Chapter 16: Acute Limb Ischemia and Thrombolysis
PAUL F. FREY, MD, MPH; PIOTR S. SOBIESZCZYK, MD
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.
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).