A Tale of Two VesselsA Tale of Two Vessels

Dr Deirdre HusseyDr Deirdre Hussey

CaseCase Mrs MW 58yrs old presented to A/E with:Mrs MW 58yrs old presented to A/E with:

Severe back pain, unable to mobiliseSevere back pain, unable to mobilise Severe pain in dorsum of right foot, constantSevere pain in dorsum of right foot, constant Similar pain left foot (not as severe)Similar pain left foot (not as severe) Discoloured right big toeDiscoloured right big toe Severe pain from ulcers on right hip and buttock Severe pain from ulcers on right hip and buttock

(had been bed bound for preceding 4 weeks as a (had been bed bound for preceding 4 weeks as a result of severe lower limb and back pain)result of severe lower limb and back pain)

CaseCase Background History:Background History: HypertensionHypertension HypercholesterolaemiaHypercholesterolaemia COPDCOPD Smoker 20-30/daySmoker 20-30/day

Meds:Meds: Plavix, Coversyl, Lipitor, Plavix, Coversyl, Lipitor,

Ventolin PRNVentolin PRN NKDANKDA

Soc Hx:Soc Hx: Married with 5 children, Married with 5 children,

smoker, C2H5OH- nilsmoker, C2H5OH- nil

ROS- as above, nil ROS- as above, nil CVS/Resp/GICVS/Resp/GI

CaseCase Vital Signs:Vital Signs: BP 150/90BP 150/90 HR 85 bpm SRHR 85 bpm SR RR 18RR 18 Afebrile Afebrile Sats 96% on RASats 96% on RA

General:General: Pt in obvious discomfort, Pt in obvious discomfort,

pale and lying on her left pale and lying on her left sideside

CVSCVS: NAD: NAD

Respiratory:Respiratory: breath sounds mildly breath sounds mildly

decreased bibasally. decreased bibasally.

Abdomen:Abdomen: Soft, non tenderSoft, non tender Firm mass above Firm mass above

Pfannenstiehl incision Pfannenstiehl incision (prev documented (prev documented fibroids)fibroids)

Bowel sounds present, Bowel sounds present, normalnormal

CaseCase Lower Limbs:Lower Limbs:

Both limbs were paleBoth limbs were pale Temperature normal bilatTemperature normal bilat Absent pulses from femoral-distal bilaterallyAbsent pulses from femoral-distal bilaterally

CaseCase Routine Investigations:Routine Investigations:

CBC: Hb 10.7g/dL, CBC: Hb 10.7g/dL, Plts 594Plts 594, WCC 9.61, WCC 9.61

U/E: urea 4.0, creat 33, Na 138, K 4.1U/E: urea 4.0, creat 33, Na 138, K 4.1

LFT’s: Bili 5, LFT’s: Bili 5, Alk Phos 160,Alk Phos 160, ALT 32 ALT 32

ESR 64, CRP 50ESR 64, CRP 50

CXR: NADCXR: NAD

Case Case ABI’s:ABI’s:

Right 0.15Right 0.15

Left 0.09Left 0.09

Echocardiogram (TTE):Echocardiogram (TTE):

EF 60%, no evidence of EF 60%, no evidence of endocarditis/valve disease endocarditis/valve disease

Vasculitis Screen:Vasculitis Screen: NegativeNegative

Thrombophilia ScreenThrombophilia Screen NegativeNegative

CaseCase

MRA:MRA: Total occlusion of aorta below Total occlusion of aorta below

renals, reconstitution at level of CFA renals, reconstitution at level of CFA bilatbilat

CaseCase Axillary-bifem bypass Axillary-bifem bypass

Bolus of heparin given intra-op and continued post op Bolus of heparin given intra-op and continued post op (target APTT 60-80)(target APTT 60-80)

Post op day 1 pt began c/o very severe right leg painPost op day 1 pt began c/o very severe right leg pain

Limb pale and pulseless on examinationLimb pale and pulseless on examination

CaseCase

Right groin exploration and thromboembolectomyRight groin exploration and thromboembolectomy

CaseCase Patient began c/o:Patient began c/o:

Severe bilat calf and foot painSevere bilat calf and foot pain

Absent pulses in below femoral bilatAbsent pulses in below femoral bilat

Both limbs pale and coldBoth limbs pale and cold

CaseCase Return to theatre on call:Return to theatre on call:

(1)Bilat groin explorations and (1)Bilat groin explorations and thromboembolectomiesthromboembolectomies

(2) Right below knee popliteal and tibial (2) Right below knee popliteal and tibial embolectomyembolectomy

(3) Right medial and lat fasciotomies(3) Right medial and lat fasciotomies

CaseCase Pt developed ARDS post op and was t/f to ITUPt developed ARDS post op and was t/f to ITU MODS/ SIRSMODS/ SIRS

CT showing ARDSCT showing ARDS

CaseCase Closure of fasciotomies and debridement of sloughy Closure of fasciotomies and debridement of sloughy

right groin woundright groin wound

Theatre specimenTheatre specimen + + growth of Klebsiella and Ecoligrowth of Klebsiella and Ecoli Commenced on Aztreonam and Vancomycin (allergy)Commenced on Aztreonam and Vancomycin (allergy) 3/12 of Ofloxacin to cover against possible graft 3/12 of Ofloxacin to cover against possible graft

infectioninfection

Vac dressing x 2/52 to right groinVac dressing x 2/52 to right groin

Plastics consult - pedicled TFL flap to right groinPlastics consult - pedicled TFL flap to right groin

CaseCase Pt discharged on warfarinPt discharged on warfarin

Mobilising with Zimmer frame on dischargeMobilising with Zimmer frame on discharge

Reviewed at OPD Oct 09 walking independentlyReviewed at OPD Oct 09 walking independently

Repeat ABI’s:Repeat ABI’s: Right 0.36Right 0.36 Left 0.69Left 0.69

DiscussionDiscussion Axillary-Bifem bypass:Axillary-Bifem bypass:

1962 Blatsdell, Hall and Louw1962 Blatsdell, Hall and Louw

Diffuse Aortoiliac diseaseDiffuse Aortoiliac disease

Aortobifem bypass is contraindicatedAortobifem bypass is contraindicated

DiscussionDiscussion Martin and Katz-Am Journal of Surgery Aug 2000 All Ax-fem bypasses 1983-1997, 60 patients:

13 presented with claudication

10 with evidence of gangrene

7 with nonhealing ulceration

30 with symptoms of rest pain

DiscussionDiscussion Morbidity rate of 6.5%

Ten patients developed graft occlusions at a mean interval of 6.5 months.

Other complications: graft infection, pseudoaneurysm, subclavian stenosis

Patency rates of 88% at 1 year, 79% at 3 years,

and 69% at 5 years

Teaching PointsTeaching Points General Operative ComplicationsGeneral Operative Complications

Bypass Surgery ComplicationsBypass Surgery Complications

Outline of Management Options of above Outline of Management Options of above complicationscomplications

Multidisciplinary approachMultidisciplinary approach