Pedal Pulses Research Articles

Blood Flow Restriction Following ACL Reconstruction

Background: Blood flow restriction (BFR) therapy is a technique that uses partial occlusion of arterial blood flow in tandem with low-load resistance training to promote an environment of metabolic stress within muscle tissue. It is hypothesized that such therapy can facilitate protein synthesis and muscle hypertrophy even in the setting of age, injury, or postoperative rehabilitation—conditions which are marred by muscle atrophy and progressive loss of function. Therefore, BFR may be a successful option to facilitate strength gains even in patients unable to perform traditional high-load resistance training. Indications: BFR therapy has been shown to be efficacious when used in healthy athletes, the elderly, or in postoperative patients undergoing rehabilitation after upper or lower extremity procedures. More specifically, BFR application in patients undergoing knee surgery has been shown to reduce muscle atrophy post operatively. Technique Description: BFR involves application of a tourniquet or occlusion cuff at 70% of the determined arterial occlusion pressure (commonly 150-180 mm Hg). The arterial occlusion pressure is calculated by observing the loss of Doppler ultrasonography signal at the pedal pulses with sequential inflation of a blood pressure cuff. This cuff should be applied as proximal as possible at the affected extremity. The patient subsequently performs 5 exercises, including 3 sets of 15 repetitions of each exercise, with 30 seconds of rest in between sets. The cuff remains inflated for all 5 exercises. Results: BFR in tandem with low-load resistance training has been shown to be effective in improving lower extremity muscle torque and mass of the quadriceps and hamstring muscles when used after knee surgery, specifically anterior cruciate ligament (ACL) reconstruction. The most commonly reported adverse outcomes after BFR include muscle soreness and sensory paresthesias; however, BFR is generally believed to be safe and acceptable for use in a broad spectrum of patients. Discussion/Conclusion: Muscle atrophy and loss of strength are hallmarks of aging, injured, and postoperative patients. Traditional means of high-intensity strength training is not feasible in these patient populations, and the use of BFR in tandem with lower intensity strength training shows promise in its ability to promote improvements in muscle strength and hypertrophy. However, more high-level research into the long-term effects, complications, and optimal BFR training regimen is warranted. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Risk Factors for Underreporting of Life-Limiting Comorbidity Among Adults With Lower-Limb Loss.

Peripheral neuropathy (PN) and peripheral arterial disease (PAD) are life-limiting comorbidities among adults with lower-limb loss that may not be adequately addressed in current care models. The objective of this study was to evaluate underreporting of PN and PAD among adults with lower-limb loss. We conducted a secondary analysis of a cross-sectional dataset of community-dwelling adults with unilateral lower-limb loss seen in an outpatient Limb Loss Clinic (n = 196; mean age = 56.7 ± 14.4 years; 73.5% male). Individuals participated in standardized clinical examinations including Semmes-Weinstein monofilament testing to assess for PN and pedal pulse palpation to assess for PAD. Bivariate regression was performed to identify key variables for subsequent stepwise logistic regression to discern risk factors. Clinical examination results indicated 16.8% (n = 33) of participants had suspected PN alone, 15.8% (n = 31) had suspected PAD alone, and 23.0% (n = 45) had suspected PN and PAD. More than half of participants with clinical examination findings of PN or PAD failed to self-report the condition (57.7% and 86.8%, respectively). Among adults with lower-limb loss with suspected PN, participants with dysvascular amputations were at lower risk of underreporting (odds ratio [OR] = 0.2, 95% CI: 0.1-0.6). For those with suspected PAD, those who reported more medication prescriptions were at lower risk of underreporting (OR = 0.8, 95% CI: 0.7-1.0). Adults with lower-limb loss underreport PN and PAD per a medical history checklist, which may indicate underdiagnosis or lack of patient awareness. Routine assessment is highly recommended in this population and may be especially critical among individuals with non-dysvascular etiology.

What are the current diabetic foot assessment methods in private podiatry practices in Flanders, Belgium: an exploratory mixed method study

BackgroundDiabetic foot assessments detect patients at risk for developing a diabetes-related foot ulceration and can significantly reduce the risk of amputation. In order to organize this assessment effectively, diabetic foot assessment guidelines are required according to the International Working Group of the Diabetic Foot. However, these international guidelines have not been adapted into a national guideline for podiatrists in Flanders, Belgium. This study aims to identify the methods and guidelines currently used to assess the diabetic foot in private podiatry practices in Flanders, Belgium and to explore the podiatrists’ opinions on developing a national diabetic foot assessment guideline.MethodsThis exploratory mixed method study was composed of an anonymous online survey comprising of open- and closed-ended questions followed by 1:1 online semi-structured interviews. Participants were recruited via e-mail and a closed private Facebook group of podiatry alumni. Data was analyzed using SPSS statistics and thematic analysis described by Braun and Clarke.ResultsThis study showed that the vascular assessment of the diabetic foot exists solely of a medical history and palpation of the pedal pulses. Non-invasive tests such as doppler, toe brachial pressure index or ankle brachial pressure index are seldom used. Only 66% reported to use a guideline for the diabetic foot assessment. There was a variety of reported guidelines and risk stratification systems in use in private podiatry practices in Flanders, Belgium.ConclusionNon-invasive tests such as the doppler, ankle brachial pressure index or toe brachial pressure index are rarely used for the vascular assessment of the diabetic foot. Diabetic foot assessment guidelines and risk stratification systems to identify patients at risk for developing a diabetic foot ulcer were not frequently used. International guidelines of the International Working Group of the Diabetic Foot have not yet been implemented in private podiatry practices in Flanders, Belgium. This exploratory research has provided useful information for future research studies.

Post-Covid-19 Recurrent Lower Limb Ischemia in Healty Young Patient

Background: Although SARS-CoV-2 infection is primarily a respiratory illness, complications such as arterial and venous thromboembolism have been reported during acute infection and in the period after its resolution.Methods: We report the case of a 33-year-old male, previously healthy patient with acute recurrent unilateral arterial thrombosis of the leg occurring one month after a mild Covid-19 infection.Results: The patient has recently been diagnosed with essential hypertension and did not have other known risk factors for arterial thrombosis. He presented to the Emergency Department with a pale left foot and absent dorsal pedal pulse and after confirmed arterial occlusion by Doppler ultrasound, he underwent urgent thromboembolectomy. The following day a computed tomography angiogram showed recurrent thrombosis of the superficial femoral artery which was then resolved in an Angio-suite by balloon dilatation. Three months later he experienced another occlusion of the left superficial femoral artery based on pronounced neointimal hyperplasia and again underwent endarterectomy with patch plastic.Conclusion: SARS-Cov-2 infection should be considered a risk factor in the development of both arterial and venous thrombo-sis during the acute phase and in the post-infective period

Validation of the Ischaemia Severity Scale (ISS) Based on Non-Invasive Vascular Assessments (SEWSS) for Predicting Outcomes of Diabetic Foot Attack.

Assessment of ischaemia severity includes a variety of measures, such as pedal pulse palpation, the ankle/brachial index (ABI), and the toe/brachial index (TBI), but there is a lack of consensus regarding which ischaemia scale is the most effective for determining outcome prognosis. The purpose of this study is to validate the application of the ischaemia severity scale (ISS) in the effective prediction of wound healing, amputations, and mortality for diabetic foot wounds (DFW). This prospective study included 235 consecutive patients graded according to the Saint Elian Wound Score System (SEWSS). The ISS is part of this system, with patients being scored as non-ischaemic (0) or having mild (1), moderate (2), or severe (3) ischaemia. Age, diabetes duration in years, and ulcer size were found to be associated with a longer mean ischaemia of increasing severity. A trend of reduction in the pulse palpation rates (70.4%, 50%, 8.5% to 0%; p < 0.01), ABI (1.1 ± 0.1, 0.86 ± 0.3, 0.68 ± 0.2, 0.47 ± 0.2, p < 0.01), TBI average values (0.90 ± 0.35, 0.62 ± 0.52, 0.50 ± 0.33, 0.10 ± 0.42, p < 0.01), wound healing success (88.7%, 57.7%, 40.7%, 12.9%; p < 0.01), and delay in weeks (Kaplan-Meier: log-rank 44.2, p < 0.01) was observed with increasing values of the ISS (0, 1, 2, and 3). The odds ratio for adverse outcomes increased for each additional level of ischaemia severity. Thus, we demonstrate that the ISS is useful in effectively predicting adverse outcomes for DFW.

Digital Ischemia Associated with Profound Anemia: A Concerning Consequence of Treatment without Transfusions

Severe anemia is associated with increased mortality and adverse cardiovascular events, but documentation of other clinical sequelae is not well known. It is rare to witness prolonged, life-threatening anemia in a clinically stable patient because it is largely prevented and treated with transfusions. In this case, we are presenting a patient with extreme anemia who cannot receive blood transfusions due to religious beliefs and is struggling with acute limb ischemia as an associated consequence. According to current literature, anemia is prevalent in patients with peripheral vascular disease, but it is not recorded as a cause. Additionally, longitudinal studies have demonstrated an association between cardiac arrests, acute myocardial infarctions, and congestive heart failure from having hemoglobin levels less than 7 g/dL but other adverse events were not studied. This unique clinical case contributes to optimizing bloodless management and treatment as well as identifying sequelae from severe anemia that has not been recorded in current research to the best of our knowledge. Patient is a 43-year-old African American female who is a Jehovah's Witness with a past medical history of delusional disorder, previous malaria infection 10 years ago, and recent travel to Ghana who presented with generalized myalgias and weakness for one week. She was transferred to our hospital for septic shock. She was also COVID-19 positive with severe thrombocytopenia, lactic acidosis, and disseminated intravascular coagulation. Physical examination was significant for scleral icterus, generalized jaundice, and tachycardia. On admission, peripheral smear confirmed 15.7% parasitemia. She was initiated on atovaquone/proguanil and artesunate for the malarial infection. Her hemoglobin on arrival was 7 g/dL (normal 12-15 g/dL) but shortly, her hemoglobin dropped to 5.5 g/dL and continued to decline. Given her religious status, she did not consent to blood transfusion products. Decision was made to maximize anemia treatment with iron infusions, B12, folate, and epoetin 20,000 units. She was also placed on a non-rebreather mask for supplemental therapy. Once the parasitemia resolved on repeated smears, the patient's hemoglobin slowly began to show improvement. Her lowest recorded hemoglobin throughout admission was 3.5 g/dL. Although she achieved resolution of her coagulation disorders and septic shock, her hospital course was complicated by the development of blue discoloration of her metatarsals bilaterally. This developed one week into her hospitalization without history of vasopressors use or history of previous vascular disease. Vascular evaluation revealed intact posterior tibialis and dorsalis pedis pulses bilaterally. Interestingly, arterial dopplers did not show thrombosis or stenosis but did reveal significantly decreased flow in the right dorsalis pedis artery. It was highly suspected that the digital ischemia is secondary to hypoperfusion from critical anemia. She is currently not a surgical candidate but is otherwise doing well, hemodynamically stable, and currently awaiting rehabilitation placement. This specific case highlights the dilemma between medical necessity and honoring religious decisions. It provides rare insight into a patient with stable, profound anemia. It also raises the question if blood transfusions could have definitively prevented or reversed the limb ischemia. Supplemental oxygen delivery, iron infusions and erythropoiesis-stimulating agents (ESAs) are the standard of care in bloodless management of Jehovah's Witnesses. However, the dosing of epoetin continues to be studied in the setting of severe anemia without blood transfusions. Furthermore, this patient brings awareness to vascular complications and introduces a new clinical outcome that can be investigated in the future. Currently, our patient continues to defy the odds with statistically unviable hemoglobin levels and remains faithful to her spirituality. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Successful conservative treatment for Ogden type-IV tibial tubercle avulsion fracture with transverse fibular fracture in 15 years old boy in remote area: a case report

Background: Tibial tubercle avulsion fracture is very rare. Its incidence has been reported to account for only 3% of all proximal tibia fractures and less than 1% of all growth plate injuries. This fracture occurs when the quadriceps are forcefully contracted against resistance, such as during jumping, or when rapid knee flexion occurs with contracted quadriceps, such as during landing. Most authors recommended surgical options in type IV tibial tubercle avulsion; however, we reported successful conservative treatment in this case report. Case report: A 15-year-old male athlete with no significant past medical history presented via emergency medical services after a ground-level fall while playing basketball which landed with his left foot in a pivot position. He felt immediate pain and swelling about the left knee, all sensation was intact, as were pedal pulses, and neurovascularly remained intact. The patient did not want to go for medical evacuation to do surgery and consent to be managed with conservative treatment with close follow-up. Conclusion: The results and prognosis of these fractures are excellent, despite the fracture pattern or treatment used, as long as an anatomical reduction is obtained

AAOS Management of Hip Fractures in Older Adults Evidence-based Clinical Practice Guideline.

AAOS Management of Hip Fractures in Older Adults Evidence-based Clinical Practice Guideline.

What a Thrombus! Blunt Aortic Injury in a Young Woman

A 20 year old haemodynamically stable woman was admitted with an acute abdomen and absent pedal pulses after a road traffic accident in which she was a restrained backseat passenger. (A) Computed tomography revealed a pneumoperitoneum, near occlusive aortic thrombus proximal to the bifurcation (arrow), and an occluded left popliteal artery. (B) Laparotomy with bowel resection, a defunctioning ileostomy, and aortic repair were performed simultaneously. The aortic injury was repaired using an interposition Dacron graft (Uni-Graft K DV, 10 mm) which was covered with aortic wall after removing aortic thrombus (asterisk). A popliteal embolectomy was performed after aortic repair. Prophylactic antibiotics were given intra-operatively.Image 1

Lower limb ulcer and Raynaud's phenomenon

A 64-year -old patient sought medical advice for an ulcer of the lower extremities (Fig 1). He also presented with claudication, chronic dyspnea, skin thickening, and late-onset Raynaud's phenomenon (RP). There were no palpable dorsalis pedis or posterior tibial pulses. Skin examination showed reduction of forehead folds, facial and tongue telangiectasias, xerosis cutis, salt-and-pepper hyperpigmentation, sclerodactyly, digital ulcerations, and pitting scars (Fig 2). Chest auscultation revealed crackles on the lower lobes.

An investigation into the detection of the pulse in conscious and anaesthetized dogs

ObjectivesTo record the success rate of veterinary professionals and students at identifying the pulse in conscious and anaesthetized dogs. To explore the influence of clinical experience, pulse location, anaesthesia and likely confounding variables on the success of pulse palpation. Study designProspective, observational, randomized study. AnimalsA total of 54 client-owned dogs scheduled for general anaesthesia. MethodsFor each dog, three participants (senior anaesthetist, anaesthesia resident/nurse, veterinary student/animal care assistant) attempted pulse palpation at three locations (femoral, radial and dorsal pedal pulse) in conscious and anaesthetized dogs. The time to pulse palpation was measured with a stopwatch for each attempt and data were modelled using a multivariate Cox regression survival analysis (significance p < 0.05). ResultsThe overall success rate of pulse palpation was 77%, with a median time of 10.91 seconds (interquartile range 9.09 seconds). Success rate was lower in conscious dogs (67%) than in anaesthetized dogs (87%). There was a 77% lower likelihood of success at the radial than at the femoral pulse [hazard ratio (HR) 0.23, 95% confidence interval (CI) 0.38–0.69, p < 0.001]. Veterinary students/animal care assistants had a 71% lower likelihood of success than senior anaesthetists (HR 0.29, 95% CI 0.22–0.39, p < 0.001). Age, weight and American Society of Anesthesiologists physical status had no significant influence. Premedication/anaesthetic drugs, heart rate or mean arterial pressure had no significant influence on the time to pulse palpation in anaesthetized dogs. The median time to palpation was less than 10 seconds for all experience groups at the femoral location. ConclusionsPalpation of the femoral location had the greatest likelihood of success with the least amount of time. Monitoring the femoral pulse during induction of anaesthesia is suggested as a method for confirming spontaneous circulation. Pulse palpation improves with clinical experience.

Woman With Leg Pain

A 50-year–old woman presented to the emergency department with severe calf pain after being pecked in the leg by a rooster 5 days earlier. She reported 2 puncture wounds from the attack, subjective fever, and progressive difficulty in walking because of the pain. She denied experiencing shortness of breath or chest pain. She arrived with a blood pressure of 131/85 mm Hg, a pulse rate of 74 beats/min, and a temperature of 37.2 °C (98.96 °F). Neurologic examination findings were normal, and she had normal posterial tibial and dorsalis pedis pulses and no warmth or redness to palpation, but she did have swelling and severe tenderness of the calf.

Iliofemoral Artery Endofibrosis Associated with Microembolization

ObjectivesEndoluminal fibrosis is a rarely described cause of exertional claudication in athletes. It typically is located to the external iliac artery,but has been described in the femoral segment as well. Rare reports have described arterial changes as a nidus for microembolic disease.MethodsCase report.ResultsA 20-year-old male presented to the emergency department with 3 months of worsening right calf claudication. He reported a history of lupus anticoagulant, not currently being treated. He was a semi-professional soccer player and very physically active until symptom onset. The patient intermittently vaped. On physical exam, he had non-palpable pulses throughout the right leg with strongly palpable pulses throughout the left. Focal fixed petechiae were noted on the right toes. Duplex ultrasound showed focal high-grade stenosis of the right common femoral artery, and a subsequent CT angiogram demonstrated near-occlusion of a segment of the common femoral and a very small diameter (3 mm) right external iliac artery (Fig 1). All other lower extremity arteries were patent. Due to concern for a thromboembolic source, we performed a right iliofemoral endarterectomy with patch angioplasty. Intraoperatively, a dense, nearly occlusive rubbery mass at the external iliac-common femoral junction was identified (Fig 2). Pathology showed benign myxoid myofibroblastic proliferation, without signs of atherosclerosis. The intraoperative findings at this point suggested an endoluminal fibrosis with distal embolization. Palpable pedal pulses were restored. CTA was repeated 2 months postoperatively which demonstrated patency of the endarterectomy and normalization of the right external iliac diameter. The patient had been placed on warfarin and hydroxychloroquine with symptom resolution.ConclusionsFig 2Intraoperative appearance of iliofemoral fibrosis.View Large Image Figure ViewerDownload Hi-res image Download (PPT) ObjectivesEndoluminal fibrosis is a rarely described cause of exertional claudication in athletes. It typically is located to the external iliac artery,but has been described in the femoral segment as well. Rare reports have described arterial changes as a nidus for microembolic disease. Endoluminal fibrosis is a rarely described cause of exertional claudication in athletes. It typically is located to the external iliac artery,but has been described in the femoral segment as well. Rare reports have described arterial changes as a nidus for microembolic disease. MethodsCase report. Case report. ResultsA 20-year-old male presented to the emergency department with 3 months of worsening right calf claudication. He reported a history of lupus anticoagulant, not currently being treated. He was a semi-professional soccer player and very physically active until symptom onset. The patient intermittently vaped. On physical exam, he had non-palpable pulses throughout the right leg with strongly palpable pulses throughout the left. Focal fixed petechiae were noted on the right toes. Duplex ultrasound showed focal high-grade stenosis of the right common femoral artery, and a subsequent CT angiogram demonstrated near-occlusion of a segment of the common femoral and a very small diameter (3 mm) right external iliac artery (Fig 1). All other lower extremity arteries were patent. Due to concern for a thromboembolic source, we performed a right iliofemoral endarterectomy with patch angioplasty. Intraoperatively, a dense, nearly occlusive rubbery mass at the external iliac-common femoral junction was identified (Fig 2). Pathology showed benign myxoid myofibroblastic proliferation, without signs of atherosclerosis. The intraoperative findings at this point suggested an endoluminal fibrosis with distal embolization. Palpable pedal pulses were restored. CTA was repeated 2 months postoperatively which demonstrated patency of the endarterectomy and normalization of the right external iliac diameter. The patient had been placed on warfarin and hydroxychloroquine with symptom resolution. A 20-year-old male presented to the emergency department with 3 months of worsening right calf claudication. He reported a history of lupus anticoagulant, not currently being treated. He was a semi-professional soccer player and very physically active until symptom onset. The patient intermittently vaped. On physical exam, he had non-palpable pulses throughout the right leg with strongly palpable pulses throughout the left. Focal fixed petechiae were noted on the right toes. Duplex ultrasound showed focal high-grade stenosis of the right common femoral artery, and a subsequent CT angiogram demonstrated near-occlusion of a segment of the common femoral and a very small diameter (3 mm) right external iliac artery (Fig 1). All other lower extremity arteries were patent. Due to concern for a thromboembolic source, we performed a right iliofemoral endarterectomy with patch angioplasty. Intraoperatively, a dense, nearly occlusive rubbery mass at the external iliac-common femoral junction was identified (Fig 2). Pathology showed benign myxoid myofibroblastic proliferation, without signs of atherosclerosis. The intraoperative findings at this point suggested an endoluminal fibrosis with distal embolization. Palpable pedal pulses were restored. CTA was repeated 2 months postoperatively which demonstrated patency of the endarterectomy and normalization of the right external iliac diameter. The patient had been placed on warfarin and hydroxychloroquine with symptom resolution. Conclusions

No Symptoms for Over 70 Years! Incidentally Discovered Congenital Dysplasia of Infrarenal Aorta

A 75 year old female with a past history of pulmonary embolism was admitted with dyspnoea. Computed tomography angiography unexpectedly revealed a significantly narrowed and completely occluded abdominal aorta at the infrarenal level. She did not have any intestinal or lower limb problems, but she had had resistant hypertension for 40 years. Bilateral femoral, popliteal, and pedal pulses were palpable. The superior mesenteric artery (violet arrow), the arc of Riolan (white arrows), and the inferior mesenteric artery (red arrow) were dilated, providing adequate blood flow to the abdomen, pelvis, and lower limbs.

Outcomes of Popliteal Endarterectomy and Infrapopliteal Angioplasty for Short Atherosclerotic Popliteal Artery Occlusion: Single-Center Case Series

Localized popliteal artery occlusion (LPAO) is a rare entity with a challenging therapy. In selected patients, open popliteal endarterectomy (OPE) with infrapopliteal balloon angioplasty (IPA) can be limb-saving. The aim of this retrospective study from Iraq-Kurdistan is to assess the procedure outcomes. Over 5years, ending at 2020, 28 patients with atherosclerotic LPAO unsuitable for femoropopliteal bypass or endovascular intervention received OPE+IPA through a medial approach under spinal anesthesia. Perioperative data were obtained from patients' records and entered into an Access database. Results were retrieved and statistically analyzed. There were 18 (64.3%) males. The mean age was 66.4±6.53years (range 52-79 years). Seventy five percent of patients had obesity, diabetes mellitus, and smoking. Twenty six (92.9%) of patients were in Rutherford category 5 and 6 with an ankle-brachial index < 0.40. Popliteal and pedal pulses were absent in 23 of 24 (95.8%) patients. Doppler ultrasound showed a good distal runoff in 1 (3.6%) patient. Computed tomography angiography revealed 20 (71.4%) femoropopliteal and 16 (57.1%) infrapopliteal lesions of types A and B as per Trans-Atlantic Inter-Society Consensus II document. Mean endarterectomy length was 5.1cm (range 3-7), patched with a vein in (17, 60.7%) and primarily closed in (11, 39.3%) patients. Early complications were none in (18, 64.3%) patients whereas 1 leg was amputated on day 30. On average, follow-up lasted 3.4years. Twenty seven (96.4%) vessels remained patent and 2 (7.1%) patients died. Our study confirms safety and efficacy of OPE+IPA for selected patients with critical limb ischemia due to LPAO.

Successful surgical repair of an eminently rare case of an incidental idiopathic Common Femoral Artery Pseudoaneurysm in a 6-year-old female child - A Case Report.

Introduction and importanceA Pseudoaneurysm is an abnormal outpouching of the arterial wall which progressively enlarges and could lead to catastrophic consequences. Ensuing damage could culminate in the loss of the affected extremity due to dissection, exsanguination, thromboembolism, or infection. Some presentations are symptomatic, whereas others are incidental findings. Timely surgical mediation is vital to eliminate the potential morbid sequelae.Case presentationWe present the case of a 6-year-old female, who was referred to the clinic due to an incidental finding of a pulsatile bulge in her right groin. We confirmed the presence of a visible pulsating bulge in the right groin associated with impalpable Popliteal and Pedal pulses. Preoperative imaging revealed an isolated Common Femoral Artery Pseudoaneurysm and hence, surgical intervention was successfully accomplished.Clinical discussionSurgical repair was achieved by pseudoaneurysmectomy and utilizing an autologous Saphenous Vein graft. From the proximal side, a primary end-to-end anastomosis was accomplished between the veinous graft and the right Common Femoral Artery (CFA). Whereas from the distal side, a direct end-to-end anastomosis was completed between the right Superficial Femoral Artery and the veinous graft.ConclusionArterial pseudoaneurysms constitute immensely rare vascular emergencies. The pediatric population is particularly vulnerable because of the rarity of occurrence of this pathology in children. Surgical intervention is the gold standard approach. Meticulous follow-up protocols ought to be carried-out to limit the possibility of recurrence. Documentation is the main building block in our profession. Physicians should possess high sense of clinical awareness when presented with such a pathology.

A poor outcome in non-occlusive thrombo-embolic limb ischaemia related to the dislocation of mural thrombus from an abdominal aortic aneurysm

BackgroundAcute thrombosis of an abdominal aortic aneurysm with acute limb ischaemia is an unusual complication and is associated with high mortality. Dislocation of the intrasaccular mural thrombus could be one of the mechanisms. For the most part, acute limb ischaemia presents with absent pulses, compatible with the clinical findings, which include pain, paraesthesia, and paralysis. Herein, we report a rare condition with detectable distal pulses in advanced limb ischaemia due to poor perfusion caused by the dislocation of mural thrombus from an abdominal aortic aneurysm.Case presentationA 74-year-old male patient with underlying hypertension and chronic renal disease presented at the emergency room with bilateral lower limb paralysis after falling on his back in the bathroom an hour prior. He reported numbness and weakness of his lower limbs, which was gradually worsening, over the past week. Physical examination showed cyanotic mottling of the lower limbs with paralysis. However, the dorsalis pedis pulse was intact. Computed tomography angiography showed a 7.3 cm abdominal aortic aneurysm containing highly irregular mural thrombus in the early phase, with slow perfusion of the contrast medium in the arteries below the bifurcation during the delayed phase. After traumatic spinal injury was excluded, an emergent endovascular aneurysm repair was performed. Although vital signs were initially stable post-surgery, both lower limbs were still paralysed and did not improve. He then experienced reperfusion injury with metabolic acidosis. There was no urine output despite intravenous hydration. Laboratory data included potassium 7.7 mEq/L, lactate 110 mg/dL, white blood cells 23,700/uL, and myoglobin 46,590 ng/mL. Even under critical medical care and continuous venovenous hemofiltration, his hemodynamic status worsened. He developed hypotension and needed endotracheal intubation because of loss of consciousness and respiratory failure. The patient finally died due to ventricular tachycardia even after several rounds of cardiopulmonary resuscitation with cardioversion.ConclusionThe unusual clinical presentation of detectable lower limb pulses in advanced limb ischaemia showed that poor blood perfusion related to dislocation of mural thrombus in abdominal aortic aneurysm might mislead clinicians and delay accurate diagnosis and treatment.

Transmitral excision of primary left ventricular thrombi presenting with acute limb ischemia

A 54-year-old Caucasian woman with a history of type II diabetes mellitus and smoking was admitted to the hospital for evaluation of pain and weakness in her right leg. She was found to have diminished strength in the right lower extremity, complete loss of sensation extending from the right foot to the mid-calf, and no palpable dorsalis pedis or posterior tibial pulses. She had normal sensation and strength in the left lower extremity but was noted to have a weak dorsalis pedis pulse on the left.

P045 Octopus Toes?

Abstract Background/Aims Takotsubo cardiomyopathy is a relatively rare condition. Its name derives from the distinctive apical ballooning seen on cardiac angiography, which resembles the shape of takotsubo, a Japanese octopus trap. The clinical presentation is similar to acute coronary syndrome (ACS). Ischaemic ECG changes and elevated serum cardiac biomarkers are seen despite normal coronary artery angiography. Methods: History A 72-year-old female presented with a five-day history of constant bilateral foot pain and toe discolouration, associated with reduced sensation. She had a past history of hypertension and Raynaud’s phenomenon. She had recently been admitted with an alcohol withdrawal seizure and had recent severe stressful life events. She denied chest pain or dyspnoea and was a non-smoker. Her medications were ramipril and thiamine. Examination: Both feet were warm to touch proximal to the toes, with tenderness and diminished sensation in the distal feet. The toes were dusky but pedal pulses were palpable with good biphasic Doppler signal. Blood pressure was 117/105 mmHg on admission, with normal nail folds and heart sound, and no splinter haemorrhages were seen. Results: Investigations Blood parameters were CRP 60 mg/L, eGFR 47 mL/min, troponin &amp;gt;25,000 ng/L, and negative RF, ANA, ANCA, MPO, PR3, C3, C4. ECG showed lateral ST-segment elevation but normal coronary vessels were seen on coronary angiography. Echocardiogram revealed hypokinetic apical region and mid-anterior wall, reduced ejection fraction 35-40 % with apical ballooning, consistent with Takotsubo cardiomyopathy. Urine catecholamines, normetadrenaline, metadrenaline and 3-methoxytyramine levels were normal when measured eight days after the initial presentation. Management Daily Iloprost was given for five days with aspirin, furosemide, spironolactone and ivabradine, but no significant improvement was observed in the ischaemic feet. Her foot pain gradually subsided but the toes remained necrotic. Over the next six months, her toes mummified and auto-amputated. She has had no further ischaemic events. Conclusion Takotsubo cardiomyopathy accounts for 1-2% of troponin positive suspected ACS. It is most common in older females. The cause is not clear, but the predominant hypothesis is that a catecholamine surge leads to microvascular spasm and myocardial stunning. Raised catecholamine levels at presentation have been documented in patients with takotsubo cardiomyopathy, and the syndrome has been described in patients exposed to exogenous catecholamines. Digital ischaemia has been described in phaeochromocytoma. We postulate that our patient’s background of Raynaud’s phenomenon predisposed her to digital ischaemia during a period of catecholamine excess, which led to takotsubo cardiomyopathy. To our knowledge, this phenomenon has not previously been described. Given the profound effect of the presumed catecholamine surge on cardiac function in takotsubo cardiomyopathy and the high prevalence of Raynaud's phenomenon in the general population, it is perhaps surprising that ischaemia in digits and other organs is not more commonly observed. Disclosure K. Yeap: None. C. Badu-Boateng: None. M. Lloyd: None.

Clinical Outcomes of a Diagnostic and Management Protocol for Popliteal Artery Entrapment Syndrome at a Large Referral Center

Popliteal Artery Entrapment Syndrome (PAES) is a rare clinical entity without a standardized algorithm for diagnosis and treatment. The objective of this study was to evaluate the clinical outcomes of a unique diagnostic and management algorithm for patients with PAES managed at a quaternary referral center. We retrospectively reviewed patients diagnosed with PAES at a single institution between 2013 and 2021. Demographics, physical exam findings, noninvasive imaging results, and angiographic images were assessed to validate a diagnostic and management algorithm (Figure1). Surgical findings, operative technique, post-operative complications, and symptomatic improvement were assessed to validate this clinical algorithm. There were 35 extremities in 23 patients treated for PAES (Table I). The mean age was 28, and 82.6% of patients were female. Physical exam revealed a decrement in pedal pulse with provocative maneuvers in 90% of treated limbs. Noninvasive studies to include treadmill exercise testing revealed a mean Ankle-brachial indices (ABI) drop of 0.28 and positional duplex demonstrated that the mean peak systolic velocity (PSV) in the popliteal artery was 78cm/sec at rest which increased to 175cm/sec with provocation. Diagnostic arteriography was performed in all patients and revealed awell-developed geniculate and sural collaterals in 100% of the treated limbs and complete effacement of the popliteal artery with active provocative maneuvers in all treated limbs (Figure2). Surgical exposure was performed via a posterior approach and intraoperative completion duplex was performed in all cases. Type III PAES was discovered in 89% of cases. Arterial reconstruction was required in 2 patients who presented with an occluded popliteal artery. All but one patient was discharged on post-operative day one. Wound complications occurred in 4 limbs (3 patients) and included seroma and hypertrophic scarring. All patients experienced symptomatic relief with a median follow-up of 4months. We reported 100% technical and clinical success in patients with PAES diagnosed and managed using our clinical algorithm. Cross-sectional imaging is not necessary for the diagnosis. Dynamic angiography confirms the diagnosis and intraoperative duplex is essential for successful clinical outcome by confirming complete release of the popliteal artery.