1. Acute Limb Ischaemia John Gan Vascular Surgeon Specialists Without Borders Seminar in Surgery Rwanda, September 2010

2. Acute ischaemia – The six Ps Pain Paralysis Pallor Pulseless Parasthaesia (Pins and needles) Poikylothermia (Perishingly cold) Chronic ischaemia – Claudication – Rest pain – Ulcers – Gangrene www.specialistswithoutborders.org

3. Acute limb ischaemia – Challenging problem – Mortality rate 25% – Limb amputation rate 35% www.specialistswithoutborders.org

4. Acute Limb Ischaemia – Sudden arterial occlusion – Tissue hypoperfusion – Ischaemic symptoms www.specialistswithoutborders.org

5. Acute limb ischaemia – Rapid occlusion leads to severe ischaemia the 6 Ps – Slow onset occlusion allows collateral formation and mild ischaemia claudication rest pain gangrene www.specialistswithoutborders.org

6. Acute limb ischaemia – 4 to 6 hours ischaemic time causes irreversible effects – Propagation of thrombus – Occlusion of outflow vessels www.specialistswithoutborders.org

7. Acute limb ischaemia – Compartment syndrome – Reperfusion injury – Systemic effects www.specialistswithoutborders.org

8. Common causes – Embolism – Thrombosis – Trauma www.specialistswithoutborders.org

9. Other causes – Thrombophilia – Other vasculopathy Aneurysm Compression syndromes vasculitis – Intra arterial injection www.specialistswithoutborders.org

10. Presentation – Emergency – Unmistakable – The six Ps Pain Paralysis Pallor Pulseless Parasthaesia (pins and needles) Poikylothermia (perishingly cold) www.specialistswithoutborders.org

11. Differential diagnosis – Venous ischaemia – Neurological condition – Low flow states www.specialistswithoutborders.org

12. Natural history – Non salvageable limb – Limb loss – Death www.specialistswithoutborders.org

13. Assessment – History – Examination – Special testing www.specialistswithoutborders.org

14. History – Degree of disability – Time factors – Possible causes www.specialistswithoutborders.org

15. Examination – Assess the affected limb The 6 ps – Compare to the “normal limb” – Assess the whole patient www.specialistswithoutborders.org

16. Examination The six Ps – Pain – Paralysis – Pallor Pulseless Parasthaesia (pins and needles) Poikylothermia (perishingly cold) www.specialistswithoutborders.org

17. Three groups of cases – Viable – Threatened Salvageable with immediate treatment Salvageable with timely treatment – Non salvageable www.specialistswithoutborders.org

18. Viable – Limb still warm – Movement and sensation intact – Pain moderate or resolving www.specialistswithoutborders.org

19. Threatened – immediate treatment required Six Ps present Absent movement Absent sensation Less than 4 to 6 hours Threatened – timely treatment required Moderate pain impaired movement impaired feeling www.specialistswithoutborders.org

20. Non salvageable – Six Ps – greater than four to six hours – Fixed staining of skin – Woody feel to limb www.specialistswithoutborders.org

21. Degree of ischaemia and causation – Embolism – Trauma – Acute on chronic www.specialistswithoutborders.org

22. Special testing – Hand held doppler – Duplex ultrasound – Angiography www.specialistswithoutborders.org

23. Management Viable cases – Observation www.specialistswithoutborders.org

24. Management Non salvageable cases – Amputation www.specialistswithoutborders.org

25. Management Threatened cases Revascularisation – Embolectomy – Bypass – Thrombolysis Compartment syndrome – fasciotomy Systemic supportive therapy – Cardiac/respiratory/renal www.specialistswithoutborders.org

26. Summary – Arterial occlusion – Causation – Emergency – Six Ps – Three categories – Appropriate treatment www.specialistswithoutborders.org

27. 1. Acute occlusion of a previously normal artery results in severe ischaemic symptoms because: a. it occurs without warning b. occlusion of a normal artery is rare c. there are few collateral vessels to supply the limb d. embolism cannot occur in a diseased artery 2. Compartment Syndrome occurs in the ischaemic limb: a. leading to a reduction in pain b. because ischaemic muscle shrinks c. when muscle is re-perfused after a period of ischaemia d. due to reduced blood flow www.specialistswithoutborders.org

28. 3. Acute limb ischaemia caused by embolism occurs due to: a. acute thrombosis of a chronic stenosis b. occlusion of an artery when clot travels from one site to another c. thrombosis of an aneurysm d. clot moving from the venous to arterial circulation in some cases 4. Features of an acutely ischaemic limb requiring immediate treatment include: a. complete paralysis b. complete sensory loss c. absent pulse and Doppler signal d. all of the above www.specialistswithoutborders.org