A 72-year-old female presents with a 2-week history of abdominal/back pain and lower extremity fatigue. She was evaluated by her physician and diagnosed with lumbosacral neuritis. Initial treatment involved lumbar corticosteroid injections. Secondarytosuddenonsetlowerextremityweaknessshepresentedtotheemergency department. Her past history included diabetes, hyperlipidemia, and obesity. In the past month, she had undergone heart catheterization which was significant for multivessel coronary artery disease. She denied any prior surgeries.

On examination, her pulse is 75 bpm, and blood pressure is 175/60. Heart sounds reveal a regular rhythm. The abdomen is soft and nontender. She has absent pulses and diminished strength in both lower extremities. Both feet are insensate. There are venous Doppler signals in the feet, but no arterial signals. Creatinine on arrival was 0.9 mg/dL, and white blood cell count was 23,000. Pre-operative CTA demonstrates infrarenal aortic occlusion with bilateral renal infarcts.

Question 1

Native arterial or graft thrombosis can be differentiated from embolic occlusion by the following:

A.  The presence of palpable pulses in the contralateral extremity B.  A history of cardiac arrhythmias

C.  The location of the occlusion

D.  The degree of profound ischemia in the affected extremity E.  All of the above

Z.M. Arthurs ( )

Department of Vascular Surgery, The Cleveland Clinic Foundation, Cleveland, OH, USA

Question 2

What is the SVS/ISCVS category of limb ischemia in this patient?

A.  Category I

B.  Category II a

C.  Category II b

D.  Category III

Question 3

What sign differentiates SVS/ISCVS Category IIa from IIb ischemia?

A.  Pulselessness B.  Sensory loss C.  Motor loss

D.  Loss of venous doppler signals

Question 4

In acute embolism, the sequence of events is:

A.  Pulselessness, pain, pallor, paresthesia, paralysis B.  Paralysis, pain, paresthesia, pulselessness, pallor C.  Pulselessness, pain, pallor, paralysis, paresthesia

The patient is taken to the endovascular suite, and based on the preoperative CTA, the left groin is accessed utilizing ultrasound guidance. An angiogram is performed from the sheath that reveals an occluded left iliac system with an isolated common femoral artery. A glide wire is traversed through the iliac system into the aorta. After confirmation of position, an aortogram is performed (Fig. 12.1).

Question 5

Treatment options for this patient include which of the following:

A.  Aortobifemoral bypass

B.  Operative thrombo-embolectomy C.  Extra-anatomic bypass

D.  Mechanical thrombectomy, thrombolysis and endovascular intervention E.  Intravenous thrombolysis

F.  Anticoagulation with heparin and coumadin

Fig. 12.1  Aortography via a left femoral approach documents infrarenal aortic and bilateral iliac occlusions

Question 6

After thrombolysis, long-term outcome is predicated on:

A.  Unmasking a “culprit lesion” that is treated via either endovascular or surgical means B.  The dose of thrombolytic agent used

C.  The duration of thrombolysis D.  The arterial outflow

E.  Assuring all acute thrombus is lysed

Thispatientunderwentlysisfromtheleftgroinwitha20cminfusioncatheter.Thrombolysis (TPA, tissue plasminogen activator, dose = 1 mg/h) was performed through a multi-side hole infusion catheter, and the following day, there was significant resolution of thrombus in the aorta/left common iliac system (Fig. 12.2). A combination of a hydrophilic wire and catheter was used to cross occlusion in the right common iliac system and gain access to the nativefemoralsystem(Fig.12.3).Asecondinfusioncatheterwasplacedthroughthisocclusion,andthrombolytictherapywascontinued.Afteranother24hoftherapy,thepatientwas returned to the endovascular suite. While there was significant improvement, there was still residual thrombus at the origin of the right hypogastric artery and right external iliac artery (Fig. 12.4). Thrombolytic therapy was continued another 24 h at 0.5 mg/h TPA.