Author + information
- Isao Aburadani1
Patient initials or identifier number
Relevant clinical history and physical exam
This case is 60 years-old woman treated for systemic lupus erythematosus with anti-phopholipid syndrome. Eight years earlier, below-knee amputation of her left lower limb was performed due to cold injury. She was brought to our emergency department because of pain in her left leg stump. Baseline angiography performed on the second admission day showed the severe narrowing of iliac and femoral artery and occlusion of popliteal artery. On the third day, we performed endovascular intervention.
Relevant test results prior to catheterization
Right femoral artery was inserted with 6Fr sheath less guiding catheter and the tip was located into left iliac artery with cross over. A 0.014 inch guidewire easily crossed to mid-portion of left superficial femoral artery (SFA). The stenosis in left iliac artery deployed with a 7.0/40 mm SMART stent and the lesion in proximal SFA was dilated with 5.0 mm balloon.
Relevant catheterization findings
Her popliteal artery occluded. We start wiring with Cruise supported by micro catheter. The wire passed the occlusion site to the distal anterior tibial artery (ATA) with relatively little effort. 3.0 mm balloon dilation performed sequentially from proximal ATA to popliteal artery. Below-knee blood flow to the stump improved.
One hour after the intervention, we noticed the remarkable swelling in the stump of her left lower limb. Although we performed computed tomography of lower limb as we suspected vascular perforation as the cause of the swelling, any extravasations were not detected. The swelling gradually got worse and slightly red. The circumference of below-knee reached to a maximum of 38 cm in 13 days. She had little pain in the swelling part but could not walk using her prosthetic leg because of the swelling. It required about 2 months before the swelling fully recovered.
The endovascular intervention of critical limb ischemia(CLI) is still challenging and furthermore the intervention of amputated leg is little known. We experienced the remarkable and persisting swelling in the stump of lower limb after the intervention of CLI. The swelling after re perfusion is thought to be self-limiting nature, but in our case, it delayed her rehabilitation because the swelling stump does not match with the shape of her prothetic leg. Treatment such as compression band etc might needed on case-by-case basis.