Acute Limb Ischemia in the Young: A Rare Case of Essential Thrombocytosis

Acute limb ischemia (ALI) is rarely observed in young populations. The hypercoagulable state is a notable cause of ALI other than artery disease progression and cardiac embolization. A hypercoagulable state occurs in essential thrombocytosis because of the overproduction of hematopoietic cells secondary to the mutation of the JAK2, CALR, or MPL genes. We report a rare case of a 37-year-old woman presenting with Rutherford IIA ALI in the left lower extremity. Laboratory data revealed she had a platelet count reaching up to 1.38 mil/μL, with other blood profiles being normal. A JAK2 mutation examination was later performed and proved positive. After careful management with catheter-directed thrombolysis, surgical thrombectomy, and cytoreductive therapy using hydroxyurea, the symptoms subsided and eventually restored the patient to physical activity in less than one month.

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Clinical outcomes of surgical embolectomy versus catheter-directed thrombolysis for acute limb ischemia: a nationwide cohort study

Journal of Thrombosis and Thrombolysis ◽

10.1007/s11239-021-02532-1 ◽

2021 ◽

Author(s):

Po-Kai Yang ◽

Chien-Chou Su ◽

Chih-Hsin Hsu

Keyword(s):

Rate Ratio ◽

Surgical Intervention ◽

Limb Ischemia ◽

Acute Limb Ischemia ◽

Antithrombotic Agent ◽

Catheter Directed Thrombolysis ◽

Significant Difference ◽

Surgical Embolectomy ◽

Adjusted Rate ◽

Adjusted Rate Ratio

AbstractIn Taiwan, the outcomes of acute limb ischemia have yet to be investigated in a standardized manner. In this study, we compared the safety, feasibility and outcomes of acute limb ischemia after surgical embolectomy or catheter-directed therapy in Taiwan. This study used data collected from the Taiwan’s National Health Insurance Database (NHID) and Cause of Death Data between the years 2000 and 2015. The rate ratio of all-cause in-hospital mortality and risk of amputation during the same period of hospital stay were estimated using Generalized linear models (GLM). There was no significant difference in mortality risk between CDT and surgical intervention (9.5% vs. 10.68%, adjusted rate ratio (95% CI): regression 1.0 [0.79–1.27], PS matching 0.92 [0.69–1.23]). The risk of amputation was also comparable between the two groups. (13.59% vs. 14.81%, adjusted rate ratio (95% CI): regression 0.84 [0.68–1.02], PS matching 0.92 [0.72–1.17]). Age (p < 0.001) and liver disease (p = 0.01) were associated with higher mortality risks. Heart failure (p = 0.03) and chronic or end-stage renal disease (p = 0.03) were associated with higher amputation risks. Prior antithrombotic agent use (p = 0.03) was associated with a reduced risk of amputation. Both surgical intervention and CDT are effective and feasible procedures for patients with ALI in Taiwan.

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RR20. Ultrasound-Accelerated Thrombolysis is Superior to Catheter-Directed Thrombolysis for the Treatment of Acute Limb Ischemia

Journal of Vascular Surgery ◽

10.1016/j.jvs.2011.03.206 ◽

2011 ◽

Vol 53 (6) ◽

pp. 106S-107S

Author(s):

Maria E. Litzendorf ◽

Jean E. Starr ◽

Bhagwan Satiani ◽

Katherine E. Notter

Keyword(s):

Limb Ischemia ◽

Acute Limb Ischemia ◽

Catheter Directed Thrombolysis

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Advances in Revascularization for Peripheral Artery Disease: Revascularization in PAD

Circulation Research ◽

10.1161/circresaha.121.318261 ◽

2021 ◽

Vol 128 (12) ◽

pp. 1885-1912

Author(s):

Joshua A. Beckman ◽

Peter A. Schneider ◽

Michael S. Conte

Keyword(s):

Intermittent Claudication ◽

Peripheral Artery Disease ◽

Clinical Presentation ◽

Rapid Development ◽

Microvascular Disease ◽

Limb Ischemia ◽

Medical Emergency ◽

Acute Limb Ischemia ◽

Peripheral Artery ◽

Artery Disease

Effective revascularization of the patient with peripheral artery disease is about more than the procedure. The approach to the patient with symptom-limiting intermittent claudication or limb-threatening ischemia begins with understanding the population at risk and variation in clinical presentation. The urgency of revascularization varies significantly by presentation; from patients with intermittent claudication who should undergo structured exercise rehabilitation before revascularization (if needed) to those with acute limb ischemia, a medical emergency, who require revascularization within hours. Recent years have seen the rapid development of new tools including wires, catheters, drug-eluting technology, specialized balloons, and biomimetic stents. Open surgical bypass remains an important option for those with advanced disease. The strategy and techniques employed vary by clinical presentation, lesion location, and lesion severity. There is limited level 1 evidence to guide practice, but factors that determine technical success and anatomic durability are largely understood and incorporated into decision-making. Following revascularization, medical therapy to reduce adverse limb outcomes and a surveillance plan should be put in place. There are many hurdles to overcome to improve the efficacy of lower extremity revascularization, such as restenosis, calcification, microvascular disease, silent embolization, and tools for perfusion assessment. This review highlights the current state of revascularization in peripheral artery disease with an eye toward technologies at the cusp, which may significantly impact current practice.

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Atrial Fibrillation is Associated with Femoropopliteal Totally Occlusive In-Stent Restenosis: A Single-Center, Retrospective, Observational Study

Journal of Interventional Cardiology ◽

10.1155/2021/8852466 ◽

2021 ◽

Vol 2021 ◽

pp. 1-8

Author(s):

Yohsuke Honda ◽

Keisuke Hirano ◽

Masahiro Yamawaki ◽

Motoharu Araki ◽

Norihiro Kobayashi ◽

...

Keyword(s):

Atrial Fibrillation ◽

Cox Regression ◽

De Novo ◽

Limb Ischemia ◽

Hazard Ratio ◽

Acute Limb Ischemia ◽

Stent Occlusion ◽

Stent Restenosis ◽

Artery Disease ◽

In Stent Restenosis

Introduction. The proportion of patients with comorbid atrial fibrillation (AF) and peripheral artery disease (PAD) has increased in this era. This study aimed to assess the relationship between AF and totally occlusive in-stent restenosis (ISR) in femoropopliteal (FP) lesions. Methods. In this study, 363 patients (461 stents) who underwent endovascular therapy with de novo stent implantation in our hospital between April 2007 and December 2016 were retrospectively evaluated. The patients were divided into two groups according to the AF status (AF group, 61 patients; sinus group, 302 patients). The primary endpoint was the incidence of totally occlusive ISR within 3 years. The secondary endpoint was the incidence of acute limb ischemia (ALI) due to FP stent occlusion. Results. Baseline characteristics were similar, except for higher age and a lower prevalence of dyslipidemia in the AF group. The incidence of a totally occlusive ISR was higher in the AF group than in the sinus group (29.5% vs. 14.6%, p = 0.004 ). A multiple Cox regression model suggested that presence of AF (hazard ratio, 2.10) and CTO lesion (hazard ratio, 1.97) which were the independent predictors of a totally occlusive ISR within 3 years. The incidence of ALI was significantly higher in the AF group than in the sinus group (3.9% vs. 0%, p = 0.0001 ). In the AF group, the introduction of an anticoagulant did not prevent the occurrence of totally occlusive ISR ( p = 0.71 ) for ALI ( p = 0.79 ). Conclusions. AF is independently associated with totally occlusive ISR of FP stents; however, anticoagulant use does not prevent stent occlusion.

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Acute Limb Ischemia in One Dose Vaccination of COVID-19

Journal of Indonesian Society for Vascular and Endovascular Surgery ◽

10.36864/jinasvs.2021.2.001 ◽

2021 ◽

Vol 2 (2) ◽

pp. 1-4

Author(s):

Kemas Dahlan ◽

Yulianto Kusnadi ◽

Edo Tondas ◽

Daffa Faturrahman

Keyword(s):

Severe Acute Respiratory Syndrome ◽

Virus Disease ◽

Limb Ischemia ◽

Hypercoagulable State ◽

Anterior Tibial Artery ◽

Acute Limb Ischemia ◽

Full Dose ◽

Arterial Perfusion ◽

State Management ◽

Tibial Artery

Introduction: The extraordinary thrombotic manifestations of Corona virus Disease-2019 (COVID-19) caused by Severe Acute Respiratory Syndrome CoV-2 (SARS-CoV-2) virus, presenting as venous and arterial thrombosis have been reported in several literatures, but in this report, we presented a special case of acute limb ischemia in a patient that has been vaccinated by COVID-19 vaccine. Acute limb ischemia (ALI) is defined as decreasing in arterial perfusion of a limb with a threat to viability of the limb and mortality. COVID-19 has been declared as a global pandemic by the WHO. Patients with COVID-19 have abnormalities in blood coagulation parameters and are prone to thromboembolic events. This hypercoagulable state caused by COVID-19 mainly manifests as venous thromboembolism while peripheral arterial involvement is less frequent. Case: A 54-year diabetic and smoker male has already got one dose COVID-19 vaccination came to our emergency unit with severe acute respiratory syndrome and pain, pale and paresthesia of his left leg. There was pneumonia pattern according to chest X-ray and a ground glass opacity in chest CT-scan, he was confirmed infected by COVID-19 according to RT-PCR test. From CT-Angiography we found multiple thrombosis in the distal aorta, superficial femoral artery (SFA), anterior tibial artery (ATA), and posterior tibial artery (PTA) of left lower extremity. Initial treatment we started with unfractionated heparin, oxygenation, intravenous fluid and analgesia. We managed the patient in isolation ward special for COVID-19. We did thrombectomy to save the limb, nevertheless in few days after we performed amputation at the level of talonavicular joint to the distal part of left foot caused by gangrene. Conclusion: Vaccination can protect from COVID-19 if we vaccinated with full dose and our immune system able to create antibody. The condition will be different in immunocompromised condition and we get not full dose vaccination. Covid-19 Patient with Diabetes and smoker could have higher risk to develop acute limb ischemia because of hypercoagulable state. Management of a COVID-19 patient with cute limb ischemia is more complicated and challenging. Although we have already vaccinated life style modification like wearing a mask, social distancing and using hand sanitizer can give us more protection from Covid 19. Keywords: acute limb ischemia, COVID-19 vaccination, heparinization, thrombectomy

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Catheter directed thrombolysis for acute limb ischemia: eight cases in two years

Cardiologia Croatica ◽

10.15836/ccar.2014.185 ◽

2014 ◽

Vol 9 (5-6) ◽

pp. 185-185

Author(s):

Majda Vrkic Kirhmajer ◽

Ljiljana Banfic ◽

Kresimir Putarek ◽

Miroslav Krpan ◽

Savko Dobrota ◽

...

Keyword(s):

Limb Ischemia ◽

Acute Limb Ischemia ◽

Catheter Directed Thrombolysis

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The Role of Catheter Directed Thrombolysis on Acute Limb Ischemia (an Evidence-Based Case Report)

Jurnal llmu Bedah Indonesia ◽

10.46800/jibiikabi.v49i1.79 ◽

2021 ◽

Vol 49 (1) ◽

pp. 3-24

Author(s):

Ali Farhan Fathoni ◽

Raden Suhartono

Keyword(s):

Case Report ◽

Adult Patient ◽

Controlled Trial ◽

Limb Ischemia ◽

Evidence Based ◽

Acute Limb Ischemia ◽

First Line ◽

Bleeding Events ◽

Catheter Directed Thrombolysis ◽

Significant Difference

Introduction. Acute limb ischemia can be managed both with surgery and thrombolysis, especially catheter-directed thrombolysis. The risk, benefit and indication of thrombolysis is already well known. However, as a first line therapy, it is unclear which intervention is more beneficial; the catheter directed thrombolysis or surgery. This report aims to elucidate which technique is more effective and safer. Method. This is an Evidence-Based Case Report based on a case of a geriatric, diabetic patient whom suffered acute limb ischemia. The report systematically search for meta-analysis, systematic review, randomized controlled trial and cohort studies from Cochrane central and PubMed for all adult patient suffering from acute limb ischemia whose are treated with catheter-directed thrombolysis or surgery as first-line intervention and comparing the outcome in terms of efficacy (clinical outcome such as patency and amputation-free rates) and safety (mortality and morbidity). Results. Subjects’ characteristics should be placed first to draw the demography. Put the study finding(s) here with no interpretation. For all adult patient regardless of their diabetic status and age there is no statistically significant difference for limb salvage, amputation, and mortality between two technique, however catheter directed thrombolysis showed reduced need for additional intervention whilst increasing risk of bleeding events. Conclusion. Neither techniques are more superior than the other but catheter-directed thrombolysis can be considered given that it reduce the need for further intervention, less invasive and even though it has risks for bleeding complication it is still lower compared to systemic thrombolysis. The selection of which technique can be up to clinician’s discretion in consideration of risk and benefit for each patient.

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