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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3712_Библиотеки_им_академика_М_И_Перельмана
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C A S E 11: CHRONIC LIMB-THREATENING ISCHAEMIA
A 65-year-old male presents to your vascular surgery outpatient clinic with dry gangrene to
his le third toe, along with severe rest pain and night pain and some ischaemic ulceration to
his adjacent toes. He has an extensive vascular surgery history (that spans many many years
and includes procedures performed in another vascular department … frankly I am struggling to
recount everything he has had done because it is very complicated and extensive, and much more
than what I include below):
•
Bilateral iliac angioplasties/stents.
•
Subsequent aorto-bifemoral bypass when the iliacs re-occluded.
•
is aorto-bifemoral bypass became infected and required explantation.
•
Following this he required a right axillo-popliteal bypass, but this occluded resulting in
a right above-knee amputation.
•
Subsequent le iliac endovascular recannalisation.
•
Subsequent le SFA occlusion recannalisation (which then occluded).
•
Now chronic le SFA occlusion that has been managed conservatively for the past few
years.
e patient says that his le foot pain is so severe that he can barely sleep, and he has to hang
his le leg out of bed at night. He has not had a myocardial infarction or a stroke before. He is
known to have chronic obstructive pulmonary disease (COPD), but according to him, it is not
that bad. He is no longer smoking. He is already on the best medical therapy (clopidogrel 75 mg
0D & atorvastatin 80 mg 0D). On examination he is very thin with very little body fat. He has no
pulses in the le leg. He has a right radial pulse. He has a le radial pulse.
See the image of the patient’s previous MRA (from 12 months ago – Figure 11.1). What do you
make of it?
A Patent infra-renal aorta. Patent le iliac system. Long SFA occlusion. Satisfactory pop-
liteal reforms. High PT take-o otherwise good 3-vessel run-o.
B Patent infra-renal aorta. Patent le iliac system but some proximal common iliac dis-
ease. Long SFA occlusion. Satisfactory popliteal reforms with normal 3-vessel run-o.
✔ C Patent infra-renal aorta. Patent le iliac system but some proximal common iliac dis-
ease. Long SFA occlusion. Satisfactory popliteal reforms. High PT take-o otherwise
good 3-vessel run-o.
D Patent infra-renal aorta. Patent iliac system but severely diseased le external iliac.
Short SFA occlusion. Diseased popliteal reforms. High PT take-o otherwise good
3-vessel run-o.
E Patent infra-renal aorta. Occluded le iliac system. Long SFA occlusion. Satisfactory
popliteal reforms. High PT take-o otherwise good 3-vessel run-o.
What is your initial management plan for this patient?
A Lower limb arterial duplex.
✔ B CT angiogram or MR angiogram lower limbs.
C Palliative care referral.
D List for le high above-knee amputation.
E List for le iliac recannalisation (again).
DOI: 10.1201/9781003497042-11
73
Vascular Surgery
Figu r e 11.1 Previous MR angiogram lower limbs.
What do you make of the CT angiogram images (see Figures 11.2 and 11.3)?
A Occluded infra-renal aorta. Occluded le iliac system and le supercial femoral artery.
Patent distal le profunda femoris artery. Recannalisation of the popliteal artery at the
adductor hiatus with 3-vessel run-o.
✔ B Occluded infra-renal aorta. Occluded le iliac system and le supercial femoral artery.
Patent but small distal le profunda femoris artery. Recannalisation of the popliteal
artery at the adductor hiatus but diseased behind the knee. ree-vessel run-o.
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Case 11: Chronic Limb-Threatening Ischaemia
Fig u re 11.2 CT angiogram image of infra-renal aorta.
C Patent infra-renal aorta. Occluded le iliac system and le supercial femoral artery.
Patent but small distal le profunda femoris artery. Recannalisation of the popliteal
artery at the adductor hiatus but diseased behind the knee. ree-vessel run-o.
D Patent infra-renal aorta. Occluded le iliac system and le supercial femoral artery.
Occluded le profunda artery. Recannalisation of the popliteal artery at the adductor
hiatus but diseased behind the knee. ree-vessel run-o.
E Occluded infra-renal aorta. Occluded le iliac system, diseased but patent supercial
femoral artery. Patent but small distal le profunda femoris artery. Recannalisation of
the popliteal artery at the adductor hiatus. ree-vessel run-o.
What are some potentially viable le leg revascularisation options?
A Right to le femoral-femoral crossover.
B Right to le femoral-femoral crossover and then femoral-AK popliteal bypass.
C Infra-renal aortic thromboendarterectomy, re-do aorto-femoral bypass, then fem-AK
popliteal bypass.
✔ D Le axillo-profunda-popliteal bypass.
E Le aortoiliac stenting followed by le fem-BK popliteal artery bypass.
What do you make of the vein mapping result (Figure 11.4)?
A Could do a le axillo-profunda-popliteal bypass using spliced basilic vein and le GSV.
B Could do a le axillo-profunda bypass using spliced basilic vein and above-knee
amputation.
C Could do a le axillo-profunda prosthetic bypass and then a profunda-popliteal bypass
using spliced basilic vein.
✔ D Could do a le axillo-profunda-popliteal bypass using two prosthetic bypasses with le
calf GSV vein cu/s.
E Could do a le axillo-profunda-popliteal bypass using spliced cephalic and basilic vein.
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Vascular Surgery
Fig u re 11.3 CT angiogram lower limbs.
e position of the vascular MDT aer reviewing the CTA is that the only options available are:
•
Le axillo-profunda-popliteal bypass.
•
Le axillo-profunda bypass and above-knee amputation.
•
Palliation.
76
Case 11: Chronic Limb-Threatening Ischaemia
Fig u re 11.4 Vein mapping result.
77
Vascular Surgery
e patient is adamant that he does not want to lose his le leg, nor does he want to be palliated. He wishes to proceed with an attempt at limb salvage, i.e. le axillo-profunda-popliteal
bypass. What are some things you would want to conrm before proceeding with such a case?
A Patient has up-to-date echocardiogram and pulmonary function tests, anaesthetic
review, and le axillary artery duplex to conrm there is a decent inow source.
B Patient has up-to-date echocardiogram and pulmonary function tests, anaesthetic
review, le axillary artery duplex to conrm there is a decent inow source, patient has
been thoroughly counselled on the risks and benets of the proposed procedure, and
his family is on board with the plan.
C Patient has up-to-date echocardiogram and pulmonary function tests, anaesthetic
review, le axillary artery duplex to conrm there is a decent inow source, patient
has been thoroughly counselled on the risks and benets of the proposed procedure,
his family is on board with the plan, that you have suitable gras available for this case,
that you have scrutinised the run-o vessels as per his previous imaging, and that you
will have a suitable (i.e. senior) surgical assistance for the case.
D Patient has up-to-date echocardiogram and pulmonary function tests, anaesthetic
review, le axillary artery duplex to conrm there is a decent inow source, patient has
been thoroughly counselled on the risks and benets of the proposed procedure, his
family is on board with the plan, that you have suitable gras available for this case, that
you have scrutinised the run-o vessels as per his previous imaging, and that you will
have a suitable (i.e. senior) surgical assistance for the case, and that you have the support
of the intensive care team.
✔ E Patient has up-to-date echocardiogram and pulmonary function tests, anaesthetic
review, le axillary artery duplex to conrm there is a decent inow source, patient
has been thoroughly counselled on the risks and benets of the proposed procedure,
his family is on board with the plan, that you have suitable infection-resistant gras
available for this case, that you have scrutinised the run-o vessels as per his previous
imaging, and that you will have a suitable (i.e. senior) surgical assistance for the case,
and that you have the support of the intensive care team.
Please review the following tness test results (Figure 11.5). Do you think this patient sounds
like a viable open surgical candidate?
A Heart is OK. Lungs are as expected. Kidneys are OK. is patient has survived every
other vascular operation. He doesn’t want to lose his leg, and he doesn’t want to die.
Why not?
B ese tests are reassuring, but this surgery seems very unlikely to be successful, and
therefore I just don’t think it is viable.
C ese tests are reassuring, but the risk of infection is just too high; therefore, I just don’t
think it is viable.
D ese tests are reassuring, but the patient is so thin and his albumin is a bit low; there-
fore, I think that his wounds will all break down, and I just don’t think it is viable.
✔ E Heart is OK. Lungs are as expected. Kidneys are OK. is patient has survived every
other vascular operation. He doesn’t want to lose his leg, and he doesn’t want to die. He
appears to have decent run-o. If he has a decent le axillary artery on duplex I think
this case is fair game … but I am going to try and get some infection-resistant gras and
make sure I cover the groin anastomoses with a muscle ap.
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Case 11: Chronic Limb-Threatening Ischaemia
Fig u re 11.5 Fitness test results.
79
Vascular Surgery
Fig u re 11.6 Left axillary artery duplex.
What do you make of this le axillary artery duplex (Figure 11. 6)?
A Triphasic ow and disease-free axillary artery – game on.
✔ B Biphasic ow in a slightly calcied axillary artery – game on.
C Monophasic ow – game over.
D Biphasic ow just ain’t good enough for me to take on a case like this. I need perfection
(i.e. triphasic ow).
E Monophasic ow – game on.
You seemingly have a reasonable le axillary artery to use as an inow source. Based upon
the imaging of the run-o vessels, what do you think is the best target vessel for your distal
anastomosis at the knee?
✔ A Posterior tibial artery in the below-knee segment (accepting this is a high posterior tibial
artery take-o as per the MRA).
B Above-knee popliteal artery.
C Anterior tibial artery.
D Peroneal artery.
E Below-knee popliteal artery just above the origin of the anterior tibial artery.
e patient ultimately went on to have a le axillary-upper thigh profunda artery bypass with a
silver-coated antibiotic-impregnated ring-enforced 8 mm gra and ipsilateral GSV Miller cu,
and a jump gra to the posterior tibial artery with a silver-coated antibiotic-impregnated ringenforced 6 mm gra and ipsilateral GSV miller cu, with sartorius ap coverage.
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Case 11: Chronic Limb-Threatening Ischaemia
Fig u re 11.7 Left foot pre-operatively.
How would you have exposed the le profunda artery?
A Re-do vertical groin cutdown (through old scar), fully expose CFA, then chase down-
wards to expose the origin of the PFA and go distally.
✔ B Incision from the anterior superior iliac spine (ASIS) swung obliquely across the le
groin and down the thigh. Expose the medial border of sartorius and li it laterally.
Expose virgin SFA underneath the sartorius muscle distal to the scarred groin, sloop it,
li it medially, and then nd virgin PFA directly underneath the SFA. At the end of the
operation the sartorius can be disconnected from the ASIS and used as a ap to cover
your anastomoses and gras.
C Mark out the profunda artery in the upper thigh using ultrasound and try and nd it
that way.
D Mark out the SFA in the upper thigh using ultrasound, then nd the profunda artery
underneath the SFA in virgin territory.
E Just make a big cut in the groin and dissect in multiple dierent planes until you nd
something vaguely resembling the profunda artery (but preferably don’t anastomose
onto the femoral nerve).
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