All Hands on Deck: The Team Approach · Failed attempt to vascularize the occluded superficial femoral popliteal artery in ... Endo then Open. Minor amputations Amputation of the

Kara S. Couch, MS, CRNP, CWCN-APJames McKee DPMMary Haddow RN, CWCN

All Hands on Deck: The Team Approach

• 74 yo DM, PAD, smoker, presented with 1 month h/o ulcers to LE’s, “my leg blew up 3 days ago”

• Severe edema

• DM

• Smoker

• Bilateral LE infection, worse on the left

Arterial Study

Right lower extremity:

Inflow arterial disease cannot be ruled out. Proximal and mid SFA occluded. DPA not visualized.

Left lower extremity:

Mid SFA is occluded, reconstitute distally then re-occludes at the left popliteal artery. Possible occlusion of the left DPA and peroneal artery.

Debridement

Multiple bilateral lower extremity infected ulcers

Debridement of multiple bilateral lower extremity ulcers with cultures

OR- Deep Tissue Culture

• MRSA susceptible to doxy, Bactrim, vanco

• Providencia rettgeri- multi-drug sensitive (Bactrim)

• Acinetobacter junii multidrug sensitive (Cipro)

ID CONSULTEDIV Antibiotics

Angiogram Revascularization

Occlusion of the right superficial femoral artery reconstitution into a small popliteal artery. Occlusion of the left superficial femoral, popliteal, proximal, anterior tibial, peroneal and posterior tibial arteries. Posterior tibial and anterior tibialartery continues down to the foot. RECOMMENDATION: The patient will need possibly distal approach for possible angiogram or type as versus amputation.

Debridement

Revascularization

Failed attempt to vascularize the occluded superficial femoral popliteal artery in endovascular technique

Left common femoral to anterior tibial artery bypass with nonreversed greater saphenous vein

Debridement

RevascularizationEndo then Open

Minor amputations

Amputation of the first and second left toe as well an incision and debridement of skin and subcutaneous tissue, muscle and fascia of the left lower extremity

PT/PT: Offloading, diabetic shoes

Debridement

RevascularizationEndo then Open

Minor amputation

Orthotist consult

More Debridement and right revascularization

Right common femoral to right popliteal below-knee artery bypass with cadaveric reverse greater saphenous vein.

Debridement of right big toe ulcer with further amputation of the toe. 3. Debridement of left leg ulcers with jet lavage

Debridement

RevascularizationEndo then Open

Minor amputation

Orthotist consult

Right RevascularizationMore debirdement

Infection management by host factor modification

• VAC- largest ulcers

• Leg elevation- held compression r/t recent bypass

• RD eval in outpatient clinic

• Smoking cessation- PCP involvement

• Orthotist involved at outpt visits

• CDE for glucose control- at outpt visits

• Was on po doxycycline after 4 weeks of Vanco/Cipro

1. Arterial work up2. Revascularization3. Debridement with ID consult- abx4. Optimize edema management within confines of recent bypass5. DM control with diabetic education involvement6. Orhtotist involvement7. Eventual STSG8. Ulcers remains closed today, pt ambulatory