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Emergency pedal bypass in a 30-year-old patient with thrombophylia and acute ischemia of the lower leg due to thrombosis of the superifical femoral artery aneurysm

Aim: To present a case of a young patient with thrombophylia and a thrombosed aneurysm of the superficial femoral artery leading to acute lower leg ischemia. Method: Case-report Result: A 30-year-old overweight patient was examined in the emergency department for acute onset of pain and paresthesia in his left foot which was cold and pale. Arterial pulse was palpable in the groin with absent distal pulses (contralateral leg had normal arterial pulsations in the dorsal pedal artery). The patient was treated for deep venous thrombosis 10 years ago and 3 months ago, and was taking 7, 5 mg of warfarin/day. No haematologic work-up was done. Emergency doppler and CT angiography showed acute occlusion of the distal segment of the superficial femoral artery (SFA) and suggested an encompasing hematoma. During exporation, a thrombosed aneurysm of the distal SFA was found. Exploration of the 3rd segment of the popliteal artery (PA) revealed chronic occlusion of the PA and of all three major branches. Exploration at the distal leg level revealed occluded anterior tibial artery so the posterior tibial artery (PTA) at the medial malleolus level was dissected, and found patent with inner diameter of 1.5 mm. Since only half of the VSM length was suitable for graft (due to varicosities), a composite Dacron-VSM graft bypass was constructed from SFA to PTA with formation of an AV fistula with concomitant vein at the distal anastomosis under magnification. Two-hours postoperatively lower leg fasciotomy was done because of compartment syndrome. Control CT angiography 10 days postoperatively confirmed bypass patency. Fasciotomy wounds were covered with split-thickness skin grafts. Hematologic work-up confirmed prothrombin gene FIl 20210A mutation. The patient was treated with heparin perioperatively, LMWH postoperatively, and continued oral anticoagulation medication on discharge. Conclusion: Acute ischemia of the lower limb is uncommon in younger patient, and is mostly caused by vascular injury. Unrecognized thrombophylia may lead to chronic occlusion of the crural arteries neccesitating an emergency distal leg/pedal bypass procedure.

acute ischemia ; femoral artery aneurysm ; thrombosis ; thrombophylia ; pedal bypass

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