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Sun Dec 2 14:29:24 GMT 2007

In acute limb ischemia, and especially with the failure to anticoaguate afib, thromboembolism is far and away most likely culprit. Thrombolysis would be highly effective and would be first line in the hands of most vascular experts who were in possession of catheter based skills.

The graft might not have any problem at all, but merely be occluded by embolism. But after the clot is dissolved, angiography can now unmask previously inapparent technical faults - usually stenosis at the distal anastamosis - and these are typically correctable percutaneously.

Sparing an elderly patient with multiple serious comorbidities from general anesthesia and open surgery would be highly desirable. Including amputation.

----- Original Message ----
From: "kmattox at aol.com" <kmattox at aol.com>
To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
Sent: Sunday, December 2, 2007 2:41:51 AM
Subject: Re: Acute Limb ischemia is elderly

Options include:

1.  NOTHING
2.  Sympathectomy
3.  Redo the fem far away bypass
4.  Amputation sometime in the future.  

As described I would favor less rather than more.  

K

Sent via BlackBerry by AT&T

-----Original Message-----
From: saad shebrain <shebrain1 at yahoo.com>

Date: Sat, 1 Dec 2007 21:46:06 
To:trauma-list at trauma.org
Subject: Acute Limb ischemia is elderly

92 year-old female with multiple co-morbidities including DM, CHF, HTN, PVD, A-fib, AAA 5.5 cm, underwent Femoral-peroneal bypass (using Propatent graft) 1 year ago for acute left foot ischemia. she stopped taking her coumadin, and other meds in the last 4 months.
  Now presented to ER with 1 day history of increasing pain in the left foot, still has sensory and motor function, no pulses or even doppler signals. the LLE is cold from midthigh-toes.
  pt is slightly demeted, but wants evrything to be done.

  vitals: A-fib, HR 80-110, BP 160s-210s/90s-110s.
  of options:
  1. angio with tPA provided that BP is well controlled ( but what about AAA, by the way a non contrast CT showed no change in size of aneurysm).
  2. Heparin drip and accept the fact if the whole graft is gone, the likelihood of limb salvage is poor.
  3.Thrombectomy of the the graft under local anesthesia and accept the fact it has notorious results when used for occluded grafts with high chance of unsuccess.

  What is the best option for this patient?

  Thanx

  SS

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Acute Limb ischemia is elderly