Vascular Case

Presentation

Patient Demographics

Mr JK

75 years old

Male

Caucasian

Diagnosis and proposed surgery

Peripheral Vascular disease (Right lower limb critical Ischaemia)

For Right Femoral-popliteal artery bypass surgery

History 1

Main complaint:

Ulceration (Tissue Loss) :

Right foot toe tips and sole

4 months history

Spontaneous onset (no antecedent trauma)

Lower limb pain

Pain:

Initially intermittent claudication Progressed to Rest Pain

over 1-2 year period

Medical history

Hypertensive on Mx

Previous stroke 10 years ago

Right Hemiparesis (Normal CT Brain: No further workup. NB Nil Hx of Carotid dis or AF)

Complete sensory and motor recovery

No significant Past Family History

History 2

Medication

Enalapril, 10mg, BD

Aspirin, 150mg, daily

Simvastatin, 40mg, nocte

Paracetamol, 1g, 6 hourly

Tramadol, 50mg, TDS

Previous surgery and Anaesthetic history

Neck surgery for excision of posterior neck growth, under general anaesthetic

Right hip replacement 2015 Spinal anaesthesia

Smoker 25 pack years

Occasional alcohol consumption

Ex-miner many decades

No family history of heart disease/CVS diseases/Dyslipidaemia

Examination findings

Bp:140/70mmHg Pulse: 80bpm regular, RR:18bpm T: 37

Cardiovascular

Soft heart sounds, no additional sounds,

Nil features of CCF (no raised JVP, pedal oedema, orthopnoea nor any PND), No AAA clinically

Absent popliteal and pedal pulses bilaterally

Lower extremities dry but warm to touch

Dry ulcers right foot

Respiratory

Airway

Beard, Dentures, Adequate neck extension and flexion, Mallapati II

Functional status = < 4 Mets

No obvious deformities, lung fields clear to auscultation

Mobility limited by Pain > SOB

Other systems No significant findings

Special Investigations

Na: 140, K: 3.0, Cl:95, CO2 : 22, Urea: 5.6, Creatinine: 72

WCC: 8.82, Hb: 11.8, Platelets: 336

Ca: 2.36, Mg: 0.97, Ph: 0.65

TSH: 0.74, HbA1C: 6.9

Normal lipogram (HDL: 0.61, Trig: 0.77, LDL: 1.09, Chol: 2.05)

Normal Spirometry: FEV1/FVC: 79, FEV1: 76, FVC : 104

ECG: sinus rhythm, Normal: conduction intervals, QRS, ST segments and T

waves and axis

Assessment/Summary

75 year old male

Peripheral Vascular Disease

Critical Limb Ischaemia

Fem pop atherosclerotic diseases

Risks:

Previous stroke

Poor functional status (Pain and SOB)

Planned for Bypass revascularization surgery

Intermediate risk Procedure

Anaesthetic Plan

Further Investigation

None required: Reasons

Unlikely to change perioperative

management
Urgent nature of procedure

Consent

Obtained for Neuraxial

Anaesthesia and General
Anaesthesia

Possible Optimization

Correct hypokalaemia

Blood on standby

Premedication

Feeds

Continue Chronic medication

Intra-operative management

Anaesthetic goals: Maintain:

Cardiac output, organ perfusion
and Haemostasis, maintain
optimal surgical conditions

IVI access: 2 18G peripheral lines

Monitors (standard ASA): ECG,

SpO2, NIBP, Temperature

Arterial line

Anaesthetic plan

Technique:

Neuraxial Anaesthesia with sedation

Bupivacaine 14mg and fentanyl 10ug (3ml intrathecal)

Precedex infusion

Adjuncts: Kefzol, 2g, ivi, Dexamethasone, 8mg, ivi

Maintenance

Spontaneous ventilation with supplementary oxygen

Goal directed fluid therapy

Forced air warmer

Hourly arterial blood gasses

Anticipated complications

Blood loss

Conversion to GA

Vein Mapping

The 1-year patency rates of vein conduit in the infrapopliteal

position reach 70-80%, whereas those of prosthetic grafts reach
30-50% at best.

Predictors of time to graft failure following infrainguinal arterial

reconstruction

Post-operative complication, female gender and a high asa grade