Case Study: Chapter 16

Chapter 16: Acute Limb Ischemia and Thrombolysis

PAUL F. FREY, MD, MPH; PIOTR S. SOBIESZCZYK, MD

CASE STUDY:

A 55-year-old man presented with sudden onset of right hand pain and pallor in the right index and ring fingers. Diagnostic angiography showed normal appearance of the innominate, subclavian, and axillary arteries. Angiogram of the distal brachial artery and its bifurcation (Video 16.1a) showed normal flow in the ulnar and interosseous arteries. The flow in the radial artery was markedly delayed. Angiogram of the distal forearm (Video 16.1b) showed that the ulnar artery filled the palmar arch. The radial artery was occluded at the wrist. Angiogram of the hand after administration of vasodilators (Video 16.1c) showed a filling defect and occlusion of the radial artery and reduced perfusion of the index and ring fingers. Further evaluation revealed a patent foramen ovale as a possible cause of acute arterial embolism.

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A 70-year-old man with a history of left femoropopliteal bypass graft presented with acute onset of pain in the right foot and calf. Clinical exam was consistent with acute limb ischemia and presumed graft thrombosis. Angiogram of the left common femoral artery (Video 16.2a) showed patent common femoral and profunda femoris arteries. A vestigial stump of the bypass graft was seen originating medially from the common femoral artery. The profunda collaterals did not reconstitute infrapopliteal vessels. A rheolytic thrombectomy catheter was positioned in the proximal graft. Pulse-spray thrombectomy reestablished flow through the graft. Despite residual thrombus in the distal popliteal artery (Video 16.2b), pedal perfusion was restored (Videos 16.2c and 16.2d). After an additional 12 hours of catheterdirected thrombolysis, brisk arterial flow was reestablished through the proximal, mid, and distal graft segments (Videos 16.2e, 16.2f, and 16.2g) and the popliteal artery (Video 16.2h).

Case Study: Chapter 16

* 1.) A 70-year-old man with a history of a 4-cm abdominal aortic aneurysm presents reporting sudden onset of pain in the left foot. On clinical exam, the foot is cool, with notable pallor. There are no palpable pulses and only a weak monophasic Doppler signal. Based on the angiogram and ultrasound images depicted below, what is the most likely etiology of acute limb ischemia?

* 2.) A 67-year-old woman is referred for endovascular treatment of acute ischemia of the right leg. Angiography identifies acute occlusion of the ostial right superficial femoral artery, with

Which of the following is the best predictor of
successful intra-arterial thrombolysis?

* 3.) A 55-year-old man with a history of aortic valve replacement with a mechanical prosthesis presents with symptoms of pain followed by numbness in the right foot. The pain started 4 hours ago and was associated with pallor and coolness to touch.

On physical exam, he reports numbness extending from the toes to the ankle. He can move his toes but reports that it requires effort to do so. Pedal pulses cannot be detected on Doppler examination. Based on the clinical exam, what is this patient’s Rutherford class?

* 4.) An 80-year-old woman with dementia was found on the floor of her apartment. She initially reported pain in the left leg, which has spontaneously resolved. The limb is cool to touch, with mottled appearance from the knee to the foot.

She is unable to flex the toes or the ankle. Doppler exam does not identify any vascular signal in the foot. What is the best treatment strategy for this patient?

* 5.) A 72-year-old woman presents with acute limb ischemia after undergoing CryoPlasty of a focal popliteal artery stenosis 4 days ago.

Arteriography reveals occlusion from the mid superficial femoral artery to the proximal anterior
tibial artery. What is the most appropriate therapy?