Ultrasound assisted catheter directed thrombolysis and aspiration thrombectomy for acute limb ischemia caused by embolization of infective endocarditis vegetations

K. Kang, R. Maholic, Gurjaipal Kang
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Abstract

Background: Endocarditis can cause peripheral emboli leading to acute limb ischemia (ALI). The standard of care for ALI from Infective Endocarditis (IE) is not established. Case Presentation: 19-year-old male with mitral valve IE had acute bilateral limb ischemia. On the left leg, the angiograms showed occlusion of iliac and superficial femoral (SFA) arteries. These lesions were unsuccessfully treated with balloon angioplasty but overnight Ultrasound catheter directed thrombolysis or Ekos thrombolysis (Ekos corporation) given at 24 mg of tissue plasminogen activator for 12 hours resulted in patency of SFA and Iliac arteries. However, the profunda femoris artery (PFA) became occluded due to embolization after Ekos lysis. Balloon angioplasty of PFA was unsuccessful and Rheolytic thrombectomy failed as well but direct aspiration of the vegetation material with a 7F guiding catheter was successful and the PFA patency was recovered, however there was distal embolization resulted in occlusion of the distal popliteal artery. Aspiration thrombectomy was successful in causing one vessel patency to the foot. The right leg had occluded PFA and popliteal artery and balloon angioplasty failed but again an excellent response to overnight Ekos thrombolysis was seen with patency of popliteal artery. The aspiration material was sent to pathology laboratory and showed IE emboli. The patient had a good angiographic and clinical result from percutaneous ultrasound catheter directed thrombolysis. The mitral valve needed to be replaced but the lower extremities had no further clinical sequelae over 6 months of follow up. Conclusions: IE septic emboli may be treated with ultrasound enhanced catheter directed thrombolysis and also by aspiration thrombectomy. Balloon angioplasty alone led to poor outcomes in our patient.
超声辅助导管溶栓及吸入性取栓治疗感染性心内膜炎植物栓塞所致急性肢体缺血
背景:心内膜炎可引起外周栓塞导致急性肢体缺血(ALI)。感染性心内膜炎(IE)引起ALI的护理标准尚未建立。病例介绍:19岁男性二尖瓣IE急性双侧肢体缺血。左腿血管造影显示髂和股浅动脉(SFA)闭塞。球囊血管成形术未能成功治疗这些病变,但夜间超声导管引导溶栓或Ekos溶栓(Ekos公司)给予24 mg组织型纤溶酶原激活剂12小时导致SFA和髂动脉通畅。然而,由于Ekos溶解后栓塞,股深动脉(PFA)被阻塞。PFA球囊成形术不成功,溶栓术也失败,但7F导管直接吸入植体材料成功,PFA恢复通畅,但远端栓塞导致腘动脉远端闭塞。抽吸取栓术成功地使足部的一条血管通畅。右腿PFA和腘动脉闭塞,球囊血管成形术失败,但过夜Ekos溶栓后腘动脉通畅,反应良好。抽吸材料送往病理实验室,显示IE栓子。经皮超声导管引导溶栓,患者血管造影及临床结果良好。需要更换二尖瓣,但下肢在随访6个月后没有进一步的临床后遗症。结论:IE脓毒性栓塞可采用超声增强导管引导溶栓治疗,也可采用吸入性取栓。单纯球囊血管成形术导致本例患者预后不佳。
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