Successful Percutaneous Treatment of Acute Bilateral Lower Limb Ischemia

ABSTRACT: Acute limb ischemia is a surgical emergency as a delay in reperfusion is associated with a high risk of irreversible tissue infarction potentially leading to limb loss and death. However, in medically compromised patients, perioperative morbidity and mortality remain high. An elderly woman with multiple comorbidities developed acute bilateral lower limb ischemia and was not felt to have a surgical revascularization option. Percutaneous restoration of reperfusion was successfully achieved by obtaining bilateral antegrade femoral arterial access followed by local infusion of fibrinolytic therapy and adjunctive thrombectomy resulting in bilateral lower extremity salvage.

J INVASIVE CARDIOL 2008;20:473–476

Key Words: acute limb ischemia; antegrade access; thrombolysis


Acute lower extremity peripheral arterial occlusion is a surgical emergency as the associated risk of limb loss or death is high. Commonly, it results from peripheral athero- or thromboembolization or vascular thrombosis at a site of severe atherosclerotic disease.1 Failure to adequately restore arterial flow in a timely manner can result in the development of irreversible tissue infarction and the opportunity for limb salvage is then lost. Arterial flow can be restored through operative revascularization with concomitant embolectomy or pharmacological dissolution of the thrombus by local delivery of a fibrinolytic agent.1,2 Patients with acute limb ischemia (ALI) are often elderly and frail, and early invasive open surgical procedures without adequate preoperative stabilization results in a high risk of perioperative cardiopulmonary complications and death.2 Therefore, percutaneous techniques for embolectomy and thrombolysis are better tolerated in medically compromised patients. We present a case of an elderly patient who developed acute bilateral lower extremity ischemia and was felt to be at high risk for surgical complications. However, percutaneous therapeutic options were also limited due to acute bilateral lower extremity involvement and limited vascular access.

Case Report. An 86-year-old female residing in a nursing home presented with a 3-day history of nausea, vomiting and progressive bilateral leg pain. Her medical history was significant for hypertension, paroxysmal atrial fibrillation (not on warfarin due to fall risk), previous cerebrovascular accident and predominantly being wheelchair bound. On physical examination, she had a sporadically irregular pulse rate of 70, and was normotensive with clear lungs and cool lower extremities. Both feet were cold to palpation, with mild pain on plantar flexion of both feet but intact motor function. Both femoral pulses were palpable, but the exam was most noticeable for an absence of pulses in the popliteal, posterior tibial and dorsalis pedis arteries bilaterally and delayed venous refill in both feet. Duplex ultrasonography revealed bilateral occlusion of her popliteal arteries with the absence of distal arterial flow. Urgent vascular surgical consultation was obtained and due to comorbidities, conservative therapy was suggested.

On consultation with the cardiovascular interventional service, a decision to proceed with diagnostic peripheral angiography was made. As clinical examination and Duplex ultrasound both confirmed bilateral lower extremity occlusions, bilateral antegrade femoral arterial access was obtained. Peripheral vascular angiography with runoff revealed bilateral complete occlusion of the popliteal arteries with absence of distal arterial flow (Figure 1). After administration of unfractionated heparin, a 0.035 inch Glidewire (Terumo, Japan) was used to traverse the occlusions bilaterally, and a 4.0 x 60 mm Agiltrac balloon (Guidant Corp., Temecula, California) was used to perform balloon angioplasty in both popliteal arteries (Figure 2). Significant intravascular thrombus was identified and bilateral 30 cm Unifuse infusion catheters (AngioDynamics, Queensbury, New York) were placed with infusion of reteplase (Retevase, PDL BioPharma, Redwood City, California) 0.2 units/hour for 24 hours.

Peripheral vascular angiography repeated after 24 hours of local fibrinolytic infusion revealed improved flow in both lower extremities with evidence of 2-vessel runoff to the right foot. However, persistent intravascular thrombus was identified in the left peroneal artery (Figure 3A) and adjunctive thrombectomy with the AngioJet catheter (Possis Medical, Inc., Minneapolis, Minnesota) resulted in single-vessel runoff into the left foot (Figure 3B). On physical examination, both feet were warm with palpable pulses in the posterior tibial arteries bilaterally. The vascular closure device AngioSeal (Abbott Vascular, Abbott Park, Illinois) was used to obtain hemostasis in both common femoral artery vascular access sites. The patient’s hospital course was otherwise uneventful, and she was transferred back to her nursing home 3 days later. She did not develop a compartment syndrome or a myonephropathic syndrome. Echocardiography revealed no evidence of a left atrial thrombus, but warfarin therapy was initiated to minimize the risk of future thrombotic events.

Discussion. This is a unique case description of a patient who presented with acute bilateral lower limb ischemia in whom the feasibility of bilateral antegrade arterial access with simultaneous infusion of local thrombolytic therapy was demonstrated. This approach followed by thrombectomy within 24 hours resulted in the restoration of distal arterial flow and bilateral lower extremity salvage.
Though safe vascular access close to the target lesion is critical for the success of percutaneous revascularization, bilateral popliteal arterial occlusion precluded the contralateral femoral artery approach (“crossover” technique) in this patient. The simultaneous crossover technique would have been possible in the presence of large common femoral arteries, but in this small, elderly woman, this approach was not felt to be appropriate. Therefore, as the crossover technique would have delayed the treatment of one leg, bilateral antegrade common femoral arterial access was obtained to treat both lower extremities simultaneously. Antegrade access is associated with a higher risk of vascular bleeding, and the technique requires diligence to consistently access the common femoral artery. The most important anatomical landmark is the mid-portion of the femoral head, which usually identifies the common femoral artery, while access at the level of the inguinal crease frequently results in puncture of the superficial or profunda femoral artery. Hemostasis in this patient was achieved on the second day with the vascular closure device AngioSeal and is possible with antegrade access in the absence of abdominal obesity and common femoral arterial access.

Patients with acute limb ischemia commonly present with pain, decreased sensory function and in advanced stages, loss of motor function. The patient we present was felt to be in TASC Stage IIb (Table 1),3,4 therefore, the possibility of limb salvage still existed with restoration of blood flow. However, the etiology for simultaneous bilateral thrombotic popliteal occlusions remains puzzling. Though simultaneous emboli to both legs due to chronic atrial fibrillation is possible, it is unlikely given the absence of any other organ demonstrating evidence of systemic embolization and both occlusions being at the same site. We hypothesized that due to immobilization of the patient in a wheelchair, chronic compression of both popliteal fossa might have led to bilateral popliteal artery thrombosis.

Vascular surgical consultation was obtained for this patient, but due to poor functional status including being nonambulatory, having a previous cerebrovascular accident and unidentifiable distal targets, she was deemed to be a poor candidate for surgical revascularization due to the high associated mortality.1,4–7 Further more, with reperfusion, the risk of developing the compartment syndrome requiring fasciotomy was felt to be high. The local delivery of intra-arterial fibrinolytic therapy for lower extremity ischemia is a well recognized technique with a relatively low complicaton rate. Three randomized clinical trials show that the administration of local fibrinolytic therapy versus surgery, as an initial strategy, reduces the risk of subsequent surgery, improves limb salvage for patients with peripheral arterial occlusion and is associated with lower mortality.5–7 Using this approach, the underlying lesions can be identified and treated by transluminal balloon angioplasty or stenting, or by elective surgical revascularization. However, severe bleeding is still a rare complication of intra-arterial thrombolysis and the associated risk of intracranical hemorrhage is 1–2%.4–7 The case we present highlights the frequent problem of residual thrombus after fibrinolytic therapy has been administered for 24–48 hours. This is best treated with adjunctive thrombectomy which helps improve limb salvage rates.8 Utilizing these approaches, we successfully restored arterial flow to both lower extremities in this patient, resulting in limb salvage without any complications. Fortunately, this patient did not develop a myonephropathic syndrome or develop a compartment syndrome, both of which can develop after reperfusion regardless of the revascularization strategy.4

In conclusion, this report demonstrates that bilateral acute lower limb ischemia can be treated percutaneously. Utilizing bilateral antegrade common femoral arterial access with simultaneous infusion of local fibrinolytic therapy and adjunctive thrombectomy, bilateral lower extremity limb salvage was achieved.