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Wave 2: Module 2: Lower Limb – Week 5 – Case 2
- February 5, 2025
- Posted by: admin
- Category: Uncategorized
Case 2
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 post-operative anticoagulation and surveillance plan?
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?
13 Comments
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Postop
Dual anti platelets , vasodilators & statins & add riavroxaban2.5 mg 1*2 on discharge
Surveillance by follow-up duplex in the clinic every 3 months
Clinical diagnosis: acute on top of chronic ischemia due to stent thrombosis
Intial management:
IV heparin infusion
Iv fluids
Oxygen supply
Admission
Urgent revascularization
Investigation:
Full lab
ECG & Echo
CXR
Vein mapping for possibility of bypass
Revascularization:
Lytic therapy is preferred than emolectomy with completion angiography
May need bypass if failed lytic therapy
Q(1):
Q(2):
Most probably acute on top of chronic ischemia due to stent thrombosis.
“Class 2A”.
Q(3):
Q(4):
Q(5):
STIlE trial and Topas trial showing efficacy and salvageability of endovascular revascularizain in cases of stent , graft stenosis
If failed …… plan for open femoro-pop bypass
Q1 my post operative medical plan would be rivaroxaban 2.5 bid plus aspirin, plus 3months follow up
Q2 The clinical diagnosis is acute on top of chronic ischemia on the right lower limb Class IIa
Q3 The initial management is
immediate heparin 5000u, oxygen supply, iv hydration and analgesia
Q4 Echocardiography plus full lab investigations
Q5 options for revascularization are thrombolysis and endovascular thrombectomy, in this case I would prefer thrombolysis with completion angioplasty
1.low doae aspirin , DOACs
2. Acute on top.of chronic ischemia ( in stent thrombosis)
3. Immidate heparinzation , O2 mask.anaglesia
4.Cbc,ECHO,ECG,CKMB, s.cr.LFT,INR
5.lytic ( the ischrmia is viable) through retrograde access, or ratarex
diagnosis.. acute on top chronic limb ischemia. In stent thrombosis .
Initial management .. heparinization , saline infusion , face mask oxygenation.
pt needs admission to OR with femoral sheath placement (heparinization) and passage of wire through lesion till reaching patent tree downward, introduction of unifuse catheter with lytic bolus and continuing saline heparin infusion of the femoral sheath.
then icu admission and follow up of GCS, urine cath for hematuria, fibrinogen level monitoring is needed for lytic follow-up. Management described is supported by European society of vascular surgery
post operative anticoagulation recommended is clopidogrel with rivarospire 2.5 mg twice daily. Statin, vasodilators, life style modifications with control of comorbidities
inv of the case
lab as sort , ABG , cbc. ECG and echo for cardiac status follow up as pt has IHD cardiac stent
Acute on top of Ch ischaemia
Immediate anticoagulant with low molecular weight heparin
Check for Full lab assessment hga1c level Lipid profile CBC creat level
Cardiac function assessment
Catheter directed thrombosis then PTA according to results of thrombolysis and
Crossings the stent dilatation resetting according to intraoperative result’s
A1post op i will start patient on low molecular weight heparin and dual antiplatelets
and discharge on rivarxban 2.5 twice daily and single antiplatlet
aurvillence by us duplex every 3 month
A2acute thrombotic rt ll ischemia class 2 a
A3 iv heparin 5000iu
o2
iv fluids
analgesia
A4 cbc
urea creat
inr
esr -crp
ecg – echo for cardiac assessment
us duplex assessment and vein mapping
CTA aorta and both ll
A5 catherter directed thrombolysis
or percutanous mechanial thrombetomy
or open surgery fem pop infra bypass
i will prefer CDT as better results in stent occlusion
A1:
I will put patient on dual antiplatelet therapy and Xarelto plus statins and vasodilators
A2:
Most probably Rutherford II-A acute on top of chronic ischemia
A3:
Admission with IV heparin and analgesic therapy
Oxygen therapy and IV fluids
A4:
Full blood panel
ECHO
CT angiography
saphenous mapping
A5: Endovascular artherectomy or
Catheter directed thrombolytic therapy
Prefer CDT contralateral approach then catherization.
A1
Low molecular weight heparin
Dual antiplatelets
Vasodilators
Statins
Then when discharged: Rivaroxaban 2.5mg twice daily with Aspirin tab 100mg to reduce cardiovascular events.
Surveillance by duplex U/S every 3 months to detect any restenosis and the flow volume along the arterial tree.
A2
Most probably acute on top of chronic ischemia due to stent thrombosis.
“Class 2A”.
A3
Hospitalization
Full heparinization
oxygenation and IV fuids
Analgesics
Prepare for urgent revascularization
A4
Full labs: CBC, coagulation profile, renal functions and electrolytes
ABG
ECG
Cardiology consulation
Internal medicine consultation
CT Aortography for lesions in aorta to be detected
Saphenous mapping for conduit availability
A5
Endovascular option is first choice as it is a case of acute on top of chronic with a compensated limb class I to IIa ALI in the form of retrograde cross over access with -mechanical thrombectomy rotarex or pharmaco mech angioget
-CDT for the thrombus load followed by angioplasty of the residual lesion
-If not available endovascular so surgery would be an option with fem pop BTK bypass vein graft
Q(1):
Low molecular weight heparin
Dual antiplatelets
Vasodilators
Statins
Then when discharged: Rivaroxaban 2.5mg twice daily with Aspirin tab 100mg to reduce cardiovascular events.
Surveillance by duplex U/S every 3 months to detect any restenosis and the flow volume along the arterial tree.
Q(2):
Most probably acute on top of chronic ischemia due to stent thrombosis.
“Class 2A”.
Q(3):
Hospitalization
Full heparinization
oxygenation and IV fuids
Analgesics
Prepare for urgent revascularization
Q(4):
Full labs: CBC, coagulation profile, renal functions and electrolytes
ABG
ECG
Cardiology consulation
Internal medicine consultation
CT Aortography for lesions in aorta to be detected
Saphenous mapping for conduit availability
Q(5):
CDT or pharmacomechanical atherectomy
open Fem-pop bypass
I would prefer contralateral approach and pig tail and rim catheter for support.
TOPAS trial concluded that endovascular apprach is better for limb salvagability.
A1..
post angioplasty i will keep the patient on dual antipletlet therapy plus low dose revaroxipan for 6 months then i will continue on single antipletlet plus revaroxipan in addition to that ststins and vasodilators
survillance duplex US will be dons every three months to detet any early in stent stenosis
A2..
my provisional diagnosis is acute instent thtombosis rutherford category IIa
A3..
PATIENT admission with the initiation of IV heparin and O2 supply analgesia and preparation of the patient for revascularization
A4..
I will ask for full lab CBC, LFT, KFT, CER, ECG,ECHO, saphenous vein mapping, and anaethesia consultation
A5..
variable options for revascularization including CDT,either mechanical or pharmaco-mechanical , atherectomy, and surgical bypass
i prefer to start with CDT from contralateral approach then using rim catheter to cross over the aortic bifurcation then inrodusing guide wire and the catheter over it
TOPAS I trial concluded that the rates of limb salvage and patient survival are similar in both surgery and thrombolysis groups
Q1
Post op LMWH
Statin
Anti plt
Vasodilators
B blockers
Low dose anticoagulant
Life style modification
Q2
Acute on top of ch ischemia Rutherford 2a most propably due to in stent restenosis not complicated
Q3
Hydration
Anti coagulation
Pain killers
Oxygenation
Diabetologist consultation
Cardio vascular consultation
Plan for angioplasty intervention
Q4
Ecg
Echo
Lipid profile
S creat- k – abg- cbc- pt
Q5
Endovascular with atherectomy tool or cather direct thrombolysis
STIlE trial and Topas trial showing efficacy of endovascular revascularizain in cases of stent , graft stenosis
If failed …… plan for open femoro-pop bypass
A1:
COMPASS anti platelets with low dose rivaroxiban
A2:
Acute on top of chronic limb ischemia class I to IIa because sensory affection could be from diabetic neuropathy and the audible doppler signals from collateral circulation
A3:
Hospitalization
Fluids
O2
Pain killer
Heparin
A4:
Imaging CTA aorta to exclude dissection
ECG
Duplex for venous mapping in case of bypass option
ABPI as base line for follow up
Labs pre op prep hba1c
A5:
Endovascular option is first choice as it is a case of acute on top of chronic with a compensated limb class I to IIa ALI in the form of retrograde cross over access with -mechanical thrombectomy rotarex or pharmaco mech angioget
-CDT for the thrombus load followed by angioplasty of the residual lesion
-If not available endovascular so surgery would be an option with fem pop BTK bypass vein graft