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    Chronic Limb Ischemia

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    Sadia Naveed
    This document summarizes chronic limb ischemia, its risk factors, clinical features, diagnostic tests, and treatment options. It discusses the classification of arterial occlusive diseases and their relationship to clinical findings. Treatment includes risk factor modification, medical management, endovascular and open surgical procedures such as bypass grafting and amputation. Post-operative care and potential complications are also outlined.

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    Chronic Limb Ischemia

    Uploaded by

    Sadia Naveed
    138 views29 pages
    This document summarizes chronic limb ischemia, its risk factors, clinical features, diagnostic tests, and treatment options. It discusses the classification of arterial occlusive diseases and their relationship to clinical findings. Treatment includes risk factor modification, medical management, endovascular and open surgical procedures such as bypass grafting and amputation. Post-operative care and potential complications are also outlined.

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    This document summarizes chronic limb ischemia, its risk factors, clinical features, diagnostic tests, and treatment options. It discusses the classification of arterial occlusive diseases and their relationship to clinical findings. Treatment includes risk factor modification, medical management, endovascular and open surgical procedures such as bypass grafting and amputation. Post-operative care and potential complications are also outlined.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    138 views29 pages

    Chronic Limb Ischemia

    Uploaded by

    Sadia Naveed
    This document summarizes chronic limb ischemia, its risk factors, clinical features, diagnostic tests, and treatment options. It discusses the classification of arterial occlusive diseases and their relationship to clinical findings. Treatment includes risk factor modification, medical management, endovascular and open surgical procedures such as bypass grafting and amputation. Post-operative care and potential complications are also outlined.

    Copyright:

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    of 29

    CHRONIC LIMB ISCHEMIA

    DR SHAKIR RAHMAN PGT SURGERY

    Peripheral Arterial Occlusive Disorders


    Involves narrowing of arterial lumens or
    damage to the lining Blood flow can be partially obstructed or completely occluded Chronic disease differs from acute Found more in men over 50 yrs Legs most frequently affected

    Risk Factors For Arterial Occlusive Disease



    HTN Hyperlipidemia Diabetes Nicotine use Inflammation Autoimmune disorders Obesity Trauma

    Classification
    1. Aortoiliac occlusive disease 2. Femoropopliteal occlusive disease 3. Tibial-peroneal disease

    Clinical Features

    Intermittent claudication Rest pain Coldness, Numbness, Paraesthesia and colour changes Ulceration and gangrene Temperature as that of the suroundings Sensations decreased Movements lost or diminished Arterial pulsation decreased or absent Arterial Bruit Decreased Venous refilling

    Relationship of clinical findings to site of disease


    Aortoiliac Obstruction-------- Claudication in both buttocks, thighs and calves.
    Femoral and distal pulses absent in both limbs. Bruit over the aortoiliac region. Impotence common (Leriche)

    Ilial Obstruction

    --------- Unilateral Claudication in thigh and calf and sometimes in buttock. Bruit over iliac region. Unilateral absence of femoral and distal pulses --------- Unilateral claudication in calf. Femoral pulse palpable with absent unilateral distal pulses. --------- Femoral and popliteal pulses papable

    Femoropopliteal
    Obstruction

    Distal Obstruction

    General Investigations

    Blood CP with ESR PT,APTT,INR Urine RE LFTs RFTs ECG Echo CXR

    Specific Investigations
    Doppler Ultrasound Duplex Imaging Angiography MRA

    Diagnostic Findings With Arterial Occlusive Disease


    Decreased Ankle-Brachial Index (ABI)
    0.50 to 0.95 indicates mild to moderate insufficiency. 0.25 or less severe
    Ankle pressure = ABI (normally 1.0) Brachial pressure

    Management of Chronic Arterial Occlusive Disease


    Smoking cessation Exercise program Weight reduction

    Medical Managment
    Risk factors modification Co-morbid conditions (coronary artery disease or

    CVA) Drugs 1. Statins 2. Antihypertensives such as beta blocker and ACE inhibitors 3. Aspirin 4. Clopidogrel

    Preoperative care
    Complete arterial evaluation Treat the underlying

    cardiac,pulmonary,cerebrovascular and renal diseases Screening for carotid disease should be performed (H/O TIA and Stroke)

    Surgical Treatment
    (1) Aortoilial occlusive disease
    a.

    open surgical therapy


    Aortobifemoral grafting

    is the tratment of choice(in low risk pt) may be performed transperitoneal or retoperitoneal appoach distal endarterectomy may be performed to improve outflow b.Femorofemoral,ilioiliac,or iliofemoral bypasses are alternative in high risk patient with unilateral iliac disease

    continued
    c- Axillobifemoral bypass alternative for high risk patients avoids intra-abdominal procedure and no need for cross-clamping the aorta d- aortoiliac endarterectomy for patients who have disease localized to distal aorta and common iliac vessels

    (2) Femoral,popliteal,and tibial occlusive disease a- Above knee occlusionan above knee femoral-popliteal bypass may be constructed b- Below knee occlusion.a distal bypass to the below knee popliteal,posterior tibial,anterior tibial or peroneal arteries may be constructed

    Types of grafts
    (1) Autologous graft
    Great sephenous vein is the vein of choice,Lesser sephenous or arm veins can also be used can be used in situ or reversed

    (2) Synthetic graft a-polytetrafluoroethylene(PTFE)grafts

    PTFE grafts have a good patency rate above knee and there is a substantial decrease in patency rate below knee b-Dacron prosthetic material is favoured for aortoiliac segment

    Endarterectomy
    may have a role in patients with limited vein availability or in the presence of an infected field

    Amputation
    Reserved for patients with gangrene or
    LEVEL OF AMPUTATION
    Is determined clinically
    A general principle is to preserves as much length of the extremity as safely possible because it improves the patients opportunity for rehabilitation persistent painful ischemia not amenable to vascular reconstruction

    continued
    (1) DIGITAL AMPUTATION
    done in diabetic patients who develop osteomylitis or severe foot infection

    (2) TRANSMETATARSAL AMPUTATION done when several toes are involved in ischemic process or after previous singledigit amputation

    (3) SYME AMPUTATION - involve the entire foot and calcaneus while preserving the entire tibia (4) BELOW KNEE AMPUTATION(BKA) -Most common type of amputation performed for patient with severe occlusive disease (5) ABOVE KNEE AMPUTATION(AKA) -Heals more easily than BKA useful in old patients who do not ambulate (6) HIP DISARTICULATION -Rarely performed

    INTRAOPERATIVE ANTICOAGULATION

    Unfractionated heparin(100 to 150

    units/kg) is administered intravenously shortly before cross-clamping aorta and supplemented as necessary until the cross-clamps are removed

    Post-operative care
    Check pulses of affected extremity frequently Monitor pain, color, sensation, motor function,

    capillary refill frequently Monitor for swelling Leg crossing and prolonged dependency of extremity is to be avoided Keep leg extended Hips flexion greater than 60 degrees should be avoided for first 72 hrs

    POST-OPERATIVE ANTITHROBOTIC THERAPY

    (1)ASPIRIN(75-325 mg/day) if sensitive to


    Aspirin then Clopidogrel(75 mg/day) (2) Warfarin (INR 2-3) is given to patients who are at high risk for thrombosis (3)Dextran 40 (0.5ml/kg/hr i/v) is administered for up to 72 hrs postoperatively in high risk grafts

    LONG TERM FOLLOW UP


    For Distal bypass grafts
    -Arterial Doppler examination every 3 months for the first 18 months,then every 6 months for a year,and then yearly -For Aortoiliac bypass grafts less frequent folllow up is necessary

    COMPLICATION
    Early complication frequently related to
    preoperative comorbid disease such as MI,CCF,Pulmonary insufficiency,and renal insufficiency Early complications include hemorrhage,embolization or thrombosis of distal arterial tree,microembolization,ischemic colitis,ureteral injuries,impotence,paraplegia and wound infection

    Late complication include anastomotic

    pseudoaneurysm or graft dilatation,graft limb occlusion,aortoenteric erosion or fistula,and graft infection

    ENDOVASCULAR OPTIONS
    Balloon angioplasty and intravascular stent
    placement produce excellent results Indicated for symptomatic stenotic lesions Short-segment stenoses (<3 cm length)of the common iliac or external iliac artery display excellent long-term patency rates when treated with angioplasty alone or with stent placement

    complications
    Arterial wall dissection Vessel occlusion(either from thrombosis or
    dissection) Arterial rupture Distal embolization

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