|Year : 2015 | Volume
| Issue : 4 | Page : 152-153
Confronting the Reality: Acute Limb Ischemia in India - An Editorial Point de Vue
Himanshu Verma1, Ramesh K Tripathi2
1 Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, USA
2 Burjeel Vascular Center, Burjeel Hospital, Abu Dhabi, UAE
|Date of Web Publication||13-Apr-2016|
Ramesh K Tripathi
Burjeel Vascular Center, Burjeel Hospital, Abu Dhabi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Verma H, Tripathi RK. Confronting the Reality: Acute Limb Ischemia in India - An Editorial Point de Vue. Indian J Vasc Endovasc Surg 2015;2:152-3
We had the opportunity to review the experience of Goyal et al. in their interesting article on acute limb ischemia (ALI) in Himachal Pradesh, India.
At the outset, we congratulate the authors for their "bold" reportage and continued surgical efforts in the face of many resource limitations.
Our commentary on the article aims to compare the ideal versus real world management of ALI. It should not be construed as an exercise to critique the surgical work of the authors that we truly appreciate. The facts are that without your efforts, almost all of these patients would have undergone a major amputation or would be dead.
We highlight a few practical concepts with a broad vascular surgery viewpoint.
| Diagnosis|| |
It is important to remember that ALI is not always necessarily an acute embolic phenomenon. A thorough history definitely helps (known cardiac history, i.e., atrial fibrillation, rheumatic heart disease, and endocarditis) predicting acute embolism whereas a history of previous claudication suggests acute on chronic phenomenon. Doppler evaluation is of great additional value to differentiate between hypoechoic thrombus in otherwise normal and distended blood vessel (suggestive of acute thrombus) versus heterogeneous echogenic plaque with multiple areas of calcification (suggestive of acute occlusion of atherosclerotic stenosis).
| Embolectomy|| |
Blind, rough, overinflated balloon embolectomy to desperately get some blood flow back could result in major intimal damage and subsequent thrombosis, especially in atherosclerotic arteries. Underlying chronic stenosis/occlusion needs to be addressed accordingly. 
| Compartment Syndrome|| |
Exclusion of compartment syndrome (CS) in ALI is not a one-stop diagnosis. In advanced ALI (Rutherford IIa or above), revascularization edema could result in compartment syndrome. At some point or the other in one's career, every surgeon has burnt his fingers by not performing fasciotomy after an otherwise successful embolectomy only to devastatingly lose a limb. 
It is mandatory to perform a four-compartment fasciotomy when there is even an iota of doubt regarding the possibility of compartment syndrome. The rule of thumb should be "if you doubt it - you should do it!"
If fasciotomy is not performed in some clear-cut situations, close monitoring should be instituted. There be any signs of impending compartment syndrome, the surgeon must maintain a very low threshold for fasciotomy. Softness of calf muscles does not rule out raised pressures in the anterior and lateral compartment as well as deep posterior compartment. Judiciously performed fasciotomies could be closed in few days' time depending on the extent of swelling and muscle necrosis by the use of VAC therapy, when indicated.
When suspected preoperatively, a fasciotomy should precede the attempted revascularization for two purposes:
- Presence of nonviable muscles would directly affect the level of amputation
- In case of isolated compartment syndrome or extensive muscle necrosis, compartment excision or amputation should be performed before any attempt of re-vascularization. Restoring blood flow in otherwise dead limb could lead to fatal reperfusion injury.
| Surgical Approach|| |
For brachial embolectomy, dissection of radial and ulnar artery bifurcation with embolectomy of the individual artery is advisable, and therefore, incision has to be at cubital fossa, which if required could be extended upward in a lazy S shape.
Popliteal embolectomy could be achieved almost always through the standard medial infra-popliteal incision and turning the patient prone is an unnecessarily prolonged exercise, which also makes follow-up wound evaluation difficult. 
- Blind embolectomy in the setting of trauma should be avoided. This is unnecessary as thrombus is due to a significant vessel wall injury that begs repair or grafting. This could have harmful consequences as the passage of inflated Fogarty balloon could convert a partially transected vessel to a complete transection. Careful computed tomography evaluation and direct exploration of vessel at the site of injury (especially if it is a focal occlusion near to fractured bone segment) are needed
- Arterial spasm should be spelt as "CLOT" and explored rather than embolectomized.
There is extensive literature available on the use of thrombolytic therapy, however in the absence of endovascular expertise, timely detection and appropriate revascularization should be aimed.
| References|| |
Earnshaw JJ. Acute ischemia: Evaluation and decision making. In: Johnston W, Cronenwett JL, editors. Rutherford's Vascular Surgery. 8 th
ed. Philadelphia, PA: Elsevier; 2014.
Wind GG, Valentine RJ. Anatomical Exposures in Vascular Surgery. Philadelphia, PA: Lippincott Williams & Wilkins; 2013.