Dr. Nadal: 89 Year Old Female
Featured Case Overview
The patient is a 89 year old female who presents with risk factors for peripheral vascular disease that include hypertension, hyperlipidemia, prior smoking history and advanced age. She presented to clinic for evaluation of a slow healing wound on her right medial calf, and right heel (Rutherford 4 ). She had undergone a total right knee arthroplasty which subsequently became infected, and then under went revision with Incision and drainage of the site, muscle flap reconstruction, and skin grafting.
The pulse exam revealed normal common femoral artery pulse bilaterally (2+) and non-palpable weakly dopplerable distal dorsalis pedis and posterior tibial arteries bilaterally.
The duplex ultrasound revealed triphasic wave forms of the common femoral arteries bilaterally with velocities in the normal range right 106 (cm/sec), left 87 (cm/sec). The right superficial femoral artery was triphasic proximally with a significant decrease in velocity (41 cm/sec), with no flow visualized in the right mid superficial femoral artery, and flow within the distal right superficial femoral artery with significantly diminished flow ( 15 cm/sec). The right popliteal artery and right anterior tibial arteries demonstrated monophasic wave forms with slightly decreased velocities (pop 50-70 cm/sec and AT 35-40 cm/sec). The right posterior tibial artery did not demonstrate any flow in the proximal and mid segments, with reconstitution of the distal right posterior tibial artery (monophasic 28 cm/sec). The entire left lower extremity demonstrated monophasic wave forms with diminished velocities in the left superficial femoral artery ( 50 cm/sec-20 cm/sec) and left popliteal and left tibial arteries velocities within the noral ranges despite being monophasic.
Toe brachial indices for the right was 0.12 and for the left was 0.38.
Wounds at Presentation
Case Outcome and Wound Progression
In summary, occluded right proximal/mid superficial femoral artery as well as occluded proximal to mid right posterior tibilal artery. Patent but moderately diseased left superficial femoral artery with patent left tibial run-off. Direct in-line flow established via previously occluded proximal and mid right superficial femoral artery and occluded proximal and mid right posterior tibial artery, completing the pedal loop. Resulting in a TBI of 0.64 which was previously 0.12.
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