Acute limb ischaemia due to vasospasm: a rare presentation

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.

Fatal disseminated paradoxical embolism in inferior sinus venosus atrial septal defect

Inferior sinus venosus arterial septal defect (ASD) is a rare congenital cardiac anomaly. As with other types of ASDs and patent foramen ovale (PFO), this defect results in arteri-venous shunting with the risk of developing paradoxical embolism (PDE) to the systemic circulation from venous emboli. We report a case of a 67-year-old lady presented to emergency department (ED) with massive pulmonary embolism (PE) and recurrent acute limb ischaemia. On CT pulmonary angiography (CTPA), an incidental finding of inferior sinus venosus ASD was discovered that has caused the PDE. Thrombolysis was administered followed by open mechanical thrombectomy. The patient developed massive lower gastrointestinal bleed post thrombolysis then passed away despite embolization. This case report describes the catastrophic effect of PDE to cause disseminated multisystem thromboembolism. It also emphasizes the importance of early detection of a possible right-to-left shunt in patients presented with recurrent acute limb ischaemia. Transthoracic echocardiography has reduced sensitivity for inferior sinus venosus ASD requiring further assessment with transoesophageal echocardiography in selected cases.

Intra-aortic balloon pumps in cardiogenic shock: an overview

The intra-aortic balloon pump was first introduced for the treatment of cardiogenic shock. It is now the most commonly used form of circulatory support, despite disappointing findings from the intra-aortic balloon pump SHOCK II trial ( Thiele et al, 2012 ). Common placement is via the femoral artery into the aorta, with the tip of the balloon sitting below the left subclavian artery and the distal end above the renal arteries. The balloon is timed to inflate at the beginning of diastole augmenting coronary perfusion and deflate on the R wave just before systole, reducing the afterload. Patients who may be considered for intra-aortic balloon pump insertion are those experiencing ST elevation myocardial infarction or complex ischaemic disease and cardiogenic shock. Despite advances in catheter size and technology, potential complications include bleeding from the insertion site, limb ischaemia and compartment syndrome. Cardiovascular nurses require specialist knowledge and skills concerning balloon console technology, nursing care and potential complications.

Peripheral vascular disease

This chapter assesses peripheral vascular disease. It begins with acute limbic ischaemia; chronic upper limb ischaemia; chronic lower limb ischaemia; intermittent claudication; and critical limb ischaemia. The chapter then turns to aneurysms; ruptured abdominal aortic aneurysm; vascular developmental abnormalities; carotid disease; vasospastic disorders; varicose veins; deep venous thrombosis; and thrombolysis. It also considers the diabetic foot and amputations, as well as complications in vascular surgery. Complications may occur in the perioperative, early, or late post-operative periods. In general, vascular patients are older and have increased cardiac, cerebral, pulmonary, and renal comorbidities. This is due to the associated risk factors of hypertension, diabetes mellitus, hypercholesterolaemia, and smoking.