72 year old male, background history of HTN, paroxysmal AF and is a smoker.
Presented to A&E with a 14 hour history of left foot pain and coldness. No previous history of intermittent claudications and no previous lower limb surgeries.
Palpable left femoral pulse only, palpable right DP and PT pulses. CRT 8 seconds on the left, 2 seconds on the right. Left foot insensate, normal plantar flexion but unable to dorsiflex the ankle. Tenderness elicited on the left anterior leg compartment.
No hand-held doppler signals found on left DP or PT
CT angiogram of the lower limbs was performed
- What is your clinical diagnosis?
- Initial management protocol for this patient?
- Please outline any other Investigations you would request?
- Options for revascularization? Please indicate your preferred modality including technical approach and what evidence would support that?
Following revascularization, a completion angiogram was performed
- What is your anticoagulation plan?
- Any post-operative investigations required?
1. Acute grade IIb lower limb ischemia. Propable embolic.
2. Initial heparinization (loading 10,000 units iv), Iv fluids, high flow O2, preparation for urgent intervention.
3. Baseline electrolytes, kidneybfunctions, blood gases to aid in post-op monitoring of re-perfusion injury.
4. Surgical method: Embolectomy using fogerty catheter, completion angiography to confirm success, priphylactic 4-compartment leg fasciotom
Percutaneous thrombectomy using pharmaco/mechanical methods .. however that’s uncommon where i practice.
Q1. ALI rutherford class IIb embolic
Q2. Good hydration
Analgesia
Heparin IV bolus 5000IU
O2 supplement
Q3. CBC RFT LFT ABG K Na PT INR CK CKMB
Q4. Open surgical thromboemblectomy through CFA use over the wire emblectomy catheter under fluroscopic control. Class IIa c
With possibility of fascitomy
Q5. Post op clexan then discuss with cardiolgy team what is the best regarding his AF either DOAC or Warfarine
Q6. Follow up CBC RFT LFT ABG PT INR CK CKMB Na K ECG ECHO compartmental pressure if fascitomy not done with revasuclriazation
Q1. ALI rutherford class IIb embolic
Q2. Good hydration
Analgesia
Heparin IV bolus 5000IU
O2 supplement
Q3. CBC RFT LFT ABG K Na PT INR CK CKMB
Q4. Open surgical thromboemblectomy through CFA use over the wire emblectomy catheter under fluroscopic control. Class IIa c
With possibility of fascitomy
Q5. Post op clexan then discuss with cardiolgy team what is the best regarding his AF either DOAC or Warfarine
Q6. Follow up CBC RFT LFT ABG PT INR CK CKMB Na K ECG ECHO compartmental pressure if fascitomy not done with revasuclriazation
Thank you Dr Abdullah
I would add to the post-operative investigations: investigating the source of embolism with a TTE or TOE, CT angiography involving the aortic arch, etc
-What is your clinical diagnosis?
based on the above mentioned data; Pt has Lt LL ALI, class threatened IIb, likely to be embolic.
-Initial management protocol for this patient?
A-E approach
O2, hemodynamics assessment (stable/unstable AF); BP (controlled or not, before administering IV UFH), then administer IV UFH 5000 IU bolus.
HR (rate/rhythm), early involvement of cardiology for peri-operative cardiac risk assessment and management, ask for ECG and Echo (cardiomyopathic? valvular/nonvalvular AF?, hydration (with caution if cardiomyopathic), UOP monitoring.
-Please outline any other Investigations you would request?
Full lab bloods, ABG, lactate, baseline K, CK, s.creat, Urea for monitoring reperfusion injury given that the patient has long duration of ischemiae (14h) and painful anterior leg compartment.and unable to dorsiflex the ankle (compartment syndrome?).
-Options for revascularization? Please indicate your preferred modality including technical approach and what evidence would support that?
CTA showing minimal atherosclerotic burden, SFA occlusion, Hx is not suggestive of any underlying PAD, also the patient has class IIb ALI which necessitate immediate revascularization
so .. I’ll go for groin incision, open surgical embolectomy using fogarty catheter with leg 4 campartment fasciotomy.
Following revascularization, a completion angiogram was performed
-What is your anticoagulation plan?
I believe this would be considered in co-ordination with the cardiology,
if the patient has non-valvular AF, DOAC can be considered.
if the patient has valvular AF, warfarin with target INR 2-3 is considered.
while bridging with clexane/UFH.
-Any post-operative investigations required?
ABG (acidosis), lactate, serial K, CK, s.creat, Urea levels for monitoring reperfusion injury.
ECG monitoring for any arrythmia.
Thank you Dr Asmaa for the comprehensive answer.
I would add to the post-operative investigations: investigating the source of embolism with a TTE or TOE, CT angiography involving the aortic arch, etc
1/Ali threatened 2b embolic
2 / hydration 5000 unit heparin
3/ full lab abg ecg echo
4/ thrombectomy
Full dose anti coagulation clexan continuation outside hospital marevan
Any alternatives to warfarin that can be used?
And are there any other investigations that you would want to conduct?
Noac
Good morning Dr Eman
I agree with your diagnosis (Rutherford Class IIb embolic ALI), but there are a few other initial management steps that you haven’t mentioned, as well as a specific investigation that is very relevant to this particular case.
What approach/techniques would you use for a thrombectomy?
Approach open thrombectomy via fogarty