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Wave 2: Module 2: Lower Limb – Week 5 – Case 1
- February 3, 2025
- Posted by: admin
- Category: Uncategorized
Case 1
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
Any post-operative investigations required?
What is your anticoagulation plan?
21 Comments
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Q1
Acute Lt lower limb ALI Rutherford class IIb threatened due to to embolism
Q2
IV heparin infusion
Iv fluid
Admission
Prepare for immediate intervention
Good oxygen supply
Q3
ECG
ECHO
Full Lab
CXR
Q4
Embolectoy using fogarty 4& 5 catheter
Followed by completion angiography
And fasciotomy may be needed due to tender calf muscle & prolonged ischemia time
Postop ABG & CBC & ECG & KFTS
Therapeutic anticoagulation after cardio consultation due to AF
Q1:
Accordingly it’s Rutherford class IIb threatened ALI lt due to embolic reason
Q2:
admission
systemic heparinization
good hydration
oxygen support
take to op theatre immediately
Q3:
Full labs preop – ecg- echocardiography -CXR
Q4:
transfemoral catheter embolectomy with fogarty and can be followed by completion angiography , mechanical thrombectomy devices also can be useful
and fasciotomy may need to be done because of prolonged time of ischemia
Q5:
ABG, CK, cbc, KFT, urine analysis
Q6:
Continue in heparin infusion pump till discharge
A1.
Based on clinical exam, history ,and CTA > this is acute embolic left lower ischemia (rutherford class IIb immediately threatened) on level of SFA downwards
A2..
A3..
A4..
Options for revascularization include
A5..
Post operative we need to know the source of thrombus and avoid reperfution and contrast complications
A6..
Q1 The clinical diagnosis is acute left lower limb ischemia class IIb
Q2 The initial management is
immediate heparin 5000u
oxygen supply, iv hydration, and opiates
Q3 I would request full lab investigations plus Echocardiography
Q4 options for revascularization are surgical embolectomy, and thrombolytic therapy, my choice in this cas would be Fogarty catheter embolectomy plus fasciotomy in addition to anti reperfusion management as this case requires immediate revascularization
my anticoagulation plan would be LMWH during admission, and may discharge the patient on DOAC plus aspirin
Acute thretened ischemia with Ant compartemental syndrome
2. Immediate heparanziation+ Iv fluid+ analgesic + O2
3. ECHO , CKMB
4.Thrombectomy ( open,percautenous), Thrombolysis (lytic therapy)
I would prefer the open thrombectomy + Fasciotomy
5. ABG,serum K ( for reperusion injury suspecion), TEE ( source of thrombi) , CTA (To evaluate aorta)
6. LMWH theraputic dose as long as he is admitted
For discharge , DOAC + low dose aspirin
diagnosis .. left lower limb acute limb ischemia.. Rutherford 2 b
Management… heparinization , saline infusion, oxygen mask
admission with base inv as cbc, crt , ABG, ECG and heart rate control
urgent surgical exploration
pt needs urgent thrombectomy and post operative angiography as pt is threatened ischemia making endovascular lytic less appropriate ( acc to the European society guidelines) , and fasciotomy for prolonged ischemia and tender calf
Post operative angiography shows patent arterial tree till DPA
post op pt needs ECG , ABG for repurfusion , s crt due to contrast administration
pt needs therapeutic anti coagulation due to prescence of paroxysmal AF with CHADs VASC score exceeding 1.
CT angiogram of the lower limbs was performed
1.What is your clinical diagnosis?
embolic acute limb ischemia – rutherford class III
2.Initial management protocol for this patient?
Heparinization
oxygenation
analgesics
iv fluids
3-Please outline any other Investigations you would request?
ABG
echocardiography
K+ Na+ creat , bicarbonate
4- Options for revascularization? Please indicate your preferred modality including technical approach and what evidence would support that?
1- transfemoral thrombectomy using over wire embolectomy catheter and complementry angiography
2- thrombolysis
3- mechanical -pharmaceutical embolectomy ( angiojet )
Following revascularization, a completion angiogram was performed
Any post-operative investigations required?
electrolytes panel
renal functions
What is your anticoagulation plan?
therapeutic anticoagulation according to cardiology consultation for AF
Acute ischaemia threatened limb
Full lab
Immediate anticoagulant
Emboolectomy IN hyprid Room
Through femoral incision+ prophylactic faciotomy+ intraoperative prophylactic against hyperkalemia and revascularization syndrome
Finally completion angiogram for assessment And management according to finding
Post operative coagulation profile+check for erevasculizaion syndrome k creat level
Anticoagulant with low molecular weight heparin
A1 my diagnosis is acute limb ischemia in lt ll class 2b with high suspecion of compartment syndrome
A2intial managgment
iv hepatin 5000IU
o2
iv fluids
analgesia
A3 investigation
cbc
urea -creat
inr
ecg -echo
A4 options
open thrombectomy
mechanical thrombectomy
catheter diarected thrombolysis
i would prefer open thrombectomy with facsiotomy
as patient class 2 b ischemia
A5 investigation post op
echo for cardiac assessment
ct angio if there is no cardiac lesion
LMWH is perfereed post op
and we can discharge patient on DOACs if there is no valvular lesion
statin
antoplatelet
What is your clinical diagnosis?acute limb ischemia Rutherford class IIb, with ant compartment syndrome
Initial management protocol for this patient?admission
analgesia
hydration According to cardiology consultation, O2 mask,
5000 heparin IV
cardiac consultation
Please outline any other Investigations you would request?full lab incuding CBC, INR, K, ABG, URINE ANALYSIS, S. CREAT, S. UREA
Options for revascularization?open embolectomy by fogarty cath
catheter guided intralesional thrombolytic therapy
mechanical thrombectomy
in addition to fasciotomy
Please indicate your preferred modality including technical approach and what evidence would support that?open thrombectomy as this case is class IIb which need to be treated immediately considering. compartmental syndrome as a prognostic sign. ESVS recommends immediate intervention in this situation
afterwards, anticoagulation is recommended beside Best medical ttt
therapeutic dose of DOACs will be selected if patient has no valvular heart disease.
daily dressing will be ordered to the fasciotom wound
regular follow up on arterial flow, sensation, motor power, and foot state
A1
Acute ischemia Class IIb mostly embolic and suspicion of leg compartment syndrome
A2
Admesion
Iv Heparin 5000 IU , Analgesia & Nasal Oxygen
Iv fluids
A3
Cbc pt ptt inr Urea creat Crp
ESR ELECTROLYTES
ECHO
A4
Options include thrombolysis , Mechanical thrombectomy, open embolectomy
Or hypbrid
I’d go For open embolectomy
And fasciotomy Dt long ischemia
A5
Completion of Cardiac investigations if not done and cardiac consultation
..
CT Aortography if cardiac embolic source is excluded
..
Renal function
A6
LMWH till discharge
Then DOACs if no Valvular Cardiac Lesion is present.
1 Lt ll acute embolic ischemia rutherford llb
2 hospitalization
Heparnization
Oxygenation
Analgesics
Iv fluids but cautiously
3 full lab CBC , pt PC INR ، creat , LFTs
Echocardiography if available
4 open surgical embolectomy or endovascular mechanical embolectomy
I prefer open embolectomy under fluroscopic guidance as it more familiar and less cost with good results
5 CBC and Creat
Investigations to control cardiac condition
6 warfarin or DOAC , antiplatelets and statin
Q(1):
L.T L.L acute ischemia, Class 2B “embolic cause”.
Q(2):
Urgent hospitalization
Full heparinization
Oxygen supplementation
Analgesics
IV fluids
Urgent revasculariztion.
Q(3):
Labs: CBC, Renal functions, electrolytes
ECG
ECHO
ABG
Cardiology consultation
Q(4):
Open approach: Transfemoral emolectomy by fogarty catheter
CDT or pharmacomechnical atherectomy or hybrid
I would prefer open Transfemoral embolectomy and fasciotomy and completion angiography.
Fasciotomy should be considered due to prolonged ischemia time “Recommendation 40” according to ESVS guidline.
-Renal functions
-CT or MR Aortography to exclude aortic lesion
-Cardiology consultation
-LMWH in hospital, statins, vasodilators, antiplatelets.
-DOAC when discharged or Warfarin if DOAC unavailable in case of valvular lesions.
Q1:
left lower limb grade 2b acute ischemia most probably embolic due to AF
Q2:
admission and iv fluids and oxygen supplementation and analgesics up to morphia and anticoagulant
Q3:
full blood count, kidney function tests, echocardiography to exclude mural thrombus or valvular disease
Q4:
open surgical thrombectomy using fogarty catheter
mechanical thrombectomy using rotarex for example
catheter directed thrombolysis
i would prefer left transfemoral exposure and fogarty catheter embolectomy then completion angiography and post revascularization fasciotomy due to long ischemia time
Q5:
ABG and cardiac consultation to control of the AF
Q6:
antiplatelet and anticoagulant and statin
A1:
Rutherford class IIb immediately threatened ALI lt due to embolic cause
A2:
Hospitalization
IV fluids
Heparinization
Pain killers
O2 supplementation
Emergent revascularization
A3:
Echo for cardiac thromus
Labs for anesthesia fitness ABG K KFT
A4:
Class IIb with threatened limb needs emergent lt transfemoral catheter embolectomy with fogarty followed by completion angiography and fasciotomy is to be done because of delayed presentation
Other options could be mechanical thrombectomy and aspiration or hybrid
No rule for thrombolysis as time factor
A5:
ABG K ck KFT CBC PTT for heparin therapy follow up
A6:
Heparin bolus or infusion pump or LMWH during hospitalization then discharge on oral anticoag
Q1
Case of acute marginally threatened limb ischemia most propably embloic type not complicated yet
Q2
Rehydration
Oxygenation
Full heparinization
Analgesic
Cardiology consultation for AF management
Q3
Ecg
Echo
Creat- crp- k – abg -cbc-pt
Q4
Open embolectomy with over wire embolectomy catheter then completion angio
Endovascular aspiration by penumbra/ indigo/ aspirex catheter ( if available )
Open one is prefered as it is rapid according to sitle & topas trial
Q5
K – abg – cbc monitoring
Q 6
LMWH till discharge then apixaban if AF
Marivan if there is valvular effect
What is your clinical diagnosis?
Acute ischemia Class IIb mostly embolic + suspicion of leg compartment syndrome
Initial management protocol for this patient?
Iv Heparin 5000 IU , Analgesia & Nasal Oxygen
Please outline any other Investigations you would request?
ECG Echocardiography but without delaying intervention
Full labs including CKmb
Options for revascularization? Please indicate your preferred modality including technical approach and what evidence would support that?
Options include thrombolysis , Mechanical thrombectomy & open embolectomy
I’d go For open embolectomy and leg Fasciotomy
Following revascularization, a completion angiogram was performed
Any post-operative investigations required?
Completion of Cardiac investigations if not done
CT Aortography if cardiac embolic source is excluded
What is your anticoagulation plan?
LMWH till discharge
Then DOACs if no Valvular Cardiac Lesion is present.
Thank you Dr Mohamed. Very comprehensive answer.
A1.
Based on clinical exam, history ,and CTA this is acute embolic lt ll ischemia rutherford class IIb immediately threatened
A2..
This patient requires admission, IV fluid hydration, bolous of 5000 IU of IV heparin , good analgesia, and O2 supply
Then preparation for immediate revascularization
A3..
I will ask for Echocardiogram to detect source of showering
I will ask for CBC, LFT, and KFT
A4..
Options for revascularization include
Open fogerty embolectomy
Percutaneous embolectomy
Either
Over the wire fogerty, pharmacological thrombolysis, pharmachomechanical, or mechanical thrombolysis
I would prefer for this delayed case an open approach of fogerty embolectomy with fasciotomy as the anterior compartment is affected
According to STILE Trial surgical revascularization of native artery is more durable than lysis
Open surgical approach over the groin and achieving control over CFA, SFA,and PFA .
Transverse arteriotomy just above the CFA bifurcation
Using multible sizes of fogerty catheter to clear all throbi from Arterial tree
Flushing the arteries by saline haparine mix
Complesion angiography
Closure of arteriotomy
Finally leg fasciotomy
A5..
Post operative we need to know the source of thrombus
TFE may be done
Or CT aortography to evaluate the aorta
A6..
As long as the patient is admitted I will keep him on LMWH
And on discharge I will discharge him on low dose asprine and life long warfarine if there is valvular lesion or atrial thrombus
Thank you Dr Mahmoud, excellent answer.
I agree that open embolectomy offers the quickest way to revascularize (unless you have the option of mechanical thrombectomy endovascularly).
Why would you prefer long-term warfarin over DOAC?
One of the absolute indications of warfarin is valvular heart disease according to INVICTUS TRIAL 2022. and I said if it was discovered by investigation that the patient is rheumatic heart disease ..but if not I will go with DOAC