Background: Peripheral artery disease is the narrowing or blockage of arteries in the peripheral circulation, primarily caused by atherosclerosis. Treatment may initially be an exercise program and a focus on reducing risk factors such as quitting smoking and treating comorbid conditions. The next step is revascularization procedures, often starting with an endovascular approach (balloon angioplasty with or without stenting) and proceeding to surgical interventions if endovascular approach fails or is contraindicated. Surgical procedures include anatomical bypasses, such as aortofemoral bypass grafting, and extra-anatomical bypasses, such as axillofemoral bypass grafting (AXFBG).

Case Presentation: A 67-year-old female with HTN, HLD, CVA with residual L sided deficits, PAD s/p L fem-AT bypass with rGSV (2020) with subsequent L CFA endarterectomy (2020), L groin debridement (2021) and recent LLE angiogram at OSH (2/5/24) who presented with acute on chronic LLE critical limb ischemia and found to have necrotic left great toe. CTA with occlusion of L common and external iliac artery with possible dissection in L CFA with reconstitution in L SFA. Preoperative diagnosis was left lower extremity ischemic ulceration. The patient underwent left axillary artery to proximal superficial femoral artery (axillofemoral) bypass 2/27/24. Patient was recovering well after surgery until post op day 3. Patient developed symptoms of post ischemic compartment syndrome. Patient had pain out of proportion on left leg, extreme tenderness to touch, worse pain with passive extension, and some swelling in the left lower extremity. Palpable pulses were unchanged from before the surgery. Left dorsalis pedis pulse was not palpable and not detected with doppler at baseline. Ultimately, vascular surgery recommended left above knee amputation, which was done on 3/11/24.

Discussion: Post-ischemic compartment syndrome is a surgical emergency caused by increased intercompartmental pressure in the lower extremity that develops following revascularization procedures for acute limb ischemia. Surgical revascularization can cause the muscles of the extremity to develop edema due to fluid extravasation or inflammatory responses following an ischemia-reperfusion injury, resulting in rapid increase in ICP. Common procedures that cause this are embolectomy or arterial bypass. Inadequate backflow, high serum CK level, positive fluid balance, and advanced-stage acute limb ischemia are predictive factors for developing compartment syndrome. This patient had an amputation instead of a fasciotomy because the limb was already not being perfused well. If she had a fasciotomy, it would not have healed well and could have put the patient at risk for infection.