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Controlled Exsanguination Of The Lower Extremities To Prevent Severe Reperfusion Syndrome During Treatment Of Prolonged Acute Bilateral Lower Extremity Malperfusion
Zachary Thomas Rengel, M.D., Miguel Manzur, M.D., Imani McElroy, M.D., Gregory Magee.
University of Southern California, Los Angeles, CA, USA.
Demographics A 59-year-old man with a history of HIV, diabetes, and coronary artery disease presented with acute bilateral lower extremity ischemia. History The patient experienced over 12 hours of progressive bilateral leg weakness and bowel incontinence, progressing to complete paralysis. On examination, the left leg exhibited near-rigor, while the right demonstrated minimal toe movement. Mottling extended to the umbilicus, though he remained hemodynamically stable and alert. Computed tomography revealed an infrarenal aortoiliac occlusion with severe atherosclerotic disease (Figure 1). Plan The patient was taken emergently for right axillo-bifemoral bypass with bilateral thromboembolectomy. To minimize reperfusion syndrome, bilateral femoral arteries and veins were controlled proximally and distally. Exsanguination was performed with 9-Fr Pruitt perfusion catheters in each femoral artery and suction via femoral venous cannulation. Both extremities were flushed with ~3 L of saline per limb until effluent was clear. Salvaged red blood cells were processed and reinfused using a cell saver. This effectively removed ischemic byproducts but resulted in intravascular depletion and coagulopathy. Volume replacement was managed with a 9-Fr central line and rapid infusion system, while coagulopathy was monitored with point-of-care viscoelastic testing (Quantra Hemostasis System, Hemosonics LLC). In total, 3.1 L of salvaged blood were reinfused, and only two units of packed red blood cells were transfused. Bilateral four-compartment fasciotomies were performed. Discussion Acute aortic occlusion carries high risk due to the metabolic consequences of reperfusion. This case demonstrates the feasibility of lower extremity exsanguination with saline flushing before revascularization as a strategy to reduce reperfusion injury. The patient’s postoperative electrolytes and lactate remained stable, and motor recovery was achieved in the right leg. Successful execution required close coordination between surgery and anesthesia to maintain hemodynamic stability and correct coagulopathy.
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