Acute limb ischaemia due to vasospasm: a rare presentation

2022 ◽  
Vol 15 (1) ◽  
pp. e246495
Author(s):  
Raed Al Yacoub ◽  
Jaymin Patel ◽  
Neha Solanky ◽  
Nila S Radhakrishnan
Keyword(s):  
Arterial Occlusion ◽  
Limb Ischaemia ◽  
Urine Drug Screen ◽  
Rare Presentation ◽  
Heroin Use ◽  
Acute Ischaemia ◽  
Left Hand ◽  
Ct Angiogram ◽  
Acute Limb Ischaemia ◽  
Urine Drug

A 30-year-old woman with active intravenous drug use presented with pain, blue discolouration, paresthesia and lack of grip strength of left hand for 1 week. Physical examination revealed blue discolouration, decreased sensation and cold to touch in the left hand. She had no palpable radial pulse. She admitted Heroin use only but the urine drug screen was also positive for amphetamine. CT angiogram of the left upper extremity was concerning for acute ischaemia due to arterial occlusion. The initial plan was for amputation. However, to salvage the limb with thrombolysis, an interventional radiology angiogram was performed. The angiogram demonstrated diffuse arterial spasm and response to nitroglycerin. She was treated with nitroglycerin drip and transitioned to a calcium channel blocker. She did improve significantly. To ensure no embolic sequelae, the patient was discharged with a month of oral anticoagulation.

scholarly journals Popliteal Artery Entrapment Syndrome Presenting with Acute Limb Ischaemia: A Case Report

2010 ◽  
Vol 2010 ◽  
pp. 1-3 ◽  
Author(s):  
Ramawad Soobrah ◽  
Adam Nawaz ◽  
Tahir Hussain
Keyword(s):  
Popliteal Artery ◽  
Young Patients ◽  
Arterial Occlusion ◽  
Rare Condition ◽  
Limb Ischaemia ◽  
Acute Ischaemia ◽  
Entrapment Syndrome ◽  
Popliteal Artery Entrapment Syndrome ◽  
Acute Limb Ischaemia ◽  
Popliteal Artery Entrapment

Popliteal artery entrapment syndrome (PAES) is a relatively rare condition that occurs in young patients as a result of anomalous anatomic relationships between the popliteal artery and the surrounding musculotendinous structures. Patients usually lack atherogenic risk factors and most commonly present with intermittent claudication in the early stages. In the later stages of undiagnosed PAES, acute ischaemia can occur as a result of complete arterial occlusion or embolism. Hence, early diagnosis and surgical release of the entrapment is crucial for good operative outcome and to prevent limb loss.

Multiorgan thromboembolic shower and its ethical implications

2021 ◽  
Vol 14 (2) ◽  
pp. e238580
Author(s):  
Amedra Basgaran ◽  
Sayani Khara ◽  
Aravinth Sivagnanaratnam
Keyword(s):  
Lower Limb ◽  
Arterial Occlusion ◽  
Kidney Injury ◽  
Lower Limbs ◽  
Limb Ischaemia ◽  
Ethical Implications ◽  
Ct Angiogram ◽  
Bilateral Lower Limb ◽  
St Elevation ◽  
Full Body

A 54 year-old man was admitted after being found on the floor of his home, thought to have been there for approximately 5 days. He was diagnosed with a non-ST elevation myocardial infarction and bilateral cerebral ischaemic infarcts, as well as an acute kidney injury driven by rhabdomyolysis. The following day, bilateral lower limb ischaemia was observed. A full body CT angiogram revealed a complete thromboembolic shower with bilateral arterial occlusion in the lower limbs, bilateral pulmonary emboli, a splenic infarct and mesenteric ischaemia. An echocardiogram revealed a large thrombus in the left ventricle as the likely thromboembolic source. Bilateral lower limb amputations were recommended, commencing a complex discussion regarding the best course of management for this patient. The discussion was multifaceted, owing to the patient’s lack of capacity, and input from multiple teams and the patient’s relatives was required. Both ethical and clinical challenges arise from this case of a thromboembolic shower.

scholarly journals A novel role for milrinone in neonatal acute limb ischaemia: successful conservative treatment of thrombotic arterial occlusion without thrombolysis

2019 ◽  
Vol 12 (12) ◽  
pp. e232440
Author(s):  
Stephanie Boyd ◽  
Vibhuti Shah ◽  
Jaques Belik
Keyword(s):  
Treatment Options ◽  
Arterial Occlusion ◽  
Term Infant ◽  
Pulmonary Vasculature ◽  
Limb Ischaemia ◽  
Ischaemia Reperfusion Injury ◽  
Phosphodiesterase 3 ◽  
Acute Limb Ischaemia ◽  
Risk Treatment ◽  
The Right

Acute neonatal limb ischaemia (NLI) is most frequently an iatrogenic complication, however, may also occur in utero due to thromboembolism. There is no widely accepted protocol for treatment of NLI and limited evidence to guide management. Thrombolysis and surgical management have been attempted, though both are associated with significant morbidities. Milrinone is a phosphodiesterase-3 inhibitor used for its vasodilatory effects on the systemic and pulmonary vasculature. There is also emerging evidence for benefit of milrinone in ameliorating ischaemia-reperfusion injury. The authors present a case report of a term infant with spontaneous perinatal acute limb ischaemia secondary to near-completely occlusive thrombosis of the right subclavian artery. The infant was successfully managed conservatively with milrinone without requirement for thrombolysis or surgical intervention. Milrinone represents a novel treatment option for neonates with acute limb ischaemia and consideration of a trial of milrinone prior to higher risk treatment options is warranted in this patient group.

scholarly journals Management Strategy in Non-Limb-Threatening Acute Ischaemia of Limbs: Should We Rethink?

2016 ◽  
Vol 2016 ◽  
pp. 1-3
Author(s):  
Syed M. Asim Hussain ◽  
Thomas Joseph
Keyword(s):  
Natural History ◽  
Vascular Surgery ◽  
Management Strategy ◽  
Cardiovascular Surgery ◽  
Adverse Outcome ◽  
Limb Ischaemia ◽  
Acute Ischaemia ◽  
First Case ◽  
Acute Limb Ischaemia

The Society of Vascular Surgery and the International Society of Cardiovascular Surgery identify three types of acute limb ischaemia to inform prognosis and management. Type 1 limb ischaemia is non-limb-threatening and is currently managed conservatively. We describe three cases of Type 1 limb ischaemia with femoropopliteal occlusion that were managed differently. The first case was initially managed conservatively but resulted in an adverse outcome following worsening of ischaemia. Overall, the cases managed with earlier intervention had good outcomes suggesting that conservative management alone may not be sufficient despite resolution of symptoms. The trend in other vessel diseases such as NSTEMI and TIA is towards earlier intervention, for example, PCI and CEA. It is likely that acute limb ischaemia has a similar natural history to these conditions. It is time to consider earlier revascularisation in selected patients with non-limb-threatening ischaemia.

Abstract 11417: Drug Abuse and Abdominal Pain: A case of Cocaine Induced Renal and Cardiac Infarction

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Rohit Malhotra ◽  
Anupam Kotwal ◽  
Joel Gore
Keyword(s):  
Abdominal Pain ◽  
Chest Pain ◽  
Left Kidney ◽  
Flank Pain ◽  
Drug Screen ◽  
Renal Infarction ◽  
Urine Drug Screen ◽  
T Wave ◽  
Ct Angiogram ◽  
Urine Drug

Introduction: A 35 year old man presented with sudden onset left-sided chest pain and left flank pain. He had known non-ischemic cardiomyopathy (EF of 40-45%), non compliant with treatment. He was in severe pain with left costovertebral angle tenderness. Initial investigations showed a WBC count of 12,000, troponin of 3.72 and a urinalysis significant for 2+ proteins but no RBCs. Initial ECG showed <1 mm ST segment elevations with T wave inversions in inferior leads. Cardiac catheterization, did not demonstrate any flow limiting disease. Serial ECGs demonstrated a resolution of the aforementioned changes and his troponins trended down. Further review revealed an extensive history of cocaine use confirmed with a positive urine drug screen. Due to worsening abdominal pain, a CT abdomen with contrast was done which showed an acute segmental infarct on the upper pole of left kidney, but a CT angiogram did not show any evidence of obstructing vascular lesion or dissection. He was discharged on oral oxycodone, diltiazem and lisinopril.The patient returned in one week with exertional chest pain that was relieved with sublingual nitroglycerin. ECG on admission showed diffuse T wave inversions which improved in 6 hours. A repeat urine drug screen was positive for cocaine. Troponins peaked at 5.03. He then complained of persistent right flank pain and a repeat CT angiogram showed a new moderate-sized segmental infarct in the mid-pole of the right kidney. His pain was managed with oxycodone and he was eventually discharged home with isosorbide mononitrate, amlodipine and lisinopril. Conclusions: Renal infarcts may be sometimes missed in the absence of imaging, but must be suspected in drug users with flank pain and inferior EKG changes. In this case, it was hypothesized that renal arterial vasospasm led to the infarct; an extension of the known effect of cocaine on coronary vessels. This case highlights the importance of ruling out renal infarction as a cause for persistent abdominal pain. Identification of the cause of infarction is important, so as not to subject patients to long term anticoagulation. Guidelines for the treatment of drug induced renal infarction are lacking and the approach to such patients, as with all substance abusers, is abstinence.

Acute Limb Ischaemia Following Elective Left Upper Lobectomy for Early NSCLC: A Rare but Serious Complication Arising from the Pulmonary Vein Stump

2020 ◽  
pp. 1-2
Author(s):  
James Elliott ◽  
Anand Iyer ◽  
James Elliott
Keyword(s):  
Pulmonary Vein ◽  
Ct Angiography ◽  
Mediastinal Lymph Node ◽  
Case Reports ◽  
Common Femoral Artery ◽  
Sudden Onset ◽  
Leg Pain ◽  
Limb Ischaemia ◽  
Left Upper Lobectomy ◽  
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].

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

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.

scholarly journals Evaluation of an opioid risk mitigation initiative for veterans undergoing hip or knee arthroplasty at San Francisco Veterans Affairs Heath Care System

2020 ◽  
Author(s):  
Tessa Rife ◽  
Christina Tat ◽  
Mahsa Malakootian
Keyword(s):  
San Francisco ◽  
Knee Arthroplasty ◽  
Risk Mitigation ◽  
Opioid Therapy ◽  
Veterans Affairs ◽  
Drug Screen ◽  
Urine Drug Screen ◽  
Urine Drug ◽  
Medication Disposal ◽  
Urine Drug Screening

Abstract Purpose Guidelines recommend evaluating the risk of opioid-related adverse events prior to initiating opioid therapy. The orthopedic service at San Francisco Veterans Affairs Health Care System (SFVHCS) has not routinely used risk assessment tools such as the Stratification Tool for Opioid Risk Mitigation, prescription drug monitoring program data, and urine drug screening prior to opioid prescribing. A quality improvement project was conducted to evaluate the number of pharmacist-provided opioid risk mitigation recommendations implemented by orthopedic providers for patients who underwent total hip or knee arthroplasty at SFVHCS. Summary A pharmacist-led workflow for completing risk mitigation reviews was developed in collaboration with orthopedic providers, and urine drug screening was added to the preoperative laboratory testing protocol. The following recommendations were communicated via electronic medical record: limit postoperative opioids to a 7- or 14-day supply based on risk of suicide and/or overdose, offer naloxone and a medication disposal bag, and order a urine drug screen if not already completed. Risk reviews were completed for 75 patients. Among 64 patients with 2-month postdischarge data available, 88% (7 of 8) of 7-day and 79% (44 of 56) of 14-day opioid supply recommendations were implemented; 41% (26 of 59) of recommendations to issue a medication disposal bag, 17% (2 of 12) recommendations to order a missing urine drug screen, and 9% (5 of 55) of recommendations to offer naloxone were implemented. Conclusion Pharmacist-performed risk mitigation reviews paired with individualized recommendations led to high rates of orthopedic provider acceptance of limiting postdischarge opioid day supplies for patients who had total hip or knee arthroplasty. Alternative strategies may increase access to naloxone. Future research should examine the impact of risk mitigation tools in reducing prescribing of long-term opioid therapy and adverse events among orthopedic surgical patients.

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