60 year old female, background history of HTN, DM, IHD with previous LAD stent. Previous right SFA angioplasty and stenting for short-distance claudication.
Presented to A&E with a 2 day history of right foot pain, pallor and decreased sensation in the toes.
Palpable femoral pulses bilaterally, left foot warm, neurologically intact, with strong monophasic DP and PT signals on hand-held doppler. Right foot CRT 5 seconds, intact motor power with decreased sensation in the toes. Damped monophasic signals elicited on PT and DP.
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?
- What is your post-operative anticoagulation and surveillance plan?
Q1:
My clinical diagnosis is acute viable ischemia ( thrombosed stent).
Q2;
Initial management includes:
1. IV 5000 IU heparin.
2.O2 supply.
3.Proper hydration
4.Adequate analgesia
Q3;
1.Routine labs: CBC, Coagulation time, liver functions, renal functions and electrolytes.
2.Lipid profile, RBG and HbA1c
3.Cardiac assessment : ECG and Echo.
4.Preparation of patient for open bypass if endovascular option would fail:
Dupplex us on tibials to assess patency and diameter.
Dupplex on both great saphenous
Q4:
Options for revascularization
1.Endovascular options
a. CDT
b.Pharmaco-mechanical thrombectomy
c.Atherectomy device
with adjuvant DCB in case of in-stent stenosis after thrombous removal.
Technique: firstly we should assess if there is suitable segment of CFA for ipsilateral access, otherwise we can consider contralateral access.
Firstly, wire should be passed through the stent, wire must be passed smoothly to predict good outcome.
2.Open surgical repair( if endovascular not available or failed)
Fem- pop infragenicular bypass.
Unfortunately, I can’t catch strong evidence to prefer option over the other.
Q5:
Low dose anticoagulant with aspirin for 6-12 moth, followed by aspirin as extended therapy.
Periodic follow up by duplex US and clinical assessment at 3, 6 ,12 months, then yearly
If duplex finding was suggesting
in-stenosis, we can consider CTA.
Q1. ALI rutherford class IIa ( acute on top of chronic thrombotic )
Q2. Good hydration
Analgesia
Heparin IV bolus 5000IU
O2 supplement
Q3. CBC RFT LFT ABG K Na PT INR CK CKMB ECG ECHO cardiac assessment anaesthiae assessment.
Veins mapping
Q4. Edovascular approch through contrallateral CFA puncture US guided ( for patients with Rutherford grade IIa acute limb ischaemia,
it is recommended that (percutaneous) catheter-directed thrombolysis is considered as an alternative to surgery) class I A
Q5. Post op short term anticogulation then either rivarospire 2.5 with aspirine100 or dual antiplatelet.
Follow up vital signs concious level, groin, calf muscle, limb examination full labs.
ALI caused by arterial thrombosis, regular follow up may be beneficial, including clinical evaluation and assessment of functional status, although specific studies addressing this issue were not identified. During follow up visits, pulse examination and ABI measurements are performed. If clinical symptoms deteriorate, or there is a significant drop in ABI, vascular imaging (DUS, CE-MRA, CTA, or DSA) is required
Thank you for the comprehensive answer Dr Abdullah. Well done
Q1:
My clinical diagnosis is acute viable ischemia ( thrombosed stent).
Q2;
Initial management includes:
1. IV 5000 IU heparin.
2.O2 supply.
3.Proper hydration
4.Adequate analgesia
Q3;
1.Routine labs: CBC, Coagulation time, liver functions, renal functions and electrolytes.
2.Lipid profile, RBG and Hb A1c
3.Cardiac assessment : ECG and Echo.
4.Preparation of patient for open bypass if endovascular option would fail:
Dupplex us on tibials to assess patency and diameter.
Dupplex on both GSV
Q4:
Options for revascularization
1.Endovascular options
a. CDT
b.Pharmaco-mechanical thrombectomy (angiojet device)
c.Atherectomy device
with adjuvant DCB in case of in-stent stenosis after thrombous removal.
Technique: firstly we should assess if there is suitable segment of CFA for ipsilateral access, otherwise we can consider contralateral access.
Firstly, wire should be passed through the stent, wire must be passed smoothly to predict good outcome.
2.Open surgical repair( if endovascular not available or failed)
Fem- pop infra-genicular bypass.
Unfortunately, I can’t catch strong evidence to prefer option over the other.
Q5:
Low dose anticoagulant with aspirin for 6-12 moth, followed by aspirin as extended therapy.
Periodic follow up by duplex US and clinical assessment at 3, 6 ,12 months, then annully.
If any clinical deterioration or duplex finding suggestive
in-stenosis, we can consider CTA.
Thank you for your answer Dr Ahmed. I would add a few points:
What is your clinical diagnosis?
based on the above mentioned data; Pt has Rt LL Acute on top of chronic ischemiae, class IIa.
Initial management protocol for this patient.
A-E approach
O2, hemodynamics assessment, BP (controlled or not, before administering IV UFH), then administer IV UFH 5000 IU bolus.
HR (rate/rhythm), early involvement of cardiology as the patient already known to have IHD, previous PCI, for peri-operative cardiac risk assessment and management, ask for ECG and Echo (cardiomyopathic? arrhythmic?), 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 (48h).
-Duplex venous mapping over bilateral LL GSV.
Options for revascularization? Please indicate your preferred modality including technical approach and what evidence would support that?
CTA showing occluded SFA stent ..so..
1-I’ll go for Endo first option; as patient has multiple co-morbidities, has class IIa ischemiae, so..Contralateral Transfemoral approach, Catheter directed throbolysis for 24 hour then reassessment and Angioplasty for the residual stenotic/occlusive atherosclerotic lesions.
2-Other option; Open Fem-BTK bypass if suitable venous conduit, failed endo, and the patient is deemed fit enough by the anaestheiae to tolerate open intervention, with completion distal angiography and ballooning of distal lesions if found.
Prophylactic leg fasciotomy can be considered given the long duration of ischemiae, and according to baseline lab results and limb condition at intervention.
What is your post-operative anticoagulation and surveillance plan?
-low dose rivaroxiban and aspirin for long-term management.
–ABG (acidosis), lactate, serial K, CK, s.creat, Urea levels for monitoring reperfusion injury.
-assessment of ABPI, limb functional status, Hb drops/groin site for any bleeding complications.
Thank you for the comprehensive answer Dr Asmaa