Acute Limb Ischemia: A rare and devastating complication of infective Endocarditis

Introduction@#In contrast to embolic events to the brain, lungs and spleen which have been comprehensively discussed in literature, acute limb ischemia (ALI) due to septic embolism (SE) from infective endocarditis (IE) are uncommonly reported. There have been no reported cases of ALI as a complication of IE among Filipinos to date making this case report the first in our country@*Case Presentation@#We report two cases of communityacquired native valve endocarditis caused by streptococcus spp. and enterococcus faecalis. Both patients had large and mobile vegetations in the mitral valve and aortic valve respectively on transthoracic echocardiography. The first one developed ALI (IIa) on the R leg after the initiation of antibiotics. The second case presented with ALI (IIa) on the R leg on admission. They were given the appropriate antibiotics and received systemic anticoagulation with heparin. The first case underwent successful emergency embolectomy on the R leg but developed new-onset ALI on the L leg and refused further intervention. Embolectomy was also recommended on the second patient who also re-fused any intervention. Despite maximal medical management, both patients subsequently expired@*Conclusion@#Infective endocarditis (IE) patients are at risk to develop SE before or during the initiation of appropriate antibiotics. ALI is a life threatening extra cardiac complication of IE. Early recognition and prompt aggressive management are therefore imperative.

Outcomes of limb and life in patients with acute lower limb ischema presenting before and after the “golden six hours”

Background: Acute limb ischemia (ALI) is any sudden decrease in limb perfusion causing a potential threat to limb viability. It is generally accepted that in a patient without underlying arterial disease who develops an acute arterial blockage has approximately six hours for revascularisation before irreversible damage occurs. This study endeavoured to analyse and evaluate the causes and clinical outcome of acute lower limb ischemia.Methods: 80 successive patients visiting Jain Institute of Vascular Sciences, Bangalore who were diagnosed to have ALI were included in this prospective study. Thromboembolectomy was performed in 48% of patients, 9% of patients were managed with anticoagulation alone, 8% of patients were treated by catheter directed thrombolysis and primary amputation was inevitable in 16 patients of class III ischemia.Results: All the five patients who presented within the golden six hours survived and their limbs could be salvaged without any morbidity. Even in patients with delayed presentation but viable limb (47 patients) functional limb salvage was possible in 39 patients (82.9%). Overall there was 72.73% limb salvage and 27.27% patients underwent amputation. There was a mortality rate of 13.16% in the study.Conclusions: Overall there was 72.73% limb salvage and 27.27% patients underwent amputation. Revascularization within six hours is ideal (only 6.25% of patients in our study); however, in delayed presentation (93.75%), physiological state of the limb, rather than elapsed time from onset of occlusion will determine the operability. Late revascularization may thus be indicated and is often successful if limb still exhibits signs of viability.

Acute Limb Ischemia Due to Cardiac Thromboembolismin a Young Patient without Myocardial Infarction or Cardiomyopathy

Acute limb ischemia secondary to systemic arterial embolism from left ventricular thrombus is a rare life threatening emergency. Peripheral arterial thrombosis superimposed on an atherosclerotic disease or thromboembolism from cardiac or aortic source are the two most common causes of acute limb ischemia. We present a case of a young healthy female who had recurrent admissions with acute lower extremity ischemia secondary to embolism from intra cardiac thrombus diagnosed by bedside doppler and computed angiogram, managed by surgical thromboembolectomy and discharge on anticoagulation.

Preliminary clinical application of catheter - directed thrombolysis with urokinase for acute limb ischemia / 介入放射学杂志

Objective To evaluate the curative effect and feasibility of catheter-directed thrombolysis with urokinase for acute limb ischemia. Methods The clinical data of a total of 21 patients with acute limb ischemia, who were treated with infusion of urokinase through UniFuse thrombolytic catheter, were retrospectively analyzed. The clinical curative efficacy, prognosis and complications of catheter - directed thrombolysis (CDT) were summarized. Results In all patients, thrombolysis therapy was effective, the clinical symptoms were alleviated, and successful limb salvage was achieved. One patient died of cerebral hemorrhage due to renal decompensation. No other serious complications such as hemorrhage, hematoma or disability occurred. Conclusion Preliminary clinical study shows that CDT with urokinase is effective and safe for the treatment of acute limb ischemia. This therapy can help reduce unnecessary surgical procedures or stent implantation, and the risk of thrombolysis is controllable. (J Intervent Radiol, 2018, 27: 262-265)

Application of AngioJet rheolytic thrombectomy in the treatment of acute limb ischemia / 介入放射学杂志

Objective To investigate the effectiveness and safety of AngioJet rheolytic thrombectomy in the treatment of acute limb ischemia (ALI). Methods The clinical data of a total of 19 patients with ALI of lower limbs, who were treated with AngioJet rheolytic thrombectomy, were retrospectively analyzed. The patients included 14 males and 5 females, with a mean age of (77.7±6.8)years old (66-90 years old). The thrombus clearance rate ≥90％ was defined as grade Ⅲ, 50％-90％ as grade Ⅱ, and <50％ as grade I, which was used to evaluate the thrombus clearance effect. The postoperative device-related complication, amputation incidence and the mortality were recorded. Results In all the 19 patients, the technical success rate was 100％. The thrombus clearance rate after initial AngioJet rheolytic thrombectomy was >50％ in all patients, among them grade Ⅲ was obtained in 14 patients (73.7％) and grade Ⅱ in 5 patients (26.3％). The symptoms of lower extremity pain, ischemia, etc. were improved. In 5 patients, macroscopic hemoglobinuria occurred once after the treatment. No serious complications such as bleeding at puncture point, hemorrhage of digestive tract, renal function damage or death occurred. Limb salvage was achieved in17, with a limb salvage rate of 89.5％, the 6-month and one-year limb salvage rates were 84.6％ (11/13) and 80.0％ (8/10) respectively. Conclusion For the treatment of ALI of lower limbs, AngioJet rheolytic thrombectomy is safe and effective, it can rapidly recover arterial blood flow. AngioJet rheolytic thrombectomy is especially suitable for the elderly patients and the patients who have high risk for surgical operation or have contraindications for thrombolysis.

Aorto-Uni-Iliac Stent Grafting and Femoro-Femoral Bypass in a Patient with a Failed and Catastrophic Endovascular Aortic Aneurysm Repair

A 78-year-old man presented at Eulji University Hospital due to an abdominal aortic aneurysm with maximum diameter of 52 mm, which had been increased from 45 mm over 6 months. He underwent embolization of the left internal iliac artery with vascular plug, prior to endovascular abdominal aortic repair with a bifurcated stent graft system. Unfortunately, the inserted vascular plug was maldeployed and protruded into left external iliac artery, and caused acute limb ischemia. Because revascularization of the occluded segment was failed, emergent hybrid approach with aorto-uni-iliac stent grafting and femoro-femoral bypass was done, successfully.

Acute Limb Ischemia and Coronary Artery Disease in a Case of Kimura's Disease

Kimura disease (KD) is an immune-mediated chronic inflammatory disease of unknown etiology. KD has many complications associated with hypereosinophilia, including various forms of allergic reactions and eosinophilic lung disease. Additionally, hypereosinophilia is associated with hypercoagulability, which may lead to thromboembolic events. A 36-year-old man with KD presented with acute limb ischemia and coronary artery occlusion. He underwent thrombectomy, partial endarterectomy of both popliteal arteries, and coronary artery stent insertion. KD is a systemic disease that affects many organs and presents with thromboembolism and vasculitis. In a patient with KD, physicians should evaluate the vascular system, including the coronary arteries.

Acute Myeloid Leukemia with Intracardiac Thrombus Presenting as Acute Limb Ischemia

No abstract available.

Recurrent Arterial Thrombosis as a Presenting Feature of a Variant M3-Acute Promyelocytic Leukemia

Acute limb ischemia (ALI) is a common vascular emergency. Hematologic malignancies are commonly associated with derangement of normal hemostasis and thrombo-hemorrhagic symptoms during the course of the disease are common. However, ALI as an initial presenting feature of acute leukemia is rare. Due to the rarity of this presentation, there is a scarcity of prospective randomized data to optimally guide the management of these patients. Current knowledge is mainly based on isolated cases. We report our experience managing a patient who presented with ALI and was found to have occult leukemia. A review of all cases with ALI as a presenting feature of acute leukemia is also presented.

Cierre primario de fasciotomías con técnica con elásticos: experiencia nacional multicéntrica / Fasciotomy closure technique with vessel loops

Aim: Present and describe the progressive fasciotomy closure technique with vessel loops. Methods: Progressive and multicentric study in the period between June of 2007 and June of 2011. Results: In 2007 we initiated the complementary treatment for fasciotomy closure related to compartment syndrome or acute ischemia cases. Progressive closure with vessel loops, the shoelace technique. In 2010's preliminary report, we published a total of 56 fasciotomies closed by this technique, with an average closure time of 9.5 +/- 3.31 days. Current report is the result of a 4 years prospective study intending to prove that is possible to associate this technique to the initial management of fasciotomies closure. This final report shows a total of 122 fasciotomies cases closed in 7.9 +/- 3.31 days, without skin grafts. Conclusion: The technique is easy to learn, reproducible and not expensive. Results show that this technique is useful in reduce the time for fasciotomy closure.

Objetivos: Presentar y describir la técnica de cierre progresivo de fasciotomías con elásticos. Métodos: Estudio prospectivo multicéntrico realizado en Santiago de Chile entre junio de 2007 y junio de 2011. Resultados: En el año 2007 se inició un protocolo de manejo del cierre de las fasciotomías realizadas a pacientes portadores de síndrome compartimental o isquemia aguda de extremidades. Utilizando una técnica de entrelazado con elásticos vasculares se realizó el cierre de las fasciotomías. En el 2010 se publicó un reporte preliminar, presentando una serie de 56 fasciotomías cerradas con esta técnica, con un promedio de cierre de 9,5 +/- 3,31 días. La serie actual es el resultado de un estudio prospectivo de 4 años de duración que ha buscado demostrar que resulta posible asociar esta técnica con elásticos al manejo inicial del cierre de las fasciotomías. Nuestro reporte final muestra un total de 122 fasciotomías cerradas en un promedio de 7,9 +/- 3,31 días sin requerir de injertos de piel. Conclusiones: Presentamos una técnica quirúrgica fácil de reproducir, de bajo costo y con buenos resultados. El uso de elásticos vasculares muestra beneficios en el tiempo de cierre de las fasciotomías.

Acute Upper Extremity Ischemia Caused by a Tumor Embolism / 日本心臓血管外科学会雑誌

A 52-year-old woman had undergone colectomy and adjuvant chemotherapy for stage IV cecal cancer with peritoneal dissemination and multiple metastases to the lung and liver. After two years of follow-up, she suddenly had right upper limb pain and was reffered to our hospital for treatment of acute upper limb ischemia. Enhanced CT revealed obstruction of the right brachial artery and metastatic lung cancer with pulmonary vein invasion. We performed emergency embolectomy with local anesthesia. The patient's perioperative course was uneventful. Pathological findings of the removed embolus revealed that it contained adenocarcinoma cells. We concluded that the embolus had originated from the metastatic lung cancer with pulmonary vein invasion.

Acute Upper Limb Ischemia due to Cardiac Origin Thromboembolism: the Usefulness of Percutaneous Aspiration Thromboembolectomy via a Transbrachial Approach

OBJECTIVE: To evaluate the usefulness of percutaneous aspiration thromboembolectomy (PAT) via a transbrachial approach in patients with acute upper limb ischemia. MATERIALS AND METHODS: From July 2004 to March 2008, eleven patients with acute upper limb ischemia were enrolled in this study. They were initially treated with thrombolysis (n = 1), PAT (n = 6), or both (n = 4) via a femoral artery approach. However, all of the patients had residual thrombus in the brachial artery, which was subsequently managed by PAT via the transbrachial approach for removal of residual emboli. RESULTS: Successful re-canalization after PAT via a transbrachial approach was achieved in all patients. Two patients experienced early complications: one experienced a massive hematoma of the upper arm due to incomplete compression and was treated by stent deployment. The other patient experienced a re-occlusion of the brachial artery the day after the procedure due to excessive manual compression of the puncture site, but did not show recurrence of ischemic symptoms in the artery of the upper arm. Clinical success with complete resolution of ischemic symptoms was achieved in all patients. CONCLUSION: PAT via a transbrachial approach is a safe and effective treatment for patients with acute upper limb ischemia.

Biologic Wet Dressing with Amnion in Muscle Necrosis of Lower Extremity Caused by Acute Limb Ischemia

Early treatment to facilitate the muscular blood flow can avert myonephropathic metabolic syndrome (MNMS) and major amputation for patients suffering with acute limb ischemia. Delayed reperfusion or microemboli in the small vessels can aggreviate: ischemic changes and lead to irreversible muscle necrosis. Amnion is an excellent biological dressing, and we tried using it to treat anterior compartment muscle necrosis (ACMN). The amnions were aseptically collected from caesarean sections. Additional betadine (1 : 3 solution) and vaseline-soaked gauzes were applied over the amnion as a daily biologic wet dressing. The amnion was replaced every three days. Finally, split skin grafting was performed on the healthy granulation tissue. We treated two patients who happened to have shin muscle necrosis. A 65-year-old man with a femoro-femoral arterial bypass showed graft thrombosis. Thirteen days after performing balloon angioplasty with stent insertion in the right femoral artery, new emboli were found in the stent and in the left popliteal artery. There was an attack of myocardial infarction the next day after embolectomy. The severe MNMS and ACMN at the right shin occurred after cardiopulmonary resuscitation. The dry gangrene was excised 3 months later, and this was followed by a skin graft 4 months later. An 81-year-old woman with atrial fibrillation showed left common femoral arterial obstruction and ACMN on the left shin during the management of congestive heart failure. The dry gangrene was excised 2 months later, and this was followed by a skin graft 3 months later. The amnion dressing shows promises for providing healthy granulation tissue for split skin grafts when treating muscle necrosis of the leg. Biologic dressing with using amnion is an option for limb salvage in the case of muscle necrosis that is caused by acute limb ischemia, although the treatment takes a long time.

Clinical Analysis of Acute Limb Ischemia

PURPOSE: Despite recent progress in the procedures of revascularization, acute limb ischemia continues to account for a wide variety of complications, culminating very often in limb loss or death. These poor results after treatment of acute limb ischemia still remains a major challenge in vascular surgery. METHOD: To evaluate the clinical characteristics and risk factors for early limb loss in acute limb ischemia, the clinical data of 87 limbs (8 upper and 79 lower limbs) in 83 patients. that underwent revascularization for acute limb ischemia at Yeungnam University Hospital from January 1995 to February 2003 were analyzed retrospectively. A Log-Rank test of Kaplan-Meier method and Cox proportional hazard analysis were performed to identify those main effects predictive of amputation free survival. RESULT: The patients, 78 males and 9 females, ranged from 30 to 83 years of age, with a mean age of 67. The highest incidence occurred among people in their 50s and 60s. The underlying causes of acute limb ischemia were arterial embolism in 42 limbs (42/87, 48.2%), arterial thrombosis in 36 (36/87, 41.3%), bypass graft occlusion in 9 (9/87, 10.3%). The primary sources of embolism were cardiac origin in 25 cases (25/42, 59.5%), aneurysmal origin in 2 (2/42, 4.8%) and unknown origin in 15 (15/42, 35.7%). As for the severity of ischemia according to SVS/ISCVS classification, 40 limbs (40/87, 46.0%) were classified as category IIa, 39 (39/87, 44.8%) as category IIb, and 8 (8/87, 9.2%) as category III. For the treatment, 66 thromboembolectomies (including 20 cases treated with intraoperative thrombolytic therapy), 19 arterial bypasses and 2 catheter directed thrombolytic therapies were performed. There were 13 major amputations and 8 mortalities at 6 months after revascularization. Cumulative 15 day, and 1, 2, 4, and 6-month amputation-free survival rate of all survival patients were 88.8%, 85.7%, 83.9%, 83.9% and 81.4% respectively. Among the univariate analysis of 26 clinical variables, 10 factors were identified as being associated with amputation-free surviva: age (P=0.01), preoperative tissue gangrene (P=0.03), preoperative skin color change (P=0.00), preoperative muscle status (P=0.00), preoperative motor and sensory deficit (P=0.00, P=0.00), severity of ischemia by clinical category (P=0.00), symptom duration (P=0.02), length of occlusion (P=0.01), and cause of occlusion (P=0.01). In multivariate analysis, age (P=0.04), and preoperative skin color change (P=0.00) predicted a poorer response to therapy. The major limb amputations were performed in 2 limbs (2/41, 4.9%) of the emboli group, and 11 limbs (11/42, 26.2%) of the thrombi group. For the limb with thrombosis, the major limb amputations were performed in 9 limbs (9/26, 34.6%) of the thromboembolectomy group and in 2 limbs (2/16, 1.3%) of the arterial bypass group. CONCLUSION: These results suggest that prompt and appropriate treatment is critically important in the management of acute limb ischemia. In thrombi cases Especially, a more aggressive surgical approach may be necessary for limb salvage.

Outcome Analysis after Treatment of Acute Limb Ischemia

PURPOSE: Acute limb ischemia is not only a limb-threatening but also a life-threatening condition. Despite the use of surgical and/or thrombolytic therapy for this urgent treatment -requiring condition, it is still reported to carry high morbidity and mortality rates. METHODS: We analyzed the treatment outcomes of 118 limbs (11 upper limbs, 107 lower limb) with acute limb ischemia treated for 103 patients (age, median: 64, male 89 female 14) at the Department of Surgery, Kyungpook National University Hospital, from March 1993 to March 1999. The underlying causes of acute limb ischemia included 62 limbs with acute arterial embolism in 51 patients, 39 limbs with acute arterial thrombosis in 37 patients, 15 limbs with graft occlusion in 14 patients, and 2 limbs of undetermined cause of limb ischemia in 1 patient. The retrospective, nonrandomized study was done. RESULTS: The underlying causes of acute limb ischemia were arterial embolism in 52.5%, arterial thrombosis in 33.1%, bypass graft occlusion 12.7%, and undetermined cause in 1.7%. Severity of ischemia according to the SVS/ISCVS classification, 107 limbs (90.7%) were classified as category II and 9 limbs (7.6%) were in category III. For the limbs with embolisms, 47 embolectomies (including 6 cases treated with adjuvant thrombolytic therapy) and 10 arterial bypasses were performed. For the limbs with thromboses, 23 arterial bypasses, 5 thrombectomies, and 4 catheter directed thrombolytic therapies were performed. For the patients with acute graft occusion, 8 redo bypasses, 4 thrombolytic therapies, and 2 thrombectomies were performed. We experienced major limb amputations in 8.1%, hospital mortality in 13.7% and recurrence of ischemic symptoms in 16.1% during the follow-up period in the embolism patients and limb amputations in 2.7%, hospital mortality in 14.3%, and recurrence of ischemic symptoms in 8.3% of the thrombosis patients. Of the patients with category II ischemia, major limb amputation and hospital mortality rates were 4.7% and 9.2%, respectively. CONCLUSION: In dealing with acute limb ischemia, prompt and appropriate selection of treatment modalities, if needed in combined modes, is critically important in improving the treatment outcomes.