Surgical management of acute limb ischemia, the first experience from Ethiopia

Abstract

Abstract Background Acute Limb Ischemia is a devastating emergency condition due to a sudden decrease in limb perfusion that threatens life or limb viability. It carries a high morbidity and mortality rate. This is the first experience to report on risk factors, etiologies and surgical outcomes of acute limb ischemia in Ethiopian.Methods A Prospective Cross-sectional Study on patients operated for acute limb ischemia at Tikur Anbessa Specialized Hospital and Teklehaimanot General Hospitals from January 1, 2018, to December 31, 2018, Addis Ababa, Ethiopia was done. They were followed for 3 months to determine risk factors, etiologies and surgical outcomes of the disease. Data were collected using a structured questionnaire. Findings were analyzed using SPSS version 20 and compared with current literature.Result A total of 102 patients were operated with a male to female ratio of 2:1 and the mean age at presentation was 54±17 years. Hypertension, 40 (39.2%), and diabetes mellitus, 32 (31.4%), were the most common risk factors followed by combined hypertension & diabetes mellitus, 20 (19.6%). The most common cause of acute limb ischemia was thrombosis, 77 (75.5%) and followed by embolism 14 (13.7%) and trauma 11 (10.8%). The source of emboli in all cases was cardiac disease due to atrial fibrillation, 9 (7.8%), myocardial infarction, 6 (5.9%) & rheumatic valvular heart disease, 4 (3.9%). The overall Presentation was very late with an average duration of 9±4.8 days and all of them arrive after 24 hours of symptom onset. One hundred eight procedures were done in 102 patients. Type of procedure performed were, thrombectomy 51(47.2%), primary amputation 24(22.2%), bypass or interposition vascular grafts 10(9.2%), embolectomy 10(9.2%), primary vascular repair 7(6.4%), and Femoro-femoral graft 6(5.5%). The 30-day amputation & mortality rate was 52.9% and 9.8% respectively. The rate of limb loss after revascularization surgery was 32.4%. Systemic complications occurred in 17.6% and local complications occurred in 35.3% of patients. On logistic regression analysis, age older than 60 years showed a four-fold risk of amputation (p = 0.017) and ten times the risk of mortality (p = 0.037) compared to 20-40 years age group. Hypertensive patients had 3 times more risk of amputation (p = 0.031) as compared to non-hypertensive patients. The duration of presentation beyond 9 days showed 4 folds risk of amputation (p = 0.021) as compared to those presented within 3 days. Previous Myocardial infarction was associated with 5 folds increase in mortality (p = 0.036) as compared to those without myocardial infarction.Conclusion This review has tried to show the overall perspective of acute limb ischemia specific to the population we serve. Patients generally presented very late with a significant number of them arrived with irreversible ischemia and tissue loss. Age ≥ 60 years; hypertension, previous myocardial infarction and delayed presentation were associated with poor surgical outcomes. An awareness to create the importance of early arrival, optimizing co-morbidities, timely detection and treating immediately on arrival of the patient, play a key role in improving surgical outcomes of acute limb ischemia. Keywords: Acute ischemia, Thrombosis, Embolism, Re-vascularization, Limb amputation