Severe Stenosis or Occlusion of Femoral and Popliteal Arteries in Elderly

Severe stenosis or occlusion of the femoral artery and popliteal artery?

Hello Doctor, my mother is 90 years old and accidentally fell while walking.
She has been lying in bed for some time now and is currently experiencing coolness and pain in her lower limbs for the past 50 hours.
During this period, she has had intermittent fever, with a maximum temperature of 37.6°C.
We have consulted two well-known hospitals, and both performed an ultrasound of the left lower limb arteries, which showed severe stenosis or occlusion of the left femoral and popliteal arteries.
One hospital recommended surgery, while the other leaned towards conservative treatment.
Given her advanced age, I am unsure what would be best for her.
I would greatly appreciate your advice.
Thank you very much.
My mother's other test results are as follows:
- Cardiac injury markers: Myoglobin 295.99 ng/ml, Creatine Kinase 12615.0 IU/L↑, Creatine Kinase MB isoenzyme: 152.3 IU/L↑, D-dimer 1.4 mg/L;
- Urinalysis and sediment examination: Urine protein 1+, Urine ketones 1+, Urine urobilinogen 1+;
- Complete blood count (five-part differential): White blood cells: 8.49 × 10^9/L; Neutrophil percentage: 83.0%↑; Red blood cells 4.55 × 10^12/L; Hemoglobin 141 g/L; Platelets 187 × 10^9/L;
- Biochemical panel (12 items): Potassium 3.32 mmol/L↓; Aspartate aminotransferase 150.7 IU/L↑; Lactate dehydrogenase 380.6 IU/L↑; Cardiac injury markers: Myoglobin: 2254.0 ng/mL↑; B-type natriuretic peptide 486.00 pg/mL↑; Myoglobin I: 0.15 ng/mL↑; Coagulation panel: International normalized ratio 1.13; D-dimer 609 µg/L↑.

- No other abnormalities were noted.
Additionally, I would like to ask what is septic shock? How can we take precautions to avoid developing septic shock? Thank you.

Wendy, 50~59 year old female. Ask Date: 2021/08/19

Dr. Hong Yuanbin reply Internal Medicine

Hello, this condition is indeed a dilemma because the surgical risks are very high.
Even if the surgery is successful, the wound may not heal well.
However, if surgery is not performed, it is anticipated that the left leg will gradually deteriorate.
Cell death can produce many toxins, such as lactic acid, which can slowly harm bodily functions.
This is what you refer to as septic shock, which we need to avoid.
The only way to prevent septic shock is to remove the necrotic tissue.
One consideration is whether the patient is currently experiencing discomfort; typically, if there is significant discomfort, surgery is favored.
If there are no particular symptoms at the moment, the preference may lean towards not operating.
Another factor to consider is the opinions of other family members, as well as the patient's own thoughts if they are fully conscious.
All of these aspects should be taken into account.
Thank you for your question.

Reply Date: 2021/08/19

More Info

In the case of your 90-year-old mother experiencing severe stenosis or occlusion of the femoral and popliteal arteries, it is crucial to weigh the risks and benefits of both surgical and conservative treatment options. Given her advanced age and the complexity of her medical condition, including elevated markers of myocardial injury and potential signs of systemic infection or inflammation, a careful and thorough evaluation is necessary.

Understanding the Condition
Severe stenosis or occlusion in the femoral and popliteal arteries can lead to critical limb ischemia, which is characterized by inadequate blood flow to the legs. Symptoms may include pain, coldness, and discoloration of the legs, as well as potential complications such as ulcers or gangrene. In elderly patients, the risks associated with surgical interventions, such as bypass surgery or angioplasty, must be carefully considered against the potential benefits.

Surgical vs. Conservative Treatment
1. Surgical Options: Surgical interventions, such as bypass grafting or endovascular procedures (like balloon angioplasty and stenting), can restore blood flow. However, these procedures carry risks, especially in elderly patients who may have comorbidities that complicate recovery. The potential for complications, such as infection, poor wound healing, and anesthesia-related risks, must be taken into account.

2. Conservative Management: Conservative treatment may involve medication to manage symptoms and improve blood flow, such as antiplatelet agents, statins, and medications to improve circulation. Physical therapy and lifestyle modifications, including smoking cessation and dietary changes, can also be beneficial. However, if the condition progresses, the risk of limb loss increases.

Evaluating the Best Course of Action
Given your mother's age and the severity of her symptoms, it is essential to have a multidisciplinary team involved in her care. This team may include vascular surgeons, cardiologists, geriatricians, and primary care physicians. They can provide a comprehensive assessment of her overall health, including her functional status, cognitive function, and any other underlying health issues.

- Assessing Symptoms: The presence of intermittent fever and elevated inflammatory markers may indicate an underlying infection or other systemic issues that need to be addressed before any surgical intervention.
- Patient Preferences: It is also vital to consider your mother's preferences and quality of life. Engaging her in discussions about her treatment options can provide insight into her values and desires regarding her care.

Avoiding Complications
Regarding your question about "toxic shock syndrome," it is a severe condition that can arise from infections, particularly those caused by certain bacteria. It is characterized by a sudden onset of fever, rash, and multi-organ dysfunction. To prevent such complications, it is essential to:
- Monitor for Signs of Infection: Regularly check for fever, increased pain, swelling, or any new symptoms that may indicate an infection.

- Prompt Medical Attention: Seek immediate medical care if there are signs of worsening condition, such as increased pain, fever, or changes in mental status.

- Wound Care: If there are any wounds or ulcers, ensure they are kept clean and monitored for signs of infection.

Conclusion
In summary, the decision regarding surgical versus conservative treatment for your mother should be made collaboratively with her healthcare team, considering her overall health, the severity of her symptoms, and her personal preferences. Continuous monitoring and prompt intervention for any signs of complications are crucial in managing her condition effectively.

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