Acute leg ischemia

Results and Outcome

Management After Treatment

Endovascular Treatment

Thrombolysis is as feasible for acute upper extremity ischemia as it is in the leg. The limited ischemia that often occurs after most embolic events because of the collateral network around the elbow also allows the time needed for planning and moving the patient to the angiosuite. The technique involves cannulation in the groin with a 7-French sheath. Long guide wires and catheters are required to reach the occluded site and makes identification of proximal lesions possible. A new arterial puncture in the brachial artery may be necessary for thrombolysis of distal occlusions.It can be argued that thrombolysis in spite of acceptable results, rarely is needed for treating this disease because open embolectomy can be performed under local anesthesia with good results and little surgical morbidity. The advantages with endovascular treatment are indeed limited. For patients in whom suspicion of thrombosis is strong or when proximal lesions are likely, it should be attempted first. However, case series indicates that results of thrombolysis are inferior for forearm occlusions. In summary, thrombolysis is an alternative but has little to offer in reducing risk or improving outcome compared with embolectomy for most patients.

Patients usually regain full function of their hand immediately after the procedure, and postoperative regimens consist of anticoagulation and a search for the embolic source. The search for cardiac sources may advocate repeated ECGs, echocardiography, and duplex ultrasound of proximal arteries.

The number of salvaged arms after surgical intervention is very high, 90–95 %, and arm function is usually fully recovered. The remaining 5–10% represents patients with extensive thrombosis involving many vascular segments and most branches of the distal arteries. The postoperative mortality is around 10–40% in most patient series, reflecting that embolization often is a consequence of severe cardiac disease. Postoperative mortality is similar for thrombolysis to treat acute arm ischemia, while early technical success is slightly lower or similar. Less favorable results with thrombolysis are achieved when the distal arteries also are obstructed.

Acute leg ischemia is associated with a great risk for amputation and death. The age of the patients is high, and to some extent acute leg ischemia can be considered an end-of-life disease. Patients’ symptoms and the clinical signs of the afflicted leg vary. Sometimes grave ischemia immediately threatens limb viability, such as after a large embolization to a healthy vascular bed. Other times the symptoms are less dramatic, appearing as onset of rest pain in a patient with claudication. This is usually due to thrombosis of a previously stenosed artery.

Table 2.Incidence of acute leg ischemia

It is the severity of ischemia that determines management and treatment. To minimize the risk for amputation or persistent dysfunction it is important to rapidly restore perfusion if an extremity is immediately threatened. When the leg shows signs of severe ischemia but is clearly viable, it is equally important to thoroughly evaluate and optimize the patient before any intervention is initiated. These basic management principles are generally applicable. Accordingly, we recommend “management by severity” rather than “management by etiology” (thrombosis versus embolus) but recognize that the latter can also be an effective strategy.

Дата добавления: 2014-12-23