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A clinical case of managing a patient with popliteal artery occlusion with severe concomitant pathology.

Patient B, born in 1950 y.
The main diagnosis: ischemic heart disease: atherosclerotic cardiosclerosis. Atrial fibrillation, permanent form, tachysystolic variant. CHF IIA Art. with reduced systolic LV function (EF 42-49%). Hypertension grade III, degree of AH 3, risk 4. Mild PAH (P 30-37 mm Hg).
Postembolic occlusion of the popliteal artery of the only left lower limb. Amputation of the right thigh at the level of the middle third of 2015. Chronic arterial insufficiency of the left lower extremity 3 tbsp.
Concomitant diagnosis: Cerebral atherosclerosis. Class III encephalopathy, mixed type, subcompensation. Consequences of the postponed cerebral infarction (04.21.2016) by ischemic type with transformation into hemorrhagic type in the middle cerebral artery basin. Right-sided hemiplegia. Total Aphasia.

Untreated atrial fibrillation gathered in one person all the possible complications: heahrt failure with reduced ejection fraction; thrombosis of the left atrium with embolism in both lower extremities (one of them was amputated due to gangrene), the second must be urgently “saved”; embolism in the brain with the development of hemispheric stroke and disability of the patient (loss of speech, productive contact with others).

computed angiography: occlusion of the popliteal artery starting from the gunter’s channel

For a long time, the patient’s relatives could not guess the cause of the severe suffering of the patient, who was bedridden due to an amputated limb and the inability to explain the cause of suffering due to brain damage during stroke. He moaned and constantly flexed his only leg, bringing it to his chest. And in such a crumpled state he spent several weeks until signs of incipient gangrene began to appear. Before contacting us, the patient repeatedly turned to vascular surgeons for help. If the patient undergoes femoral-distal shunting, how to keep the shunt working Because the patient constantly brings the affected leg to the chest and the shunt can bend and thrombosed? It is impossible to explain to him the need to keep the leg in a straightened state, because Is there no productive contact with the patient?

extravasation of contrast when attempting to undergo popliteal artery occlusion

The first option to restore blood flow is an attempt of an endovascular balloning: to pass through the occlusion zone and expand with a balloon. But! The guidewire extends beyond the artery and the contrast agent is visible in the surrounding tissue.

An attempt to go from top to bottom again unsuccessful
An attempt to go from bottom to top – again unsuccessful

Femoral-popliteal bypass – the last option for solving the problem.

Postoperative computed angiography. Functioning femoral-popliteal bypass.

In the postoperative period, the patient was placed with splints to immobilize the limb in order to avoid involuntary flexion in the knee joint. Finaly? the patient was discharged with a saved limb.