A Case of Aorta-iliac Thromboembolism

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A Case of Aorta-iliac Thromboembolism

  1. 1. Dr TEFFY JOSE M4 UNIT PROF. Dr G ELANGOVAN’S UNIT
  2. 2. <ul><li>25 yr old female patient, Shanthakumari from Arakkonam presented with </li></ul><ul><li>H/o B/l lower limb pain – 2 days </li></ul><ul><li>- sudden onset , cramping , L > R </li></ul><ul><li>H/o B/l leg swelling - 2 days </li></ul><ul><li>H/o palpitation – ↑2 days ; at rest </li></ul><ul><li>H/o breathlessness at rest – 1 day </li></ul>
  3. 3. <ul><li>H/o orthopnoea + </li></ul><ul><li>No h/o chestpain / syncope </li></ul><ul><li>No h/o abdominal pain / ↓urine output </li></ul><ul><li>No h/o fever </li></ul><ul><li>No other significant history </li></ul>
  4. 4. <ul><li>Pt is a known case of rheumatic heart disease- underwent CMC at 15 yrs of age </li></ul><ul><li>H/o CVA – Lt MCA infarct 3 yrs ago .ECHO revealed( MS/MR/AR/PHT/AF/LAA clot) on irregular treatment including T.Acitrom 2 mg OD </li></ul>
  5. 5. <ul><li>O/E: </li></ul><ul><li>conscious, oriented </li></ul><ul><li>Dyspnoeic , tachypnoeic </li></ul><ul><li>Afebrile </li></ul><ul><li>Mild pallor + </li></ul><ul><li>B/l pitting pedal edema + ( minimal ) </li></ul><ul><li>PR – 110/min ; irregularly irregular ; apex pulse deficit > 10 </li></ul><ul><li>BP – 110/70 mm hg Rt arm sitting position </li></ul><ul><li>RR – 24/min </li></ul><ul><li>T- normal </li></ul><ul><li>JVP elevated </li></ul>
  6. 6. <ul><li>CVS : </li></ul><ul><li>apex in Lt 5 th ICS ½ inch medial to MCL </li></ul><ul><li>diastolic thrill + at apex </li></ul><ul><li>Lt parasternal heave + </li></ul><ul><li>MA - S1 S2 + ; S1 varying in intensity ; MDM + </li></ul><ul><li>TA - S1 S2 + ; systolic murmur + grade 3/6 </li></ul><ul><li>PA - S1 S2+ ; loud P2 + ;ESM + grade 3/6 </li></ul><ul><li>AA - S1 S2 + </li></ul>
  7. 7. <ul><li>RS :NVBS + B/L ; Basal crackles + B/L </li></ul><ul><li>PA : NAD </li></ul><ul><li>CNS : consicous ,oriented </li></ul><ul><li>Rt UMN facial palsy + </li></ul><ul><li>Tone ↑Rt UL &LL </li></ul><ul><li>Reflexes exaggerated Rt UL & LL </li></ul><ul><li>Plantar extensor Rt side </li></ul>
  8. 8. <ul><li>Local examination both lowerlimbs : </li></ul><ul><li>pale,cold , no other skin changes </li></ul><ul><li>B/l pitting pedal edema + - minimal </li></ul><ul><li>Lt foot drop + </li></ul><ul><li>Lt calf minimal tenderness / </li></ul><ul><li>B/L femoral , popliteal,posterior tibial , anterior tibial ,dorsalis pedis pulses absent </li></ul>
  9. 9. <ul><li>Rheumatic heart disease – post CMC status ; MS / TR / PHT in AF in CCF with </li></ul><ul><li>Acute b/l lower limb ischemia </li></ul><ul><li>? Aortoiliac embolism </li></ul><ul><li>? Infective endocarditis </li></ul>
  10. 10. Investigations CBC - Hb 10 TC 6,700 DC P64 L35 E1 ESR 6/12 PCV 31 platelet 1,80,000 RFT - RBS 130 Urea 18 Creatinine 0.6 sodium 138 potassium 4.8 urine routine normal LFT – T Bil 0.8 D Bil 0.5 SGOT 37 SGPT 39 ALP 70 T protein 6.5 S albumin 4.5 FLP – T CH 160 TG 130 HDL 45 LDL 60
  11. 11. others HIV Negative Blood culture sensitivity No growth USG abdomen & pelvis Normal study PT 14.5 aPTT 38 INR 1.2
  12. 13. Initial treatment <ul><li>Back rest with nasal oxygen </li></ul><ul><li>Inj frusemide 40 mg IV BD </li></ul><ul><li>Inj cefotaxim 1 g IV BD </li></ul><ul><li>Inj Heparin 5000 U IV QID </li></ul><ul><li>Inj ranitidine 50 mg IV BD </li></ul><ul><li>Tab digoxin 0.25 mg (5/7) OD </li></ul><ul><li>Tab penicillin 250 mg BD </li></ul>
  13. 14. <ul><li>Vascular surgery opinion : </li></ul><ul><li>Hand doppler : </li></ul><ul><li>IMP : RHD - ? Saddle embolism of aorta ; </li></ul><ul><li>? Infective endocarditis </li></ul><ul><li>Advised to – continue Inj heparin </li></ul><ul><li>- 64 slice CT angiogram abdominal aorta & both lowerlimb run off </li></ul>Right Left Popliteal a biphasic flow biphasic flow Posterior tibial biphasic flow venous flow Dorsalis pedis biphasic flow venous flow
  14. 15. <ul><li>Cardiologist opinion : </li></ul><ul><li>ECHO </li></ul><ul><li>MS moderate ; MVO 1.1cm₂ </li></ul><ul><li>thickened ,calcified with restricted mobility of </li></ul><ul><li>both AML &PML </li></ul><ul><li>aortic valve thickening </li></ul><ul><li>MR mild </li></ul><ul><li>AR mild ; no AS </li></ul><ul><li>TR severe ; PHT severe </li></ul><ul><li>autocontrast in LA ; no LA clot </li></ul><ul><li>no vegetations </li></ul><ul><li>normal LV function </li></ul>
  15. 19. <ul><li>Hypodense intraluminal acute thrombus within aortic bifurcation, contiguously propagating into right common iliac artery completely occluding & into left common iliac artery narrowing the lumen </li></ul><ul><li>Another long segment thrombus within left common femoral & superficial femoral arteries </li></ul>
  16. 20. <ul><li>Final diagnosis : </li></ul><ul><li>Rheumatic heart disease – </li></ul><ul><li>- moderate MS/mild MR/mild AR </li></ul><ul><li>- severe TR/severe PHT </li></ul><ul><li>- in atrial fibrillation </li></ul><ul><li>in CCF </li></ul><ul><li>SADDLE EMBOLISM of aorta </li></ul><ul><li>Old CVA – lt MCA infarct </li></ul><ul><li>No evidence of infective endocarditis </li></ul>
  17. 21. <ul><li>After anaesthetic fitness ↓ LA, </li></ul><ul><li>Bilateral transfemoral embolectomy was done using 6F Fogarty catheter. </li></ul><ul><li>Intraop findings - saddle embolus </li></ul><ul><li>- Lt femoral thrombus + </li></ul><ul><li>proximally & distally </li></ul><ul><li>Post op – hand doppler -> triphasic flow in Rt PTA & Lt PTA </li></ul>
  18. 22. <ul><li>Post operatively, pt was shifted to IMCU : </li></ul><ul><li>Normal diet </li></ul><ul><li>IVF @ 50 ml/hr </li></ul><ul><li>Inj cefoperazone sulbactum IV BD </li></ul><ul><li>Inj enoxaparin 0.4 ml sc bd </li></ul><ul><li>Inj dextran 40 IV OD </li></ul><ul><li>Inj ranitidine 50 mg IV BD </li></ul><ul><li>Tab lasix 40 mg OD </li></ul><ul><li>Tab aspirin 150 mg OD </li></ul><ul><li>Tab clopidogrel 75 mg OD </li></ul><ul><li>Tab digoxin 0.25 mg ( 5/7) </li></ul><ul><li>Tab verapamil 40 mg BD </li></ul><ul><li>Tab Penicillin 250 mg BD </li></ul><ul><li>2 units of packed cell transfusion </li></ul>
  19. 23. <ul><li>On POD 1, pt had persistent AF with RVR, </li></ul><ul><li>On POD 2, pt went in for cardiorespiratory arrest, was resuscitated & put on mechanical ventilation- regained consciousness on day 3;weaned off & extubated 3 days later </li></ul><ul><li>LMWH was continued for 1 wk ; then switched over to Tab Acitrom 2 mg OD monitoring INR </li></ul>admission surgery POD7 POD 12 INR 1.2 1.6 2.2 2.2
  20. 24. <ul><li>Pt was discharged on POD 15 : </li></ul><ul><li>conscious , oriented </li></ul><ul><li>not dyspnoeic / tachypnoeic </li></ul><ul><li>PR-90/min;irregularly irregular </li></ul><ul><li>BP-110/70 mmhg </li></ul><ul><li>JVP- not elevated </li></ul><ul><li>CVS –varying S1 +; MDM + ; loud P2 + </li></ul><ul><li>RS-clear </li></ul><ul><li>CNS – residual rt hemiparesis + </li></ul><ul><li>L/E: -all peripheral pulses well felt & equal on both sides </li></ul><ul><li>-both lower limbs toe movt normal, </li></ul><ul><li>warmth & sensation felt </li></ul><ul><li>- triphasic flow present in rt & lt DPA & PTA </li></ul>
  21. 25. <ul><li>Advised to continue; </li></ul><ul><li>Tab lasix 40 mg OD </li></ul><ul><li>Tab digoxin 0.25 mg OD (5/7) </li></ul><ul><li>Tab verapamil 40 mg BD </li></ul><ul><li>Tab acitrom 2 mg OD </li></ul><ul><li>Tab penicillin 250mg BD </li></ul><ul><li>Foot drop splint </li></ul>
  22. 26. ACUTE AORTIC OCCLUSION <ul><li>Infrequent, but potentially catastrophic </li></ul><ul><li>Early mortality rate of 31-52% </li></ul><ul><li>CAUSES </li></ul><ul><li>1.Embolic occlusion of the infrarenal aorta at the bifurcation ‘saddle embolus’ </li></ul><ul><li>2.Acute thrombosis of the abdominal aorta </li></ul>
  23. 27. <ul><li>95% of aortic emboli originate from lt side of the heart </li></ul><ul><li>– LA secondary to AF in rheumatic MS ; </li></ul><ul><li>- LV secondary to MI,aneurysm or dilated cardiomyopathy </li></ul><ul><li>atrial myxoma,prosthetic valve thrombus,acute bacterial or fungal endocarditis </li></ul>
  24. 28. <ul><li>75-80% of thrombotic aortic occlusions occur in the setting of underlying severe aortoiliac occlusive disease; </li></ul><ul><li>frequently precipitated by low flow state secondary to heart failure or dehydration </li></ul>
  25. 29. <ul><li>CLINICALLY; </li></ul><ul><li>Sudden onset of excruciating b/l lower extremity pain ; </li></ul><ul><li>Assoc weakness ,numbness & paresthesia </li></ul><ul><li>Non classic </li></ul><ul><li>Sudden onset b/l lower extremity weakness </li></ul><ul><li>Severe hypertension(renal a ) </li></ul><ul><li>Abdominal pain ( mesentric ischemia) </li></ul><ul><li>Myonecrosis – secondary hypotension, </li></ul><ul><li>hyperkalemia,myoglobinuria,ATN </li></ul><ul><li>Death – within hours </li></ul>
  26. 30. <ul><li>DIAGNOSIS ; </li></ul><ul><li>Extremities cold,pale,cyanotic; </li></ul><ul><li>oftenmottled,reticulated,reddish blue appearance -> gangrene </li></ul><ul><li>Absent pulses beyond abdominal aorta </li></ul><ul><li>Absent capillary refill </li></ul><ul><li>Signs of ischemic neuropathy – D/d -> spinal cord infarction or compression </li></ul>
  27. 31. <ul><li>Confirmed by aortography </li></ul><ul><li>prompt surgical intervention without angiography if the diagnosis is strongly suspected </li></ul><ul><li>to evaluate renal /mesenteric artery involvement </li></ul>
  28. 32. <ul><li>MANAGEMENT: </li></ul><ul><li>IV heparin therapy ,while pt awaits surgery </li></ul><ul><li>Saddle embolus ->transfemoral arterial approach↓LA using Fogarty balloon tipped catheter </li></ul><ul><li>-> direct transabdominal aortotomy </li></ul><ul><li>- Thrombotic occlusion ->direct aortic reconstruction or revascularization with aortofemoral or axillofemoral bypass </li></ul>
  29. 33. <ul><li>Operative mortality – 31-40% ; as high as 85% among pts with severe LV dysfunction or a hypercoagulable state </li></ul><ul><li>Limb salvage rates are as high as 98% </li></ul><ul><li>Lifelong anticoagulant therapy is necessary in almost all cases after surgery to prevent recurrent emboli. </li></ul>

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