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

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.