# Clinical Cases: Vascular Surgery

## Case 1: Acute Limb Ischemia

### Patient Demographics
- **Age:** 72 years
- **Sex:** Male
- **Occupation:** Retired banker

### Chief Complaint
"My left leg suddenly became cold and painful 4 hours ago."

### History of Present Illness
The patient reports sudden onset of severe left leg pain that began 4 hours ago while watching television. The pain started in his calf and rapidly progressed to involve his entire leg. He noticed his leg became pale and cold. He is unable to move his toes. He has no history of claudication or peripheral vascular disease. He does have a history of atrial fibrillation and admits to being non-compliant with his anticoagulation.

### Past Medical History
- Atrial fibrillation (diagnosed 2 years ago)
- Hypertension
- Type 2 diabetes
- On warfarin but INR frequently sub-therapeutic (non-compliance)

### Medications
- Warfarin (non-compliant)
- Metoprolol 50 mg BID
- Lisinopril 20 mg daily
- Metformin 1000 mg BID

### Physical Examination
- **Vitals:** BP 148/92, HR 88 (irregular), RR 18, Temp 36.8°C
- **Cardiac:** Irregularly irregular rhythm
- **Left lower extremity:**
  - Pale, cool to touch from mid-thigh distally
  - No palpable pulses (femoral weak, popliteal/DP/PT absent)
  - Absent ankle-brachial index (not measurable)
  - Decreased sensation below knee
  - Unable to wiggle toes (paralysis)
  - No muscle tenderness on palpation (yet)
- **Right lower extremity:** Normal pulses, warm, normal sensation

### The Six P's of Acute Limb Ischemia
1. **Pain:** Severe, sudden onset ✓
2. **Pallor:** Pale leg ✓
3. **Pulselessness:** Absent distal pulses ✓
4. **Paresthesias:** Decreased sensation ✓
5. **Paralysis:** Cannot move toes ✓
6. **Poikilothermia:** Cold leg ✓

### Rutherford Classification
**Class IIb - Threatened (marginally salvageable)**
- Sensory loss beyond toes
- Mild-moderate motor deficit
- Requires urgent revascularization

### Laboratory Results
- INR: 1.3 (sub-therapeutic)
- Creatinine: 1.2 mg/dL
- CK: 340 U/L (mildly elevated)
- Lactate: 2.8 mmol/L
- Hemoglobin: 13.4 g/dL
- ECG: Atrial fibrillation with controlled rate

### Imaging

**CT Angiography (rapid):**
- Filling defect in left common femoral artery
- No flow beyond proximal superficial femoral artery
- Embolic occlusion pattern (abrupt cutoff, no collaterals)
- No significant atherosclerotic disease
- Right leg: Patent arterial tree

### Diagnosis
Acute limb ischemia, Rutherford Class IIb, likely cardioembolic (atrial fibrillation)

### Management
Given Class IIb limb ischemia (threatened but salvageable):
- **Immediate heparinization:** IV heparin bolus + infusion
- **Urgent surgical revascularization**
- Time is critical: "Time is tissue"

### Operative Procedure
**Emergency surgical embolectomy:**
- General anesthesia
- Groin incision, exposure of common femoral artery
- Longitudinal arteriotomy
- Passage of 4F and 3F Fogarty balloon catheters
- Extraction of organized thrombus from SFA and popliteal
- Excellent back-bleeding and in-flow established
- Completion angiogram: Restored flow to tibial vessels
- Arteriotomy closure
- Fasciotomies NOT performed (reperfusion time <6 hours, no compartment syndrome)

### Postoperative Management
- Heparin continued, transitioned to warfarin
- Monitor for reperfusion injury
- Serial CK levels (peaked at 2,400 U/L, trended down)
- Urine output monitored (myoglobin clearance)
- Foot elevated, warm

### Postoperative Course
- Leg warm, pink, pulses palpable
- Sensation returning
- Motor function improving
- No compartment syndrome
- Discharged POD 4 on warfarin (goal INR 2-3)

### Long-term Management
- Lifelong anticoagulation for atrial fibrillation
- Cardiology follow-up
- Patient education on medication compliance
- INR monitoring clinic enrollment

### Teaching Points
1. Acute limb ischemia is a vascular emergency
2. "Six P's" for clinical diagnosis
3. Rutherford classification guides management urgency
4. Embolism (cardiac source) vs. thrombosis (atherosclerotic) have different implications
5. Immediate anticoagulation with heparin
6. Revascularization method depends on etiology and presentation
7. Monitor for reperfusion injury and compartment syndrome

### Clinical Image
![CT Angiography Acute Limb Ischemia](case_01_image.jpg)

**Image Description:** CT angiography demonstrating acute arterial occlusion of the superficial femoral artery. The abrupt cutoff of contrast with minimal collateral formation is characteristic of an acute embolic event.

**Attribution:** Image from Wikimedia Commons, Category:Computed tomography angiography. Source: https://commons.wikimedia.org/wiki/Category:Computed_tomography_angiography

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## Case 2: Abdominal Aortic Aneurysm

### Patient Demographics
- **Age:** 68 years
- **Sex:** Male
- **Occupation:** Retired truck driver

### Chief Complaint
"My doctor found an enlarged blood vessel in my belly on an ultrasound."

### History of Present Illness
The patient underwent an abdominal ultrasound for unrelated kidney symptoms, which incidentally revealed an abdominal aortic aneurysm. He is asymptomatic from a vascular standpoint - no abdominal pain, no back pain, and no symptoms of rupture. He has a history of smoking and was previously told he had "hardening of the arteries."

### Past Medical History
- Hypertension (20 years)
- Hyperlipidemia
- COPD (mild, on inhalers)
- Coronary artery disease (MI 5 years ago, medically managed)
- Peripheral artery disease (claudication at 2 blocks)
- Former smoker (60 pack-years, quit 3 years ago)

### Family History
- Father died of "burst aorta" at age 65
- Brother has AAA under surveillance

### Medications
- Aspirin 81 mg daily
- Atorvastatin 80 mg daily
- Lisinopril 20 mg daily
- Metoprolol 50 mg BID
- Albuterol inhaler PRN

### Physical Examination
- **Vitals:** BP 148/82, HR 68, BMI 28
- **Cardiovascular:** Regular rhythm, no murmurs
- **Abdomen:** Pulsatile mass palpated in periumbilical region, non-tender
- **Lower extremities:** Diminished but palpable pulses bilaterally, no ulcers

### Initial Imaging

**Screening Ultrasound:**
- Infrarenal AAA: 5.2 cm maximum diameter

### Additional Imaging for Surgical Planning

**CT Angiography (Abdomen and Pelvis):**
- Infrarenal AAA: 5.4 cm maximum diameter
- Adequate infrarenal neck: 2.0 cm length, 24 mm diameter
- Neck angle: 30 degrees
- Minimal thrombus in aneurysm sac
- Iliac arteries: Common iliacs 1.4 cm bilaterally (ectatic but not aneurysmal)
- No iliac occlusive disease
- Suitable anatomy for endovascular repair (EVAR)

### Risk Stratification for Rupture
- **Size:** 5.4 cm (threshold for repair typically 5.5 cm in men)
- **Growth rate:** Unknown (first detection)
- **Risk factors:** Male, smoker, family history, hypertension
- **Estimated annual rupture risk:** 3-5%

### Society Guidelines
- Repair recommended for:
  - AAA ≥5.5 cm in men, ≥5.0 cm in women
  - Rapid growth (>0.5 cm in 6 months)
  - Symptomatic AAA (any size)
- This patient: 5.4 cm - close to threshold

### Multidisciplinary Discussion
Given:
- Size approaching repair threshold
- Strong family history of rupture
- Suitable EVAR anatomy
- Patient preference after discussion

**Decision:** Proceed with elective EVAR

### Preoperative Optimization
- Cardiology clearance (stress test negative for ischemia)
- Pulmonary function testing (moderate COPD, optimized)
- Smoking cessation maintained
- Blood pressure optimization

### Operative Procedure
**Endovascular Aneurysm Repair (EVAR):**
- Bilateral femoral artery cutdowns
- Bifurcated modular stent graft deployed
- Main body: Infrarenal fixation
- Bilateral iliac limbs placed
- Completion angiogram: No endoleak, excellent positioning
- Aneurysm sac excluded

### Postoperative Course
- Monitored overnight in step-down unit
- Pedal pulses intact
- No groin complications
- Discharged POD 1

### Surveillance Protocol
- CT angiography at 1 month, 6 months, then annually
- Monitor for:
  - Endoleak (persistent blood flow into aneurysm sac)
  - Sac expansion
  - Graft migration
  - Limb occlusion

### 1-Month CT Follow-up
- No endoleak
- Aneurysm sac stable
- Graft in good position

### Teaching Points
1. AAA often asymptomatic - screening important in high-risk patients
2. US Preventive Services Task Force recommends one-time screening for men 65-75 who have ever smoked
3. Size is primary determinant of rupture risk
4. EVAR vs. open repair: Similar long-term outcomes, EVAR has lower perioperative mortality but requires lifelong surveillance
5. Anatomic suitability determines EVAR candidacy
6. Medical optimization essential (statins, blood pressure, smoking cessation)
7. Family history increases risk and may lower treatment threshold

### Clinical Image
![Abdominal Aortic Aneurysm CT](case_02_image.jpg)

**Image Description:** CT angiography demonstrating an infrarenal abdominal aortic aneurysm with mural thrombus. The maximum diameter exceeds 5 cm, approaching the threshold for elective repair. Note the relationship to the renal arteries and iliac bifurcation.

**Attribution:** Image from Wikimedia Commons, Category:CT images of abdominal aortic aneurysms. Source: https://commons.wikimedia.org/wiki/Category:CT_images_of_abdominal_aortic_aneurysms

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## Case 3: Carotid Artery Stenosis

### Patient Demographics
- **Age:** 71 years
- **Sex:** Male
- **Occupation:** Retired professor

### Chief Complaint
"I had an episode where I couldn't see out of my right eye for a few minutes."

### History of Present Illness
The patient experienced sudden onset of complete vision loss in his right eye 3 days ago. He describes it as "a curtain coming down" over his vision. The episode lasted approximately 5-8 minutes, then resolved completely. He felt well otherwise during and after the episode. He has no residual visual symptoms. He presented to his ophthalmologist who noted normal exam and referred him for carotid evaluation. He denies weakness, numbness, speech difficulty, or other neurological symptoms.

### Past Medical History
- Hypertension
- Hyperlipidemia
- Type 2 diabetes
- Coronary artery disease (2-vessel disease, medically managed)
- Former smoker (40 pack-years, quit 10 years ago)

### Medications
- Aspirin 81 mg daily
- Atorvastatin 80 mg daily
- Metoprolol 50 mg daily
- Lisinopril 20 mg daily
- Metformin 1000 mg BID

### Physical Examination
- **Vitals:** BP 138/82, HR 66
- **Neurological exam:** Completely normal, no deficits
- **Eyes:** Visual acuity normal, fundoscopy - possible cholesterol embolus (Hollenhorst plaque) in right retinal artery
- **Neck:** Right carotid bruit present
- **Cardiac:** Regular rhythm, no murmurs

### Diagnosis
**Amaurosis fugax** (transient monocular vision loss) - a form of transient ischemic attack (TIA) suggesting embolic source from right internal carotid artery

### Imaging Workup

**Carotid Duplex Ultrasound:**
- Right internal carotid artery: 80-90% stenosis
- Left internal carotid artery: 40% stenosis
- Bilateral atherosclerotic plaque

**CT Angiography (Head and Neck):**
- Confirms right ICA stenosis: 85% (NASCET criteria)
- Ulcerated plaque
- Left ICA: 40% stenosis
- Intracranial vessels: No significant stenosis
- No evidence of acute infarct

**MRI Brain:**
- No acute infarct
- Small chronic lacunar infarcts (microvascular disease)
- No large territory deficits

### Risk Assessment
- **Symptomatic** carotid stenosis (recent amaurosis fugax)
- **High-grade** stenosis (85%)
- **Stroke risk without intervention:** 20-26% at 2 years (NASCET data)
- Strong indication for revascularization

### Treatment Options
1. **Carotid endarterectomy (CEA):** Gold standard for symptomatic stenosis
2. **Carotid artery stenting (CAS):** Alternative, especially if high surgical risk
3. **Medical therapy alone:** For patients with prohibitive surgical risk

### Preoperative Assessment
- Cardiology clearance (acceptable risk for CEA)
- No significant contralateral carotid disease that would affect clamping
- Good surgical anatomy

### Decision
Carotid endarterectomy (CEA) chosen - standard of care for symptomatic high-grade stenosis with acceptable surgical risk

### Operative Procedure
**Right Carotid Endarterectomy:**
- General anesthesia with EEG monitoring
- Longitudinal arteriotomy from common carotid to ICA beyond plaque
- Shunt NOT required (adequate collateral flow)
- Complete endarterectomy with eversion technique
- Primary closure (no patch required given adequate vessel size)
- Completion duplex: Widely patent, no residual disease

### Pathology
- Atherosclerotic plaque with ulceration and intraplaque hemorrhage
- High-risk features for embolization

### Postoperative Course
- Neuro checks every 2 hours x 24 hours
- Blood pressure strictly controlled (avoid hyperperfusion syndrome)
- No neurological deficits
- Discharged POD 2

### Post-Procedure Management
- Continue aspirin indefinitely
- High-intensity statin therapy
- Blood pressure optimization
- Diabetes management
- Surveillance duplex at 1 month, 6 months, then annually

### Teaching Points
1. Amaurosis fugax (transient monocular blindness) is a TIA and warrants urgent evaluation
2. Symptomatic carotid stenosis >70% benefits from revascularization (NASCET trial)
3. CEA should be performed within 2 weeks of symptoms for maximum benefit
4. Hollenhorst plaques = cholesterol emboli from carotid plaque
5. Medical therapy alone (aspirin + statin + BP control) is adjunct, not replacement for intervention in symptomatic high-grade stenosis
6. Complications of CEA: Stroke, cranial nerve injury, MI, hyperperfusion syndrome

### Clinical Image
![Carotid Stenosis Ultrasound](case_03_image.jpg)

**Image Description:** Carotid duplex ultrasound with Doppler demonstrating high-grade stenosis of the internal carotid artery. The elevated peak systolic velocity and turbulent flow pattern are consistent with significant narrowing exceeding 70%.

**Attribution:** Image from Wikimedia Commons, Category:Ultrasound images. Source: https://commons.wikimedia.org/wiki/Category:Ultrasound_images