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Case Reports and Images in Surgery

 
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Chronic critical limb ischemia due to cardioembolism treated with thromboembolectomy
Bruce L. Tjaden Jr.1, Clay Quint2
1MD,Chief Surgery Resident, Department of Surgery, The University of Kansas Medical Center, Kansas City, Kansas, U.S.A.
2MD, PhD, Assistant Professor, Department of Surgery, Vascular Division, The University of Kansas Medical Center, Kansas City, Kansas, U.S.A.

Article ID: 100012Z12BT2016
doi:10.5348/Z12-2016-12-CL-4

Address correspondence to:
Bruce L. Tjaden Jr
MD, 4005 Genessee St
Kansas City
Missouri
USA, 64111

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How to cite this article
Tjaden Jr. BL, Quint C Chronic critical limb ischemia due to cardioembolism treated with thromboembolectomy. Int J Case Rep Images 2016;2:12–14.


Case Report

A 39-year-old female with a history of methamphetamine abuse, untreated atrial fibrillation, and three prior cardioembolic strokes presented to the emergency department with a left hemispheric transient ischemic attack. She was admitted to the neurology service, and treated with tissue plasminogen activator (TPA). Her neurologic symptoms resolved. After several days in the hospital, she voiced complaints about her left leg, which she said had been painful for three weeks. She was unable to move her ankle or toes. She could not walk due to these complaints. On examination, she lacked pedal pulses on the left side, and monophasic Doppler signals were obtainable only in the posterior-tibial location.

Cardioembolic disease was suspected, given her history of arrhythmia and drug use. An echo showed no signs of valvular vegetations or mural thrombi. A Computed tomography angiogram was obtained (Figure 1), which demonstrated a completely occlusive thrombus extending from the junction of the left external iliac and common femoral arteries to the tibioperoneal trunk. Collaterals from the internal iliac artery reconstituted the profunda femoris, which in turn reconstituted the posterior tibial and peroneal arteries. Notably, none of her vessels demonstrated any calcification, consistent with an embolic instead of atherosclerotic pathogenesis. Due to the longstanding nature of her complaints, an embolectomy was thought to be unlikely to succeed. As she had suitable ipsilateral saphenous vein, she was taken to the operating room with plans for a bypass.

Dissection was started in the groin. The saphenofemoral junction, distal external iliac artery, femoral artery bifurcation, and below knee popliteal artery were exposed. The saphenous vein was dissected along its course. The patient was heparinized, and an arteriotomy was made in preparation for an iliofemoral endarterectomy as well as the proximal anastomosis. Surprisingly, this revealed fresh-appearing clot without any fibrinous organized component. A balloon embolectomy catheter was able to be passed easily below the knee. Withdrawal of the catheter yielded a very elongated thrombus (Figure 2) followed by pulsatile backbleeding. Balloon catheter embolectomy of the external iliac artery yielded a short segment of thrombus with a fibrinous cap, and explosive pulsatile bleeding. At this time, the arteriotomy was closed by performing a patch angioplasty with bovine pericardium. The patient regained pedal pulses, and was able to ambulate postoperatively.


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Figure 1: Reconstructed images from computed tomography angiography demonstrating occlusion of the common femoral artery, with reconstitution of the profunda femoris and tibioperoneal trunk.



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Figure 2: Clot retrieved from the Turner's iliofemoral popliteal segment. Ruler for scale, with centimeter markings along bottom margin.


Discussion

The management of an ischemic limb is dictated not only by the timing of the inciting event (acute versus chronic) but also by its pathogenesis (embolic versus atherosclerotic). Usually, embolectomy is only effective in the acute setting of a macroembolic event in patients without preexisting atherosclerotic disease. Indeed, situations treatable by simple embolectomy are increasingly rare in the modern era, due to the widespread prevalence of concomitant peripheral arterial disease and the relative rarity of cardioembolism due to arrhythmia or myocardial infarction [1].

This case is unusual in that the patient's longstanding ischemia was still able to be treated via balloon catheter embolectomy. It is unclear why the Turner's clot had failed to organize, but her history of drug abuse may have played a role. Thrombocytopenia is a known side effect of methamphetamine use [2], and the patient was mildly thrombocytopenic (platelet count 96 K/uL) on admission. While not enough to produce clinical bleeding, this slight hematologic derangement may have kept her post-embolic clot slightly more pliable, allowing for revascularization without a bypass.


Conclusion

In certain cases of chronic or subacute embolic arterial occlusion, it may possible to restore flow via simple balloon catheter embolectomy. Consideration should be given to attempting this prior to performing the distal exposure for bypass or vein dissection.


Keywords

Cardioembolism, Chronic, Critical, Limb, Thromboembolectomy


Acknowledgements

Pamela Jones, the best surgical technician that we have ever worked with, for her longstanding support and encouragement, and her passion for vascular surgery.


References
  1. Hallet JW Jr, Mills JL, Earnshaw JJ, Reekers JA, Rooke TW. eds. Comprehensive Vascular and Endovascular Surgery. 2ed. Philadelphia: Mosby Elsevier; 2009.    Back to citation no. 1
  2. Barceloux DG. Medical Toxicology of Drug Abuse: Synthesized Chemicals and Psychoactive Plants. Hoboken: John Wiley & Sons; 2012.    Back to citation no. 2

Suggested Reading
  • Wahlberg E, Olofsson P, Goldstone J. Emergency Vascular Surgery - A Practical Guide. Berlin: Springer; 2007.
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Author Contributions
Bruce L. Tjaden Jr. – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Clay Quint – Analysis and interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published
Guarantor of submission
The corresponding author is the guarantor of submission.
Source of support
None
Conflict of interest
Authors declare no conflict of interest.
Copyright
© 2016 Bruce L. Tjaden Jr. et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.



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