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๐๐ฐ๐๐๐ฒ-๐ผ๐ป-๐๐ต๐ฟ๐ผ๐ป๐ถ๐ฐ ๐๐ถ๐บ๐ฏ ๐๐๐ฐ๐ต๐ฒ๐บ๐ถ๐ฎ ๐๐ฟ๐ผ๐บ ๐ฎ ๐ฃ๐ฟ๐ผ๐ฏ๐ฎ๐ฏ๐น๐ฒ ๐ ๐ถ๐๐๐ฒ๐ฑ ๐ง๐ฟ๐ฎ๐๐บ๐ฎ๐๐ถ๐ฐ ๐ฆ๐๐ฝ๐ฒ๐ฟ๐ณ๐ถ๐ฐ๐ถ๐ฎ๐น ๐๐ฒ๐บ๐ผ๐ฟ๐ฎ๐น ๐๐ฟ๐๐ฒ๐ฟ๐ ๐๐ป๐ท๐๐ฟ๐
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A 65-year-old lady presented with a three-month history of progressively worsening right lower limb claudication, which had progressed to rest pain and significant functional limitation.
Clinical examination revealed a palpable femoral pulse but absent popliteal and distal pulses. There was evidence of distal embolization with ischemic changes involving the toes.
An important clue emerged during detailed history taking.
Several years previously, the patient had sustained a traumatic laceration to the medial aspect of the right thigh. The wound had been sutured at the time and apparently healed uneventfully. However, no records were available regarding vascular assessment, and the patient was unable to recall whether distal pulses had been documented following the injury.
In retrospect, this raised suspicion of a previously unrecognized vascular injury with delayed progression to symptomatic arterial occlusion.
Cardiac evaluation, including echocardiography, demonstrated no potential embolic source.
There was no evidence of abdominal aortic aneurysm or proximal arterial pathology.
Duplex ultrasonography demonstrated a short-segment occlusion of the distal superficial femoral artery at the level of the previous thigh scar.
Importantly, the artery proximal and distal to the lesion appeared otherwise relatively normal, and a good quality ipsilateral great saphenous vein was available.
The working diagnosis was acute-on-chronic limb ischemia secondary to thrombosis of a chronic distal superficial femoral artery lesion, most likely related to previous traumatic arterial injury with subsequent distal embolization.
The patient was commenced on therapeutic low molecular weight heparin.
Although symptoms improved partially, significant ischemic symptoms persisted and operative intervention was undertaken.
Surgery was performed under combined spinal-epidural anesthesia.
The popliteal artery appeared macroscopically normal with no significant atherosclerotic disease.
Distal embolectomy was performed to clear embolic material and establish satisfactory distal outflow. No embolus or significant residual distal obstruction was identified.
Attempts to pass a Fogarty catheter proximally through the popliteal artery were unsuccessful due to the distal superficial femoral artery occlusion.
The superficial femoral artery was then explored proximal to the occluded segment. The proximal vessel demonstrated healthy inflow and a macroscopically normal lumen.
Given the localized nature of the disease, a short bypass was constructed using ipsilateral reversed great saphenous vein.
Following completion of the bypass, excellent distal pulses were restored with immediate improvement in limb perfusion.
The patient made an uncomplicated recovery with significant improvement in rest pain and ischemic symptoms.
Because of the evidence of distal embolization, anticoagulation was continued during the postoperative period to minimize the risk of further thromboembolic complications.
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๐๐ฒ๐ ๐๐ฒ๐ฎ๐ฟ๐ป๐ถ๐ป๐ด ๐ฃ๐ผ๐ถ๐ป๐๐
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A detailed history often provides the most important diagnostic clue.
Seemingly minor penetrating or blunt limb trauma may result in occult arterial injury that presents years later.
Intimal injury can remain clinically silent for prolonged periods before progressing to thrombosis or embolization.
A palpable femoral pulse does not exclude significant distal arterial occlusive disease.
Duplex ultrasonography remains an excellent first-line investigation for lesion localization, conduit mapping, and operative planning.
Before diagnosing arterial embolism, proximal embolic sources such as the heart and aorta should be excluded.
Distal embolectomy helps establish satisfactory outflow and removes potentially limb-threatening distal embolic material.
In localized arterial disease, a short autogenous vein bypass can provide excellent patency and durable limb salvage.
Appropriate perioperative anticoagulation may reduce the risk of recurrent thrombosis and distal embolization.
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๐๐๐ฌ ๐ ๐๐ฆ๐ฆ๐๐๐
The most important investigation in this case was not the duplex scanโit was the history. A forgotten thigh injury years earlier provided the clue to a chronic arterial injury that eventually presented as limb-threatening ischemia.
This case serves as a reminder that vascular trauma may not always declare itself immediately. Delayed consequences of missed intimal injuries can present years later, and successful treatment depends on combining careful history taking, thoughtful investigation, and precise surgical reconstruction.
Patient identity protected. Images shared for educational purposes with appropriate consent.
