Acute Limb ischemia is elderly

[Sise, Mike MD]

I saw this ladies twin sister last week and her brother yesterday. This has become the face of acute care vascular surgery. Agree with Dr. Mattox. Added caveat - when you use any conduit other than vein for a fem - far away tell the patient and family that it may not work for long and that the next step may be amputation. One trip to the angio suite for lytic Rx if not contraindicated or, if patient healthy enough, to the OR for thrombectomy may be warranted if the limb is viable.
 
The last three I've seen have developed thrombosis in the setting of severe pneumonia or acute cardiac decompensation and the choice was clear - amputation or, in one recent 92 yr old man, comfort care.
 
Where or where are those great above knee fem-pops and AFBs that many of us signed up to do as vascular surgeons 20 yrs ago?
 
Mike Sise
San Diego

________________________________

From: kmattox at aol.com [mailto:kmattox at aol.com]
Sent: Sun 12/2/2007 2:41 AM
To: Trauma & Critical Care mailing list
Subject: Re: Acute Limb ischemia is elderly



Options include:

1.  NOTHING
2.  Sympathectomy
3.  Redo the fem far away bypass
4.  Amputation sometime in the future. 

As described I would favor less rather than more. 

K


Sent via BlackBerry by AT&T

-----Original Message-----
From: saad shebrain <shebrain1 at yahoo.com>

Date: Sat, 1 Dec 2007 21:46:06
To:trauma-list at trauma.org
Subject: Acute Limb ischemia is elderly


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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