A 70-year-old patient presented with symptoms of right lower limb pain and paresthesia. This pain and paresthesia was insidious, gradual and progressive in onset and is associated with a burning sensation. There was no history of fall or any injury to the leg. Upon physical examination, Dorsalis pedis artery pulse and posterior tibial artery pulse on the right lower limb was not palpable.
This absence of pulses indicates there was something wrong in his right lower limb arterial system. To know the exact problem and to get a better view of patients lower limb arterial system he was advised to get a CT angiogram done.
- The CT angiogram revealed
- A Long segment occlusion with absent contrast opacification seen at the distal segment of the right superficial femoral artery
(SFA), right popliteal artery. - Complete occlusion with absent contrast opacification seen at right anterior, posterior tibial arteries, peroneal artery,
dorsal pedis arteries. - Complete occlusion with absent contrast opacification seen at the left tibial peroneal trunk, left posterior tibial artery,
peroneal artery.
The patient and the patient attenders have been explained about the seriousness of the situation and the need to get a femoro distal bypass surgery is done immediately and delay may lead to even more complications like the onset of gangrene and spread of gangrene which leads to limb amputation.
Patients complete surgical workup and pre-anaesthetic check-up was done and all the reports were normal and the patient was cleared fit for surgery.
Surgery was done under general anaesthesia and initially, Thrombectomy of all the occluded arteries both distal and proximal was attempted and lots of thrombus has been removed both acute and chronic using Fogarty French 4.0 catheter however the flow was not restored. Fogarty was able to pass only up to a certain extent and after that, there was a complete blockage. So, a right saphenous vein was cultured and after gaining the control of the common femoral artery the vein is reversed and grafted. Post grafting the blood the flow was restored and the pulse was bounding.
Post-surgery patient has been placed on a high dose of antibiotics, analgesics and anticoagulants and was in observation for a few days. Patients pain and paraesthesia were completely regressed and the pulses were bounding.
The advantages of this bypass surgery are that the results would be remarkable and the use of saphenous vein of the patient himself gives us the advantage of having lower complications post-op which would occur on using external graft like kinking of graft etc. the elasticity of the saphenous gives the patient the freedom of having free limb movements.
Dr. C . Chandra Shekar, DNB, FIVS, FEVS (Department of Vascular and Endovascular Surgery)
Dr. Ch. Anudeep, MBBS, (MS) (Department of Vascular and Endovascular Surgery)
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