Strategy of Early Revascularization with Percutaneous Catheter Directed Intra-Arterial Thrombolysis for Acute Upper Limb Ischemia : A Case Report
Author : M.R. Ramadhan, M. Failasufi, N. Kurnianingsih, D. Sargowo
Upload Date : 19-04-2018
Background: Acute Upper Limb Ischemia (AULI) is much less incident than ischemia of the lower limbs, it can nevertheless result in severe functional impairment. The treatment options for this life-threatening condition are open surgery, percutaneous endovascular treatment and intravenous systemic thrombolysis. Current percutaneous treatment with catheter-mediated infusion of fibrinolytic agents has been an established and effective treatment for AULI for years up to now.
Case Presentation: A 55-year-old female patient was admitted to cardiovascular intensive care unit with acute right upper limb ischemia. Associated diseases included arterial hypertension and chronic ischemic heart disease. The patient was in atrial fibrillation rhythm with normal ventricular response. The Doppler examinations revealed extensive brachial artery thrombosis with no demonstrable collateral or distal flow. In arteriography found total occlusion in the one-third proximal of right brachial artery. A 3,5-6F guiding-catheter was positioned via transfemoral approach into the right internal brachialis artery and Alteplase was given 1 mg/hour intravenous catheter for 48-hours concomitant with unfractionated heparin through vein-access with monitoring of fibrinogen and aPTT, oral medication including Clopidogrel 1x75mg, Cilostazol 2x50mg and Atorvastatin 1x40mg. We have re-evaluation using Doppler and arteriography, with results showing a significant improvement, in which there is a flow of filled up to the distal right superior arterial. The patient recovered and was discharged after 5-days observation.
Discussion: Patients with AULI due to cardiac origin performed early revascularization shows superior success rates. Percutaneous Intra-Arterial Thrombolysis (PIAT) is effective for patients with AULI with grade-1A recommendation for Rutherford stage I-IIA. Clinical success on setting of AULI is usually synonymous to limb salvage. Final post-procedural arteriography should be obtained as a baseline value to compare in clinical follow-up visits.
Conclusion: Strategy of early revascularization with PIAT via transfemoral approach in patients with AULI is a valuable, safe and effective treatment.
KEYWORDS : Intra-Arterial Thrombolysis, Acute Upper Limb Ischemia.