ACUTE ARTERIAL

OCCLUSION
By
Dr .V. Srinivas
• Acute limb ischemia is any sudden decrease
or worsening in limb perfusion causing a
potential threat to extremity viability
• Acute limb ischemia secondary to thrombosis
or embolus is true emergency
 Epidemiology
 Incidence: 1.7 cases / 10,000 people / Yr.
 Elderly
 Male > female
 11-27%of elderly have peripheral arterial
disease
 Mortality 15%, Amputation 10-30%
 Medical co-morbidities common
 CVD 12%, CAD 45%, DM, 31%, HTN 60%, CHF
13%
 Etiology
 either an embolus, thrombosis, or a
combination of the two may produce the
obstruction
 Etiologies of Acute Arterial
Occlusion
 Emboli
 In situ thrombosis
 high grade native vessel of graft stenoses
 Vascular inflammatory diseases
 Trauma
 External compression
 Dissection
 Compartment syndrome
 Severe venous diseases
 Hypercoagulable states
 Etiology
 Thrombotic occlusion is significantly more
common cause of acute limb ischemia than is
embolism.
 Emboli originate from the heart in 80-90 %
with atrial fibrillation being the cause in two
thirds of all peripheral emboli.
 Mural thrombus in the ventricle after recent
myocardial infarction is the second most
common cause.
 Etiology
 Other causes of emboli include atrial
myxomas, vegetations from valve leaflets, and
parts of prosthetic devices such as mechanical
valves.
 Noncardiac causes include thrombi from
aneurysms and atheromatous plaques.
 Iatrogenic embolization can happen during
angiograhic procedures of the aorta and larger
vessels
 ARTERIAL EMBOLI

Source of Embolus in 300 Patients

Atrial Fibrillation 231
R.H.D. 48
Acute MI 50
Atherosclerotic plaque 7
Unknown 12
 Etiology
 Thrombosis unrelated to atherosclerotic disease can
occur at an area of vessel injury during invasive
studies.
 Peripheral arterial supply can be obstructed by
vasospastic or inflammatory conditions like Raynaud
disease and Thromboangitiis obliterans (young
smokers)
 Limb ischemia can also seen with central causes like
thoracic aortic dissection and Takayasu arteritis.
 Etiology
 Low cardiac output states like cardiogenic or
hypovolemic shock may also present with limb
ischemia
 Cardiac tamponade, ischemic cardiomyopathy,
valvular heart disease can impair left ventricle
function and lead to leg ischemia in patients with
existing peripheral vascular disease.
 Mechanisms of Disease – Embolism

A clot or piece of plaque which

has moved within the arterial
system from its point of
origin and has lodged at a new
location, leading to a sudden
interruption of blood flow to
an organ or a body part, e.g.
digit, leg, arm, brain.
 Pathophysiology
 Acute limb ischemia leads to cell death and
irreversible tissue damage.
 After prolonged arterial obstruction, reperfusion may
not be fully attainable due to distal edema and
thrombi forming in the microcirculation.
 Peripheral nerves and skeletal muscle are very
sensitive to ischemia and irreversible damage can
occur within 6 h of anoxia
 Non-embolic ischemia is due to atherosclerosis of the
vessels
 Pathophysiology
 Progression of ischemic injury can occur through
several mechanisms:
 i) propagation of clot to include collateral vessels

 ii) ischemia-related distal edema leading to high

compartment pressures
 iii) fragmentation of clot in the microcirculation

 iv) edema of the microvasculature cells

 clinical diagnosis of arterial
embolism in the leg
 may be suggested by the following features:
 (a) sudden onset of symptoms,
 (b) known embolic source,
 (c) absence of preceding claudication,
 (d) presence of normal pulses and Doppler
systolic blood pressures in the unaffected
leg.
 Acute Arterial Occlusion
6 Ps
Pain
Pallor
Pulselessness
Paresthesia
Paraparesis
Poikilothermia
 History
 Present illness
primarily to pain or function.
The suddenness and time of onset of the pain
location and intensity
 Past history
a history of claudication
heart disease (eg, atrial fibrillation)
aneurysms (ie, possible embolic sources).
concurrent disease or atherosclerotic risk
factors hypertension, diabetes, tobacco abuse,
hyperlipidemia,
family history of heart attacks, strokes, blood
clots, or amputations.
 Sites of Embolization

 Bifurcations
 Femoral - 40%
 Aortic - 10-15%
 Iliac - 15%
 Popliteal - 10%
 Upper extremities - 10%
 Cerebral - 10-15%
 Mesenteric/visceral - 5%
 Palpable Pulses
Location of Obstruction
Femoral Popliteal Pedal

- - - Aortoiliac segment

+ - - Femoral segment

+ ++ - Distal popliteal ± tibials

(Popliteal anerysm)
+ + - Distal popliteal ± tibials
Differential diagnosis of acute limb
ischemia
 Levels of severity
 I. Viable:
 II. Threatened viability:
 III. Major, irreversible ischemic change:
 Acute Arterial Occlusion
the viable limb (class 1)
 Lack of rest pain
 Presence of pedal arterial doppler flow
 Ankle systolic pressures > 30mmHg
 Acute Arterial Occlusion
the threatened limb (class 2)
 Rest pain
 Mild sensory/motor deficits
 Absent arterial doppler signals
 Intact venous flow
 Acute Arterial Occlusion
irreversible ischemia (class 3)
 Profound sensory/motor dysfunction
 Absent skin capillary blood flow
 Absent arterial and venous doppler signals
Clinical categories of acute limb
ischemia
Rutherford classification
 Diagnosis
 Clinical evaluation is the most useful diagnostic tool.
 Capillary refill is not reliable alone
 A hand –held Doppler can detect the presence or
absence of a pulse.
 If a pulse is detected, then the ankle-brachial index
(ABI) and segmental leg pressures should be checked
 An ABI<0.5 indicates acute arterial obstruction
 If time permits, do a duplex ultrasound
 Investigations for acute limb
ischemia
 1 Arteriography
 2 Doppler arterial study
 3 MRA
Example of
acute
arterial
embolus

“Saddle”
Embolus of
right iliac
artery
 Imaging in acute limb ischemia
 Pre-intervention full imaging (usually by
angiography) should be performed, if possible,
to confirm the diagnosis and to illustrate the
distribution and localization of the occlusion
 any imaging not unduly delay the subsequent
therapeutic intervention
 Predicting outcome in acute limb
ischemia

 There is a need for objective measures

("markers") of the severity of acute limb
ischemia, and specifically for definitive tests
of tissue viability and reversibility of
ischemia, to predict outcome more
accurately, especially between categories
IIb and III.
 Treatment
 Goals of therapy include restoration of blood flow,
preservation of limb and life, and prevention of
recurrent thrombosis
 Current practice includes UFH to prevent clot
extension, venous thrombosis, the appearance of
thrombi distal to the obstruction, and reocclusion.
 Fluid resuscitation and treatment of heart failure and
dysrhythmias are sometimes necessary to improve
limb perfusion.
 Definite treatment includes surgery or thrombolysis
 Acute Arterial Occlusion
Treatment Options
 Endovascular Therapy
 Peripheral Transluminal Angioplasty*
 Peripheral Stenting*
 Atherectomy (adjunctive)
 Thrombolytic Therapy (adjunctive)
 Embolic or foreign body retrieval
 Surgery
 Bypass grafts*
 Fasciotomy
 Amputation*
 Endarterectomy
*Rosenfield K, Isner JM, Chap. 97 Textbook of Cardiovascular Medicine 1998
 Factors for consideration in choosing
intervention for acute limb ischemia

 The choice as to which intervention should be

used for acute limb ischemia should be based on
 ‧ location and anatomy of lesion
 ‧ duration of acute limb ischemia
 ‧ type of clot
 ‧ patient-related risks
 ‧ surgery-related risks
 ‧ contraindications to thrombolysis
 Anticoagulant therapy in acute limb
ischemia

 Intravenous heparin at full anticoagulant

dosage should be given as soon as the
diagnosis of acute limb ischemia has been
made, provided that heparin is not
contraindicated
Vasoactive drugs or sympathectomy in
acute limb ischemia

 There is no evidence that "vasoactive"

drugs or sympathectomy are of benefit in
the treatment of acute limb ischemia.
 Thrombolysis after arteriography in acute
limb ischemia

 If the decision is made to proceed with

thrombolysis after arteriography, then the
intrathrombus infusion method should be
used, which can be performed successfully
in most cases.
High-dose systemic thrombolysis in arterial
occlusion

 Intravenous administration of high doses of

currently available thrombolytic agents
should no longer be used for the treatment
of arterial occlusion in the leg.
 Acute Arterial Occlusion
considerations for endovascular and surgical
therapy

 Location of occlusion
 Embolism vs thrombus
 Duration of ischemia
 Native artery or graft
 Patient-related risks
 Intervention-related risks
 Contraindications to thrombolysis
 Other Endovascular Techniques

 Percutaneous aspiration thrombectomy

(PAT)
 Percutaneous mechanical thrombectomy
(PMT)
 Indications for surgery in acute
limb ischemia

 Immediately limb-threatening ischemia

(class IIb and early class III) is
preferentially treated surgically.
 Fasciotomy in acute limb ischemia

 Fasciotomy should be performed at the

primary procedure if the acute severe
ischemia has been prolonged or if signs of
increased compartment pressure develop.
 Predicting the requirement for
fasciotomy

 There is a need for an easy and accurate

test to predict which patients require a
fasciotomy.
 Long-term anticoagulation after
thromboembolectomy

 There is a need for further information to

determine whether long-term
anticoagulation is useful after successful
thromboembolectomy in the absence of a
proven source of emboli.
 Acute Arterial Occlusion
Treatment Pathway
Acute Arterial
Occlusion
(thromboembolism)

Heparin unless
contraindicated

Class IIa Class IIb

Class I Class III
Marginally Immediately
viable Not viable
threatened threatened

Amputation
Treat as per chronic Close monitoring Urgent
After
Limb ischemia Urgent angiography thromboembolectomy
demarcation
THANK U