ACUTE ON CHRONIC LIMB ISCHEMIA – HYBRID THERAPY AT A TERTIARY CARE CENTER- CASE SERIES

Acute on chronic limb ischaemia is an urgent situation characterized by an abrupt interruption in a persistently compromised limb artery. The primary cause is an embolus originating from the heart or the an acute creation of a thrombus resulting from the rupture of a pre-existing atheromatous plaque. This may also result from acute thrombosis as seen in TAO, hyperhomocysteinemia, Raynaud's phenomenon, high altitudes, sickle cell phenomenon, hyperpyrexia, heat stroke, severe dehydration and hemoconcentration, hyperhemoglobinemia, polycythaemia, and trauma with a precipitating component. CASE HISTORY In the present study, 11 cases were considered; 4 cases were of upper limb ischemia and the remaining 7 cases were of lower limb ischemia. All 7 lower limb cases had a history of intermittent claudication of various degrees and were on standard medical management, while two female patients were totally asymptomatic and without any medical or treatment history and were newly detected with type-2 diabetes mellites. Of them, one female had an acute left upper limb ischemia, and the other had acute lower limb ischemia. In the other patient population, one male patient had right upper limb ischemia due to the cervical rib causing classical thoracic outlet syndrome. In contrast, the other was a young female with a bilateral cervical rib causing thoracic outlet syndrome. The remaining 7 were male patients, all with a history of chronic smoking, and one of them is a post-PTCA {8 months ago} and not on any medication for the past 45 days. Nine cases were subjected to CT peripheral angiography, except 2 cases where limb jeopardy was most eminent with borderline renal parameters. Angiography showed total occlusion of external iliac and superficial femoral arteries in lower limbs among 6 cases and occlusion of the right popliteal artery in a 40-year-old male diabetic, and that of distal subclavian and axillary and brachial arteries in the upper limbs, respectively. CONCLUSION Patients with acute on chronic limb ischemia need to be addressed on emergent basis and may need combined modality of medical and minimally invasive treatment so as to achieve optimal limb revascularization and limb salvage.