E-Science Station

Mr. W

A 43-year-old man came to our ER complaining sudden severe pain at his left lower limb below knee for 2 days, cold palpated, pale visibly, numb at his first digit of toes, able to walk and wiggle his toes, no prior trauma, no hematologic disorders. Continuous infusion with heparin was initiated. Doppler Ultrasound showed inaudible artery, audible vein. Percutaneous Aspiration Thrombectomy with balloon angioplasty were applied, Angiography reevaluation showed flow positive,symptoms diminished.

Doppler Ultrasound examination showed in audible signals from left poplitea to the distal artery but audible venous signals. He was classified into Rutherford stage IIA.

An immediate arteriography identified a total occlusion (thrombus type) from left poplitea to the distal artery. Percutaneous aspiration thrombectomy and balloon angioplasty were applied.

First we did an asepsis antisepsis at left inguinal area, procedure was performed under local anesthesia, initiated by inserting a 6-Frsheath via left common femoral artery. A 3.5/6-F JR guiding catheter was then inserted under fluoroscopy guidance which passed through left femoral artery to poplitea artery, angiography revealed total occlusion (thrombus type) start from proximal of left poplitea artery. Victory 14 guiding wire was inserted up to distal posterior tibial artery, we then decided to use Thrombuster II for thrombus aspiration, we did several times aspiration to completely remove clots, reangiography identified flow started to show positive, continued with multiple predilatation using 2.5x120 mm (8-14 atm) Coyote balloon. Victory 14 guiding wire was then passed through to the medial plantar artery, predilatation with the same 2.5x120 mm Coyote balloon (4-8 atm), angiography reevaluation showed flow positive up to distal artery.

Acute limb ischemia (ALI) is a sudden decrease in limb perfusion causing a potential threat to limb viability. Presentation is up to 2 weeks following the acute event. Timing of presentation is related to severity of ischemia. The findings of ALI include 5P: Pain, Pulselessness , Pallor, Paresthesia, Paralysis. Categories of ALI on presentation, divided into viable (I), threatened (IIA, IIB) and irreversible (III) based on Rutherford criteria, differentiating between arterial and venous flow signals. This patient fulfilled the Rutherford stage IIA criteria, which he didn’t have any muscle weakness, sensory loss limited only at his first toe, inaudible left poplitea artery but audible vein signals by doppler examination. He was initiated an intravenous heparin to limit the propagation of thrombus, taken directly to the cath lab to do an immediate angiograph examination. For secondary prevention of symptomatic PAD after percutaneous transluminal angioplasty we gave aspirin (80mg/day), Statins, Vit E, Allopurinol, Sodium Bicarbonate to reduce the level of oxidative stress developed after ischemic reperfusion. When a patient is suspected to ALI, questions to be asked are the history and physical examination, determine the severity of ALI for the consideration in earlymanagement decisions. Is the limb still viable, is its viability immediately threatened or perhaps there is already irreversible changes that interfere the limb salvation.