Vascular Surgery - Case Files Flashcards
What is lower extremity peripheral vascular occlusive disease? (acute and chronic)
Ischemia in the lower extremities caused by arterial stenosis.
Acute ischemia is typically characeterised by a sudden onset of pain, pallor and pulselessness (main 3 Ps, remember the other 3 Ps - paresthesiae, perishingly cold and paralysis).
Chronic arterial ischemia manifests as lower extremity pain with exercise and resolves with rest
A 57 year old is able to walk only 40 yards before stopping because of right calf and thigh cramping. He is diabetic and takes an oral hypoglycemic agent, a long acting beta-blocker and a statin-class lipid lowering agent. He smokes on pack of cigarettes a day. He has normal right leg pulses but no pulses in the left groin and leg. What is the site of the occlusion?
- Left aortoiliac system
- Left SFA
- Right SFA
- Left internal carotid artery
- Infrarenal aorta
Left aortoiliac system
His symptoms imply occlusive disease above the common femoral level - confirmed by the absence of a femoral pulse
The patient described previously is managed medically. Returns 8 mths later with continued calf pain, as well as nonhealing ulcers between his third and fourth toes. Pulse examination is unchanged. Which of the following arteries is most likely to be additionally involved?
- Occlusion in his left internal iliac artery
- Occlusion in his left SFA
- Occlusion in his right SFA
- Occlussion in his right aortoiliac artery
- Infrarenal aorta
Occlusion in his left SFA
When patients with arterial occlusive disease progress from claudication to tissue loss, multilevel disease is usually present. There is likely to be diseaesin both the aortoiliac and superificial femoral arteries.
An 82-year-old woman with history of severe dementia and left cerebrovascular accident (CVA) is noted to have a gangrenous toe and an erythematous left foot. She is severely debilitated by her dementia and CVA and is bedbound.
Her physical examination reveals normal temperature, normal femoral pulses, diminished left popliteal pulse, and nonpalpable left pedal pulses. Her right lower extremity vascular examination reveals normal femoral pulse and diminished popliteal and pedal pulses. Her left great toe and second toe have dark eschars at the tip with surrounding erythema extending to the mid foot.
Which of the following is the most appropriate treatment option?
- Obtain an angiogram of the aorta and left lower extremity to identify the areas of occlusion and treat the blockage with angioplasty and stent placement. After blood flow is restored to the foot, proceed with toe amputation and wound care.
- Obtain an angiogram of the aorta and left lower extremity, followed by an arterial bypass operation to restore flow to the lower extremity. After blood flow is restored to the foot, proceed with toe amputation and wound care.
- Initiate systemic heparin therapy.
- Perform left below-the-knee amputation.
- Wound care and long-term antibiotic therapy.
**Perform left below the knee amputation **
- Left below-the-knee amputation may be the most appropriate treatment for this elderly, nonambulatory patient with artery occlusion at the femoral artery level.
- Given the ischemic changes in the left first and second toes, it is highly probable that the patient also has occlusive disease in the tibial arteries as well.
- Revascularization of the lower extremities is generally not indicated in nonambulatory patients, and given the evidence of soft tissue infection of the foot, an amputation may be the best option for this patient at this time.
- Antibiotics alone are generally insufficient for the treatment of soft tissue infections associated with tissue ischemia.
A 57-year-old man presents with acute onset of right foot pain. He states that he had been in his usual state of health until 6 hours ago, when he developed sudden onset of right foot and leg pain. Associated with the pain, the patient has noted the onset of numbness in his right toes. His past medical history is significant for hypertension. Physical examination reveals irregular pulse rate of 120 beats/min, blood pressure of 130/82 mm Hg, and respiratory rate of 24 breaths/min. His rhythm on the cardiac monitor shows irregularly, irregular rate without the presence of p waves.
His right lower extremity has a bluish discoloration and is cool to the touch below the mid-thigh. His aortic pulse is normal, his right femoral pulse is normal, and the right popliteal and pedal pulses are absent. The femoral, popliteal, and pedal pulses are normal on the left. Which of the following is the most appropriate management option for this patient?
- Systemic heparinization, right femoral artery thrombectomy
- Systemic heparinization, angiography, and placement of right SFA stent
- Systemic heparinization
- Systemic thrombolytic therapy
- Right femoral-popliteal artery bypass
Systemic Thrombolytic Therapy
- This patient’s acute onset of symptoms and the presence of normal vascular examination in the left lower extremity are highly suggestive of a recent embolic event leading to occlusion of the right SFA.
- It is important to initiate heparin therapy to prevent the propagation of thrombus in the right lower extremity; at the same time, because the process has been in place for several hours and the patient has clear signs of ischemia, additional vascular imaging may actually delay treatment.
- An additional procedure to consider in this individual following reestablishment of blood flow is right lower leg fasciotomy to prevent the development of compartment syndrome.
- The patient may be best served by early operative thrombectomy. In some patients with acute embolic events and no significant ischemia, arteriography with intra-arterial delivery of thrombolytics may be indicated.
- Operative bypass grafting is generally not indicated for patients with acute arterial insufficiency related to embolic processes.
