Tomáš Novotný II. chirurgická klinika LF MU a FN u sv. Anny Acute peripheral arterial occlusion [USEMAP] •result of a sudden deterioration in the arterial blood supply • •Causes – –arterial embolism –arterial thrombosis – –other causes •trauma •iatrogenic causes •occlusion of a vascular reconstruction Acute ischemia [USEMAP] •result of a material (embolus) passing through the arterial tree and obstructing a peripheral artery • •Source –the heart –atherosclerotic debris –tumors –foreign bodies –… – Arterial embolism Source: http://www.secondscount.org/heart-condition-centers/info-detail-2/cardiac-embolism-stroke Výsledek obrázku pro embolism [USEMAP] •most commonly the result of progressive atherosclerotic narrowing in peripheral arteries • •hypercoagulable states •shock •arterial dissection Arterial thrombosis R:\AZV_2015\Kniha\obrázky\FotkyFoto_8552915_L.jpg [USEMAP] •depends on –size of occluded artery –available collaterals (physiological or developed) – •e.g. superficial femoral artery occlusion in the presence of well-established collaterals may be entirely asymptomatic Clinical presentation http://upload.wikimedia.org/wikipedia/commons/e/e7/Gray528.png [USEMAP] •sensory loss •motor loss •sudden pain •cold leg •white leg •absent peripheral pulses Clinical presentation R:\DistCOVID\pics\foot_IIb.jpg Source: Ruhterford‘s Vascular Surgery 8th Edition [USEMAP] •sensory loss •motor loss •sudden pain •cold leg •white leg •absent peripheral pulses Clinical presentation Source: Ruhterford‘s Vascular Surgery 8th Edition [USEMAP] •History – •clinical presentation assessment, duration – •source of embolism –atrial fibrillation, previous myocardial infarctions, valvular heart disease, … – •peripheral arterial disease •intermittent claudication • •atherosclerosis risk factors •Physical findings – •rule of Ps –pain –pallor –paresis –pulse deficit –paresthesia –poikilothermia • •aneurysms •irregular pulse •contralateral extremity • Clinical assessment [USEMAP] •Embolism •History –source of embolism –no claudication • •Physical findings –irregular pulse, … –normal peripheral pulses in contralateral extremity • • •Thrombosis •History –no source of embolism –claudication • •Physical findings –regular pulse, … –no peripheral pulses in contralateral extremity • Embolism vs. thrombosis Embolism might occur in a patient with claudication/peripheral arterial disease and without known sources of embolism in history and vice versa! ! [USEMAP] Classification of Acute Limb Ischemia Category / class Description / Prognosis FINDINGS DOPPLER SIGNALS Sensory Loss Muscle Weakness Arterial Venous I. Viable Not immediately threatened None None Audible Audible II. Threatened a. Marginally Salvageable if promptly treated Minimal (toes) or none None Inaudible Audible b. Immediately Salvageable with immediate revascularization More than toes, associated with rest pain Mild, moderate Inaudible Audible III. Irreversible Major tissue loss or permanent nerve damage inevitable Profound, anesthetic Profound, paralysis (rigor) Inaudible Inaudible [USEMAP] •the anatomical location of arterial occlusion –aortic occlusion –iliac occlusion –femoropopliteal occlusion –popliteal and infrapopliteal occlusion – •Imaging may be valuable • •However, there may be no time! Diagnosis [USEMAP] Aortic occlusion [USEMAP] •Computed Tomographic (CT) Angiography – •usually available 24/7 – •the investigation of choice for acute arterial ischemia Diagnosis - imaging R:\DistCOVID\pics\CT_okl.jpg [USEMAP] •Duplex ultrasonography –availability? – •Digital subtraction angiography –less accessible than CT angiography –best choice when an endovascular solution to the arterial occlusion is likely – •Magnetic resonance angiography (MRA) –not suitable –usually not available at off hours Diagnosis - imaging [USEMAP] •Anticoagulation –immediate anticoagulation with intravenous calcium heparin can stabilize the condition of the leg –the potential for immediate reversal with protamine makes calcium heparin the drug of choice – •Ancillary supportive measures –oxygen delivered by facemask –intravenous fluid administration –analgesia Initial management [USEMAP] •Anticoagulation • •Operative intervention –embolectomy or thrombectomy using Fogarty catheters –vascular reconstruction (bypass, endarterectomy, patch angioplasty) – •Endovascular intervention –percutaneous intra-arterial thrombolysis –mechanical thrombectomy / aspiration embolectomy – Treatment [USEMAP] •Category I –medical therapy –elective revascularization (optional) – •Category IIa –immediate revascularization not necessary –endovascular or surgical options may be considered – •Category IIb (sensory and motor deficit) –immediate revascularization is necessary –surgical revascularization is generally preferred –endovascular options may be considered Treatment selection [USEMAP] •Category III –primary amputation should be considered Treatment selection Source: Ruhterford‘s Vascular Surgery 8th Edition [USEMAP] •Embolectomy or thrombectomy – –balloon catheters are passed proximally and distally until no visible thrombus is removed and a pulse or backflow is established – –completion angiography is important to evaluate the effectiveness of thrombus removal Operative intervention Source: Ruhterford‘s Vascular Surgery 8th Edition [USEMAP] • • •Bypass • • • • •Endarterectomy and patch plasty Operative intervention Source: Ruhterford‘s Vascular Surgery 8th Edition [USEMAP] •Catheter-directed thrombolysis –tissue plasminogen activators are used (e.g. Actilyse) Endovascular treatment Source: Ruhterford‘s Vascular Surgery 8th Edition [USEMAP] •Percutaneous mechanical thrombectomy –devices •hydrodynamic •rotational •aspiration thrombectomy catheters Endovascular treatment EPOS™ Source: https://epos.myesr.org/esr/viewing/index.php?module=viewing_poster&pi=138573 [USEMAP] •The medical state of a patient who presents with acute leg ischemia is a good prognostic index of survival. • •The outcome after treatment for acute limb ischemia is often poor. Prognosis [USEMAP] •Patients are on average about 4 years older. • •seldom threatens the limb • •treatment is to prevent late complications –activity-induced arm fatigue and pain (up to 50% patients have late symptoms if untreated) • •cardiac embolism is the main cause •atherosclerosis is rare Upper limb ischemia [USEMAP] •often cold feeling and numbness rather than pain in the arm • •diagnosis is clinical –(can be confirmed by duplex imaging) • •up to 20% of patients with acute arm ischemia do not survive the acute event! Upper limb ischemia [USEMAP] •is an increase in intracompartmental pressure • •up to 20% of patients after revascularization • •mechanism is ischemia-reperfusion • •risk factors –prolonged ischemia time (>6 hours); young age; insufficient arterial collaterals; acute time course for arterial occlusion; hypotension; poor back-bleeding from the distal arterial tree at embolectomy Compartment syndrome [USEMAP] •Fasciotomy Compartment syndrome [USEMAP] Fasciotomy - indications Absolute Indications Potential Indications • Tense compartment plus either: • Pain with passive motion of muscles traversing the same compartment or • Paresis or paresthesias referable to the same compartment • Tense compartment in a patient who cannot be examined serially due to obtundation or need for other operations. • ICP minus mean blood pressure <40 mm Hg • ICP minus diastolic blood pressure <10 mm Hg • Acute ischemia >6 hr with few collaterals • Combined arterial and venous traumatic injuries • Phlegmasia cerulea dolens • Tense compartment after crush injury • Tense compartment after fracture ICP, Intracompartmental pressures. Source: Ruhterford‘s Vascular Surgery 8th Edition [USEMAP] •large quantities of intracellular potassium, phosphate, myoglobin, and creatine phosphokinase are liberated • •Hyperkalemia –dialysis or continuous veno-venous hemofiltration might be needed – •Myoglobinuria –tea-colored urine Systemic sequelae of myonecrosis E:\Archiv\OperFotoUsable\myoglobinurie.JPG [USEMAP] •Myoglobinuria induces –renal vasoconstriction –tubular cast formation –direct heme protein-induced cytotoxicity • •Management of myoglobinuria –aggressive crystalloid infusion –forced diuresis –alkalinization of the urine with bicarbonate (optional) –hemodialysis is not a useful Systemic sequelae of myonecrosis [USEMAP] Thank you for your attention! [USEMAP]