Presentation
Treatment of a challenging case of acute limb ischemia
Treatment of a challenging case of acute limb ischemia (external iliac, common femoral and popliteal artery) with the Indigo thrombectomy system – Step by step procedure and description of decision making for this case
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Nice try! Did the patient experienced reperfusion syndrome postoperatively with need for fasciotomies? It seems a bit ackward to me the multiplicity of occlusive lesions on the basis of an emboli phenomenon eg. 3 remote sites infespopliteal, CFA as well as iliac axis thrombus from a single atrial thrombus? I would personally put into play the scenario of a atheromatous steno-occlusive lesion either in the popliteal or CFA site. In such case, an open CFA preparation with proximal and distal embolectomy effort would immediately remove thrombus and would decrease the amount of subsequent contrast agent needed to check for remnant stenotic disease proximally or centrally i.e., in order to differentiate the thrombotic vs. embologenic phenomenon and proceed immediately with primary stenting. This would also be faster. Admittedly, remnant thrombus in the popliteal segment would necessitate local injection of theombolytic agent with potential need for further thrombectomies distally; but then, again, such approach would be time and cost effective, let alone the fact that it would enable-if needed- CFA endarterectomy and hybrid approach.
Hi Stratos! Thank you for your comment. Your approach is also safe and easy, but we do not have any evidence about cost effectiveness. Let me please disagree with your concept. The angiography after the aspiration thrombectomy showed no atherosclerotic lesions at the level of the CFA or even popliteal artery. Thus, I still believe that this was an embolism. The total amount of contrast agent used was 60ml. If we had an atherosclerotic lesion in the CFA, your approach would be the treatment of choice. In our case, we prevented any wound complication, we reduced the hospital stay, we did not use lysis and of course also no ICU. The total operation time was 49 minutes.
I am looking forward to your comment on this.
Theo, thanks for your interest and your prompt reply! Certainly this was an embolism after all, since the angiographic picture left no doubt about that. I just raised a concern about the initial approach of this case, leaving a place for thrombosis in the differential diagnosis based on the peculiar -according to my opinion- picture of 3-sites embolization. Certainly, the pros and cos of each approach encourage the scientific dialog and enrich the phycisian’s armamentarium!