Document Detail

Acute embolic occlusion of the left common iliac artery treated with intra-arterial thrombolysis and percutaneous thrombectomy.
Jump to Full Text
MedLine Citation:
PMID:  19543496     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
Acute embolic occlusion of the common iliac artery is a rare medical emergency that is not only limb-threatening, but also potentially life-threatening. Several treatment options exist for acute limb ischemia, although no treatment is clearly best. We report a case of acute embolic occlusion of the left common iliac artery in a patient with atrial fibrillation who was treated successfully using mechanical thrombectomy following intra-arterial thrombolysis.
Authors:
Wang-Soo Lee; Kwang Je Lee; Wang Seong Ryu
Related Documents :
22976606 - Fatal tracheo-innominate artery fistula after tracheostomy in a patient with pelizaeus-...
1065306 - Gangrene following intra-arterial injection of procaine penicillin.
8402106 - Acute limb deterioration during intra-arterial thrombolysis.
25035766 - Evaluation of karl storz cmac tip™ device versus traditional airway suction in a cada...
24857936 - Inadvertent subclavian artery cannulation and options for management.
1950996 - Intraoperative valvuloplasty in calcific aortic stenosis: a study comparing the mechani...
Publication Detail:
Type:  Case Reports; Journal Article     Date:  2009-06-08
Journal Detail:
Title:  The Korean journal of internal medicine     Volume:  24     ISSN:  1226-3303     ISO Abbreviation:  Korean J. Intern. Med.     Publication Date:  2009 Jun 
Date Detail:
Created Date:  2009-06-22     Completed Date:  2009-07-22     Revised Date:  2013-05-23    
Medline Journal Info:
Nlm Unique ID:  8712418     Medline TA:  Korean J Intern Med     Country:  Korea (South)    
Other Details:
Languages:  eng     Pagination:  153-5     Citation Subset:  IM    
Affiliation:
Department of Internal Medicine, College of Medicine, Chung-Ang University, Dongjak-gu, Seoul, Korea.
Export Citation:
APA/MLA Format     Download EndNote     Download BibTex
MeSH Terms
Descriptor/Qualifier:
Acute Disease
Arterial Occlusive Diseases / radiography,  therapy*
Combined Modality Therapy
Embolism / radiography,  therapy*
Female
Fibrinolytic Agents / administration & dosage*
Humans
Iliac Artery* / radiography
Middle Aged
Thrombectomy*
Thrombolytic Therapy*
Tomography, X-Ray Computed
Treatment Outcome
Urokinase-Type Plasminogen Activator / administration & dosage*
Chemical
Reg. No./Substance:
0/Fibrinolytic Agents; EC 3.4.21.73/Urokinase-Type Plasminogen Activator
Comments/Corrections

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

Full Text
Journal Information
Journal ID (nlm-ta): Korean J Intern Med
Journal ID (publisher-id): KJIM
ISSN: 1226-3303
ISSN: 2005-6648
Publisher: The Korean Association of Internal Medicine
Article Information
Download PDF
Copyright © 2009 The Korean Association of Internal Medicine
Received Day: 01 Month: 7 Year: 2008
Accepted Day: 18 Month: 8 Year: 2008
Print publication date: Month: 6 Year: 2009
Electronic publication date: Day: 08 Month: 6 Year: 2009
Volume: 24 Issue: 2
First Page: 153 Last Page: 155
ID: 2698625
PubMed Id: 19543496
DOI: 10.3904/kjim.2009.24.2.153

Acute Embolic Occlusion of the Left Common Iliac Artery Treated With Intra-Arterial Thrombolysis and Percutaneous Thrombectomy
Wang-Soo LeeA1
Kwang Je LeeA1
Wang Seong RyuA1
Department of Internal Medicine, College of Medicine, Chung-Ang University, Seoul, Korea.
Correspondence: Correspondence to Kwang Je Lee, MD. Division of Cardiology, Department of Internal Medicine, Chung-Ang University Hospital, 224-1 Heukseok-dong, Dongjak-gu, Seoul 156-756, Korea. Tel: 82-2-6299-1404, Fax: 82-2-825-7571, heartlee@cau.ac.kr

INTRODUCTION

Acute embolic occlusion of a limb artery is a rare but serious medical emergency because acute limb ischemia is not only limb-threatening, but also potentially life-threatening. It requires prompt diagnosis and management. Surgery, local thrombolysis, percutaneous thrombectomy, and stenting have all been used to treat acute embolic limb ischemia, but the best treatment strategy remains controversial.

We report a case of acute embolic occlusion of the left common iliac artery in a patient with atrial fibrillation who was treated successfully with combined local thrombolysis and mechanical thrombectomy.


CASE REPORT

A 56-year-old woman was admitted to our hospital with sudden-onset pain, absent pulses, paresthesia, and pallor of the left lower extremity that had begun 10 hours before admission. She had been diagnosed with atrial fibrillation at another hospital 4 years before this presentation.

Computed tomographic (CT) angiography of the left lower extremity showed total occlusion of the proximal left common iliac artery (Fig. 1). Initially, we performed intra-arterial thrombolysis with urokinase 200,000 units for 1 hour. Follow-up angiography revealed antegrade flow with large residual thrombi (Fig. 2), so we decided to perform a percutaneous mechanical thrombectomy through the ipsilateral femoral artery using the OASIS™ thrombectomy system (Medi-Tech/Boston Scientific, Watertown, MA) (Fig. 3). Immediate post-procedural angiography demonstrated almost complete patency of the previously occluded artery. Follow-up CT angiography 14 days later showed a normal left common iliac artery (Fig. 4).

The patient tolerated the procedures well with no complications and was clinically stable at the 9-month follow-up.


DISCUSSION

A recent epidemiologic study showed that peripheral artery obstruction occurs in 14 of every 100,000 people in the general population [1]. The most common cause of non-traumatic acute limb ischemia is embolism or thrombosis. The heart is the major source of emboli in patients with valvular disease with or without atrial fibrillation or ventricular mural thrombus after myocardial infarction. Thrombotic obstructions of the peripheral arteries are generally associated with atherosclerotic progression. However, differentiating these two pathologies clinically is difficult in most cases, and impossible in 10-15% of cases [2,3].

Classically, the symptoms of acute limb ischemia are dominated by the six Ps (pain, pallor, paralysis, poikilothermia, paresthesias, and pulselessness) or 'blue toe syndrome' [4]. Patients in whom acute limb occlusion is suspected are evaluated using digital subtraction angiography (DSA), duplex ultrasonography, CT angiography, and magnetic resonance angiography. Although DSA is regarded as the gold standard for limb ischemia imaging, CT angiography has recently come into wider use [5-7].

Various options have been proposed for the management of acute embolic limb ischemia. For years, surgical procedures such as embolectomy, bypass, and amputation were considered the gold standard treatment for total common iliac artery occlusion. However, early operative intervention has several procedural limitations and is characterized by a high mortality rate, with a 30-day mortality rate of 15-25% [8,9].

Randomized studies have shown that thrombolysis is generally as effective as surgery. Therefore, local thrombolysis has become a treatment modality in appropriately selected patients [10,11]. Moreover, several recent studies have reported that percutaneous mechanical thrombectomy has a high success rate, with low ampu-tation and mortality rates [12,13]. Primary endovascular stenting is not usually considered for the treatment of acute embolic limb lesions due to the fear of distal embolization [14]. Therefore, instead of using surgery or stenting, we decided to combine treatment with intra-arterial thrombolysis and percutaneous thrombectomy.

In conclusion, initial local thrombolysis followed by mechanical thrombectomy, as performed in this case, is an option for treating acute embolic occlusion of the common iliac artery.


References
1. Davies B,Braithwaite BD,Birch PA,Poskitt KR,Heather BP,Earnshaw JJ. Acute leg ischaemia in GloucestershireBr J SurgYear: 1997845045089112902
2. Dormandy J,Heeck L,Vig S. Acute limb ischemiaSemin Vasc SurgYear: 19991214815310777242
3. Panetta T,Thompson JE,Talkington CM,Garrett WV,Smith BL. Arterial embolectomy: a 34-year experience with 400 casesSurg Clin North AmYear: 1986663393533952607
4. Halperin JL. Evaluation of patients with peripheral vascular diseaseThromb ResYear: 2002106V303V31112359343
5. Ascher E,Hingorani A,Markevich N,Schutzer R,Kallakuri S. Acute lower limb ischemia: the value of duplex ultrasound arterial mapping (DUAM) as the sole preoperative imaging techniqueAnn Vasc SurgYear: 20031728428912712369
6. Willmann JK,Baumert B,Schertler T,et al. Aortoiliac and lower extremity arteries assessed with 16-detector row CT angiography: prospective comparison with digital subtraction angiographyRadiologyYear: 20052361083109316055691
7. Huegli RW,Aschwanden M,Bongartz G,et al. Intraarterial MR angiography and DSA in patients with peripheral arterial occlusive disease: prospective comparisonRadiologyYear: 200623990190816641335
8. Henry M,Rath PC,Klonaris C,Katsargyris A,Henry I,Hugel M. Peripheral vascular diseases: an update on endovascular therapyIndian Heart JYear: 20055774776616521655
9. Ouriel K,Veith FJ,Sasahara AA. A comparison of recombinant urokinase with vascular surgery as initial treatment for acute arterial occlusion of the legsN Engl J MedYear: 1998338110511119545358
10. The STILE InvestigatorsResults of a prospective randomized trial evaluating surgery versus thrombolysis for ischemia of the lower extremityAnn SurgYear: 19942202512668092895
11. Ouriel K,Veith FJ,Sasahara AA. Thrombolysis or peripheral arterial surgery: phase I resultsJ Vasc SurgYear: 19962364738558744
12. Müller-Hülsbeck S,Kalinowski M,Heller M,Wagner HJ. Rheolytic hydrodynamic thrombectomy for percutaneous treatment of acutely occluded infra-aortic native arteries and bypass grafts: midterm follow-up resultsInvest RadiolYear: 20003513114010674458
13. Ansel GM,George BS,Botti CF,et al. Rheolytic thrombectomy in the management of limb ischemia: 30-day results from a multicenter registryJ Endovasc TherYear: 2002939540212222998
14. Berczi V,Thomas SM,Turner DR,Bottomley JR,Cleveland TJ,Gaines PA. Stent implantation for acute iliac artery occlusions: initial experienceJ Vasc Interv RadiolYear: 20061764564916614147

Article Categories:
  • Case Report

Keywords: Peripheral vascular disease, Thrombolytic therapy, Thrombectomy, Embolism.

Previous Document:  A case of hepatocellular carcinoma within hepatocellular adenoma in a non-cirrhotic male.
Next Document:  Acute fibrinous and organizing pneumonia following hematopoietic stem cell transplantation.