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Acute limb ischaemia

  • Effects of sudden arterial occlusion depends on state of collateral supply
  • Collateral supply in leg usually inadequate unless pre-existing occlusive disease

Aetiology of acute limb ischaemia

  • Embolism
    • Left atrium in patients in atrial fibrillation
    • Mural thrombus after myocardial infarct
    • Prosthetic and diseases heart valves
    • Aneurysm or atheromatous stenosis
    • Tumour, foreign body, paradoxical

Acute ischaemia due to intra-arterial injection of temazepam

  • Thrombosis
  • Other
  • Trauma
  • Dissecting aneurysm
  • Raynaud's Syndrome

Clinical features of limb ischaemia

  • Clinical diagnosis depends on the 6 'p' s
    • Pain
    • Paraesthesia
    • Pallor
    • Pulselessness
    • Paralysis
    • Perishing with cold
  • Fixed staining is a late sign
  • Objective sensory loss requires urgent treatment
  • Need to differentiate embolism from thrombosis
  • Important clinical features include
    • Rapidity of onset of symptoms
    • Features of pre-existing chronic arterial disease
    • Potential source of embolus
    • State of pedal pulses in contralateral leg

Management of acute ischaemia

Initial

  • Heparinise & analgesia
  • Treat associated cardiac disease
  • Treatment options are:
    • Embolic disease - embolectomy or intra-arterial thrombolysis
    • Thrombotic disease - intra-arterial thrombolysis / angioplasty or bypass surgery

Emergency embolectomy

  • Can be performed under either general or local anaesthesia
  • Display and control arteries with slings
  • Transverse artereotomy performed over common femoral artery
  • Fogarty balloon embolectomy catheters used to retrieve thrombus
  • If embolectomy fails - on-table angiogram and consider
  • Bypass graft or intraoperative thrombolysis

Thrombectomy specimen

Picture provided by John Byrne, Albany Medical Centre, New York, USA

Intra-arterial thrombolysis

  • Arteriogram and catheter advanced into thrombus
  • Streptokinase 5000u/hr + heparin 250u/hr
  • Alternative thrombolytic agents include urokinase or tissue plasminogen activator (tPA)
  • Repeat arteriogram at 6 -12 hours
  • Advance catheter and continue thrombolysis for 48 hours or until clot lysis

  • Angioplasty of chronic arterial stenosis may be necessary

  • Success 60-70% but needs careful case selection
  • Not suitable if severe neuro-sensory deficit
  • Thrombolysis can be accelerated by:
    • Pulse spray through multiple side hole catheter
    • Aspiration thrombectomy - debulking thrombus aspiration
    • High dose over shorter time
  • Complications
  • Mortality of 1-2%
  • Bleeding - CVA, retroperitoneal

Bibliography

Beard J D  Gaines P A.  Management of the acutely ischaemic leg.  Curr Pract Surg 1995;  7:  123-130.

Beattie D K  Davies A H.  Management of the acutely ischaemic limb.  Br J Hosp Med 1996;  55:  204-208.

Earnshaw J J.  Thrombolysis in acute limb ischaemia.  Ann R Coll Surg Eng 1994;  76:  216-222.

Engledow A H.  Crinnion J N.  Acute lower limb ischaemia.  Hosp Med 2002;  63:  412-415

Golledge J  Galland R B.  Lower limb intra-arterial thrombolysis.  Postgrad Med J 1995;  71:  146-150.

 

 
 

Last updated: 05 January 2008

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