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Chapter 24. Vascular

You are called to the emergency department for what is described as cellulitis and find a 78-year-old male with a history of diabetes, coronary artery disease, an irregular heart rate with an international normalized ratio (INR) of 1.1, and a tobacco abuse history of 2 packs per day for 60 years. He reports severe right foot pain started suddenly while he was watching television 3 hours before presenting at the emergency department, where he’s waited to be seen another 3 hours. On exam, his right foot is pale and cooler than the left with no palpable right dorsalis pedis or posterior tibial pulses and decreased sensation. What is the next step in your management?

A. STAT duplex ultrasound

B. Immediate heparin anticoagulation and admit to the floor

C. Heparin, immediate thromboembolectomy and fasciotomy

D. Routine arteriogram with possible lysis the following morning

E. Thromboembolectomy with heparin drip anticoagulation

This patient has acute arterial ischemia, likely secondary to embolization of cardiac etiology. Prompt heparin anticoagulation and surgical thromboembolectomy are key to management. Immediate arteriogram with possible lysis could also be considered, but treatment should not generally be delayed until the following day. Because you are evaluating this patient at least 6 hours after the embolic event, fasciotomy should be included in this patient’s management.

An obese 63-year-old male is admitted to the medical service for pneumonia with a history significant for diabetes, HTN, and end-stage renal disease on hemodialysis. You are consulted for nonhealing ulcers and asked to evaluate the patient for peripheral arterial bypass. On exam, you find him sitting in a chair with severely edematous legs and chronic bilateral shallow, nontender medial malleolar ulcers. Though difficult to examine, dorsalis pedis and posterior tibial pulses are palpable bilaterally. How should you explain to the patient and his medical team why arterial bypass is not indicated at this time?

A. Despite progression of his peripheral arterial disease to ulceration, his disease is not severe enough to warrant urgent revascularization

B. Peripheral arterial bypass is not indicated for venous disease

C. Pneumonia is an absolute contraindication to anesthesia and surgery

D. Because his ulcers are chronic, revascularization can be performed electively following appropriate cardiopulmonary optimization

E. His disease is too far progressed and requires bilateral amputation

The examination findings described in the question are consistent with venous ulcers having a typically nontender, moist, broad base over the medial malleolus associated with severe edema (can be pitting or nonpitting depending on chronicity ...

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