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===Recommendation for Revascularization for CLI:===
__NOTOC__


{| class="wikitable"
{{CMG}}; {{AE}}
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.'''In patients with CLI, [[revascularization]] should be performed when possible to minimize tissue loss.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''2.'''An evaluation for [[revascularization]] options should be performed by an interdisciplinary care team before amputation in the patient with CLI.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO]])''<nowiki>"</nowiki>
|-
|}


====Recommendations for Endovascular Revascularization for CLI:====
== Demographic / Medical history ==
{| class="wikitable"
* '''Demographic''': 77, M
|-
* '''Past Medical History:''' HTN, BPH, CAD w CABG, MI, AVR
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
* '''Past Surgical History:'''  
|-
** AVR (#25 magna ease valve) on 12/14/17
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.'''Endovascular procedures are recommended to establish in-line blood flow to the foot in patients with nonhealing wounds or [[gangrene]].''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''<nowiki>"</nowiki>
** Stent on 10/10/2017
|-
** CABG in 2007
|}
** Appendectomy in 1957


== Pre-endoscopic medical therapy ==
* '''Medications:'''
{| class="wikitable" style="width:82%"
** Metoprolol
|-
** DAPT
| colspan="1" style="text-align:center; background:LemonChiffon" |Conditional recommendation ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]])
** Tamsulosin
|-
| bgcolor="LemonChiffon" |1. Intravenous infusion of erythromycin (250 mg ~ 30 min before endoscopy) should be considered to improve diagnostic yield and decrease the need for


repeat endoscopy. However, erythromycin has not consistently been shown to improve clinical outcomes
== Procedure ==
* '''Index Procedure Date/Time''':
** mm/dd/YYYY at xx:xx  [insert date and time]
* '''Index Procedure Detail''': 
** On mm/dd/YYYY at xx:xx [insert date and time] the subject underwent a [select surgical correction] for [select etiology].  
** Access site details
** The site reported that there were/were not procedural complication(s).


|-
== Event(s) ==
| bgcolor="LemonChiffon" |2. Pre-endoscopic intravenous PPI (e.g., 80 mg bolus followed by 8 mg / h infusion) may be considered to decrease the proportion of patients who have
'''Event (1):'''
* '''Site Reported Event Onset Date: 12/26/2017'''


higher risk stigmata of hemorrhage at endoscopy and who receive endoscopic therapy. However, PPIs do not improve clinical outcomes such as further
* '''Event summary''':
** Symptoms and sign: Subject presented with
*** Right leg collapse,
*** Right arm and right leg weakness
** Episodes lasted approximately  2 -10 minutes and ranged from 1-4/day
** No visual or speech difficulties, no headache or neck pain
** No history of vertigo, syncope, loss of consciousness or seizures
** Other important symptoms related to the chief complaint.
** Physical assessment:
*** Normal neurological exam
*** BP: 124/66
*** HR: 96
== Laboratory data ==
* '''Lab studies list: ('''Date/ name/ value)
** 01/04/2018 / HDLC / 31
** 01/03/2018 / INR / 1.2


bleeding, surgery, or death
== Diagnostic tests ==
|-
* 01/03/2018 '''TTE'''
| bgcolor="LemonChiffon" |3. If endoscopy will be delayed or cannot be performed, intravenous PPI is recommended to reduce further bleeding.
** Mild left ventricular hypertrophy with normal systolic function and left ventricular diastolic dysfunction
|-
** Moderate left atrial enlargement
|}
** Bioprosthetic aortic valve peak vel 2 m/s and mean grad 6.4 hg, no AI
 
* 01/03/2018 '''MR Brain'''
== Gastric lavage ==
** NO evidence of vascular occlusion
{| class="wikitable"
** No evidence of restricted diffusion to suggest infarction
|-
* 01/03/2018 '''MRA H/N'''
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Conditional recommendation (Class IIa)]]
** Eccentric filling defect in the left internal carotid artery just distil to the bifurcation that may be from calcification / nonocclusive thrombus
|-
* 01/03/2018 '''Carotid US(Preliminary)'''
| bgcolor="LemonChiffon" |1. Nasogastric or orogastric lavage is not required in patients with UGIB for diagnosis, prognosis, visualization, or therapeutic effect
** Right: 1-49% stenosis of right internal carotid
|-
** Left: 1-49% stenosis of left internal carotid
|}
** Bilateral vrtebral arteries patent with antegrade flow
 
* 01/03/2018 '''EEG'''
== Timing of endoscopy ==
** Normal awake EEG
{| class="wikitable" style="width:82%"
** No epilitiform discharges, focal changes or other abnormalities
|-
==Consults==
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Conditional recommendation (Class IIa)]]
*Neurology consult : 01/03/2018
|-
*Recommendations:  
| bgcolor="LemonChiffon" |Timing of endoscopy
**CBC,CMP
1. Patients with UGIB should generally undergo endoscopy within 24 h of admission, following resuscitative efforts to optimize hemodynamic parameters and
**Admission to neurology service
 
**MRI brain with or without contrast
other medical problems.
**MRA of the extracranial and intracranial circulation
|-
**Carotid duplex US
| bgcolor="LemonChiffon" |2. In patients who are hemodynamically stable and without serious comorbidities endoscopy should be performed as soon as possible in a non-emergent
**EEG
setting to identify the substantial proportion of patients with low-risk endoscopic fi ndings who can be safely discharged.
*Date and time of consult
|-
*Suggested treatments:
| bgcolor="LemonChiffon" |3. In patients with higher risk clinical features (e.g., tachycardia, hypotension, bloody emesis or nasogastric aspirate in hospital) endoscopy within 12 h may
**Aspirin 81mg chew tab
 
**Clopidogrel 75 mg tab
be considered to potentially improve clinical outcomes.
**Enoxaparin 40mg inj
|-
**Metoprolol succinate 25mg extended release
|}
==Clinical course==
 
*
===Endoscopic diagnosis===
*Date and time of events,
 
*Patient condition got worse or better.
{| class="wikitable"
==Treatment and outcome==
|-
*List of relevant medical treatments
| colspan="1" style="text-align:center; background:LightGreen" |Strong recommendation ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]])
**Aspirin 81mg chew tab
|-
**Clopidogrel 75 mg tab
| bgcolor="LightGreen" |1. Stigmata of recent hemorrhage should be recorded as they predict risk of further bleeding and guide management decisions. The stigmata, in descending
**Enoxaparin 40mg inj
risk of further bleeding, are active spurting, non-bleeding visible vessel, active oozing, adherent clot, fl at pigmented spot, and clean base .
**Metoprolol succinate 25mg extended release
|-
*Out come - Discharged home
|}
 
== Endoscopic therapy ==
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |Strong recommendation [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |1. Endoscopic therapy should be provided to patients with active spurting or oozing bleeding or a non-bleeding visible vessel.
|-
| bgcolor="LightGreen" |2. Endoscopic therapy should not be provided to patients who have an ulcer with a clean base or a fl at pigmented spot .
|-
| bgcolor="LightGreen" |3. Epinephrine therapy should not be used alone. If used, it should be combined with a second modality.
|-
| bgcolor="LightGreen" |4. Thermal therapy with bipolar electrocoagulation or heater probe and injection of sclerosant (e.g., absolute alcohol) are recommended because they
reduce further bleeding, need for surgery, and mortality.
|-
|}
 
 
 
== Timing of endoscopy ==
{| class="wikitable" style="width:82%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Conditional recommendation (Class IIa)]]
|-
| bgcolor="LemonChiffon" |Timing of endoscopy
1. Patients with UGIB should generally undergo endoscopy within 24 h of admission, following resuscitative efforts to optimize hemodynamic parameters and
 
other medical problems.
|-
| bgcolor="LemonChiffon" |2. In patients who are hemodynamically stable and without serious comorbidities endoscopy should be performed as soon as possible in a non-emergent
setting to identify the substantial proportion of patients with low-risk endoscopic fi ndings who can be safely discharged.
|-
| bgcolor="LemonChiffon" |3. In patients with higher risk clinical features (e.g., tachycardia, hypotension, bloody emesis or nasogastric aspirate in hospital) endoscopy within 12 h may
 
be considered to potentially improve clinical outcomes.
|-
|}
 
 
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' An interdisciplinary care team should evaluate and provide comprehensive care for patients with CLI and tissue loss to achieve complete wound healing and a functional foot''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''2.''' In patients with CLI, wound care after [[revascularization]] should be performed with the goal of complete wound healing''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''<nowiki>"</nowiki>
|-
|}
 
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |<nowiki>"</nowiki>'''1.''' In patients with CLI, intermittent pneumatic compression (arterial pump) devices may be considered to augment wound healing and/or ameliorate severe ischemic rest pain. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''<nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon" |<nowiki>"</nowiki>'''2.''' patients with CLI, the effectiveness of [[hyperbaric oxygen therapy]] for wound healing is unknown. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''<nowiki>"</nowiki>
|-
|}
 
===References===
{{Reflist|1}}

Latest revision as of 16:44, 18 June 2018


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Demographic / Medical history

  • Demographic: 77, M
  • Past Medical History: HTN, BPH, CAD w CABG, MI, AVR
  • Past Surgical History:
    • AVR (#25 magna ease valve) on 12/14/17
    • Stent on 10/10/2017
    • CABG in 2007
    • Appendectomy in 1957
  • Medications:
    • Metoprolol
    • DAPT
    • Tamsulosin

Procedure

  • Index Procedure Date/Time:
    • mm/dd/YYYY at xx:xx [insert date and time]
  • Index Procedure Detail:
    • On mm/dd/YYYY at xx:xx [insert date and time] the subject underwent a [select surgical correction] for [select etiology].
    • Access site details
    • The site reported that there were/were not procedural complication(s).

Event(s)

Event (1):

  • Site Reported Event Onset Date: 12/26/2017
  • Event summary:
    • Symptoms and sign: Subject presented with
      • Right leg collapse,
      • Right arm and right leg weakness
    • Episodes lasted approximately 2 -10 minutes and ranged from 1-4/day
    • No visual or speech difficulties, no headache or neck pain
    • No history of vertigo, syncope, loss of consciousness or seizures
    • Other important symptoms related to the chief complaint.
    • Physical assessment:
      • Normal neurological exam
      • BP: 124/66
      • HR: 96

Laboratory data

  • Lab studies list: (Date/ name/ value)
    • 01/04/2018 / HDLC / 31
    • 01/03/2018 / INR / 1.2

Diagnostic tests

  • 01/03/2018 TTE
    • Mild left ventricular hypertrophy with normal systolic function and left ventricular diastolic dysfunction
    • Moderate left atrial enlargement
    • Bioprosthetic aortic valve peak vel 2 m/s and mean grad 6.4 hg, no AI
  • 01/03/2018 MR Brain
    • NO evidence of vascular occlusion
    • No evidence of restricted diffusion to suggest infarction
  • 01/03/2018 MRA H/N
    • Eccentric filling defect in the left internal carotid artery just distil to the bifurcation that may be from calcification / nonocclusive thrombus
  • 01/03/2018 Carotid US(Preliminary)
    • Right: 1-49% stenosis of right internal carotid
    • Left: 1-49% stenosis of left internal carotid
    • Bilateral vrtebral arteries patent with antegrade flow
  • 01/03/2018 EEG
    • Normal awake EEG
    • No epilitiform discharges, focal changes or other abnormalities

Consults

  • Neurology consult : 01/03/2018
  • Recommendations:
    • CBC,CMP
    • Admission to neurology service
    • MRI brain with or without contrast
    • MRA of the extracranial and intracranial circulation
    • Carotid duplex US
    • EEG
  • Date and time of consult
  • Suggested treatments:
    • Aspirin 81mg chew tab
    • Clopidogrel 75 mg tab
    • Enoxaparin 40mg inj
    • Metoprolol succinate 25mg extended release

Clinical course

  • Date and time of events,
  • Patient condition got worse or better.

Treatment and outcome

  • List of relevant medical treatments
    • Aspirin 81mg chew tab
    • Clopidogrel 75 mg tab
    • Enoxaparin 40mg inj
    • Metoprolol succinate 25mg extended release
  • Out come - Discharged home
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