Polling Station

Poll 02/02/2019 – 28/02/2019

The acute limb ischemia

Patient’s characteristics

Gender: Female

Age: 65 years old

Comorbidity: Arterial hypertension, Dyslipidemia

Symptoms:  Acute onset of claudication (<2 weeks), Rutherford class 3 of the left limb

Previous operations: None

ABI: 0.5

DUS: Occlusion of the left popliteal artery

Question #1

Which is your primary treatment option?
  • Revascularization

  • Conservative

The expert: Hany Zayed MD, MSc, FRCS
This lady presents with symptoms of intermittent claudication. From the CTA and DSA, she has reasonable inflow down to her left Popliteal artery. Of note, she has a well-developed network of mature collaterals at the level of the popliteal occlusion. This, in addition to the short history of symptoms, might indicate that this is an acute on top of chronic ischaemia and she might have had a significant underlying popliteal disease already. In the absence of symptoms of Critical Limb Ischaemia, I tend to do the following: - Conservative management: Best medical therapy, Supervised Exercise Programme, Risk factor modification etc. - Investigate for: Thrombophilia, proximal source of emboli (CTA aorta, Echo and 24 hr ECG) - Close clinical follow up to watch out for symptoms or signs of CLI
Question #2

Which would be your primary revascularization method?
  • Catheter directed thrombolysis (CDT)

  • Endovascular thrombectomy +/- CDT

  • Surgery

The expert: Hany Zayed MD, MSc, FRCS
If this lady presented with CLI, my primary revascularisation strategy would be: - If she is fit and has a good quality venous conduit: I would elect to do a left SFA to P3/TPT bypass - If not fit or has no reasonable venous conduit: I will proceed with Endovascular thrombectomy +/- CDT.
Question #3

Which of the following modalities would be your primary endovascular thrombectomy option?
  • Aspiration thrombectomy

  • Rotational thrombectomy

  • Syringed based aspiration

  • Pharmaco-mechanical Thrombectomy

  • Ultrasound-assisted catheter-directed low-dose thrombolysis

The expert: Hany Zayed MD, MSc, FRCS
My first choice would be PMT. This has the advantage of debulking any underlying atherosclerotic lesions, with the aim of trying to avoid stenting in this challenging anatomical area.
Question #4

Which is your medical treatment of choice in case of endovascular thrombectomy:
  • Vit. K antagonist

  • New oral anticoagulation

  • Clopidogrel

  • Aspirin

  • Dual antiplatelet therapy

  • Combined anticoagulation and antiplatelet therapy

The expert: Hany Zayed MD, MSc, FRCS
Our protocol is as follows: - If her thrombophilia screen was positive: combined anticoagulation and single antiplatelet. - If her thrombophilia screen was negative: Dual antiplatelet therapy
Question #5

Do you routinely perform inherited thrombophilia workout in cases of embolic disease?
  • Yes

  • No

The expert: Hany Zayed MD, MSc, FRCS
Yes, it is a part of our standardized protocol to investigate acute ischaemia.
Question #6

Do you routinely perform neoplastic disease workout in patients with acute limb ischemia?
  • Yes

  • No

The expert: Hany Zayed MD, MSc, FRCS
Testing for tumor markers is not part of our routine protocol. However, we feel that the CTA aorta (covering from major aortic arch branches to mid-SFAs) is likely to pick up any solid organ neoplasms. Signs of many haematological malignancies would also be detected during perioperative investigations.
Question #7

Do you routinely perform total body CT angiography in order to identify the source of the clot?
  • Yes

  • No

The expert: Hany Zayed MD, MSc, FRCS
Yes, as explained above.