(Disclaimer: This article is for general use only, and the information in the following content has been processed to protect patient privacy)
Abstract: This is a case of a middle-aged male patient with a previous history of atrial fibrillation and no regular medication. Sudden onset of severe pain in the left lower extremity was indicated by emergency ultrasound: thrombosis and lumen occlusion of the superficial femoral and popliteal arteries in the left lower extremity. At the time of admission, the left lower extremity had decreased sensorimotor function, pain, pulselessness, numbness, dyskinesia and other 5P signs existed, and the risk of ischemic necrosis was considered, so the left lower extremity femoral artery was dissected and Fogarty catheter embolization was performed urgently. After the operation, the pain of the affected limb disappeared and the sensorimotor function was restored.
Basic information】Male, 68 years old
Disease Type】Left lower extremity arterial embolism
Hospital】Liaoning Provincial People’s Hospital
Date of Consultation】April 2022
Treatment plan】Femoral artery dissection of the left lower limb, Fogarty catheter embolization
Treatment period】7 days of hospitalization and 1 month of outpatient follow-up
Treatment effect] The 5P signs disappeared after the operation, and ultrasound showed clear blood flow 1 month after the operation.
I. Initial consultation
In April 2022, a 68-year-old male patient came to the emergency room with sudden onset of pain, numbness and coldness in the left lower extremity for 18 hours. The left superficial femoral artery and popliteal artery had thrombosis and lumen occlusion. The patient had a past history of atrial fibrillation and had been taking Betalac to control the ventricular rate, but was not taking anticoagulants regularly. He had a history of smoking for more than 20 years. He had poor diet and poor sleep, was unable to lie down, and had significant pain at night, holding his knees in a sitting position.
II. Treatment history
After admission, the degree of ischemia was quickly assessed, and CTA of the lower extremity arteries indicated the possibility of left lower extremity artery embolism, superficial femoral artery and popliteal artery thrombosis, and lumen embolism. Considering the patient’s previous history of atrial fibrillation and the irregular use of anticoagulants, it was considered that the atrial embolus had dislodged and blocked the lower limb artery, resulting in acute arterial ischemia. In addition, the patient’s lower extremity had been ischemic for too long, and he had already experienced inability to move his toes and loss of sensory function. The department decided to perform an emergency left femoral artery dissection and Fogarty catheter embolization. A small incision was made in the femoral artery, and a Fogarty catheter was inserted to remove the thrombus from the proximal and distal femoral artery. The patient’s postoperative symptoms were significantly relieved, blood flow was restored, and the sensory-motor function of the limb was eventually restored.
III. Treatment results
The patient’s immediate postoperative effect was remarkable. The patient’s symptoms of limb pain, numbness and coldness were significantly relieved, and the pulsation of the femoral artery, popliteal artery and dorsalis pedis artery of the left lower limb could be palpated. On the second day after surgery, the patient’s skin temperature gradually turned warm, skin color turned red, and sensory function gradually recovered. One month after discharge, the patient had no significant discomfort on the ultrasound. The ultrasound results showed that the arterial flow in the left lower limb was smooth and there was no significant stenosis or occlusion.
IV. Precautions
After the treatment, the patient’s discomfort was relieved, so we felt relieved that the patient’s condition improved, but we still suggested the patient to pay attention to the following matters after discharge.
1, it is recommended that patients still need to strictly monitor their heart rate after discharge, in addition to taking medication (such as betalactam) and other heart rate control, radiofrequency ablation can also be considered appropriately, in addition, long-term regular anticoagulation therapy is also necessary to avoid re-occurrence of embolism.
2, after the operation, we should pay attention to the swelling degree of the calf, some patients due to long time arterial ischemia, reperfusion will cause osteo-fascial compartment syndrome, such as great tension, need to promptly notify the doctor, if necessary, incision and reduction of tension.
3.After recanalization of vascular embolism, due to long time ischemia, ischemia-reperfusion injury will occur, and some patients will have a sharp increase in intermuscular pressure, which will induce osteo-fascial compartment syndrome, and serious cases can only be amputated, so we should pay attention to the degree of swelling of the calf after surgery, and if the tension is great, it needs to be incised and reduced in time.
V. Personal insight
Lower extremity arterial embolism is the most common clinical condition of acute lower extremity arterial ischemia, and irreversible tissue damage will occur after 6-8 hours of limb ischemia. Patients with severe arterial embolism will show the typical 5P signs, namely pain, pallor, pulselessness, paresthesia, and paralysis. Therefore, once arterial embolism is suspected, prompt and rapid surgery should be performed to remove the embolism. As in the case of the patient, the symptoms were effectively relieved after treatment, avoiding the possibility of ischemic gangrene in the limb and reducing the possibility of amputation. However, it is also important to pay attention to the changes of skin temperature and color and tension of the calf after embolization to detect the possibility of re-embolization or osteo-fascial compartment syndrome early.