Pt has ALI 2b due to thrombosed POP anyrusm with distal embolisation and no distal run off.
Started heparin IV bolus
Good analgesia
Hydration
O2 supplementation
Full labs
Prepare blood
General and cardia assessment
Contra lat. Limb examination
Discuss with the pt and familly the possible intervention and high risk off limb loss ..
Pop exposure thrmobectomy. with possible bolus thrombolytic if ther is run off visible then ligation of anyrusm and bypass if no visible runn off wait and see ( anticogulate the patient and prepare the pt for AKA
Thanks Ahmed and abdullah for your valuable comments, you right we usually place the catheter in distal vessels and i usually give 15 mg, i would start with bolus of 5mg every minutes to reach total of 15 mg as described before by Abdullah. one tip just be carful specially in elderly patient as they ae usually on heparin infusion in this situation and be guided with activated clotting time ACT as excessive anticoagulation plus TPA can cause disaster like ICH.
i agree with above knee amputation decision as limb is unsalvageable, you are counselling your patient and he asked you a few questions about the prognosis.
what will be the predicted mortality next 2 to 5 years?
what is the likelihood of him able to walk after amputation?
what is the complication of the amputation operation ?
–>Five-year mortality after major amputation ranges from 40–82% after below-knee amputations and 40–90% after above-knee amputations, with an overall average of about 62%
Source:
1- Thorud JC, Plemmons B, Buckley CJ, Shibuya N, Jupiter DC. Mortality after nontraumatic major amputation among patients with diabetes and peripheral vascular disease: a systematic review. J Foot Ankle Surg. 2016 May-Jun;55(3):591-9. doi: 10.1053/j.jfas.2016.01.012. Epub 2016 Feb 19. PMID: 26898398.
2-Stern JR, Wong CK, Yerovinkina M, et al. A meta-analysis of long-term mortality and associated risk factors following lower extremity amputation. Ann Vasc Surg. 2017 Jul;42:322-327. doi: 10.1016/j.avsg.2016.12.015. Epub 2017 Apr 5. PMID: 28389295.
–> possibility to walk after aka is 21-29 % depends on muscle state wound healing and rehabilitation.
1.Following AKA, mortality ranges from 39 to 80% in five years. 2. Predictors of good walking ability following lower limb amputation include cognition, fitness, ability to stand on one leg, independence in activities of daily living and pre-operative mobility, usually ranges from 20 -30 %.
3. Complications following AKA 1.Muscle atrophy. 2.Surgical site wound infections, dehiscence, and wounds from prosthetic wear. 3.flexion contractures 4.Phantom limb and phantom limb pain 5.Post-traumatic stress disorder (PTSD) and depression 6.Neuroma formation
References Qaarie M. Y. (2023). Life Expectancy and Mortality After Lower Extremity Amputation: Overview and Analysis of Literature. Cureus, 15(5), e38944. https://doi.org/10.7759/cureus.38944
Sansam, K., Neumann, V., O’Connor, R. J., & Bhakta, B. (2009). Predicting walking ability following lower limb amputation: a systematic review of the literature. Journal of rehabilitation medicine, 41(8), 593-603.
Myers, M., & Chauvin, B. J. (2023). Above-the-knee amputations. In StatPearls [internet]. StatPearls Publishing.
thanks peter, ahmed and abdullah for all your promp answers , a lot of point s raised about managing of thrombosed popliteal aneurysm with no run off. I agree with your suggestion about the need for urgent embolectomy of run off vessels given the threatened limb situation , two questions
1- if you use Catheter direct thrombolysis, where will you leave the catheter ( pop aneurysm or pop artery or distal vessels and if so which one? Abdullah what is the bolus of TPA? and what is contraindciation of thrombolysis ( things to ask about in history) ?
2- you manage to open PT with thrombectomy which stopped at the ankle with small branch to distal peroneal artery and you decided to do am exclusion bypass to proximal PT? next day on you ward round you see the patient leg and there is no sensation or motor power below mid-calf with mottled leg, what is your next step?
Q1:
I think no role to place the catheter in pop.artery, it should be placed in one of tibialis.
Bolus dose is usually around 8 mg
Contraindications can be classified into absolute and relative
absolute ones include: cerebrovascular event (including transient ischaemic attack) within the last two months, active bleeding events, recent gastrointestinal bleeding, neurosurgery within the last two months.
Relative as major non-vascular surgery or trauma within the last 10 days, uncontrolled hypertension, Intracranial tumour, hepatic failure, particularly those with coagulopathy.
Q2:
This is picture of non-salvageable limb, patient must be prepared for AKA in urgent way after discussion with patient and his relatives.
Q1. In TPT or vessele who wire is pass to it distally
Bolus according to type Of drug y use for ex. Alteplase 15 mg IVP bolus over 1-2 minutes, THEN 0.75 mg/kg IV infusion over 30 minutes (not to exceed 50 mg), and THEN 0.5 mg/kg IV over next 60 minutes…
Contraindication attached
Depending on Hx (AAA) , clinical examination and CTA, Patient shows Lt LL acute limb ischemia ( class 2b) because of thrombosed popliteal aneurysm with no distal run off.
We can start with primary measures iv heparin, hydration, analgesia and oxygen supply.
The aneurysm needs to be repaired with exclusion bypass or interposition graft, but firstly patent distal run-off is mandatory.
In general,CDT is proper option. However given class 2b ischemia, i think open thrombectomy ( either with fogarty over the wire or retrograde ) can provide immediate patent outflow.
This presentation is associated with high risk of AKA, so such complication must be discussed frankly with the patient and his relatives
Pt has ALI 2b due to thrombosed POP anyrusm with distal embolisation and no distal run off.
Started heparin IV bolus
Good analgesia
Hydration
O2 supplementation
Full labs
Prepare blood
General and cardia assessment
Contra lat. Limb examination
Discuss with the pt and familly the possible intervention and high risk off limb loss ..
Pop exposure thrmobectomy with possible bolus thrombolytic if ther is run off visible then ligation of anyrusm and bypass if no visible runn off wait and see ( anticogulate the pt and prepare the pt for AKA
Pop aneurysm e no distal run off
*Thrombectomy hybrid completion angio stent
*cdt lytic therapy….to Lydia thrombus then definitely management either endo or bypass
Based on CTA, the patient has thrombosed pop A aneurysm complicated by distal embolisation with no run off in the crural vessels. As the symptoms started 5 hours ago and he has decreased motor power and acute ischemic pain, this condition might be classified as Rutherford 2b.
I have to explain to the patient in the consent process that his limb is threatened and there is high risk to limb loss at above knee level.
My plan will be urgent exploration of below knee pop A, trial of doing embolectomy and find a patent artery for landing of the exclusion bypass, Hybrid theatre is recommended for usage of Fogarty over the wire and angiogram if needed.
If failed AKA will be the last option.
65 years old gentleman presented to A&E with acute pain and weakness of the left leg, started 5 hours ago, impaired sensation and motor power (2 out of 5 ). background of previous EVAR for 6 cm AAA in 2019, HTN, T2DM and Angina.
Full hx medication hx hx of stoppage of antiplt or anticoagilant
Full examination pulse bp
Full vascular examination palpation pulse bilaterally..warmth cap refill
Hand held doppler
Hydration… Iv heparin
Full lab CBC inr bg lft kft
Ecg echo
Duplex
Cta if level of ischemia above femoral
Pt has ALI 2b due to thrombosed POP anyrusm with distal embolisation and no distal run off.
Started heparin IV bolus
Good analgesia
Hydration
O2 supplementation
Full labs
Prepare blood
General and cardia assessment
Contra lat. Limb examination
Discuss with the pt and familly the possible intervention and high risk off limb loss ..
Pop exposure thrmobectomy. with possible bolus thrombolytic if ther is run off visible then ligation of anyrusm and bypass if no visible runn off wait and see ( anticogulate the patient and prepare the pt for AKA
Thanks Ahmed and abdullah for your valuable comments, you right we usually place the catheter in distal vessels and i usually give 15 mg, i would start with bolus of 5mg every minutes to reach total of 15 mg as described before by Abdullah. one tip just be carful specially in elderly patient as they ae usually on heparin infusion in this situation and be guided with activated clotting time ACT as excessive anticoagulation plus TPA can cause disaster like ICH.
i agree with above knee amputation decision as limb is unsalvageable, you are counselling your patient and he asked you a few questions about the prognosis.
what will be the predicted mortality next 2 to 5 years?
what is the likelihood of him able to walk after amputation?
what is the complication of the amputation operation ?
–>Five-year mortality after major amputation ranges from 40–82% after below-knee amputations and 40–90% after above-knee amputations, with an overall average of about 62%
Source:
1- Thorud JC, Plemmons B, Buckley CJ, Shibuya N, Jupiter DC. Mortality after nontraumatic major amputation among patients with diabetes and peripheral vascular disease: a systematic review. J Foot Ankle Surg. 2016 May-Jun;55(3):591-9. doi: 10.1053/j.jfas.2016.01.012. Epub 2016 Feb 19. PMID: 26898398.
2-Stern JR, Wong CK, Yerovinkina M, et al. A meta-analysis of long-term mortality and associated risk factors following lower extremity amputation. Ann Vasc Surg. 2017 Jul;42:322-327. doi: 10.1016/j.avsg.2016.12.015. Epub 2017 Apr 5. PMID: 28389295.
–> possibility to walk after aka is 21-29 % depends on muscle state wound healing and rehabilitation.
–> complications
Phantom limb
Wound infection
Ulcer
Fall
Neuroma
Flexion contracture
Neuroma
1.Following AKA, mortality ranges from 39 to 80% in five years.
2. Predictors of good walking ability following lower limb amputation include cognition, fitness, ability to stand on one leg, independence in activities of daily living and pre-operative mobility, usually ranges from 20 -30 %.
3. Complications following AKA
1.Muscle atrophy.
2.Surgical site wound infections, dehiscence, and wounds from prosthetic wear.
3.flexion contractures
4.Phantom limb and phantom limb pain
5.Post-traumatic stress disorder (PTSD) and depression
6.Neuroma formation
References
Qaarie M. Y. (2023). Life Expectancy and Mortality After Lower Extremity Amputation: Overview and Analysis of Literature. Cureus, 15(5), e38944. https://doi.org/10.7759/cureus.38944
Sansam, K., Neumann, V., O’Connor, R. J., & Bhakta, B. (2009). Predicting walking ability following lower limb amputation: a systematic review of the literature. Journal of rehabilitation medicine, 41(8), 593-603.
Myers, M., & Chauvin, B. J. (2023). Above-the-knee amputations. In StatPearls [internet]. StatPearls Publishing.
thanks peter, ahmed and abdullah for all your promp answers , a lot of point s raised about managing of thrombosed popliteal aneurysm with no run off. I agree with your suggestion about the need for urgent embolectomy of run off vessels given the threatened limb situation , two questions
1- if you use Catheter direct thrombolysis, where will you leave the catheter ( pop aneurysm or pop artery or distal vessels and if so which one? Abdullah what is the bolus of TPA? and what is contraindciation of thrombolysis ( things to ask about in history) ?
2- you manage to open PT with thrombectomy which stopped at the ankle with small branch to distal peroneal artery and you decided to do am exclusion bypass to proximal PT? next day on you ward round you see the patient leg and there is no sensation or motor power below mid-calf with mottled leg, what is your next step?
Q1:
I think no role to place the catheter in pop.artery, it should be placed in one of tibialis.
Bolus dose is usually around 8 mg
Contraindications can be classified into absolute and relative
absolute ones include: cerebrovascular event (including transient ischaemic attack) within the last two months, active bleeding events, recent gastrointestinal bleeding, neurosurgery within the last two months.
Relative as major non-vascular surgery or trauma within the last 10 days, uncontrolled hypertension, Intracranial tumour, hepatic failure, particularly those with coagulopathy.
Q2:
This is picture of non-salvageable limb, patient must be prepared for AKA in urgent way after discussion with patient and his relatives.
Q1. In TPT or vessele who wire is pass to it distally
Bolus according to type Of drug y use for ex. Alteplase 15 mg IVP bolus over 1-2 minutes, THEN 0.75 mg/kg IV infusion over 30 minutes (not to exceed 50 mg), and THEN 0.5 mg/kg IV over next 60 minutes…
Contraindication attached
Q2. Prepare pt for major amputation
Depending on Hx (AAA) , clinical examination and CTA, Patient shows Lt LL acute limb ischemia ( class 2b) because of thrombosed popliteal aneurysm with no distal run off.
We can start with primary measures iv heparin, hydration, analgesia and oxygen supply.
The aneurysm needs to be repaired with exclusion bypass or interposition graft, but firstly patent distal run-off is mandatory.
In general,CDT is proper option. However given class 2b ischemia, i think open thrombectomy ( either with fogarty over the wire or retrograde ) can provide immediate patent outflow.
This presentation is associated with high risk of AKA, so such complication must be discussed frankly with the patient and his relatives
Pt has ALI 2b due to thrombosed POP anyrusm with distal embolisation and no distal run off.
Started heparin IV bolus
Good analgesia
Hydration
O2 supplementation
Full labs
Prepare blood
General and cardia assessment
Contra lat. Limb examination
Discuss with the pt and familly the possible intervention and high risk off limb loss ..
Pop exposure thrmobectomy with possible bolus thrombolytic if ther is run off visible then ligation of anyrusm and bypass if no visible runn off wait and see ( anticogulate the pt and prepare the pt for AKA
Thanks Iman for your prompt and detailed assessment, patient has femoral pulse and absent popliteal and pedal pulses.
CTA shows large thrombosed popliteal aneurysm with no obvious runoff patent vessel below popliteal artery? what will be your next step?
Pop aneurysm e no distal run off
*Thrombectomy hybrid completion angio stent
*cdt lytic therapy….to Lydia thrombus then definitely management either endo or bypass
Based on CTA, the patient has thrombosed pop A aneurysm complicated by distal embolisation with no run off in the crural vessels. As the symptoms started 5 hours ago and he has decreased motor power and acute ischemic pain, this condition might be classified as Rutherford 2b.
I have to explain to the patient in the consent process that his limb is threatened and there is high risk to limb loss at above knee level.
My plan will be urgent exploration of below knee pop A, trial of doing embolectomy and find a patent artery for landing of the exclusion bypass, Hybrid theatre is recommended for usage of Fogarty over the wire and angiogram if needed.
If failed AKA will be the last option.
65 years old gentleman presented to A&E with acute pain and weakness of the left leg, started 5 hours ago, impaired sensation and motor power (2 out of 5 ). background of previous EVAR for 6 cm AAA in 2019, HTN, T2DM and Angina.
what is your next step of management?
Full hx medication hx hx of stoppage of antiplt or anticoagilant
Full examination pulse bp
Full vascular examination palpation pulse bilaterally..warmth cap refill
Hand held doppler
Hydration… Iv heparin
Full lab CBC inr bg lft kft
Ecg echo
Duplex
Cta if level of ischemia above femoral
Ali 2b