Acute Limb Ischemia - J. Nugroho Eko, MD, PhD, FIHA.pdf

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)


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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


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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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What are the common sites for embolus

lodgment in the arterial tree?


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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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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


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Thrombolysis


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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


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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


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Thank You


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Acute Limb Ischemia - J. Nugroho Eko, MD, PhD, FIHA.pdf