Heart Science Journal 2025.
: 118-122
Contents list available at w.
Case Report Precision in practice, save the limb, save the life: Early detection of grade IIA acute limb ischemia and management using catheter-directed thrombolysis - A case report Nisa Amnifolia Niazta1,3*.
Novi Kurnianingsih2,3.
Dea Arie Setiawan2,3 1Brawijaya Cardiovascular Research Center.
Department of Cardiology and Vascular Medicine.
Faculty of Medicine.
Universitas Brawijaya.
Malang.
Indonesia.
2Department of Cardiology and Vascular Medicine.
Faculty of Medicine.
Universitas Brawijaya.
Malang.
Indonesia.
3 Dr.
Saiful Anwar General Hospital.
Malang.
East Java.
Indonesia
ARTICLE INFO
ABSTRACT
Keyword :
Acute Limb Ischemia.
Catheter-directed Thrombolysis.
Peripheral Artery Disease.
Background: Acute limb ischemia is an emergency condition that causes high morbidity and mortality.
Endovascular revascularization in acute limb ischemia showed better in-hospital clinical outcomes than surgical revascularization.
Case illustration: A 67-year-old man was referred by internal medicine at the rural area hospital with a diagnosis of acute limb He complained of sudden left leg pain and numbness of the left leg 2 days prior to hospital admission.
He was a heavy smoker and had a predisposition for atrial fibrillation.
He received heparinization at the previous hospital.
Upon arriving at Saiful Anwar Hospital, a physical examination showed severe left leg pain and was difficult to move.
His left leg was pulseless, paresthesia and poikilothermia.
Duplex ultrasound revealed a thrombus in the left popliteal artery with no flow downwards.
diagnosed the patient with Acute Limb Ischemia Rutherford IIA left inferior extremity.
We decided to perform catheter-directed thrombolysis with the Alteplase regiment.
Post catheter-directed thrombolysis angiography evaluation showed TIMI flow II at the left leg after 24-hour catheter-directed thrombolysis.
The patient did not complain of leg pain or numbness anymore.
Conclusion: Good outcomes in this patient were obtained through the ability to make correct initial diagnosis, early administration of heparin, and immediate referral to a cardiovascular center that can provide endovascular treatment.
Catheterdirected thrombolysis is the right choice for grade IIA acute limb ischemia.
Introduction Acute limb ischemia is deAned as a severe hypoperfusion of the limb that happens less than 2 weeks and is characterized by 5P .
ain, pallor, pulselessness, poikilothermia, paresthesias, and 1 Incidences of acute limb ischemia have been observed in 15Ae26 individuals per 100,000 in the US annually.
Reports indicate that 1-year mortality rate exceeds 40%.
The lower extremities are 20 times more likely than the upper extremities to experience acute limb 2 Acute limb ischemia is an emergency limb that poses a significant risk to life and has a high rate of morbidity and mortality.
Understanding the presentation, clinical assessment, and preliminary workup, which includes noninvasive imaging evaluation, in order to make a suitable approach to management.
Immune responses, including the presence of antibodies, play a role in vascular health, influencing disease progression and clinical outcomes.
Recent studies on the predictors of high titers of anti-SARS-CoV-2 antibodies in convalescent plasma donors offer valuable insights into the intersection of immune function and vascular complications.
Treatment options for acute limb ischemia include surgery, percutaneous intervention, and catheter-directed thrombolysis (CDT).
4-6 Prognosis and outcome of acute limb ischemia are mostly dependent on prompt diagnosis and start of appropriate and efficient However, clinicians should be aware of potential complications following reperfusion, such as compartment 7 There are varying reports that amputation rates vary between 10% and 30%, whereas the 30-day mortality rate is about 15%.
Endovascular revascularization for acute limb ischemia has been demonstrated in recent series to be safe and successful, with success rates that are comparable to surgical series and comparable, even lower perioperative morbidity and mortality.
Here we present a rare case of suspected bilateral acute limb ischemia that obtained appropriate pretreatment before endovascular intervention, substantially reducing mortality and morbidity.
Case Illustration A 67-year-old man, a heavy smoker, who had prior atrial fibrillation normal ventricular response (CHADSVASC score 4-HASBLED score .
, and heart failure, presented with a 3-day history of sudden left leg pain while doing light activity.
Initially described as a tingling sensation in the toe, the pain subsequently radiated to the calf and did not alleviate with rest or positional changes.
The left leg showed no signs of The patient reported numbness, and the leg began to feel cold and difficult to move due to pain.
Upon arrival at the emergency room, the patient was normotensive with a blood pressure of 124/76 mmHg, a heart rate of 85Ae101 bpm irregularly irregular, a respiratory rate of 18 times per minute, an oxygen saturation of 97% room air, and a temperature of 36.
7AC.
The vascular examination of the lower leg revealed * Corresponding author at: Brawijaya Cardiovascular Research Center.
Department of Cardiology and Vascular Medicine.
Faculty of Medicine.
Universitas Brawijaya.
Malang.
Indonesia.
- Dr.
Saiful Anwar General Hospital.
Malang.
East Java.
Indonesia E-mail address: nisaamnifolianizta@gmail.
com (N.
Niazt.
https://doi.
org/10.
21776/ub.
Received 19 November 2024.
Received in revised form 1 January 2025.
Accepted 3 January 2025.
Available online 30 April 2025 N.
Niazta, et al.
Heart Science Journal 2025.
: 118-122
Table 1.
Rutherford Clinical classifications of acute limb ischemia Findings Category Description/prognosis Viable II .
Threatened Not immediately threatened Marginally Salvageable if promptly treated Immediately Salvageable with immediate i Irreversible Major tissue loss or permanent nerve damage inevitables Sensory loss None Minimal .
or none More than with rest pain Profound.
Doppler signals Muscle None Arterial Venous Audible Audible None Inaudible Audible Mild.
Inaudible Audible Profound, .
Inaudible Inaudible Table 2.
Common Causes of Acute Arterial Ischemia (Embolism and Thrombosi.
Arterial embolism Arterial Thrombosis Atherosclerotic heart disease Atherosclerosis Coronary artery disease Low-flow states Acute myocardial infarction Congestive heart failure Arrhythmia Hypovolemia Valvular heart disease Hypotension Rheumatic Hypercoagulable states Degenerative Vascular grafts Congenital Progression of disease Bacterial Intimal hyperplasia Prosthetic Mechanical Artery-to-artery Arterial plaque rupture Aneurysm Trauma Atherosclerotic plaque Aortic/arterial dissection Idiopathic External compression Iatrogenic Iatrogenic Paradoxical embolus Trauma Other Air Amniotic fluid Fat Tumor Chemicals Drugs Table 3.
Clinical characteristics of Acute Arterial Embolism and Thrombosis Arterial embolism Arterial Thrombosis Arrhythmia No arrhythmia Sudden onset Sudden or slower onset Severe signs and symptoms Less severe signs and symptoms No history of claudication, rest pain History of claudication, rest pain No risk factors for peripheral vascular disease Risk factors for peripheral vascular disease Normal contralateral pulse exam Abnormal contralateral pulse exam No physical findings of chronic limb ischemia Physical findings of chronic limb ischemia pallor in the left leg, with a prolonged capillary refill time (> 3 second.
and minimal calf tenderness.
Neurologically, there was sensory impairment affecting more than just the toes, which was accompanied by limb weakness in the left leg.
Bilateral femoral pulses were palpable with absent pulses on the left popliteal and pedal arteries.
The electrocardiographic evaluation revealed atrial fibrillation with a normal ventricular response.
The chest X-ray was cardiomegaly, whereas the laboratory results were within normal limits.
The echocardiogram showed reduced LVEF .
% by biplan.
, with left atrial and left ventricular dilatation, mild mitral regurgitation, moderate tricuspid regurgitation with high probability of PH, and no intracardiac Doppler examination .
revealed a thrombus at the left popliteal artery.
Multiphasic spectral doppler was obtained from the left femoral communal artery until the left distal superficial femoral Monophasic spectral doppler was obtained at the left distal posterior tibial artery and no flow from the left popliteal artery until the left arcuate artery.
We assessed the patient as ALI Rutherford IIA left inferior extremity.
We planned for catheter-directed thrombolysis.
Angiography of the left leg .
showed total occlusion and acute thrombus at the level of the distal superficial femoral artery with inadequate collateral flow to the distal.
We decided to place a side-hole guiding catheter inside the thrombus and give the patient Alteplase 5mg/hour on the left leg and heparin 250 IU/hour for 24 hours.
We conducted a serial fibrinogen check, consistently finding levels Angiography evaluation after 24-hour catheter-directed thrombolysis of the left leg was TIMI flow II at the distal superficial femoral, popliteal, anterior tibial artery, and TIMI flow I at the posterior tibial artery.
The patient no longer felt pain in the left leg.
He was able to move his toes, and paresthesia was decreased.
Duplex ultrasound showed multiphasic spectral doppler at the left proximalAedistal superficial femoral artery, monophasic spectral doppler at the left posterior tibial artery, and no flow at the anterior tibial artery and left dorsalAearcuate artery.
No reperfusion injury after the catheter-directed The patient was able to walk.
We planned for per-oral anticoagulation treatment and walking exercise cardiac rehabilitation.
Niazta, et al.
Heart Science Journal 2025.
: 118-122
Table 4.
Contraindications to thrombolysis per Society of Interventional Radiology Absolute contraindications Active clinically significant bleeding Intracranial hemorrhage Presence/development of compartment syndrome Absolute contraindication to anticoagulation Relative contraindications Bleeding Bleeding diathesis Disseminated intravascular coagulation Established cerebrovascular accident .
ithin two month.
Neurosurgery or intracranial trauma .
ithin three month.
Cardiopulmonary resuscitation .
ithin ten day.
Major surgery or trauma .
ithin ten day.
Eye surgery .
ithin three month.
Intracranial tumor, vascular malformation, aneurysm, or seizure disorder Uncontrolled hypertension Recent internal hemorrhage or visceral biopsy Recent major gastrointestinal bleed .
ithin ten day.
Serious allergic reaction to thrombolytic agent, anticoagulant, or contrast which cannot be controlled by premedication Severe thrombocytopenia Pregnancy or immediate postpartum state Severe Severe liver dysfunction with associated coagulopathy Bacterial endocarditis Bleeding diathesis Disseminated intravascular coagulation Diabetic hemorrhagic retinopathy Life expectancy less than 1 year Figure 1.
Doppler Ultrasound showed no flow and thrombus at the right superficial femoral artery (A,B), and right popliteal artery (C,D).
Spectral Doppler no flow and thrombus at the left popliteal artery (E,F) N.
Niazta, et al.
Heart Science Journal 2025.
: 118-122
Figure 2.
Angiography right leg showed Total occlusion at the level of the mid superficial femoral artery with inadequate collateral (A) vs Angiography after 24-hours catheter-directed thrombolysis revealed mid superficial femoral artery TIMI flow II, and distal SFA total occlusion with acute thrombus appearance, inadequate flow in the superficial femoral artery with adequate collateral until the right posterior tibial artery (B).
Digital subtraction angiography of the right leg after 24-hours catheter-directed thrombolysis (C).
Angiography left leg showed Total occlusion and acute thrombus at the level of the distal superficial femoral artery with inadequate collateral flow to distal (D) vs Angiography after 24-hours catheter-directed thrombolysis revealed TIMI flow II at the distal superficial femoral, popliteal, anterior tibial artery, and TIMI flow I at the posterior tibial artery (E).
Digital subtraction angiography of left leg after 24-hours catheter-directed thrombolysis (F) Discussion written by Irma et al.
reported bilateral limb ischemia, which was successfully treated with CDT using streptokinase.
Acute limb ischemia can occur through the mechanisms of atherosclerosis, thrombosis, cardiac embolism, embolization from aneurysmal thrombus, and peripheral bypass graft thrombosis, or iatrogenic during arterial catheterization .
ee table .
Establishing a diagnosis of acute limb ischemia begins with identifying signs and symptoms that correspond to the 6Ps .
ain, pulses, pallor, paresthesias, paralysis, and poikilothermi.
, as well as exploring risk factors .
amily history of diabetes mellitus, smoking, atrial fibrillation, stroke, coagulopathy, or autoimmun.
and history of previous intervention/surgery procedures.
Genetic predispositions, such as ACE polymorphisms influencing vascular function, may also play a role in the development of these risk factors.
8 Physicians need to confirm the contraindications for thrombolysis (Table .
Laboratory examinations needed include a complete blood count.
PT/INR, basic metabolic panel .
BUN, creatinin.
, and baseline fibrinogen .
f thrombolysis is considere.
Imaging in ALI includes vascular ultrasound.
CTA, or MRI, which may be able to evaluate the etiology.
Echocardiography may reveal thrombus or endocarditis and can also evaluate for pulmonary hypertension, which may present with findings such as right ventricular strain.
Treatment options for acute limb ischemia include surgery, percutaneous intervention, and catheter-directed thrombolysis (CDT).
4-6 Prognosis and outcome of acute limb ischemia are mostly dependent on prompt diagnosis and start of appropriate and efficient There are varying reports that amputation rates vary between 10% and 30%, whereas the 30-day mortality rate is about Primary surgical intervention was used for many years, but it came with a high risk of morbidity and death.
10 These outcomes are not only influenced by clinical factors, but also by broader determinants such as socioeconomic status, healthcare access, and public health Similar multifactorial determinants have been highlighted in other public health contexts, such as the decline of notified dengue infections in Indonesia in 2017.
11 It is not advised to treat ALI with a systemic thrombolytic drug because to the significant risk of morbidity and death as well as the unfavorable clinical results.
12 A case report A 2013 Cochrane review of five studies including 1283 patients showed comparable results comparing surgery versus endovascular therapy for limb salvage and death in 30 days, 6 months, and 1 year.
The endovascular therapy groups had higher incidences of severe bleeding .
8% vs.
OR 95% CI = 2.
and stroke .
3% vs.
OR 95% CI = 6.
More severe degree of intervention was performed on surgical patients (OR 95% CI = 5.
The complication rate may be slightly skewed upward due to the fact that most of the treated patients in the STILE trial had occlusions more than 2 weeks.
14,15
A Propensity-Score Matched Analysis conducted by Dhaval Kolte et al.
484 patients hospitalized with acute limb Revascularization in acute limb ischemia demonstrated superior inhospital clinical results compared to surgical revascularization.
Patients treated with endovascular revascularization showed significantly lower rates of in-hospital mortality .
8% vs 4.
P = 0.
, outcome of death/myocardial infarction/stroke .
2% vs 7.
P<0.
myocardial infarction .
9% vs 2.
P = 0.
, fasciotomy .
P<0.
, acute renal impairment .
5% vs 11.
P =
, major bleeding .
7% vs 21.
P<0.
, need of transfusion .
3% vs 18.
P<0.
, and a shorter length of stay .
days versus 5 days.
P<0.
when compared to those undergoing surgical The puncture site may be established on the opposite leg using a 21-gauge micro puncture, guided by ultrasonography to identify the common femoral artery, 1 cm from the bifurcation.
We expect a single puncture to minimize bleeding complications in lysis procedures.
We placed a 6-french sheath at the end of the common iliac artery after An angiography was conducted using 25 ml of contrast at a speed of 10 ml/second.
Upon crossing the obstructed segment, the wire is removed, and the catheter is placed within the lesion, ensuring the lytic agent is precisely located at the thrombus site.
A sterile adhesive N.
Niazta, et al.
Heart Science Journal 2025.
: 118-122
patch is applied to the catheter area of the hub sheath to stabilize the catheter during overnight thrombolysis.
Tissue plasminogen activator .
PA) was infused at a rate of 0.
5 to 1 mg per hour.
400Ae600 units of subtherapeutic heparin are administered through the sheath's sidearm every hour.
We obtained serial fibrinogen levels every six hours.
administered half the tPA dose If fibrinogen falls to less than 150 mg/dl.
Normal saline is given via the infusion catheter, and the tPA is stopped if the level falls below 100 mg/dl.
If the fibrinogen level exceeds 100 mg/dl or 150 mg/dl, the appropriate dosage of tPA is Therapeutic dosages of heparin are initiated via the sidearm of the sheath if the level remains below 100 mg/dl.
Until the patient is able to have another angiography, only saline should be administered through the lysis catheter.
The patient frequently undergo lysis overnight and is returned for angiography on the following day, unless the occlusion is an exceptionally short and acute occlusion.
This procedure is repeated until all leftover clots are removed from the vessel, with or without the use of balloon or suction thrombectomy.
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Conclusion Acute limb ischemia is a vascular emergency necessitating rapid and accurate diagnosis and witreatment to minimize amputations and mortalilty.
Along with initiating the heparin infusion, the patient should be classified as either endovascular or surgical depending on their clinical symptoms, utilizing the Rutherford classification and noninvasive imaging if it is accessible.
Rutherford classifications IAeIIb limb ischemia can be safely and successfully treated using endovascular procedures such as catheter-directed thrombolysis according to recent evidence.
:100763.
1 Ethics Approval and Consent to participate Patient has provided written informed consent prior to involvement in the study.
Pemberton M.
Varty K.
Nydahl S.
Bell PR.
The surgical management of acute limb ischaemia due to native vessel occlusion.
Eur J Vasc Endovasc Surg 1999.
:72-76.
doi: 10.
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Consent for publication Not applicable.
Dhewantara PW.
Jamil KF.
Fajar JK.
Saktianggi PP.
Nusa R.
Garjito TA, et al.
Original Article: Decline of notified dengue infections in Indonesia in 2017: Discussion of the possible determinants.
Narra J 2021.
:e23.
doi: 10.
52225/narraj.
3 Availibility of data and materials Data used in our study were presented in the main text.
Patel NH.
Krishnamurthy VN.
Kim S.
Saad WE.
Ganguli S.
Walker TG, et al.
Quality improvement guidelines for percutaneous management of acute lower-extremity ischemia.
J Vasc Interv Radiol 2013.
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4 Competing interests Not applicable.
5 Funding Source Not applicable.
6 Authors contributions Idea/concept: NAN.
Design: NAN.
Control/supervision: NK.
DAK.
Data collection/processing: NAN.
NK.
DAK.
Analysis/interpretation: NAN.
NK.
DAK.
Literature review: NAN.
NK.
DAK.
Writing the article: NAN.
Critical review: NK.
DAK.
All authors have critically reviewed and approved the final draft and are possible for the content and similarity index of the manuscript.
7 Acknowledgements We thank to Brawijaya Cardiovascular Research Center
References