Rajarajan, V (2009) Perioperative Outcome in patients with Acute Lower Extremity Ischemia. Masters thesis, Madras Medical College, Chennai.
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Abstract
INTRODUCTION: According to the 2007 Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II), acute limb ischemia is defined as a sudden decrease in limb perfusion that causes a potential threat to limb viability (manifested by ischemic rest pain, ischemic ulcers, and/or gangrene) in patients who present within two weeks of the acute event. The management of acute arterial occlusion remains a challenge for vascular specialists. Surgical thromboembolectomy and bypass grafting were the mainstays of therapy for many years. Subsequently, thrombolytic therapy and percutaneous transluminal angioplasty (PTA) have become treatment options for selected patients. Despite these advances, the morbidity, mortality, and limb loss rates from acute lower extremity ischemia remain high. Thus, regardless of the treatment modality used, early diagnosis and rapid initiation of therapy are essential in order to salvage the ischemic extremity. The best defense against limb loss is prompt initiation of therapy. Thus, once the diagnosis of acute arterial occlusion has been made by history and physical examination, the Seventh ACCP Consensus Conference on Antithrombotic Therapy recommends that the patient should immediately receive 10,000 units of intravenous heparin followed by a continuous heparin infusion3. Anticoagulation will prevent further propagation of thrombus, and inhibit thrombosis distally in the arterial and venous systems due to low flow and stasis. Time is crucial, the decision to administer heparin is based upon the clinical evaluation and should not be delayed while waiting for diagnostic procedures to be performed. AIM OF THE STUDY: To evaluate the perioperative outcome of all patients presented with first episode of acute arterial occlusion of lower limbs to our department for the period of two years. MATERIALS AND METHODS: Design of the study: Prospective study. Study period: February 2007 to February 2009. All patients presented with acute lower limb ischemia to the Department of vascular surgery, Madras Medical College, Chennai over the above period were studied. The patients presented for the first episode alone were included in the study. Vascular examination was done thoroughly in all patients. They were classified according to the Rutherford’s classification of acute limb ischemia, duration of ischemia, level of occlusion, associated risk factors, probable etiological factor and treatment offered. All patients were investigated preoperatively by echocardiography and looked for the source of embolism. In selected group of patients, preoperative angiograms were done depends on the severity of ischemia. Those patients presented with limb threatening ischemia were taken up directly to the operation theatre after minimum basic investigations. The patients included in the study were divided according to the etiology of embolism or thrombosis. The diagnosis of embolism or thrombosis was determined from a consideration of history, clinical examination, presence or absence of clot in echocardiography and angiography. All patients who had undergone surgeries alone were taken up for the study. The patients being managed conservatively with oral anticoagulation or thrombolytic agents were excluded from the study. Only those who underwent surgeries alone were analysed for category improvement, outcome including the mortality during the in hospital postoperative period. Inclusion criteria: First episode of Acute Lower extremity Ischemia, Acute Thrombosis, Acute Embolism. Exclusion criteria: Multiple thromboembolism involving other regions, Recurrent thrombosis, Bypass Graft Thrombosis, Dissection, Trauma, DVT gangrene, Septic arterial occlusion. Depending on the limb viability status and irrespective of the duration of ischemia, all patients were undergone revascularization procedures in emergencies as well as in elective theatres. All limb threatening ischemia patients underwent emergency embolectomy or thrombectomy and patients with non limb threatening ischemia were angiographically evaluated and subjected for elective bypass procedures. Compartmental fasciotomy were done as and when required during the postoperative period. All patients presented with irreversible ischemia underwent amputations were also included in the study. Patients who had successful outcome following revascularisation in the postoperative period were made ambulant independently and following amputations with walking frame. Secondary major amputations and minor amputations were performed for patients those advanced ischemia and depending on the line of gangrene demarcation respectively, following revascularization. All patients were started on therapeutic heparinisation soon after admission. This was continued postoperatively. This was slowly overlapped with oral anticoagulation only when the revascularised limb do not require any further surgical intervention before the time of discharge. CONCLUSION : Embolism is still the commonest causes of acute lower limb ischemia and cardiac is the commonest source. Rheumatic heart disease is still more prevalent in our population even though there is a changing trend in the disease pattern towards atherosclerotic heart disease and peripheral atherosclerosis. Even though it appears that the incidence of rheumatic heart disease is seemingly decreasing, the need of penicillin prophylaxis for rheumatic fever should be encouraged in the lower socioeconomic groups. The increased incidence of embolism could be due to non compliance of oral anticoagulation therapy and inadequate anticoagulation due to lack of monitoring. Class III ischemia is the commonest presentation, probably because of lack of awareness in the public and availability of expertise. Though the patients presented within a week of the onset of symptoms, the mortality in these patients were high. This could be due to various reasons, in limbs with class III ischemia as a consequence of which there will be metabolic derangements and also the need for urgent intervention without improving the general condition. So, this could be minimized by improving the general condition in those categories of patients where delay would not worsen the ischemia. Other modalities of treatment like thrombolytics and or anticoagulation alone should be considered for non limb threatening ischemia. The benefit of limb salvage surgery must be weighed against the risk of increased mortality and the choice of treatment should be based on the influence of relevant factors on survival rates and amputation.
| Item Type: | Thesis (Masters) |
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| Uncontrolled Keywords: | Perioperative Outcome ; patients ; Acute Lower Extremity Ischemia. |
| Subjects: | MEDICAL > Vascular Surgery |
| Depositing User: | Kambaraman B |
| Date Deposited: | 24 Jul 2017 02:53 |
| Last Modified: | 10 Jun 2018 11:03 |
| URI: | http://repository-tnmgrmu.ac.in/id/eprint/2072 |
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