1. A Tale of Two Vessels
Dr Deirdre Hussey

2. Case Mrs MW 58yrs old presented to A/E with:
Severe back pain, unable to mobilise
Severe pain in dorsum of right foot, constant
Similar pain left foot (not as severe)
Discoloured right big toe
Severe pain from ulcers on right hip and buttock (had been bed bound for preceding 4 weeks as a result of severe lower limb and back pain)

3. Case Background History: Hypertension Hypercholesterolaemia COPD
Smoker 20-30/day
Meds:
Plavix, Coversyl, Lipitor, Ventolin PRN
NKDA
Soc Hx:
Married with 5 children, smoker, C2H5OH- nil
ROS- as above, nil CVS/Resp/GI

4. Case Vital Signs: BP 150/90 HR 85 bpm SR RR 18 Afebrile Sats 96% on RA
General:
Pt in obvious discomfort, pale and lying on her left side
CVS: NAD
Respiratory:
breath sounds mildly decreased bibasally.
Abdomen:
Soft, non tender
Firm mass above Pfannenstiehl incision (prev documented fibroids)
Bowel sounds present, normal

5. Case Lower Limbs: Both limbs were pale Temperature normal bilat
Absent pulses from femoral-distal bilaterally

6. Case Routine Investigations: CBC: Hb 10.7g/dL, Plts 594, WCC 9.61
U/E: urea 4.0, creat 33, Na 138, K 4.1
LFT’s: Bili 5, Alk Phos 160, ALT 32
ESR 64, CRP 50
CXR: NAD

7. Case ABI’s: Right 0.15 Left 0.09 Echocardiogram (TTE):
EF 60%, no evidence of endocarditis/valve disease
Vasculitis Screen:
Negative
Thrombophilia Screen

8. Case
MRA:
Total occlusion of aorta below renals, reconstitution at level of CFA bilat

9. Case Axillary-bifem bypass
Bolus of heparin given intra-op and continued post op (target APTT 60-80)
Post op day 1 pt began c/o very severe right leg pain
Limb pale and pulseless on examination

10. Case
Right groin exploration and thromboembolectomy

11. Case Patient began c/o: Severe bilat calf and foot pain
Absent pulses in below femoral bilat
Both limbs pale and cold

12. Case Return to theatre on call:
(1)Bilat groin explorations and thromboembolectomies
(2) Right below knee popliteal and tibial embolectomy
(3) Right medial and lat fasciotomies

13. Case Pt developed ARDS post op and was t/f to ITU MODS/ SIRS
CT showing ARDS

14. Case
Closure of fasciotomies and debridement of sloughy right groin wound
Theatre specimen + growth of Klebsiella and Ecoli
Commenced on Aztreonam and Vancomycin (allergy)
3/12 of Ofloxacin to cover against possible graft infection
Vac dressing x 2/52 to right groin
Plastics consult - pedicled TFL flap to right groin

15. Case Pt discharged on warfarin
Mobilising with Zimmer frame on discharge
Reviewed at OPD Oct 09 walking independently
Repeat ABI’s:
Right 0.36
Left 0.69

16. Discussion Axillary-Bifem bypass: 1962 Blatsdell, Hall and Louw
Diffuse Aortoiliac disease
Aortobifem bypass is contraindicated

17. Discussion Martin and Katz-Am Journal of Surgery Aug 2000
All Ax-fem bypasses , 60 patients:
13 presented with claudication
10 with evidence of gangrene
7 with nonhealing ulceration
30 with symptoms of rest pain

18. Discussion Morbidity rate of 6.5%
Ten patients developed graft occlusions at a mean interval of 6.5 months.
Other complications: graft infection, pseudoaneurysm, subclavian stenosis
Patency rates of 88% at 1 year, 79% at 3 years, and 69% at 5 years

19. Teaching Points General Operative Complications
Bypass Surgery Complications
Outline of Management Options of above complications
Multidisciplinary approach