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Title:

Management of Critical Limb Ischemia

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2.Treat outflow lesions if infection or symptoms persisted ... Paresis of the extremity. Refractory ischemic rest pain. Sepsis. Limited life expectancy ... – PowerPoint PPT presentation

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Title: Management of Critical Limb Ischemia


1
Management of Critical Limb Ischemia
  • From ACC/AHA Guidelines for the Management of PAD

2
Critical Limb Ischemia
  • 5P
  • Pain
  • Pulselessness
  • Pallor
  • Paresthesia
  • Paralysis

3
Medical treatment
  • Class III
  • PentoxifyllineI(Trental) is not useful.
  • Class IIb
  • IV PGE-1, or iloprost for 728 days reduce
    ischemic pain and facilitate ulcer healing,
    limited to small percentage of patients

4
Endovascular Treatment
  • Class I
  • 1.Treat inflow lesions first
  • 2.Treat outflow lesions if infection or
    symptoms persisted
  • 3.Use vasodilator for augmentation of
    intra-arterial pressure measurement

5
Thrombolysis
  • Class I
  • Catheter-based thrombolysis , with acute limb
    ischemia of less than 14 days
  • Class IIa
  • Mechanical thrombectomy, for adjunctive therapy
  • Class IIb
  • more than 14 days

6
Surgery for Critical Limb Ischemia
  • Patients with CLI in whom open surgical repair is
    anticipated should undergo assessment of
    cardiovascular risk.

7
Consideration of surgery
  • Relief of rest pain
  • Healing of ulcers
  • Prior revascularization attempts
  • The type of procedure
  • The patients overall ability to recover

8
Primary amputation
  • Significant necrosis of weight-bearing portions
    of the foot
  • Uncorrectable flexion contracture
  • Paresis of the extremity
  • Refractory ischemic rest pain
  • Sepsis
  • Limited life expectancy

9
Aortoiliac Occlusive Disease
  • Aortobifemoral bypass
  • Iliac endarterectomy, patch angioplasty, or
    aortoiliac or iliofemoral bypass
  • Axillofemoral-femoral bypass
  • Vein gt Prosthetic conduit
  • Patency of prosthesis below knee ?

10
Infrainguinal Disease
  • Bypass to the above-knee or below-knee popliteal
    a. with autogenous v.
  • The point of origin for bypass stenosis lt 20,
    most distal a.
  • Femoral-tibial a. bypass with v.

11
Infrainquinal disease
  • Composite sequential femoropopliteal-tibial
    bypass, and bypass to an isolated popliteal a.
    segment
  • Prosthetic femoral-tibial bypass
  • Class IIa
  • Prosthetic below-knee popliteal artery bypass

12
Post surgical care
  • Maximal cardiovascular ischemic risk reduction
    therapies
  • Bypass all major distal stenosis and occlusions
    if symptoms persisted.
  • F/U at least 2 years,
  • Duplex for vein grafts
  • ABI for synthetic grafts (0.91.3)

13
Cardiovascular Risk Reduction
  • a. Lipid-Lowering Drugs
  • b. Antihypertensive Drugs
  • c. Diabetes Therapies
  • d. Smoking Cessation
  • e. Homocysteine-Lowering Drugs
  • f. Antiplatelet and Antithrombotic Drugs

14
Lipid-Lowering Drugs
  • Class I
  • Statin, LDL lt 100
  • Class Iia
  • Statin, LDL lt 70 (high risk patients)
  • Fibric acid derivative

15
Antihypertensive Drugs
  • Class I
  • BP lt 140/90
  • lt 130/80 (DM, CRD)
  • Beta blockers are not contraindicated.
  • Class IIa
  • ACEI reduce risk of cardiovascular disease for
    symptomatic patients

16
Diabetes Therapies
  • Class I
  • Foot care
  • Class IIa
  • HbA1c lt 7,
  • for improve cardiovascular outcome
  • reduce microvascular complication

17
Smoking Cessation
  • Class I
  • Comprehensive smoking cessation intervention

18
Homocysteine-Lowering Drugs
  • Class IIb
  • Folic acid and Vit.B12 for homocysteine gt 14
    µmole/l patients

19
Antiplatelet and Antithrombotic Drugs
  • Class I
  • Aspirin 75325mg qd
  • Clopidogrel 75mg qd
  • reduce risk of MI, stroke, or vascular death
  • Class III
  • Warfarin is not indicated.
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