Percutaneous thrombectomy or ultrasound-accelerated thrombolysis for initial management of acute limb ischaemia

Patients undergoing Left Upper Lobectomy (LUL) appear to be at risk of a unique post-operative complication that is not well-documented: Pulmonary Vein (PV) stump thrombosis +/- systemic arterial embolisation [1-3]. We describe the details of a rare case from our institution, present a review of this subject from the limited literature available, and suggest potential strategies to anticipate, detect and manage this entity. A 70 year old female patient underwent left upper lobectomy and mediastinal lymph node sampling via repeat left thoracotomy. The procedure was unremarkable apart from some adhesions. She progressed well post-operatively on the ward. On post-operative day 2 the patient developed sudden-onset left leg pain and paraesthesia and CT-Angiography confirmed the diagnosis of left common femoral artery embolus and left superior PV stump thrombosis. The patient returned to theatre for femoral embolectomy, continued systemic anticoagulation, and made an excellent recovery thereafter. The aetiology of this complication has been documented in some case reports, but it is not explored further in trials or thoracic surgery texts [2-3]. One cohort study involving CT-angiography after lobectomy surgeries found that left upper lobectomy was unique as a risk factor for PV stump thrombosis1. It may be related to the relatively longer LSPV stump and stasis of blood in the stump [4].

Download Full-text

A case report of multisite arterial thrombosis in a patient with coronavirus disease 2019 (COVID-19)

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytaa339 ◽

2020 ◽

Author(s):

Marco Angelillis ◽

Marco De Carlo ◽

Andrea Christou ◽

Michele Marconi ◽

Davide M Mocellin ◽

...

Keyword(s):

Myocardial Infarction ◽

Case Report ◽

Arterial Thrombosis ◽

Leg Pain ◽

Nasopharyngeal Swab ◽

Limb Ischaemia ◽

Total Occlusion ◽

Left Common Iliac Artery ◽

Acute Limb Ischaemia ◽

The Right

Abstract Background A systemic coagulation dysfunction has been associated with COVID-19. In this case report, we describe a COVID-19-positive patient with multisite arterial thrombosis, presenting with acute limb ischaemia and concomitant ST-elevation myocardial infarction and oligo-symptomatic lung disease. Case summary An 83-year-old lady with history of hypertension and chronic kidney disease presented to the Emergency Department with acute-onset left leg pain, pulselessness, and partial loss of motor function. Acute limb ischaemia was diagnosed. At the same time, a routine ECG showed ST-segment elevation, diagnostic for inferior myocardial infarction. On admission, a nasopharyngeal swab was performed to assess the presence of SARS-CoV-2, as per hospital protocol during the current COVID-19 pandemic. A total-body CT angiography was performed to investigate the cause of acute limb ischaemia and to rule out aortic dissection; the examination showed a total occlusion of the left common iliac artery and a non-obstructive thrombosis of a subsegmental pulmonary artery branch in the right basal lobe. Lung CT scan confirmed a typical pattern of interstitial COVID-19 pneumonia. Coronary angiography showed a thrombotic occlusion of the proximal segment of the right coronary artery. Percutaneous coronary intervention was performed, with manual thrombectomy, followed by deployment of two stents. The patient was subsequently transferred to the operating room, where a Fogarty thrombectomy was performed. The patient was then admitted to the COVID area of our hospital. Seven hours later, the swab returned positive for COVID-19. Discussion COVID-19 can have an atypical presentation with thrombosis at multiple sites.

Download Full-text

Indian Summer for Acute Limb Ischaemia

European Journal of Vascular and Endovascular Surgery ◽

10.1016/j.ejvs.2021.01.022 ◽

2021 ◽

Author(s):

Jonothan J. Earnshaw

Keyword(s):

Limb Ischaemia ◽

Acute Limb Ischaemia

Download Full-text

Limb ischaemia and below-knee amputation following life-saving patent ductus arteriosus stent in a critically ill infant

Cardiology in the Young ◽

10.1017/s104795111400167x ◽

2014 ◽

Vol 25 (6) ◽

pp. 1206-1209

Author(s):

Apinya Bharmanee ◽

Srinath Gowda ◽

Harinder R. Singh

Keyword(s):

Ventricular Septal Defect ◽

Patent Ductus Arteriosus ◽

Septal Defect ◽

Ductus Arteriosus ◽

Limb Ischaemia ◽

Knee Amputation ◽

Pulmonary Flow ◽

Life Saving ◽

Acute Limb Ischaemia ◽

Patent Ductus

AbstractLimb ischaemia is a rare but catastrophic complication related to cardiac catheterisation. We report an infant weighing 3 kg with unrepaired tricuspid atresia type 1b, small patent ductus arteriosus, and ventricular septal defect presenting with cardiogenic shock owing to progressively reduced pulmonary blood flow from closing ventricular septal defect and patent ductus arteriosus. An emergency palliative ductal stent was successfully placed with marked clinical improvement. However, acute limb ischaemia developed necessitating above-knee amputation, despite medical management and vascular surgery. The cause of limb loss in our patient was catheterisation-related vascular injury causing arterial dissection–arterial thrombosis in the presence of shock and coagulopathy. This report emphasises the complexity in managing limb ischaemia associated with coagulopathy and highlights the importance of early recognition of reduced pulmonary flow in a single ventricle patient. Timely elective placement of a surgical systemic to pulmonary shunt would prevent catastrophic clinical presentation of compromised pulmonary flow and avoid the need for an emergent life-saving intervention and its associated complications.

Download Full-text

Anaemia: A risk factor for death and adverse outcomes following surgery for acute lower limb ischaemia

Vascular ◽

10.1177/17085381211026167 ◽

2021 ◽

pp. 170853812110261

Author(s):

Daniel Perren ◽

Lauren Shelmerdine ◽

Luke Boylan ◽

Craig Nesbitt ◽

James Prentis ◽

...

Keyword(s):

Risk Factor ◽

Cox Model ◽

Univariate Analysis ◽

Adverse Outcomes ◽

Limb Ischaemia ◽

Risk Of Death ◽

Kaplan Meier ◽

Acute Limb Ischaemia ◽

Impact On Survival ◽

Poor Outcomes

Introduction Acute limb ischaemia (ALI) forms a significant part of the vascular surgery workload and carries with it high rates of morbidity and mortality. Anaemia is also common amongst vascular surgical patients and has been linked with poor outcomes in some subgroups. We aimed to assess the frequency of anaemia in patients with ALI and its impact on survival and complications following revascularisation to help direct future efforts to optimise outcomes in this patient group. Methods A retrospective analysis of prospectively collected departmental data on patients undergoing surgical intervention for ALI between 2014 and 2018 was performed. Anaemia was defined as a pre-operative haemoglobin (Hb) of <120 g/L for women and <130 g/L for men. The primary outcome was overall survival, assessed with the Kaplan–Meier estimator, with application of Cox proportional hazard modelling to adjust for confounding covariates. Results There were 158 patients who underwent treatment for ALI: 89 (56.3%) of these were non-anaemic with a mean Hb of 146 (SD = 18.4), and 69 (43.7%) were anaemic with a mean Hb of 106 (SD = 13.4). Anaemic patients had a significantly higher risk of death than their non-anaemic counterparts on univariate analysis (HR = 2.11, 95% CIs, 1.28–3.5, p = 0.0036). There was ongoing divergence in survival up to around 6 months between anaemic and non-anaemic groups. Under the Cox model, anaemia was similarly significant as a predictor of death (HR = 2.15, 95% CIs, 1.17–3.95, p = 0.013), accounting for recorded comorbidities, medication use and blood transfusion. Conclusions Anaemia is a significant and independent risk factor for death following revascularisation for ALI and can be potentially be modified. Vascular surgical centres should ensure they have robust pathways in place to identify and consider treating anaemia. There is scope for further work to assess how to best optimise a patient’s levels of circulating haemoglobin.

Download Full-text