Role of Surgeon in management - PowerPoint Presentation

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Role of Surgeon in management of Limb Ischemia

Dr

Mohd

.

Azam

Haseen

Assistant Professor Cardiothoracic surgery

JNMC, AMU, Aligarh

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Ischemia

Acute ischemia(ALI)

Chronic

ishemia

(CLI)

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Definition of ALI

Sudden decrease in limb

perfusion causing a potential threat to viability

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Etiology of ALI

Embolus

ThrombusTraumaIatrogenic causes

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Acute Arterial Occlusion

Pallor

Pulselessness or unequal pulsesParesthesias

PainParalysisPolikothermia

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Investigations for acute limb ischemia

Clinical examination

Doppler arterial studyArteriography - CT or DSAMRA

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Embolus Blood clot, fat or gas

Causes – AF, CMP, MI, LV aneurysm, Prosthetic heart valves ,atherosclerotic debris from DTA

Femoral and popliteal arteries are favoured sites

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Thrombus Atherosclerotic obstruction

Hypercoagulable

statesAortic/arterial dissectionBypass conduit occlusion

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Traumatic ischemiaCivilian injury- UL

Military injury – LL

Poor prognosis if nor urgently repaired

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Traumatic ALIOutcomes depends on

mechanism of injury –

sharp,blunt,crushingSite of injuryIschemia time

Associated musculoskeletal injurycomorbity

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Chronic Limb Ischemia (CLI)

The prevalence: >55 years is 10%–25%

70%–80% of affected individuals are asymptomatic

Pt’s with PVD alone have the same relative risk of death from cardiovascular causes as those CAD or CVD PVD pt’s = 4X more likely to die within 10 years than pt’s without the disease.

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Chronic Limb Ischemia (CLI)Mortality approaches 25% at 1 year after diagnosis

Additional 25% require major amputation

Amputation increases morbidity and mortality – 50% mortality at 5 yearsOnly 65% BKA amputees ambulatory 1 yrOnly 29% AKA amputees ambulatory 1 yr

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Defining a Population “At Risk” for Lower Extremity PAD

Age

<50 years with diabetes, and one additional risk factor (e.g., smoking, dyslipidemia, hypertension, or hyperhomocysteinemia)

50 - 69 years and history of smoking or diabetesAge 70 years and olderLeg symptoms with exertion (suggestive of claudication) or ischemic rest painAbnormal lower extremity pulse examinationKnown atherosclerotic coronary, carotid, or renal artery disease

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RISK FACTORS FOR PAD

Age

SexRaceFamily historySedentary life-style

SmokingHyperlipidemiaHypertension

Diabetes mellitusHypercaogulabilityHyperhomocysteinemiaRenal insufficiency

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Causes of CLI

Atherosclerosis

Thromboangiitis obliterans

(Buerger’s diseaseVasculitis Atheroembolic disease

Thrombotic disordersPopliteal aneurysm

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Individuals With PAD Present in Clinical Practice With Distinct Syndromes

Asymptomatic

:

Without obvious symptomatic complaint (but usually with a functional impairment).Classic claudication: Lower extremity symptoms confined to the muscles with a consistent (reproducible) onset with exercise and relief with rest.

“Atypical” leg pain: Lower extremity discomfort that is exertional but that does not consistently resolve with rest, consistently limit exercise at a reproducible distance, or meet all “Rose questionnaire” criteria.

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Individuals With PAD Present in Clinical Practice With Distinct Syndromes

Critical limb lschemia

:

Ischemic rest pain, nonhealing wound, or gangrene/Acute limb ischemia: The five “P”s, defined by the clinical symptoms and signs that suggest potential limb jeopardy: Pain

PulselessnessPallorParesthesiasParalysis (& polar, as a sixth “P”).

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Clinical Presentations of PAD

~15%

Classic (Typical)

Claudication

~33%Atypical Leg Pain(functionally limited)

50%

Asymptomatic

1%-2

%

Critical

Limb Ischemia

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Four Hallmarks of CLIResting Pain

Non-Healing Ulcers

Dry GangreneAbsence of a Palpable Pulse

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Claudication vs. Pseudoclaudication

Claudication

Pseudoclaudication

Characteristic of discomfort

Cramping, tightness, aching, fatigue

Same as claudication plus tingling, burning, numbness

Location of

discomfort

Buttock, hip, thigh,

calf, foot

Same as

claudication

Exercise-induced

Yes

Variable

Distance

Consistent

Variable

Occurs with standing

No

Yes

Action for relief

Stand

Sit, change position

Time to relief

<5 minutes



30 minutes

Also see Table 4 of

Hirsch AT, et al.

J Am Coll Cardiol.

2006;47:e1-e192.

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Leg Pain Has a Differential Diagnosis

Spinal canal

stenosis

Peripheral neuropathyPeripheral nerve painHerniated disc impinging on sciatic nerve Osteoarthritis of the hip or kneeVenous

claudicationSymptomatic Baker’s cystChronic compartment syndromeMuscle spasms or crampsRestless leg syndromeAlso see Table 3 of Hirsch AT, et al.

J Am Coll Cardiol. 2006;47:e1-e192.

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Arterial Venous Neuropathic

Chronic ischemia and types of foot ulcers

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Hemodynamic Noninvasive Tests

Resting Ankle-Brachial Index (ABI)

Exercise ABI

Segmental pressure examinationPulse volume recordings

.

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http://www.nhlbi.nih.gov/health/dci/Diseases/pad/pad_diagnosis.html

ABI

=

Lower extremity systolic pressureBrachial artery systolic pressure

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Interpreting the Ankle-Brachial Index

ABI

Interpretation

Symptoms

1.00–1.29

Normal

--

0.91–0.99

Borderline

--

0.71- 0 .90

Mild disease

Intermittent

claudication

0.41

–

0.70

Moderate disease

Severe

claudication

≤

0.40

Severe disease

Tisse

loss ,rest pain

≥

1.30

Noncompressible

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ABI Limitations

Incompressible arteries (elderly patients, patients with diabetes, renal failure, etc.)

Resting ABI may be insensitive for detecting mild aorto-iliac occlusive disease

Not designed to define degree of functional limitation Normal resting values in symptomatic patients may become abnormal after exerciseNote: “Non-compressible” pedal arteries is a physiologic term and such arteries need not be “calcified”

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Exercise ABI Testing

Confirms the PAD diagnosis

Assesses the functional severity of claudication

May “unmask” PAD when resting the ABI is normalAids differentiation of intermittent claudication

vs. pseudoclaudication diagnoses

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Proportion Stopping

During 6-Minute Walk

<0.5

0.5-0.7

0.7-0.90.9-1.1Mean Distance Achieved

in 6-Minute Walk

70

60

0

10

20

30

40

50

1.2-1.5

<0.4

0.4-0.5

0.5-0.6

0.6-0.7

0.7-0.8

0.8-0.9

0.9-1.0

1.0-1.1

1.1-1.2

Patients (%)

ABI

McDermott MM, et al.

Ann Intern Med.

2002;136:873-883.

1600

400

0

800

1200

1.1-1.5

Feet

ABI and Functional Outcomes

ABI

ABI=ankle-brachial index

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Toe-Brachial Index Measurement

The toe-brachial index (TBI) is calculated by dividing the toe pressure by the higher of the two brachial pressures.

TBI values remain accurate when ABI values are not possible due to non-compressible pedal pulses.

TBI values ≤ 0.7 are usually considered diagnostic for lower extremity PAD.

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Arterial Duplex Ultrasound Testing

Diagnose

anatomic location and degree of

stenosis.surveillance following

surgery Duplex ultrasound of the extremities can be used to select candidates for:endovascular intervention surgical bypass, andto select the sites of surgical

anastomosis.

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Magnetic Resonance Angiography (MRA)

Excellent

arterial picture

No ionizing radiationNoniodine–based intravenous contrast medium rarely causes renal insufficiency or allergic reaction~10% of patients cannot utilize MRA because of:Claustrophobia

Pacemaker/implantable cardioverter-defibrillatorObesityGadolinium use in individuals with an eGFR <60 mL

/min has been associated with nephrogenic

systemic fibrosis (NSF)/

nephrogenic

fibrosing

dermopathy

Takes time to acquire image

Not easily available

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Computed Tomographic Angiography (CTA)

Requires iodinated contrast

Requires ionizing radiation

Produces an excellent arterial pictureFast image acquisition

Readily available

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Treatment of CLIMedical management

Surgical

RevascularizationEndovascular TherapyAmputation

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PharmacotherapyCilastazole

Pentoxiphylline

Naftidofuryl Herbal drugs

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Additional strategies

Smoking cessation (disease progression)

Manage CADControl BP to less than 140/90 mmHg (non-diabetics) or less than 130/80 mm/Hg (diabetics and individuals with chronic renal disease

)Target LDL cholesterol of less than 100 mg/dl.Strict Diabetic control

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Additional strategies

Antiplatelet

therapy - Aspirin, in daily doses of 75 to 325 mg / Clopidogrel (75 mg per day)

For pt. with intermittent claudication - Supervised exercise training should be performed for a minimum of 30 to 45 minutes, in sessions performed at least three times per week for a minimum of 12 weeks.

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PCI/SurgeryIndications/Considerations:

Poor response to exercise rehabilitation + pharmacologic therapy.

Significantly disabled by claudication, poor QOLMorphology of the lesion (low risk + high

probabilty of operation success)PCI:Angioplasty and StentingShould be offered first to patients with significant comorbidities who are not expected to live more than 1-2 years

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Bypass Surgery:

Reverse the saphenous vein for

femoro-popliteal bypassSynthetic prosthesis for aorto-iliac or

ilio-femoral bypassOthers = iliac endarterectomy & thrombolysisAmputation: Last Resort

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Case 1:45 yr male with claudication and rest pain

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Case 2 : 70 yr male with rest pain and gangrene in left LL

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Case 3 : 40 yr male with claudication and rest pain LL

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Femoro tibial bypass

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Endovascular Therapy

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Endovascular TherapyEstablished modality in west

minimally invasive

Less time consumingCosmetically better resultsSurvival advantage in few conditionsCost is prohibitiveLong learning curve

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