Endovascular Management of Acute Limb Ischemia from Septic Emboli

Case Files by Dr. George

Submitted on Wed, 04/03/2013 - 15:56
Authors

Rajeev Mareddy, DO, Jon C. George, MD

ABSTRACT: Embolic events occur in many cases of infective endocarditis and can involve the brain, lungs, bowel, and extremities. We present a case of lower extremity acute limb ischemia from septic emboli treated with combined percutaneous rheolytic thrombectomy and balloon angioplasty.

VASCULAR DISEASE MANAGEMENT 2013:10(4):E71-E74

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Case Report

A 42-year-old white male presented with severe chest pain and fever. Past medical history included mitral valve endocarditis and the patient had a mitral valve replacement with a bioprosthetic valve 6 years prior as well as perioperative pacemaker placement. Transesophageal echocardiogram revealed a dense tissue mass in the right atrium on the pacemaker lead as well as the atrial and ventricular surfaces of the mitral valve. He underwent surgical mitral valve replacement as well as removal of infected pacemaker leads with reimplantation of a new device. 

Two days post surgery, he developed new onset left leg parasthesias, discoloration, and pulselessness. Peripheral angiography revealed a left profunda femoris (PF) subtotal occlusion with a hazy filling defect consistent with thrombotic emboli, in addition to ostial 100% superficial femoral artery (SFA) occlusion (Figure 1). Due to recent extensive surgical mitral valve replacement in the setting of endocarditis, followed by infected pacemaker lead extraction, the patient was deemed to be high risk for repeat vascular surgery, and a percutaneous approach to management of septic embolization was pursued.

A 7 French Ansel sheath (Cook Medical) was advanced from the right femoral artery access site across the aortoiliac bifurcation over an Amplatz Super Stiff Guidewire (Boston Scientific) into the left common femoral artery. A V-18 Control Wire guidewire (Boston Scientific) was used to cross the filling defect into the left PF, while a second wire was used to cross the lesion into the SFA. Next, a 7 French JR4 guiding catheter advanced over this wire for manual aspiration and retrieval of a moderate amount of thrombotic debris. 

A 4 x 20 mm Sterling Balloon Dilatation Catheter (Boston Scientific) was then inflated distal to the thrombus in the PF and retrieved along with the guiding catheter to trap any embolic material between the balloon and the guide (Figure 2). Finally, the AngioJet catheter (Bayer HealthCare Radiology & Interventional) was advanced over the  V-18 wire into the PF and SFA for rheolytic thrombectomy (Figure 3). Subsequent angiogram revealed moderate improvement in flow with persistent thrombotic material in both PF and SFA. A 6 x 100 mm Sterling Balloon Dilatation Catheter and a 4 x 30 mm Sterling Balloon Dilatation Catheter were then used to perform simultaneous kissing angioplasty of the SFA and PF respectively with good expansion (Figure 4). Final angiogram revealed significant improvement in flow through the SFA and PF segments with minimal residual thrombotic debris that were non-flow limiting (Figure 5). The patient was noted to have clinical reperfusion of his left lower extremity with resolution of symptoms, and he was discharged on hospital day 17 with a 6-week course of intravenous antibiotics.

Discussion

Acute limb ischemia (ALI) is a consequence of peripheral arterial disease and a common vascular emergency.1 An embolic event occurs in 22% to 50% of cases of infective endocarditis (IE) and can involve organs and extremities.2 The incidence of embolization causing ALI is unknown, but in one case series of IE, it occurred in 7 of 90 cases (7.7%).3 In another series, 14 of 285 (4.9%) had peripheral acute ischemic syndromes.4 Up to 65% of embolic events involve the central nervous system.5 Emboli can occur before diagnosis, during therapy, or after therapy is completed, although most occur within the first 2 to 4 weeks of antimicrobial therapy.6 

The best treatment for this complication of IE is unknown. For many years surgical intervention was performed and entailed significant morbidity and mortality.  Thrombolysis is avoided in patients with septic embolization because of concerns about concurrent intracerebral mycotic aneurysms and the risk of hemorrhage.7

Percutaneous mechanical thrombectomy (PMT) devices have mainly been used in treatment of patients with contraindications to thrombolytic therapy.8 Up to 20% of patients with ALI have contraindication to thrombolytics.9 Although not studied, the use of PMT is less likely to result in hemorrhagic complications. Another advantage is the shorter procedural time.4 PMT devices have also been used as adjunctive procedure for incomplete thrombolysis as a method to debulk the thrombotic mass before local lysis. 

PMT is a well-documented therapy for ALI.10,11 Various thrombectomy catheters are available and have been tested in the treatment of acute and subacute peripheral arterial thromboembolic occlusions.9,11-13 Only the AngioJet catheter is approved for peripheral arterial applications. Rheolytic mechanical thrombectomy has had particular success in coronary and noncoronary applications: up to 86% in removing thrombus from thrombotic vein grafts and in native coronary arteries with angiographic evidence of thrombus.14 It has the greatest efficacy in removing thrombus less than 48 hours old. In one study, rheolytic thrombectomy removed 70% of the obstruction in 21 patients with thrombotic occlusion causing ALI, allowing restoration of antegrade flow and limb salvage in 95% of patients and 6-month limb salvage in 89% of patients.15 However, in this particular study, recurrent thrombosis occurred in 4 out of 21 (18%) patients.

Rheolytic thrombectomy employs a high-speed saline jet to create a low-pressure region within the catheter tip to then aspirate surrounding fluid, tissue, and thrombus via a  Venturi effect into the catheter where the high-speed saline jets macerate the thrombus into smaller particles and propels the particles through the catheter lumen out of the body.16 

Rheolytic devices can also adversely incite hemolysis and renal failure due to free hemoglobin release, which then requires fluid administration.4 Therefore the manufacturer recommends application of less than 10 minutes to prevent excessive hemolysis.

We present a case of IE complicated by septic embolization and managed percutaneously with significant improvement. PMT may be a viable option for ALI caused by emboli secondary to an infective source, such as in the case described herein. 

References

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  2. Baddour LM, Wilson WR, Bayer AS, et al. Committee on rheumatic fever, endocarditis, and kawasaki disease in the young; council on clinical cardiology, stroke, and cardiovascular surgery and anesthesia; American Heart Association; Infectious Diseases Society of America. Circulation. 2005;111(23):e394-e434.
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  8. Rilinger N, Görich J, Scharrer-Pamler R, et al. Mechanical thrombectomy of embolic occlusion in both the profunda femoris and superficial femoral arteries in critical limb ischaemia. Br J Radiol. 1997;70:80-84.
  9. Results of a prospective randomized trial evaluating surgery versus thrombolysis for ischemia of the lower extremity. The STILE trial. Ann Surg. 1994;220(3):251–268.
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  12. Lichtenberg M, Käunicke M, Hailer B. Percutaneous mechanical thrombectomy for treatment of acute femoropopliteal bypass occlusion. Vasc Health Risk Manag. 2012;8:283-289.
  13. Zafar N, Prasad A, Mahmud E. Utilization of an aspiration thrombectomy catheter (Pronto) to treat acute atherothrombotic embolization during percutaneous revascularization of the lower extremity. Catheter Cardiovasc Interv. 2008;71(7):972-975.
  14. Ramee SR, Schatz RA, Carozza JP, et al. Results of the VeGAS I pilot study of the Possis coronary AngioJet thrombectomy catheter. Circulation. 1996;94(Suppl 1):I-619.
  15. Silva JA, Ramee SR, Collins TJ, et al. Rheolytic thrombectomy in the treatment of acute limb-threatening ischemia: Immediate results and six-month follow-up of the multicenter AngioJet registry. Cathet Cardiovasc Diagn. 1998;45(4):386–393.
  16. Baim DS, Grossman W, eds. Grossman’s Cardiac Catheterization, Angiography, and Intervention, 6th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2000.

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Editor’s Note: Disclosure: The author has completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr. George reports consultancy to Boston Scientific. Dr. Mareddy reports no disclosures related to the content of this article.

Manuscript received February 14, 2013; provisional acceptance given March 13, 2013; final version accepted March 19, 2013.

Address for correspondence: Jon C. George, MD, Director of Clinical Research, Division of Cardiovascular Medicine, Deborah Heart and Lung Center, 200 Trenton Road, Browns Mills, NJ, 08015, USA. Email: georgej@deborah.org