Acute Limb Ischaemia (ALI) Refers To The Sudden: Interruption of Arterial Blood Supply

• Acute limb ischaemia (ALI) refers to the sudden
interruption of arterial blood supply.
• The affected artery becomes totally occluded by

thrombi or an embolus which prevents blood flow to
the tissue beyond the obstruction
• It is a vascular emergency that is limb-threatening

and life-threatening
ACUTE LIMB ISCHEMIA
 Incidence : 1.5 cases per 10,000 persons a year

 Despite urgent revascularization, amputation
occurs in 10 to 15% of patients during
hospitalization
 Mortality : 15 to 20% of patients die within 1 year
 Revascularization within 12 hrs: Mortality 19%,
Amputation 7%
 Delay > 12 hrs : Mortality 31%, Amputation 22%
CLINICAL FEATURES
• Pain (symptom)
Signs of acute
ischaemia • Pale/Pallor
• Pulseless
• Parasthesia
6Ps • Paralysis
• Poikilothermia
CLINICAL FEATURES
Pale Inspection (Color)

• Early: Pale
Fixed • Later: Cyanosed -> mottling ->
mottling & Fixed mottling & cyanosis
cyanosis
An area of
fixed cyanosis
surrounded by
reversible
mottling
Pallor
Reversible
Motting
CLINICAL FEATURES
Pulseless Palpation
• Palpate pulses:
Compare with the other side &
write it down on a sketch
• Temperature:
The limb is cold with a level of Femoral Popliteal
temperature change (compare
the two limbs)
• Slow capillary refilling of the skin

after finger pressure
Posterior tibial Dorsalis pedis

CLINICAL FEATURES
Parasthesia Palpation
Progress of Sensory loss
• Loss of sensory Light touch

function Vibration sense
• Numbness will Proprioreception
progress to anesthesia
Deep pain
Pressure sense Late
CLINICAL FEATURES
Paralysis Palpation
• Loss of motor function: Indicates advanced limb
threatening ischemia
• Late irreversible ischemia: Muscle rigid
• Intrinsic foot muscles are affected first, followed by
the leg muscles
• Detecting early muscle weakness is difficult because
toes movements are produced mainly by leg
muscles
ACUTE LIMB ISCHEMIA
Acute arterial Acute arterial Acute

Emboly
traumatic
Causa
embolism thrombosis ischaemia

15%
Thrombus
85%
Previous normal artery Previous diseased artery
.
N G Naidoo, MB ChB, FCS (SA); P S Rautenbach, MB ChB; D Kahn, MB ChB, FCS (SA), ChM
Department of Surgery, Groote Schuur Hospital and University of Cape Town
ACUTE EMBOLIC ISCHEMIA
Embolus sudden occlude

a relatively healthy artery
Usually arrest at arterial

bifurcation (aortic, iliac,
femoral popliteal)
An embolus can originate from: mitral stenosis,

atrial fibrillation, thrombus, atrial myxoma
RUTHERFORD
DIAGNOSIS CRITERIA
Viable Threatened Non-Viable
Pain Mild Severe Variable
Capillary refill Intact Delayed Absent
Motor deficit None Partial Complete
Sensory deficit None Partial Complete
Arterial Audible Inaudible Inaudible
doppler
Venous Audible Audible Inaudible
doppler
Treatment Urgent Work- Emergency Amputation
up surgery
ESC Guidelines on Peripheral Artery Disease, 2011

RUTHERFORD
DIAGNOSIS CRITERIA

DIAGNOSTIC IMAGING
(+) Gold standard

(+) Access use for further invasive
therapy
(+) Localize the obstruction
(+) diagnose an embolus  Sharp cutoff,
reversed meniscus or clot silhouette
(-) Invasive
(-) May not show leg/foot vessels in very
low flow state
(-) Contrast induced nephrotoxicity (CIN)
DIAGNOSTIC IMAGING
(+) Non-invasive, non-nefrotoxic

(+) Useful to diagnose anatomic
location and degree of
stenosis
(-) Time consuming

(-) Limitation in suprainguinal
evaluation
DIAGNOSTIC IMAGING
MANAGEMENT
Medical Treatment
Revascularization
Amputation
MEDICAL TREATMENT
• Anti platelet and antithrombotic drugs :

Aspirin 75-325 mg (1A) or alternative clopidogrel
(75mg/d) to reduce risk of MI, stroke or vascular
death in patient prior lower extremity
revascularization or prior amputation (IB).
Combination aspirin+clopidogrel (IIB-B)
• Intravenous unfractionated heparin (UFH)
⁻ Bolus of 80 U/kg followed by infusion of 18 U/kg
to achieved aPTT target of 2-2.5x control
REVASCULARIZATION
MANAGEMENT
• Endovascular
– Intra artrial thrombolysis  CDT
– Percutaneous aspiration thrombectomy (PAT)
– Percutaneous mechanical thrombectomy (PMT)
– Ballon angioplasty with or without stenting
• Open surgical revascularization

– Thromboembolectomy
– Bypass surgery
– Intraoperative thrombolysis
– End to end anastomose
– Hybrid Procedures
MANAGEMENT
Grade 1 Grade IIa-IIb Grade III

MANAGEMENT

PAD Upper Extremity Artery
Disease
Overview
• The subclavian artery and brachiocephalic
trunk are the most common upper extremity
locations for atherosclerosis.
• subclavian stenosis unequal arm BP ≥ 10–15
mmHg in systolic
• ischaemia or steal symptoms—due to flow
reversal in the vertebral artery
• Subclavian steal syndrome : visual
disturbances, syncope, ataxia, vertigo,
dysphasia, dysarthria, and facial sensory
deficits occurring during efforts made by the
arms (hyperabdution test)
• Brachiocephalic occlusive disease can cause a
stroke or transient ischaemic attack in carotid
and vertebral territories. Ischaemic symptoms
may include exercise-induced fatigue, pain,
and arm claudication.
• In severe cases, especially in distal disease,
rest pain and digital ischaemia with necrosis
can develop.
Clinical examination
• unequal arm BP,
• absent pulses (axillary, brachial, and radial/ulnar),
and cervical or supraclavicular bruits.
• Ischaemic findings such as finger ulcers or
necrosis are rare.
• pain, pallor, paraesthesia, or coldness should be
evaluated.
• The Allen test confirming adequate hand
perfusion
Diagnosis
• Duplex USG
• MRA
• CTA
Therapy
• Risk factor control and best medial therapy
• Revascularization  symptomatic patients
with a TIA /stroke, coronary subclavian steal
syndrome, ipsilateral haemodialysis access
dysfunction, or impaired quality of life
• revascularization : endovascular and surgical
procedures
Carotid Artery Disease
Overview
• Carotid artery disease occurs when fatty
deposits (plaques) clog the blood vessels that
deliver blood to your brain and head (carotid
arteries).
• The blockage increases your risk of stroke,
Carotid artery disease develops slowly. The
first sign that you have the condition may be a
stroke or transient ischemic attack (TIA).
Symptoms
• Early stages : asymptomatic
• The condition may go unnoticed until causing
a stroke or TIA.
• Carotid artery disease causes about 10 to 20
percent of strokes
• Carotid artery disease can lead to stroke
through: reduced blood flow, ruptured
plaques, blood clot blockage.
Diagnosis
• Anamnesis and physical examination  a
bruit over the carotid artery
• Duplex Ultrasound
• CT or MRI, to look for evidence of stroke or
other abnormalities.
• CT angiography or MR angiography, which
provides additional images of blood flow in
the carotid arteries..
Duplex USG & Angiography
Therapies
• Reduce risk Factors
• Medication : anti platelet, statin
• Carotid endarterectomy, opens the affected

carotid artery and removes the plaques
• Carotid angioplasty and stenting,

Carotid Endarterectomy
Carotid Angioplasty
and Stenting
Vertebral Artery Disease
Overview
• Stenosis of the vertebral artery may account
for up to 20% of posterior circulation
ischaemic strokes
• the optimal management of vertebral artery
stenosis has received limited attention, and is
poorly understood.
• Diagnosis : USG, MRA, CT scan, Angiography

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• Acute limb ischaemia (ALI) refers to the sudden

interruption of arterial blood supply.

• The affected artery becomes totally occluded by

• It is a vascular emergency that is limb-threatening

 Incidence : 1.5 cases per 10,000 persons a year

Pale Inspection (Color)

• Slow capillary refilling of the skin

Posterior tibial Dorsalis pedis

Progress of Sensory loss

• Loss of sensory Light touch

Acute arterial Acute arterial Acute

embolism thrombosis ischaemia

Previous normal artery Previous diseased artery

Embolus sudden occlude

Usually arrest at arterial

An embolus can originate from: mitral stenosis,

ESC Guidelines on Peripheral Artery Disease, 2011

ESC Guidelines on Peripheral Artery Disease, 2011

(+) Gold standard

(+) Non-invasive, non-nefrotoxic

(-) Time consuming

• Anti platelet and antithrombotic drugs :

• Open surgical revascularization

Grade 1 Grade IIa-IIb Grade III

ESC Guidelines on Peripheral Artery Disease, 2011

ESC Guidelines on Peripheral Artery Disease, 2011

• Medication : anti platelet, statin

• Carotid endarterectomy, opens the affected

• Carotid angioplasty and stenting,

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