Case 32: Cold feet
You are called to see an 85 year old woman in coronary care who has cold feet. Her legs are weak and she has altered sensation. The neurology registrar has already seen her and an urgent MRI was performed. There is no evidence of spinal cord compression. You have arranged an urgent CT angiogram. Two adjacent slices and a coronal reconstruction are shown.
1. What does the CT show?
The scan has been performed during the arterial phase of contrast. There is an abrupt cessation of flow within the aorta above the bifurcation.
2. What is the likely cause for her cold feet?
A large thromboembolus from a cardiac source had lodged at the aortic bifurcation resulting in complete occlusion. Both legs had become acutely ischaemic.
3. What are the options for management?
To save this womans legs and life she needs urgent revascularization. The option of palliation may be appropriate in the patient who has other significant acute medical problems of a life threatening nature.
The initial approach is to perform bilateral groin exploration and proximal embolectomy. If this is unsuccessful the decision is made to proceed to open aorto-iliac embolectomy and possible aorto-bifemoral bypass. The third option which may be preferred in an unwell patient is axillary-bi-femoral bypass grafting.
The final step should be prophylactic calf fascitomies as she has had significant leg ischaemic time.