Contemporary Peripheral Revascularization: By Drip or By Suction or By Surgery? George Eigbire MD, Jose Barrientos MD, Brian Allen MD, Syed Saad MD, Glenn Johnson MD
Case : A 35-year-old man sought emergency medical attention due to a persistent throbbing pain in his left leg over the last 24 hours. His medical and social histories are remarkable for active tobacco smoking, self-employment as a tattoo artist, and he suffered a traumatic injury from a riot grenade explosion 1 year ago. He takes no medications. Based upon diminished arterial pulsation on exam, he underwent a CT angiogram of the lower extremities revealing a complete occlusion of the left popliteal artery with reconstitution in the tibio-peroneal trunk as well as an occlusion of the distal left anterior tibial artery. Additionally, numerous metallic densities in the subcutaneous soft tissues of the thigh muscles and a filling defect compatible with non-occlusive thrombus was present in the right common iliac artery. Urgent invasive vascular revascularization of the left lower extremity was planned, and IV heparin initiated. A Cragg-McNamara catheter was advanced proximal left popliteal occlusion and a prolonged infusion of tPA given. Repeat angiography showed unsuccessful revascularization with persistent thrombosis within the left popliteal and anterior tibial arteries. At that point, thrombectomy was performed with an aspiration catheter (PENUMBR Indigo Aspiration System) yielding excellent angiographic results. A hypercoagulable work up resulted in the detection of heterozygous methylene- tetrahydrofolate reductase (MTHFR) gene mutation. MTHFR enzyme defect results in elevated levels of homocysteine.
Discussion
Acute limb ischemia is associated with significant morbidity and mortality. In our patient, prolonged local fibrinolytic therapy was ineffective in treating the occlusion, necessitating therapy escalation. There is growing literature on the use of catheter thrombectomy as a viable alternative to open surgery in these patients, particularly when other modalities have failed.
Conclusion :
Mechanical aspiration thrombectomy can be considered a viable option in patients presenting with arterial thrombosis, particularly in patients that that have failed other modalities.
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