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8/18/2019 Acute Limb Ischemia - J. Nugroho Eko, MD, PhD, FIHA.pdf
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CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
CURRICULUM VITAEDR. Dr. J. NUGROHO E. P, Sp.JP(K) , FIHA, FAsCC, FICA
• J. Nugroho E.P was born in Yogyakarta-Indonesia in 1968 and is the staff of the Cardiovascular Department – Dr. Soetomo General Hospital.
• Education :
• 1992 : Medical degree, Gajah Mada University, Jogjakarta-Indonesia
• 2003 : Cardiovascular Specialist, Airlangga University, Surabaya- Indonesia Cardiologist
certification by National Board of Examination, The Indonesian Heart Association
• 2013 : Consultant Cardiologist (Vascular Cardiology) by National Board of Certification/
Collegiums of Cardiology & Vascular Medicine)
• 2014 : Doctoral degree, Airlangga University, Surabaya - Indonesia• Training in board :
• 2005 : ECHO Singapore
• 2007 : Singapore, Cardiac CT Course
• 2007 : Peripheral Computed Tomography, UCLA, los Angeles
• 2010 : Cardiac MRI Siriraj Hospital Bangkok, Thailand
• 2011 : Vascular Training, Harapan Kita – National Heart Centre, Jakarta
• 2012 : Echocardiography and Vascular Training in Philipine Heart Centre, Quezon City
• 2013 : Fellowship on Intermediate Interventional Cardiology, Dr. Soetomo Teaching
Hospital Faculty of Medicine AirlanggaMemberships:
• Member Indonesian Medical Association
• Member Indonesian Heart Association
• Fellow of ASEAN Federation of Cardiology (FAsCC)
• Fellow of International College Angiology (FICA)
8/18/2019 Acute Limb Ischemia - J. Nugroho Eko, MD, PhD, FIHA.pdf
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History & Exam FindingsFurther Hx:
• 2 days ago pain on left LEA• CVA 4 years ago
Examination:• Inspection:
o LLL: below the knee is pale/cool
• Palpation:
o Irregularly irregular pulse
o LLL Capillary return is sluggish
o No pulses palpable below L femoral artery
o All pulses palpable but appear reduced in R leg
Impression?60yo female with a L Acute Ischemic limb , untreated AF and
symptomatic PVD.
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Defined as a sudden decrease in limb
perfusion that threatens the viability of the
limb
less than 14 days’ duration
Symptoms develop over a period of hours to
days
Variable ischaemic clinical manifestations
Potential risk of limb loss
incidence 1.5 cases per 10,000 persons per
year. Shishehbor Mehdi H, 201
ACUTE LIMB ISCHEMIA
8/18/2019 Acute Limb Ischemia - J. Nugroho Eko, MD, PhD, FIHA.pdf
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CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Thrombosis ( 50% of cases )
artherosclerosis (native or bypass)
Aneurysm
Trauma
Vasculitis
Hypercoagulable states
Embolism ( 30% of cases )
Uncommon causes : Arterial dissection
Naidoo et al, 2013
CAUSES
OF ACUTE LIMB ISCHEMIA
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What is the possible source for an
embolus?
Spontaneous (80%)Cardiac source
arrhythmias, MI, prosthetic valve, endocarditis
Non-Cardiac source
Proximal Aneurysm, Paradoxical emboli
Iatrogenic (20%)
Angiographic manipulation
Surgical manipulation
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CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
What are the common sites for embolus
lodgment in the arterial tree?
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CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
What are the features
of an acute ischemic limb?
REMEMBER THE 6 P’S:
1. PAIN
1. PALLOR
1. PULSELESNESS
1. PERISHING COLD (POIKILOTHERMIA)
1. PARASTHESIAS
1. PARALYSIS
Fixedmottling &
cyanosis
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Investigations
Acute Limb Ischemia is a
CLINICAL DIAGNOSIS
If time allows, especially if atherosclerotic thrombosis is
suggested, preoperative angiography is often wise
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CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Palpation arteries ( detect pulse,
temperature and pallor )
Presence of flow with a Doppler
instrument
Duplex Ultrasonography
Computed Tomographic Angiography
Magnetic Resonance Angiography
Contrast Angiography
Kovacs et al, 2013
DIAGNOSTIC METHODS
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Naidoo et al, 2013
CLINICAL CLASSIFICATION OF
ACUTE LIMB ISCHEMIA
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Naidoo et al, 2013
ALGORITHM FOR
THE DIAGNOSIS AND TREATMENT OF ACUTE LIMB
ISCHEMIA
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Acute Limb Ischemia (ALI)
Patients with ALI and a salvageable
extremity should undergo an emergent
evaluation that defines the anatomic level of
occlusion, and that leads to prompt
endovascular or surgical intervention.
Patients with ALI and a non-viable extremity
should not undergo an evaluation to define
vascular anatomy or efforts to attempt
revascularization.
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CT Angiography Digital Subtraction
Angiography
Value of angiography
Localizes the obstruction
Visualize the arterial tree & distal
run-off Can diagnose an embolus:
Sharp cutoff, reversed meniscus or clot
silhouette
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CTA has potential advantages over MRA
Pts with PPI or ICD may be imaged safely with CTA
Metal clips, stents, and prostheses usually do not causesignificant CTA artifacts
Has higher resolution
Can provide images of calcification in the vessel wall
Scan times are significantly faster with CTA than with
MRA
Claustrophobia not a problem
CTA also has potential disadvantages compared withMRA
Requires iodinated contrast, which may be nephrotoxic
Requires ionizing radiation
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ENDOVASCULAR REVASCULARISATION
Goal to restore blood flow as rapidly
With the use of drugs, mechanical devices, or both
Ischemia for 12 to 24 hours would not be safe
should not undergo catheter-directed therapies.
Two modalities exist:
CDT ( Catheter Directed Thrombolysis )
PMT ( Percutaneus Mechanical Thrombectomy )
Rooke TW et al, 2011
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CATHETER-DIRECTED THROMBOLYSIS
Technique currently used to clear arteries, arterioles andcapillary beds
Thrombolytic agents or rt-PA use to enable clotdissolution.
Deliver thrombolytic agent to thrombus
Success determined by the ability cross a thrombosed
Complications :
bleeding (12.5% ) distal embolisation
Rasavi, Hoffman, 2003
8/18/2019 Acute Limb Ischemia - J. Nugroho Eko, MD, PhD, FIHA.pdf
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Thrombolysis
8/18/2019 Acute Limb Ischemia - J. Nugroho Eko, MD, PhD, FIHA.pdf
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Simple aspiration with or without thrombolytic
agent
best for high risk surgery and not suitable for CDT.
Complications
distal embolisation
haemolysis
fluid overload with select
Rasavi, Hoffman, 2003
PERCUTANEOUS MECHANICAL
THROMBECTOMY
8/18/2019 Acute Limb Ischemia - J. Nugroho Eko, MD, PhD, FIHA.pdf
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SURGICAL REVASCULARISATION
balloon catheter embolectomy,
transluminal thrombectomy
vascular bypass procedures
Endarterectomy
patch-plasty
intraoperative thrombolysis
hybrid procedures (surgery and endovascular
procedures, viz. angioplasty/stenting).
Comerota ,Gravett , 2009
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SURGICAL REVASCULARISATION
Transfemoral Fogarty catheter-based techniques best suited for
embolic or thrombosed vascular graft
Iliac native vessel thrombectomy + stent residual stenosis >
30%
Infra inguinal native vessel thrombosis thrombectomy,endarterectomy, patch angiography
Complication :
Amputation (10-30% )
Mortality ( 10-20 % )
Result :
degree ALI
Comorbidities Aliason et al, 2003
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Surgical Thromboembolectomy Procedure
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MRS T 73 yo Dx ALI
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ENDOVASCULAR VERSUS SURGICAL
REVASCULARIZATION
Similar rates of limb salvage Thrombolysis
higher rates of stroke and major hemorrhage within 30
days
12 month rates of survival were higher
No differences in amputation free survival, deaths, or
health relatec quality of life
Surgery hospital costs one third higher
The Bypass Versus Angioplasty
in Severe Ischaemia of the Leg ( BASIL ) trial
Comerota ,Gravett , 2009
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The surgery versus thrombolisis
for ischemia of the lower extremity ( STILE ) trial
Thrombolysis higher rates of ischemia, amputation,complications
Rate of amputation free survival higher sympton less than 14 days
Rates limb salvage , survival did not differ
Thrombolysis complication rate higher
In the thrombolysis or Pheriperal Arterial Surgery
( TOPAS ) trial
Naidoo et al, 2013
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Catheter directed thrombolysis
Best result in viable or marginally threatened limb
Recent occlusion ( no more than 2 weeks )
Preferred for immediately threatened limb
Symptoms occlusion more than 2 weeks
Surgical revascularisation
Tendera et al, 2011
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ALI defined as a sudden decrease in limb perfusion
that cause acute thrombosis or embolism
less than 14 days’ duration
The features as parasthesia, pain, pollar, pulseless,
poikilothermia, paralysis
Prompt diagnosis and revascularization ( by
endovascular or by surgical ) reconstruction reduce
the risk of limb loss
Amputation is performed in patients with
irreversible damage
SUMMARY
8/18/2019 Acute Limb Ischemia - J. Nugroho Eko, MD, PhD, FIHA.pdf
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Thank You
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