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Difficulty: HardSurgical and Procedural Interventions

A 64-year-old woman with a history of rheumatic mitral stenosis and atrial fibrillation presents to the emergency department reporting sudden, severe right leg pain that began 2 hours ago. She admits to running out of her prescribed anticoagulant medication three weeks ago. Vital signs include a blood pressure of 142/88 mm Hg142/88 \text{ mm Hg} and a heart rate of 112/min112/\text{min} with an irregularly irregular rhythm. Physical examination of the right lower extremity reveals a cold, pale leg with visible mottling. There is complete loss of light touch sensation over the dorsum of the foot, and the patient is unable to dorsiflex her toes. Palpation reveals a strong right femoral pulse, but popliteal, dorsalis pedis, and posterior tibial pulses are absent. Bedside continuous-wave Doppler ultrasound demonstrates absent arterial signals but audible venous signals in the right foot. Which of the following interventions are indicated in the immediate management of this patient? (Select all that apply)

  1. Initiate an intravenous infusion of unfractionated heparinAnswer
  2. Prepare the patient for urgent operative thromboembolectomyAnswer
  3. C
    Obtain a computed tomography angiography of the lower extremities
  4. D
    Schedule the patient for primary major limb amputation
  5. E
    Administer a loading dose of oral rivaroxaban

Answer

Initiate an intravenous infusion of unfractionated heparin AND Prepare the patient for urgent operative thromboembolectomy.
The correct interventions for an immediately threatened limb (Rutherford category IIb) due to acute arterial occlusion are systemic anticoagulation to halt thrombus propagation and emergent surgical revascularization to restore blood flow. The presence of motor weakness and sensory loss, combined with audible venous Doppler signals, confirms that the limb is salvageable but requires immediate operation rather than delayed imaging.

Step-by-Step Solution

1
Classify the severity of acute limb ischemia based on clinical findings.
The patient exhibits sensory loss, motor deficit (inability to dorsiflex), absent arterial Doppler signals, but present venous Doppler signals.
These findings define Rutherford category IIb (immediately threatened) ischemia.
2
Determine the necessity of initial pharmacologic stabilization.
Immediate systemic anticoagulation with intravenous unfractionated heparin is required.
Heparin prevents propagation of the clot and protects the collateral circulation while preparing for definitive therapy.
3
Select the appropriate definitive intervention.
Urgent surgical revascularization (such as open thromboembolectomy) is indicated.
A category IIb limb is immediately threatened and requires emergent restoration of blood flow without delaying for time-consuming advanced imaging.

Key Concept

Management of Rutherford category IIb (immediately threatened) acute limb ischemia requires simultaneous administration of intravenous unfractionated heparin and urgent surgical revascularization without delaying for advanced imaging.
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Topics

Surgical and Procedural Interventions

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