Chronic Limb Ishchemia

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Case Presentation:

Case Presentation Dr. Tahir Ayub Surgical Unit 1

Introduction:

Introduction Name……………. ..Muhammad Mursaleen Age/Sex……………34/M Occupation ………..laborer resident of………… Muzafar Ghar Admitted………… .OPD on 13-07-2007

Chief Complaint:

Chief Complaint Painful right leg………One and half year. Healed Ulcer on the Right medial malleolus.

HOPI:

HOPI Patient was alright 2 years back when he developed pain in the right leg initially it was on exertion latter gradually it progressed to walking a few steps. Pain used to aggravate of elevation and relieve by taking rest. Patient developed Ulcer on Medial Malleous of Right Leg 8 months ago that healed slowly.

Personal history:

Personal history Smoker for two and half year. Non Diabetic Non Hypertensive Cholesterol normal

Examination::

Examination: GPE: A young man of average built and height lying comfortably in bed well oriented in time place with following vitals B.P…….140/90mmHg Pulse….88/m Temp…98.6F Pallor, Jaundice,Clubbing,Cyanosis negative Superficial group lymph node impalpable

Local Examination:

Local Examination RIGHT LEG: Marked wasting of muscles as compared to the left. 1*2 cm no healing arterial ulcer on the medial mallolus. All the other Systemic Exam Normal.

CVS:

CVS Pulse:80/m ,regular, normal volume S1+S2+0 Peripheral Pulses: Right posterior Tibial and Dorsalis Pedis not palpable. Left Posterior Tibial and Dorsalis Pedis weakly palpable.

Doppler USG:

Doppler USG Fibro fatty plaque of 3cm length and 4 cm width in middle position of R femoral artery causing 90% obstruction. Multiple plaques seen in Femoral and Popliteal artery traces of blood flow seen. No blood Flow in Dorsali Pedis Artery seen. An incompetent thick wall in spheno-Femoral junction all other veins normal.

Peripheral Angiogram:

Peripheral Angiogram Lower Limbs Right Femoral artery shows tight proximal stenosis followed by total occlusion at mid level. Distal vessels fills very late faintly through collaterals up to knee joint level Right anterior tibial artery blocked at mid calf level Left limb vessels normal

CT PERIPHERAL ANGIOGRAM:

CT PERIPHERAL ANGIOGRAM Right Femoral artery has tight stenosis in proximal third and has total occlusion at mid thigh level. Right popliteal and anterior tibial not visualized, reformation of Rt. posterior tibial through collateral. Big collateral visualized connection the lower one third of femoral artery to proximal segment of posterior tibial Posterior tibial artery is graft able.

PLAN:

PLAN Single vessel reconstruction.

SURGERY:

SURGERY Femoro posterior tibial reverse venous graft

POST OP RECOVERY:

POST OP RECOVERY Post of recovery was smooth Wound dehiscence accures manage accordingly Ulcer heels smoothly Posterior tibial and Dorsalis Pedis palpable. No complaint of rest pain or claudication.

Follow Up:

Follow Up Patients with chronic critical limb ischemia require lifelong follow-up for a number of reasons. patients require rehabilitation to hasten their return to maximal independence. Careful attention to nutritional status. Some authorities recommend periodic surveillance with duplex ultrasonography.

Literature:

Literature The term CLI should be used in clearly define term to differentiate between the two major spectra of disease i.e. Intermittent claudication Critical limb ischaemia Management and out come of these two conditions are different so the impact individual and resources required for management differs. IC described patients in whom the degree of ischaemia does not constitute and immediate threat to a limb. In Critical limb ischemia the Limb is threatened by the degree of ischemia as determined by the rest pain or tissue loss.

Atiology :

Atiology Atherosclerosis RISK FACTORS Smoking Hyperlipidaemia Apolipoprotein Hypertension Diabetes mellitus Antioxidant Vitamins deficiency Fibrinogen and rheological Sedentary life style Type IA personality homocysteine

D/D:

D/D Popliteal artery entrapment syndrome Persistent sciatic artery Fibro muscular dysplasia Cystic adventitial disease Spinal canal Compartment syndrome

INVESTIGATION:

INVESTIGATION The ankle brachial pressure index Exercise test Routine blood investigation Plethysmography Transcuotanious oxygen tension Isotope blood flow Duplex ultrasonography Arteriography MRA CTA Cardiac investigation

MANAGEMENT:

MANAGEMENT MANAGEMENT OF RISK FACTOR PHARMACOTHERAPY Pentoxifyllie Neftidrofurly Cilostazol Aspirin Diprimadole Ticlopidine Clopidogrel and prostaglandins Calcium channel blocker

ENDO VASCULAR INTERVENTION IN IC:

ENDO VASCULAR INTERVENTION IN IC PTA PTA depends upon Site of lesion Type of lesion Available interventional equipment Expertise of the personal Aorto-iliac lesions give better results Good run of into calf good results

ENDO VASCULAR TREATMENT OF AORTO-ILIAC DISEASE :

ENDO VASCULAR TREATMENT OF AORTO-ILIAC DISEASE Aorto-iliac angioplasty Aorto-iliac stenting Femoro-popliteal angioplasty

SURGERY FOR INTERMITTANT CLAUDICATION:

SURGERY FOR INTERMITTANT CLAUDICATION SUPRAINGUINAL RECONSTRUCTION Aorto-bifemoral bypass DIRECT ANATOMICAL RECONSTRUCTION 10 years = 80 to 90 % Aorto-iliac endarterectomy EXTRA ANATOMICAL RECONSTRUCTION Axillo-byfemoral graft 5 year = 35%

PowerPoint Presentation:

Femoro-femoral bypass 5 years = 80% INFRA-INGUINAL BYPASS Femoro-popliteal 2 years = 80% PTFE (Graft) 4 years = 54% Vein 4 years =76%

PowerPoint Presentation:

FEMORO-TIBIAL/PEROLEAL PROFUNDA PLASTYS

GRAFTS:

GRAFTS Autogenous Vein bypass. great saphenous vein. small sphenous vein. cephalic and basilic vein. common femoral vein. reversed autogenous great sphenous vein. In-situ autogenous great sphenous vein.

PowerPoint Presentation:

Angioscopy Prosthetic bypass Synthetic grafts Textile - dacrom Non textile- e-PTFE Biological grafts human umbilical vein Composite grafts

TYPICAL PATENCY RATES OF SURGICAL RECONSTRUCTION:

TYPICAL PATENCY RATES OF SURGICAL RECONSTRUCTION ONE YEAR PATENCY RATES Aorto-ilio femoral ______________ 90% Femoro Popliteal (AK) Vein ______75% Femoro Popliteal (AK) Prosthetic ______65% Femoro Popliteal (BK) Vein ______70% Femoro Popliteal (AK) Prosthetic ______60% Femoro Tibial vein __________________70% Femoro Tibial Prosthetic _____________40%

COMPLICATIONS OF BYPASS GRAFTS:

COMPLICATIONS OF BYPASS GRAFTS GRAFTS FAILURE GRAFT INFECTION LOCAL VASCULAR COMPLICATION LOCAL NON-VASCULAR COMPLICATION

NON-VASCULAR MANAGEMENT:

NON-VASCULAR MANAGEMENT PHARMACHOTHERAPY LUMBER SYMPATHECTOMY AMPUTATIONS

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