta, fem and pop
Complication spost-embolectomy
Reperfusion injury
- Local swelling - compartment syndrome
- Acidosis and arrhythmia secondary to potassium increased
- ARDS
- GI oedema: endotoxic shock
Chronic pain syndromes
thombosis Mx
Emergency reconstruction if complete occlusions
angiography _ angioplasty
Thrombolysis
Amputation
