Introduction

Edema of a lower extremity after femoropopliteal bypass surgery is a common problem[₁]. Thrombotic occlusion in lower extremity deep veins after vascular reconstructive surgery is a nonfrequent complication.

Case Presentation

Our case was a 56-year-old male. His chief complaints were coldness and discoloration of his left lower limb that started about 36 hours ago. He also defined mild sensorimotor deficit. His past medical history was significant for claudication with a walking distance of 50 meters for 3 months and coronary arterial bypass operation he underwent 5 years ago. Emergent terminal aortography and lower extremity arterial DSA revealed that there were diffuse atherosclerotic disease, 80% stenosis in left common femoral artery and 70% stenosis in distal segments of left superficial femoral artery. Left crural arteries could not be visualized. Absence of collateral vascular structures at this level led us to the diagnosis of embolus (Figures 1&2).

Figure 1

Figure 1

Figure 2

Figure 2

His cardiac rhythm was atrial fibrillation. Therefore, transthoracic echocardiography was carried out revealing no intracardiac thrombus. Ejection fraction was calculated as 20% and left ventricular diameter was measured as 86/74 mm. With all these findings, the possible diagnosis was made as acute arterial thrombus developed on an atherosclerotic basis and emergent femoral embolectomy was planned. Large amount of thrombus material was obtained from inside the superficial femoral artery. Distal pulses were not palpable after the embolectomy. Therefore, supragenual femoropopliteal bypass surgery was performed with 8mm ringed e-PTFE graft (Seal PTFE-Gelatin sealed ePTFE Vascular Prosthesis T7008ES) subsequently. Distal crural pulses were palpable during postoperative period; but, on 5^th postoperative day he started to suffer from swelling and warmness of his operated limb. Homan’s sign was positive in physical examination. With these findings, venous Doppler ultrasound was performed to rule out deep vein thrombosis (Figure 3).

Figure 3

Figure 3

This investigation showed thrombus within left common femoral vein extending caudally. Thrombus material obliterated the lumen totally extending to the crural veins (Figures 4&5).

Figure 4

Figure 4

Figure 5

Figure 5

Continuous intravenous heparin infusion and oral anticoagulation with warfarin sodium were initiated. Target ACT value was around 200-250 seconds whereas target INR value lied between 3 and 3.5. After reaching targeted INR values, heparin infusion was stopped. Prophylactic parenteral antibiotherapy and anti-inflammatory therapy that were started after surgery were continued. Elevation of the affected extremity was obtained. Serum tumor markers were negative. Whole abdominal ultrasound revealed no compressing neoplasia. He showed prominent symptomatic relief and was discharged on 8^th day after he developed DVT. His ambulatory medical therapy (warfarin sodium+ enteric coated acetylsalicylic acid) was regulated for routine outpatient controls.

Discussion

In thrombotic occlusion of the deep veins after arterial reconstructive surgery,heparin therapy must usually administered in acute phase. The overall benefit of antiplatelet agents, specially aspirin therapy prevents thrombotic complication in other vascular beds, and reduces long-term cardiovascular morbidity and mortality. Oral anticoagulation by vitamin K antagonists, alone or combined with aspirin is perhaps an appropriate choice in selected patients with high risk of thrombosis[₂].

In the study of AbuRahma et al., 72 patients were evaluated before and after surgery with noninvasive venous testing and venography. Twenty-nine (40%) of the 72 patients had postoperative edema. A similar proportion of patients with edema had deep venous thrombosis as patients without edema (3/29 [10%] vs 3/43 [7%], respectively). No association was found between edema and type of graft used or severity of preoperative symptoms. This study indicates that deep venous thrombosis is not an important cause of edema that occurs after bypass surgery and that intraoperative lymphatic disruption probably causes most cases of this complication[₁].

In the study of Herreros et al., fifteen consecutive patients who underwent femoro-popliteal reconstructions were examined comparatively by X-Ray and radionuclide lymphograms during the first postoperative week. The role of venous and lymphatic involvement and the significance of the surgical technique on the presence and extent of the postoperative edema was investigated. Phlebography confirmed venous obstruction in one case[₃].

In the study of Morrison et al., radiological thrombosis was demonstrated on six occasions in the leg veins in 66 patients following the placement of 71 femoropopliteal bypass grafts. The incidence was similar for grafts with the lower anastomosis either above or below the knee joint. No predisposing factors to venous thrombosis were apparent other than blood dyscrasias[₄].

Although the antithrombotic potential of oral anticoagulants is undisputed, bleeding complications constitute a serious problem. One of the main causes for these complications has been a lack of standardization of the prothrombin time. The introduction of the International Normalized Ratio (INR) has led to a better standardization of prothrombin time[₅]. Furthermore, oral anticoagulants should be given to patients after femoropopliteal bypass. A relatively mild oral anticoagulant treatment (INR 2-3) is sufficient to prevent recurrences of venous thrombosis and pulmonary emboli. The duration of treatment in patients with venous thromboembolism depends on some clinical features and the results of clotting tests which indicate an increased tendency to thrombosis[₅].