Acute Limb ischemia is elderly

Sun Dec 2 16:19:24 GMT 2007

I agree with Meredith and would only add...

1.  She needs an angiogram with runoff first before any decisions are made.  I say this because she if she is in fact demarcating at the midthigh then it begs the question whether or not the profunda is out.  If it is, then I would favor being a little more aggressive if tPA fails (which I would attempt through the CFA above the graft first, ONLY if she remained neurologically intact in the foot given her at-a-glance perioperative mortality) to open the profunda to heal an AKA or even whether an open profunda would collateralize below the knee.  

2.  If systemic heparinization and tPA fails then proceed to local graft thrombectomy ONLY, and aggressively open the profunda if at all possible (under local).  Get a sense as to whether or not she walks:  If she doesn't ambulate then stop after thrombectomy and await demarcation and interval amputatation.  

If she does walk then there has to be a very frank conversation with the patient and her family about the risks of graft revision, which place the low likelihood of limb salvage in the face of  a fem-below knee distal anastamosis with plastic an operation which fares terribly in specific after occlusion and subsequent revisions and the potential need for fasciotomies and the consequences of reperfusion ABOVE the risk to her life.  Everyone needs to understand that before proceeding.

Good luck.

Ben Reynolds, PA-C
Pittsburgh, PA

----- Original Message ----
From: meredith mcbride <mmcbridemd at yahoo.com>
To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
Sent: Sunday, December 2, 2007 9:29:24 AM
Subject: Re: Acute Limb ischemia is elderly

In acute limb ischemia, and especially with the failure to anticoaguate afib, thromboembolism is far and away most likely culprit. Thrombolysis would be highly effective and would be first line in the hands of most vascular experts who were in possession of catheter based skills.

The graft might not have any problem at all, but merely be occluded by embolism. But after the clot is dissolved, angiography can now unmask previously inapparent technical faults - usually stenosis at the distal anastamosis - and these are typically correctable percutaneously.

Sparing an elderly patient with multiple serious comorbidities from general anesthesia and open surgery would be highly desirable. Including amputation.

----- Original Message ----
From: "kmattox at aol.com" <kmattox at aol.com>
To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
Sent: Sunday, December 2, 2007 2:41:51 AM
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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