Acute Limb ischemia is elderly

[saad shebrain]

92 year-old female with multiple co-morbidities including DM, CHF, HTN, PVD, A-fib, AAA 5.5 cm, underwent Femoral-peroneal bypass (using Propatent graft) 1 year ago for acute left foot ischemia. she stopped taking her coumadin, and other meds in the last 4 months.
  Now presented to ER with 1 day history of increasing pain in the left foot, still has sensory and motor function, no pulses or even doppler signals. the LLE is cold from midthigh-toes.
  pt is slightly demeted, but wants evrything to be done.
   
  vitals: A-fib, HR 80-110, BP 160s-210s/90s-110s.
  of options:
  1. angio with tPA provided that BP is well controlled ( but what about AAA, by the way a non contrast CT showed no change in size of aneurysm).
  2. Heparin drip and accept the fact if the whole graft is gone, the likelihood of limb salvage is poor.
  3.Thrombectomy of the the graft under local anesthesia and accept the fact it has notorious results when used for occluded grafts with high chance of unsuccess.
   
  What is the best option for this patient?
   
   
  Thanx
   
  SS
   




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