A 68-year-old gentleman with a history of ischaemic heart disease who had percutaneous coronary angiography (PCA) several weeks ago presents to the ED with a lump in the right groin. He is a keen gardener and has a history of inguinal hernia. It has been gradually increasing in size, is not reducible and is tender to palpate. He also complains of weakness in his right leg. His vital signs are HR 88, BP 132/78, temp 36.9°C.
Which is the MOST likely diagnosis?
Answer: C: Femoral artery pseudoaneurysm or false aneurysm is a recognized complication of femoral artery catheterization occurring in approximately 7.5% of femoral artery catheterizations. It is due to oozing of the arterial blood into the surrounding tissues through the puncture site, which has failed to seal. The haematoma is confined by the surrounding fascia and eventually becomes encapsulated by fibrous tissue. It does not contain all three layers (intima, media and adventitia) of the femoral artery wall so it is a pseudoaneurysm and not a true aneurysm. The presentation is typically with an expanding pulsatile mass, pain or tenderness. They may also present with paraesthesia or limb weakness from compression of surrounding structures. Complications of pseudoaneurysms include rupture, distal embolization, thrombosis leading to ischaemia, local skin ischaemia, neuropathy and pain. An ultrasound is diagnostic and the patient should be referred to the vascular team for ongoing management (thrombolysis or embolectomy).
It is difficult to differentiate between periarterial haematoma and femoral artery pseudoaneurysm in the immediate postprocedural period; however, this patient is several weeks after the procedure so false aneurysm is the more likely diagnosis. Femoral hernias originate below the inguinal ligament. They are less common than inguinal hernias but are more likely to become incarcerated or strangulated. They are generally asymptomatic; however, they can cause groin discomfort that is worse on standing and can present with nausea, vomiting and abdominal pain. Given the history of this patient the diagnosis of femoral hernia is unlikely.
In incarcerated inguinal hernia, the patient will present with pain, nausea, vomiting, low-grade fever and a hernia that is no longer reducible. Complications include strangulation, bowel obstruction and bowel perforation. If the hernia becomes strangulated then the patient appears more toxic and can be in septic shock.
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Which ONE of the following is TRUE regarding Boerhaave’s syndrome?
Answer: A: Boerhaave’s syndrome is a transmural oesophageal rupture that results from sudden raised intraluminal pressure caused by uncoordinated vomiting with the pylorus and cricopharyngeus closed. In the majority of cases it occurs secondary to this forceful emesis. Less commonly Boerhaave’s syndrome can occur as a result of coughing, straining, seizures or during labour. The most common location for the rupture to occur is the left lower posteriolateral wall of the oesophagus. The highest incidence occurs in middle aged males (age 40–60 years).
CXR can be normal in up to 30% of patients. The most common CXR finding in a patient with Boerhaave’s syndrome is a left-sided pleural effusion. Other findings include pneumothorax, hydropneumothorax, pneumomediastinum and subcutaneous emphysema.
Mackler’s triad, which consists of vomiting, chest pain and subcutaneous emphysema, is the classic presentation of Boerhaave’s syndrome. Other clinical features that may be present include hoarse voice, tracheal shift and cervical vein distention. If left untreated these patients are at a high risk of developing sepsis, multiorgan failure and death as a result of chemical and bacterial mediastinitis. The mortality rate varies depending on the length of delay to treatment and can range from 20 to 90%.
Swallowing can exacerbate the pain and precipitate coughing due to the communication between the pleural cavity and the oesophagus. Haematemesis is not typically seen and if present can help differentiate a Mallory-Weiss tear from Boerhaave’s syndrome.
A 69-year-old man who has been immobile for 3 days presents with sudden onset of painful right lower leg. The leg is pale and cool to touch. He has a past medical history that includes, hypertension, non-insulin-dependent diabetes and heavy smoking. He has recently been treated for atrial fibrillation and is now rate controlled.
Which ONE of the options below is the most CORRECT? This patient should:
Answer: A: The patient most likely has an acute embolic arterial occlusion secondary to his recent diagnosis of atrial fibrillation. Atrial fibrillation is associated with peripheral emboli in at least 60% of cases.
Acute arterial occlusion of a limb is most commonly a result of embolism (90% of cases). Emboli usually lodge at arterial bifurcation points with the most common site being the femoral artery bifurcation (up to 50% of cases). Atheroemboli originate in the large proximal arteries. They tend to be smaller and therefore lodge in the smaller arteries such as the digital arteries resulting in ischaemic toes.
The typical presentation of an acute ischaemic limb involves one or more of the six Ps:
Interestingly, acute ischaemia may be masked in patients with peripheral vascular disease because they often have good collateral circulation. The aim of management is to resuscitate the patient and restore blood flow to preserve the limb. If acute limb ischaemia is suspected the patient should promptly be given intravenous unfractionated heparin. This patient has acute limb ischaemia from arterial embolism so should have intravenous unfractionated heparin and referral to the vascular surgeon for consideration of an embolectomy. Fibrinolysis is not suitable for this patient because it is a limb-threatening event that is time critical. Clot lysis can take up to 72 hours to be effective and is therefore not a suitable treatment. Thrombolysis should be considered for non-limb-threatening ischaemia.
A patient with a history of intravenous drug use presents with an acutely painful hand. It is cool, pale and mottled. Radial and ulnar pulses are present. The second–third fingertips are dusky in colour and there is pain on both passive and active wrist movement. Other than an elevated creatine kinase level of 3000 IU/L (35–145 IU/L normal range), laboratory investigations are all within the normal range.
What is the MOST likely diagnosis?
Answer: B: This patient has inadvertently injected a drug (such as benzodiazepine) intra-arterially and is starting to develop compartment syndrome secondary to the consequential oedema and limb swelling. When a drug has been injected into an artery the patient experiences immediate burning pain (sometimes known as a ‘flash’ or a ‘hand trip’ – intense burning pain from the site of injection to the digits, fingers or toes depending on site of injection). Within a few hours, constant severe pain and mottling of the limb appears, the hand may be cool with decreased capillary refill. As time progresses the limb becomes swollen but distal pulses are often still palpable. Signs and symptoms of compartment syndrome develop if treatment has not been sought and occasionally intraarterial drug injection can present as an acute ischaemic limb.
The presence of compartment syndrome in this case is demonstrated by pain on active and passive movement of the wrist. Time taken to develop compartment syndrome is variable. Tissue loss, rhabdomyolysis and renal failure are also recognized complications of inadvertent intraarterial injection.
The presentation is not consistent with deep vein thrombosis (DVT). DVT would be more likely to present with a red warm swollen arm and tenderness to palpation along the deep veins. There are similarities to an acute ischaemic limb; however, this diagnosis is excluded as peripheral pulses are present.
The mechanism of injury from the intraarterial artery drug delivery is not well understood but there are several thoughts on how it occurs:
There is no agreed ideal management of such patients. However, this patient should be given analgesia, limb elevation, commenced on a heparin infusion, compartmental pressures should be measured and a Doppler ultrasound, plus or minus angiography (arteriography) should be done to evaluate the extent of the vascular damage. The patient should have urgent consultation with a vascular surgeon as signs of compartment syndrome are present and fasciotomy may be indicated.
Other management options that have been mentioned in the literature include:
A combination of the above can produce good results.
What is the MOST appropriate next step?
Answer: D: This patient has inadvertently injected a drug (such as benzodiazepine) intra-arterially and is starting to develop compartment syndrome secondary to the consequential oedema and limb swelling. When a drug has been injected into an artery the patient experiences immediate burning pain (sometimes known as a ‘flash’ or a ‘hand trip’ – intense burning pain from the site of injection to the digits, fingers or toes depending on site of injection). Within a few hours, constant severe pain and mottling of the limb appears, the hand may be cool with decreased capillary refill. As time progresses the limb becomes swollen but distal pulses are often still palpable. Signs and symptoms of compartment syndrome develop if treatment has not been sought and occasionally intraarterial drug injection can present as an acute ischaemic limb.
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