Vnitřní lékařství 5/2020

KAZUISTIKA Acute limb ischemia due to paradoxical embolism treated with systemic thrombolysis | E49  / Vnitř Lék 2020; 66(2): e48–e51 /  VNITŘNÍ LÉKAŘSTVÍ www.casopisvnitrnilekarstvi.cz 40 minutes of duration in spinal anesthesia. The intervention consisted of reposition, wiring and placement of a plaster splint (replaced 10 days later with an orthesis). She was discharged from hospital due to favo‑ rable evolution on the third day. Nadroparin 0.4 ml subcutaneously once daily was recommended till complete mobilization. The patient was on active rehabilitation 21 days after surgery and the traumato‑ logist decided to apply the orthesis for 7 more days and stop the low molecular weight heparin (LMWH) prophylaxis. Two months (56-days) after surgery the patient was brought by ambulance to the Emergency Department of the University Hospital. On her way to the rehabilitation center and after getting of the car, the patient experienced sudden breathlessness, dizziness without loss of consciousness and profuse sweating. At the same time, she felt numbness in the left lower and upper extremities. On day before she had noticed swelling of the left calf. Deep vein thrombosis com‑ plicated with pulmonary embolism was suspected. D‑dimer value was > 8 563.60 mg/l FEU (reference range 0.00–470.00), Troponin T 56.41 μg/l (reference range 3–14) and NT‑proBNP 342.5 ng/l (reference range 5–125). Computed tomographic (CT) pulmonary angiography confirmed the suspected diagnosis of pulmonary embolism showing bilateral embolism into all lobar branches of the pulmonary artery (fig. 1). The patient was admitted to the Intensive Care Unit in a hemo‑ dynamically stable condition (blood pressure 106/60 mm Hg, pulse rate 80 bpm) and treatment with nadroparin 0.8 ml subcutaneously every 12 hours was initiated. Subsequently the patient complained again about numbness and coldness in both the left upper and lower extremities. Pulses over left radial artery, left dorsalis pedis artery and left tibialis posterior artery were not palpable, examination with handheld Doppler system showed a mono‑phasic flow over all the above‑mentioned arteries. Patent fora‑ men ovale/septal defect was suspected in first place; aortic dissection was considered as well. Transthoracic echocardiography did not detect any significant abnormality. As the transesophageal echocardiography was not readily available, CT examination of the aorta was performed. The CT scan ruled out suspected aortic dissection, however showed complete occlusion of the left subclavian artery of 7 cm of length at the site of the subclavian – vertebral artery bifurcation (fig. 2) and 12 mm long partial occlusion of superior mesenteric artery (fig. 3) without signs of intestinal ischemia. Color Duplex ultrasound of the left upper and lower extremities confirmed the occlusion of the left subclavian artery and detected an acute obliteration of the left common femoral artery with hypo‑ echogenic embolus extending from the transition point of the left external iliac artery into the left common femoral artery down to the bifurcation site of the left common femoral artery. No atherosclerotic changes were visible. At the same time, subacute thrombosis in the left popliteal vein was detected. Vascular surgeon decided not to perform embolectomy at this point, with general anesthesia being of high risk due to recent pulmonary embolism and local anesthesia being not viable due to the extent of the occlusion (supratherapeutic dose of the local anesthetic would have been needed). Interventional radiologist decided against pharmacomechanical thrombolysis for the left upper and lower extremity arteries due to the extent of the finding. Therefore, vascular medicine specialist, vascular surgeon and inter‑ ventional radiologist decided to administer systemic thrombolysis with alteplase (100 mg over 2 hours), followed by continuous un‑ fractionated heparin infusion. The administration of thrombolysis occurred 22 hours after initial symptoms. Fig. 1.  Bilateral embolism into all lobar branches of the pulmonary artery. Arrows pointing towards the emboli Fig. 2. Occlusion (arrows) of the left subclavian artery of 7 cm of length at the site of the subclavian – vertebral artery bifurcation