1. Acute Limb Ischemia: Medical and Endovascular Therapy
CRT 2013
Washington, DC
February 24, 2013
Acute Limb Ischemia: Medical and Endovascular Therapy
Michael R. Jaff, DO
Associate Professor of Medicine
Harvard Medical School
Medical Director
Vascular Center
Massachusetts General Hospital
Boston, Massachusetts

2. Michael R. Jaff, DO Consultant Abbott Vascular (non-compensated)
American Genomics, Inc
Becker Venture Services Group
Bluegrass Vascular Therapies
Cordis Corporation(non-compensated)
Covidien (non-compensated)
Ekos Corporation (DSMB)
Hansen Medical
Medtronic (non-compensated)
Micell, Incorporated
Primacea
Trivascular, Inc.
Equity
Access Closure, Inc
Embolitech, Inc
Hotspur, Inc
Icon Interventional, Inc
I.C.Sciences, Inc
Janacare, Inc
Northwind Medical, Inc.
PQ Bypass, Inc
Primacea
Sadra Medical
Sano V, Inc.
TMI/Trireme, Inc
Vascular Therapies, Inc
Board Member
VIVA Physicians (Not For Profit
501(c) 3 Organization)

3. Acute Limb Ischemia
Any sudden decrease in limb perfusion causing a potential threat to limb viability
True definition of a vascular emergency
Time is critical
6 hours to neurologic compromise
12-18 hours to non-salvagable limb
TASC 2. J Vasc Surg 2007;45 (Suppl): S 5 A-S 67 A

4. Embolic Etiology 60-70% from cardiac source Atrial fibrillation
Previously from valvular disease
Currently from complications of ASHD (75%)
Especially anterior MI
Atrial fibrillation

5. Site of Embolization 70% lower extremities 10-15% upper extremity
10% visceral
10-20% cerebral

6. Acute arterial occlusion
Other causes:
Artery-to-artery embolization
AAA – ‘Blue toe syndrome’
Popliteal aneurysm
Atheromatous embolization
Lower extremities
Cerebral
Paradoxical embolization

7. Livedo Reticularis Associated with Atheromatous Embolization

8. Acute arterial occlusion
Thrombotic arterial occlusion
--Thrombosis of pre-existing atherosclerotic stenosis
--Graft thrombosis
--Hypercoagulable states
--Trauma
--Aortic dissection
--Iatrogenic (catheterization)
--Phlegmasia Cerulea Dolenx
--Low-flow states

9. How Do Patients with ALI Usually Present?
TASC 2. J Vasc Surg 2007;45 (Suppl): S 5 A-S 67 A

10. Clinical Presentation
Pain
Pallor
Parasthesias
Pulselessness
Paralysis
Poikilothermia
The 6 “P’s”

11. Clinical Characteristics
Characteristic Embolus Thrombosis
Onset of sx
Rapid/immediate
Slower/insidious
Prior sx
Infrequent
Frequent
Duration of sx before presentation
Short
Longer
Opposite leg
Normal
Abnormal
Heart disease (Afib, MI)
=/-
Goal of immediate Rx
Eliminate embolus
Correct underlying dz
Pharmacologic Rx
Anticoagulation
Platelet inhibition
Results of embolectomy
Good
Poor
Amputation risk
Lower
Higher

12. Management Identification of etiology Intravenous Heparin
Arteriography +/-

13. Acute arterial occlusion
Clinical category
Viable or Threatened Irreversible
Amputation
Identify etiology +/- heparin
Embolic Thrombotic
Viable Immediately Threatened
Heparin – large doses [Duration ?]
Surgical Embolectomy Heparin +/- angiogram (Avail. of angio?)
+ / - arteriography Angiogram Immediately to the OR
Consider endo Rx On-table angio
Suction thrombectomy Immediate revasc
Cath-Directed Thrombolytic Rx

14. Surgical Revascularization
Embolectomy
Lower extremity
Upper extremity
Fogarty catheter
1963
Bypass

15. Surgical Thrombo-embolectomy using a Fogarty catheter

16. Endovascular Catheter-directed thrombolysis
Catheter-directed thrombectomy
PTA/stent

17. Acute Limb Ischemia— Symptoms 4 hours

18. Surgery vs CDT
TASC 2. J Vasc Surg 2007;45 (Suppl): S 5 A-S 67 A

19. Thrombolysis vs. Surgery-- Randomized Trials in PAD
Duration of Ischemic Limb Symptoms
Rochester
Mean 40 hours (but 50% of patients with symptoms < 24 hours)
STILE
Mean 50 days
TOPAS
Mean 4 days

20. Thrombolysis vs Surgery-- Randomized Trials in PAD
Severity of Ischemia
Percent of Patients

21. Thrombolysis vs Surgery-- Randomized Trials in PAD
Limb Salvage Rates
Symptom Onset <24 hours, SEVERE
Amputation rates low with either thrombolysis or surgery (ROCH)
Symptom Onset 24 hr-14 days, MODERATE
Amputation rates low with either thrombolysis or surgery
?Lower amputation rates with thrombolysis (STILE)
Symptom Onset >14 days, MILD-MODERATE
Amputation rates HIGHER with thrombolysis (STILE)

22. Following CDT

23. 80 year old female s/p right total knee replacement 7 weeks ago presents with a 4 day history of severe right leg pain and swelling
PMH:
Polymyalgia rheumatica
Raynaud’s disease
Hypertension
OA of bilateral knees, s/p knee replacement
Left S1 radiculopathy in the past treated with epidural injections
24 Pack year h/o tobacco use
Patient reports that she called orthopaedic surgeon 2 days after pain onset; MRI of back was obtained and patient was given a Medrol dosepack

24. 80 year old female s/p right total knee replacement 7 weeks ago presents with a 4 day history of severe right leg pain and swelling
Physical Exam:
+ Marked cyanosis of the right foot with dramatic coolness of the distal right calf, ankle and foot.
+ Tenderness of the right calf tibialis anterior muscle group
+ Weakness of the dorsiflexors of the right foot and toes.
Absence of LT on the dorsum of the right foot
Absent right popliteal, DP, PT pulses.
Doppler with absent right DP, PT arterial signal.
Preserved venous Doppler signal
Labs: CK-2229 Cr- 1.3

25. Iliofemoral angiography

26. SFA Angiography

27. Popliteal/Below knee angiography

28. Popliteal thombectomy

29. Residual thrombus below knee

30. Extraction thombectomy/tPA of PT/AT/peroneal

31. Angiojet in all three BK vessels

32. PTA AT/peroneal/PT

33. Residual SFA stenosis

34. Final Pictures, Day 1 PT and DP Pulses palpable post procedure
Infusion catheter placed in SFA for tPA infusion and patient sent to CCU overnight

35. Day 2, Post 8 hours tPA infusion

36. “Touch up” work on AT

37. Final Angiographic Result

38. Final Angiographic Result

39. 45 minutes post procedure…
Patient develops intractable pain in right leg
Pulses in DP/ PT preserved
Anterior compartment with tenderness to palpation, decrease in sensation to sharp and light touch between the first and second toes
Stryker Pressure (anterior compartment): 11 and 13
Despite borderline anterior compartment pressures, clinical suspicion prompted transfer to OR for four compartment fasciotomy

40. Follow up
Post op, patient wound vac placed; in hospital closure of the posterior compartment; anterior compartment to heal by secondary intention
Warfarin/heparin during hospitalization; complicated by GI bleeding (single gastric angiodysplastic lesion which was cauterized)
Patient discharged to rehab facility on ASA and Plavix; will have follow up IgM anticardiolipin Ab (mildly positive) in 4 months

41. Acute Limb Ischemia Prompt recognition is key
Time is of the essence
Rapid administration of IV heparin
Lysis vs Surgical Thrombectomy
Treatment of culprit lesion/etiology
Mechanical Thrombectomy may emerge as useful tool