Interesting Case Rounds

1
Interesting Case Rounds

• Rebecca Burton-MacLeod
• R4, Emergency Medicine
• Aug 3, 2006

2
History

• 81M
• CC numbness in left arm and SOBOE
• HPI symptoms started suddenly while pt was
  swimming 4hrs earlier
• clumsiness in L arm
• Diaphoretic, dizzy
• 2d hx of SOBOE
• No specific chest pain

3
History contd

• No palpitations
• No headache
• Normal left leg function, normal speech/ vision
• No previous similar symptoms

4
PMHx

• Paroxysmal Afib
• Pacemaker x 10yrs
• Angina 20yrs prior
• CHF
• Scrotal hernia
• BPH and TURP

• Meds
• Lasix
• Warfarin
• Fosinopril
• Bisoprolol
• Taking all meds regularly

5
On exam

• Vitals Afebrile, P 105 irreg, BP (R arm) 152/80,
  R 23, sats 92 r/a
• Normal HS, no murmurs
• JVP 3cm ASA, mild bilateral pitting edema to LE
• Lungsdec A/E to R base
• Abdosoft, non-tender
• NeuroCN normal, normal tone, power, reflexes
  sl decreased sensation entire L arm
• MSKno bony tenderness L arm, full ROM

6
Any thoughts ?
7
Investigations ?

• CBC, lytes, Cr, INR/PTT, TNT (4hour)
• EKG
• CXR

8
Test results

• Normal CBC
• Normal lytes, Cr
• TNT negative
• INR 1.2
• EKGAfib, T wave inversion in V4-6 (new compared
  to previous EKG)

9
CXR
10
Any further thoughts ?
11
Management ?
12
Case contd

• No signif improvement
• Continues to c/o clumsiness in L arm

13
CT head
14
Re-examine pt

• C/o coolness in L arm
• Decreased radial/brachial pulses in L arm
• Pt had presented to ED 1mo ago with epistaxis
• Nose packed
• Vit K given to reverse warfarin (INR gt9)

15
CT angio

• saddle-like intraluminal filling defect in L
  main PA with extension filling L upper lobe
  arterial branches

16
CT angio
14.5cm L distal axillo-brachial artery occlusion
17
Problem list

• CHF
• Afib
• PE
• L ischemic arm
• Low INR

18
Management

• Pt admitted to Vascular service
• Heparinization started
• Pt underwent L brachial embolectomy the following
  day
• Long term anticoagulation (with close monitoring
  to ensure therapeutic INR !)

19
Acute upper limb ischemia
20
Acute upper limb ischemia

• Is far more uncommon than lower limb ischemia
• Upper extremity has good collateral circulation
  and low rate of atherosclerosis
• Responsible for 15 of vascular procedures for
  ischemic limbs
• Of all embolization sites, upper extremity cases
  accounts for only 8
• Functional limb impairment occurs in ¾ of cases
  if left untreated

21
Upper extremity anatomy
22
Causes

• Main causes of upper limb ischemia
• Thromboembolic disease
• Traumatic injuries
• Aortic dissection
• Atherosclerosis and chronic limb ischemia
• Subclavian steal s/o
• Thoracic outlet s/o
• Iatrogenic causes

23
Upper limb ischemia
Ali, T et al. Vasc Surg. 2001.
24
Thromboembolic events

• 62 of pts have associated Afib
• 84 have associated CAD

25
Differentiation of Thrombus vs. Embolus

• Embolus
• Usual identifiable source for embolus (Afib)
• Rarely hx of claudication
• Few findings suggestive of occlusive disease
• Sharp demarcation of ischemia
• Minimal atherosclerosis, sharp cutoff, few
  collaterals on arteriography

• Thrombus
• Less common to find identifiable source for
  embolus
• Often hx of claudication
• Often findings suggestive of occlusive disease
  (contralateral limb pulses diminished/absent)
• Diffuse ischemia
• Diffuse atherosclerosis, tapered irregular
  cutoff, well-developed collaterals on
  arteriography

Rosens. Ch 82.
26
Diagnosis

• 5 Ps
• Pain
• Pallor
• Pulselessness
• Paresthesias
• Paralysis

27
Acute limb ischemia
28
Management

• For limb-threatening ischemia
• Emergency Fogarty catheter embolectomy
• /- vascular bypass grafting if in situ
  thrombosis as cause of ischemia
• If above measures fail, then primary amputation

29
Heparin ?

• Should be started immediately
• 80U/kg IV bolus, then 18U/kg/h maintenance
  infusion
• Minimizes clot propagation and obviates further
  embolism
• No formal studies done to establish beneficial
  role

30
GP IIb-IIIa antagonist ?

• Pilot trial randomized 70 pts to urokinase
  abciximab vs. urokinase placebo
• Amputation-free survival at 90d was 96 with GP
  IIb-IIIa group vs. 80 with placebo
• More rapid thrombolysis in first group, but also
  higher rate of non-fatal major bleeding

31
Thrombolysis ?

• May be considered in non-limb-threatening
  ischemia (takes 6-72h for effect)
• Therefore, most useful if known thrombosis
• IV thrombolysis initially used, but now mostly
  replaced by catheter-directed thrombolysis

32
Thrombolysis ?

• One trial comparing IA streptokinase, IA rt-PA,
  and IV rt-PA
• Angiographic success rates 80 vs. 100 vs. 45
• 30 day limb salvage rates 60 vs. 80 vs. 45
  respectively
• Comparison of rt-PA with urokinase showed faster
  lysis with rt-PA but 24h and 30d clinical success
  rates were similar

Clogett GP et al. Chest. Sept 2004.
33
Surgery vs. thrombolysis

• Cochrane Review 2006.
• 5 trials with 1283 participants
• No signif difference in limb salvage or death at
  30d, 6mos, 1yr
• Thrombolysis was significantly associated with
  higher stroke rates (1.3), major hemorrhage
  (8.8), distal embolization (12.4)
• Concluded insufficient evidence to advocate for
  universal initial treatment

34
Case conclusion

• Pt felt to have developed thromboembolic disease
  resulting in L ischemic arm and PE
• Likely due to subtherapeutic INR
• ? Due to epistaxis and vitamin K administration

35
Vitamin K to reverse anticoagulation
DeLoughery TJ et al. Crit Care Clin. July 2005.
36
Questions ?