Dr TEFFY JOSEM4 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 / syncopeNo h/o abdominal pain / ↓urine outputNo h/o feverNo 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, orientedDyspnoeic , tachypnoeicAfebrileMild 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/LPA : NADCNS : 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

InvestigationsCBC - 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 treatmentBack rest with nasal oxygenInj frusemide 40 mg IV BDInj cefotaxim 1 g IV BDInj Heparin 5000 U IV QIDInj ranitidine 50 mg IV BDTab digoxin 0.25 mg (5/7) ODTab penicillin 250 mg BD

Vascular surgery opinion :

Hand doppler :

IMP : RHD - ? Saddle embolism of aorta ; ? Infective endocarditisAdvised 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/hrInj cefoperazone sulbactum IV BDInj enoxaparin 0.4 ml sc bdInj dextran 40 IV ODInj ranitidine 50 mg IV BDTab lasix 40 mg ODTab aspirin 150 mg ODTab clopidogrel 75 mg ODTab digoxin 0.25 mg ( 5/7)Tab verapamil 40 mg BDTab Penicillin 250 mg BD2 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 ODTab digoxin 0.25 mg OD (5/7)Tab verapamil 40 mg BDTab acitrom 2 mg ODTab penicillin 250mg BDFoot drop splint

ACUTE AORTIC OCCLUSIONInfrequent, but potentially catastrophicEarly mortality rate of 31-52%

CAUSES1.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 & paresthesiaNon classic- Sudden onset b/l lower extremity weakness- Severe hypertension(renal a )- Abdominal pain ( mesentric ischemia)

Myonecrosis – secondary hypotension, hyperkalemia,myoglobinuria,ATNDeath – within hours

DIAGNOSIS ;

Extremities cold,pale,cyanotic;oftenmottled,reticulated,reddish blue

appearance → gangreneAbsent pulses beyond abdominal aortaAbsent 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.