Case – 10

Case – 10

Diagnosis

Acute ischemia left leg secondary to occluded graft.

History

Acute onset of pain left leg and foot 30 hours before presenting to the hospital. The foot and lower ½ of the leg went cold and felt slightly numb. The movement was also partially reduced.

PMH

Known diabetic with severe PVD involving the small arteries of the legs. She also has CAD.

The pateint had a Femoro-distal bypass using a synthetic graft (PTFE ringed 8mm * 70 cm). The proximal anastomosis was on the distal SFA and the distal on the anterior tibial artery in the upper 1/3 using a miller cuff. The graft was patent for the last 2 years with good distal pulses at the dorsalis pedis artery.

Examination

The patient was not in pain when she came to the hospital. There were reasonable movements of the foot and the sensation was less than the contra-lateral foot. The distal half of the left foot seemed slightly cyanosed and cold. The coolness extended to the middle of the leg. There was no tenderness of the calf but the foot was tender on deep pressure.

Hospital course

The patient was admitted as an emergency and had urgent investigation. The relevant ones were:

Bloods

Hb – 11.3 gm%     WBC – 7400/cu mm       Blood sugar (R) – 140 mg%

Creatinine – 1.7 mg%      Serum K – 5.5       PT – 14.4/12 sec

APTT – 49/28 sec

CXR – WNL

Echocardiogram

Enlarged LA; normal LV; mild MR; moderate systolic dysfunction;

LVEF – 30%

The patient was given a course of anticoagulation using LMWH

Colour Doppler Study

The arteries are severely calcified. The graft is thrombosed and lies medial  to Popliteal artery in the lower 1/3 of thigh. It passes behind the knee and laterally is attached to the upper 1/3 of Anterior Tibial Artery. All three of the below knee arteries are occluded with poor collaterals.

Peripheral Angiogram

Patent left SFA. The Popliteal is occluded and reforms just above the knee and is occluded again. Plenty of collaterals. No graft is visible.

Options

Following the presentation and investigations the options before us were:

  1. Surgery – to perform an Embolectomy through the graft and perhaps salvage the limb. This was not done because due to diabetes there may be a progression of distal disease leading to out-flow obstruction and subsequent occlusion of the graft again. Also the patient was a poor cardiac risk with LVEF – 30%
  2. Thrombolysis – there was no cardiac contraindication and the risk of surgery was eliminated. The chances of success were about 50%.

These options were discussed with the family and it was decided to give thrombolysis.

Thrombolysis –

An intra-arterial catheter was inserted and the tip was placed at the origin of t.he graft at the distal SFA. A bolus of 2,25000 u Urokinsas was given followed by an infusion of 2,25000 u / hour for 24 hours.

A check Angiogram done the following morning showed:

The graft remained occluded and the picture was almost identical to the one before thrombolysis.

Further management

Since thrombolysis did not work it was stopped the following day. The patient was re-started on LMWH + Antiplatelet drugs. She was not having pain the condition of the leg was unchanged. The patient is being treated conservatively hoping for collaterals to open and salvage. The anterior compartment of the leg is very tender which is probably due to the ischemic muscles below. The posterior compartment is non tender. The patient has no fever and the white cell count is 7400. Her createnine is 1.7 and urea > 100.   She is on anticoagulants.

The patient was given a course of Prostaglandin E1 infusion for 5 days. The leg became less painful and tender. The tenderness was confined to the foot. Presently we are not sure if this change in condition is due to epidural Tedigesic infusion or the vasodilation due to Prostaglandin E1. The entire management has been discussed by the family on a regular basis. After a week the patient developed pain in the right groin with a prominent swelling and bruising. There was a bruit over the site. Ultra sound showed abb

false aneurysm at the site of the intra-arterial thrombolysis. It was probably due to anticaogularion. Compression under ultrasound guidance was done and the fistula closed. The patient was pain free. Anticaogulation had to be stopped temporarily.

A wait and watch policy is being adopted presently if things worsen she may need a BKA.

The pain on the left foot worsened and it became more cyanosed. The white cell count started rising. It was considered to do an amputation. This was discussed with the family and consent taken.

Surgery­

Left Above knee Amputation –

The muscles in the anteriolateral compartment were non-viable but looked healthy in the posterior and anterior compartments. The skin was viable and bleeding. Since only one attempt could be made at removing the leg considering the cardiac condition of the patient, it was considered appropriate to go for an above knee amputation. The muscles above the knee were fine and bleeding normally. The graft when cut was patent and had to be sutured with prolene. The wound was left open though there was no infection.

Subsequently, developed DVT of the right leg that improved on conservative management – elevation, stockings and anticoagulation.

Condition on discharge

The patient is much more stable with no fever and a normal WBC count. The wound of the stump looks healthy with no inflammation. The right leg is swollen above the knee in the upper thigh due to elevation but the leg is normal. The patient has impending bed sores which need regular change of position and sitting out on the chair.

I feel she would improve at home as she would have to sit out of bed. Besides there is minimal risk of cross infection at home.

Advise on discharge 

  1. Diabetic diet
  2. Progressively increasing mobility with support and walker
  3. Tab Oflox 200 mg bd * 10 days
  4. Tab Lasix 40 mg od
  5. Tab Pantocid 40 mg od
  6. Tab Shelcal 500 mg bd
  7. Nutrecal DM 3 tsf qid
  8. Cap Tramazac 50 mg qid
  9. Tab Cardvas 6.25 mg in morning and 3.125 mg in the evening
  10. Tab Tryptomer 10 mg bd
  11. inj Claxane 0.4 ml s/c bd – to stop when PT test shows value twice control
  12. Tab Ecospirin 150 mg od
  13. Tab Plavix 75 mg od
  14. Tab warfarin 3 mg od and to adjust dose according to PT test
  15. PT test weekly and inform
  16. Cremaffin 20 ml bd
  17. Tab Alprax 0.5 mg HS
  18. Cap Proxyvon 1 sos
  19. Inj Human Insulin regular — > 100 – 6 units

      > 175 – 10 units

          To review in the OPD after 7 days

(Dr. JAISOM CHOPRA)

Consultant Vascular Surgeon