CASE PRSENTATION

DR CHANDRAKUMAR
• BABU RAM SHARMA

• M/ 56, 164 cm/ 45 kg/ 1.43m2

• CLERK IN FARDIDABAD CORPORATION

• PALWAL DISTRICT, HARYANA

PRESENTING COMPLAINTS

• Pain in the buttocks and lower limbs - 3 YEARS

• Chronic non healing ulcer left foot,
post disarticulation of great toe 8 MONTHS
History of present illness
• Apparently well 3 years back
• Developed gluteal pain and pain along the lower limbs from three
years
• Pain is brought about by walking
• Not present on taking the first step
• Pain is repeatedly present in the same muscle group and by walking
the same distance
• Pain is typically relieved by rest
• The distance at which he developed pain gradually decreased and transformed
to pain at rest since one year

• Because of pain and inability to walk, his life style is restricted and affected
severely

• Patient has erectile dysfunction from one year

• 8 months back developed blackish discoloration of left great toe, was associated
with fever, which was not responding to local debridement, which resulted in
disarticulation of the toe.

• The resulting ulcer has failed to heal till date

• h/o altered sensations in the foot from one year

• Slipping of foot ware

• Decreased sensation in the foot bilaterally

• Constipation not responding to laxatives and fibre diet

No history of

• Swelling of legs/ venous

• Pain abdomen after a meal
engorgements
• Chest pain/ palpitation
• Facial puffiness/ decreased urine

• Giddiness/ loss of consciousness output

• Weakness of any limb/ slurring of • Polyuria/ polydipsia

speech/ incontinence • Xanthomas

Past history
No h/o
• Chronic cough (productive/ dry), Weight loss, Night sweats
• Icterus/ seizure disorders
• Cardiac disorders
• Chronic ailments ( not diabetic/ hypertensive)
• Rashes/ joint swellings
Surgeries in the past
• Underwent appendectomy 10 years back
Personal history
• Smoker from 5 years, stopped one year back

• Smoked beedis, 5-6/ day

• Not alcoholic

• No sexual promiscuity

• Mixed diet

• Normal bowel and bladder habits

• Disturbed sleep because of pain, not responding to analgesics

Family history
• No family member is known to have suffered similar complaints/
cardiac/ cerebrovascular events
General examination

• Conscious, coherent, oriented to time, place and person

• No anemia/ jaundice/ clubbing/ lymphadenopathy/ pedal edema

• PR80 beats/ min, regular, normal volume, vessel wall thickening

present, no radio-radial delay. Absent pulsations in lower limbs
bilaterally

• BP- 110/ 67 (RUL), 114/ 65 (LUL), lower limb?

Examination of peripheral vascular system
Inspection of lower limbs
• Disarticulated left great toe

• Non healing ulcer on the great toe stump

• Ulcer is shallow, iatrogenically induced, with exposed proximal phalanx, partially covered by pale granulation

• Another ulcer on the heel (left foot), 2x 2 cm, covered by granulation tissue, dry.

• A punched out 1x 1 cm ulcer on the under surface of right knee, no active discharge.

• Brittle toe nails

• Transverse ridges over the nails

• Skin over the toes- edematous, shiny and with loss of hair

• Necrotic skin patch over distal foot, with erythema

• No varicosities
• No e/o cellulitis/ joint effusion
• No restriction of joint movements
?
Palpation Auscultation
• No bruit
• Upper limb pulse equal bilaterally in

subclavian, brachial, radial and ulnar

arteries

• Lower limb absent femoral, popliteal,

PTA & DPA

Provisional diagnosis

• A case of peripheral vascular disease, probably involving infra-inguinal

vessels, along with aorto-iliac disease, in a stage of critical limb

ischemia, with no co-morbid factors, probably atherosclerotic etiology

aggravated by smoking history.

Work up

For confirmation of diagnosis For Etiology and work up

• CBC
• ABI, Ankle Pressure, TcPO2 • RBS/ GTT
• ESR
• DUS Limbs & abdomen (AAA)
• LFT, KFT
• VDRL, Viral markers
• CTA/ MRA
• Lipid profile
• DSA • CAG
AORTO-ILIAC DISEASE
AFB- SOME USEFUL TIPS

• Never dissect underneath the proximal aorta if the left renal vein has
not been visualized anteriorly.

• In at least 10% of cases, the left renal vein runs posterior to the aorta
and can easily be damaged by a retrograde clamp.

• If this ever happens, the bleeding can be torrential and difficult to

control.
AFB- SOME USEFUL TIPS

• If the aortic disease is at the level of the renal arteries, place the proximal
clamp above the renal vessels.

• Exposure is often improved if the left renal vein is retracted in a vessel loop.

• It is crucial to visualize both renal arteries before placing the clamp.

• To prevent postoperative renal dysfunction, the proximal anastomosis

should be completed in less than 30 minutes
• Perform the proximal aortic anastomosis in either an end-to-side or
an end-to-end fashion.

• Perform an end-to-side anastomosis when there is an aberrant renal

artery that supplies a large portion of the kidney or a large mesenteric
artery that must be preserved.

• Another indication is a male patient who does not want to develop

libido after surgery and who has significant disease of the external
iliac vessels or a hypoplastic aorta
• An end-to-end anastomosis is indicated if there is coexisting aortic aneurysmal
disease or complete aortic occlusion that extends up to the renal arteries.

• Most surgeons prefer an end-to-end anastomosis, believing that it yields much

better hemodynamic results than an end-to-side anastomosis does.

• However, there is no solid evidence that one technique is superior to the other
in this regard; the final choice is strictly personal.

• Some evidence suggests that intraoperative atheroembolic episodes may be

less frequent with end-to-side anastomoses.
• The distal anastomoses in the two sides of the groin are usually made

at the bifurcation of the common femoral artery and onto the

proximal deep femoral artery, regardless of the status of the

superficial femoral artery.

COMPLICATIONS AFTER AFB

• Myocardial infarction (MI) is a well-known complication after aortic bifemoral

bypass

• Renal failure is not common after aortic bifemoral bypass.

• Worsening of kidney function is more likely if there is preexisting renal failure, if the
aorta is clamped above the renal arteries, or if the renal vein is ligated or damaged.

• Other factors that can worsen renal injury include the use of contrast dye,
dehydration, and embolism
• When extensive dissection is performed over the distal aorta and left common iliac
artery, decreased sexual function may result.

• If the periaortic sympathetic fibers are damaged, retrograde ejaculation can occur.

• Precise surgical technique is the only way to prevent this disturbing side effect.

• On the distal aorta, dissection should be limited to the right side.

• If severe iliac artery disease is present, an end-to-side anastomosis is preferred to

maintain retrograde flow to the external iliac branches.

• Some surgeons perform iliac artery endarterectomy to improve erectile function, but
the results are not consistent, and there is a risk of nerve injury