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A Case of Aorta-iliac Thromboembolism
 

A Case of Aorta-iliac Thromboembolism

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    A Case of Aorta-iliac Thromboembolism A Case of Aorta-iliac Thromboembolism Presentation Transcript

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