(CS-130) Case Report - Common Things Can Be Uncommon

Introduction:

Purpose:  
 
To highlight the importance of evaluating for arterial insufficiency at bedside in a young female patient with history of smoking and diabetes mellitus. 

Methods:

Description:
 
A 42 year old lady, poorly controlled insulin requiring diabetes mellitus with a recent HemoglobinA1c of 8.2, tobacco smoker, anxiety, fibromyalgia, necrobiosis lipoidica, prior skin grafts came to the wound clinic as a new patient after recent hospital discharge for non-healing bilateral lower extremity wounds for 2 months duration and pain. She was treated as infected venous stasis ulcers in the hospital and was discharged on doxycycline. She reported significant pain and unable to sleep and in tears. 
Her review of systems was significant for shortness of breath on minimal exertion and pain in her lower extremities. 
Examination revealed purplish discoloration along with feeling cold in both feet, bilateral pitting pedal edema, several wounds in both legs with areas of black eschar and slough noted in wounds. Femoral pulses were not palpable, but dopplerable with multiphasic signal. Dorsalis Pedis and Posterior Tibial arteries were not palpable and had feeble monophasic signal. Arterial dopplers done from recent hospitalization showed monophasic flow noted throughout both the lower extremity arterial system suggestive of proximal arterial occlusive disease. 
Patient was admitted to the hospital after consultation with vascular team.
CT angiogram pelvis with run off was done which showed focal high-grade narrowing of the infrarenal abdominal aorta without occlusion. Endograft to aorta was placed with immediate restoration of color to the extremities. 

Results:

Discussion: Lesson Learned
 
Infrarenal abdominal aortic stenosis is a rare phenomenon that can occur in young women with h/o smoking and hyperlipidemia. In our case, patient’s h/o necrobiosis lipoidica was misleading. 
ABI and bedside Dopplers are valuable tools. As shown earlier, the study pointed us towards proximal block.

References
 
Spyridon Monastiriotis, Shang Loh, Apostolos Tassiopoulos, Nicos Labropoulos,Clinical characteristics and outcome of isolated infrarenal aortic stenosis in young patients,
Journal of Vascular Surgery, Volume 67, Issue 4, 2018, Pages 1143-1149, ISSN 0741-5214,
https://doi.org/10.1016/j.jvs.2017.07.136.
(https://www.sciencedirect.com/science/article/pii/S0741521417320864)