Acute Limb ischemia in elderly

[saad shebrain]

Than you all,
  All options you give are more than reasonable.
   
  Now, discussion with family and pt they preferred to proceed with throbolytics with risk of bleeding.
   
  Angio done, Complete Graft occlusion, with some collaterals for the profunda.
  tPA started, overnight, Fibrinogen drop to 118, 68, tPA was D/Cd per IR at 2 AM, although some said you could decrease the dose to quarter/h, in AM H/H 12/35, fibrinogen 60.
  6AM pt lost the pulse in Rt DP,PT.
   
  Pt was taken to IR, the graft Still completely occluded. MECHANICAL thrombectomy cleared the clot, and flow distally to ankle (PT was achived), on the Rt leg, the Pop at trifurcation is out.
   
  Decision was stop and take sheth out and start heparin drip once pt returned to ICU.
  in IR suite, BP was 110-140/50-70s, HR 110-140s A-fib
   
  Rt groin hematoma was noticed after removing the sheath, 30 min pressure applied.
   
  In ICU hematoma was larger, and H/H wa 6/18, pH 6.98, pt desat, intubated, became hypotensive, multiple CPRs and drugs. she was transfused and prepared for a trip to OR for groin X-ploration. she required 2 pressors
  ECHO; 30% EF, severe MR.
   
  abdomen was distended.
   
  in OR, the puncture in her CFA, was not enogh to explain her drop in H/H. apprx. 500 ml blood in the thigh. no concern about significan retroperitoneal bleeding from the CFA puncture site.
   
  on return to ICU pt developed bradycardia and cardiac arrest.
   
  Q:
  1. Could this pt develop severe DIC with clot to Right (intact) leg vs. clott triggered by the sheath.
  2. if we suspect AAA rupture, is there any role for US at bed side, if not and pt is unstable at this point, is DPL going to help.
  3. could the tPA quickly accelerate her AAA rupture.
  4. anything to be done differently in this patient.
   
  Thankx
   
  SS
   
   




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