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Relevant clinical history and physical exam
A 33-year old female was admitted to our ER with sudden-onset pain and cyanosis in her left leg since 3 days. She had a history of baby-delivery 3 months ago and developed DOE and orthopnoe since then. Absent of left lower limb pulse on examination.
Relevant test results prior to catheterization
Laboratory tests on admission were as follows: WBC16700/μL, D-Dmier >5μg/ml. Duplex USG and CT angiography showed occlusion in left common femoral artery (CFA). We decided to perform emergency angiography. TTE showed reduced LV function, EF: 25% with LV thrombus.
Relevant catheterization findings
The emergent peripheral angiography showed total occlusion of left Internal and Extenal Iliac Artery through distal without any significant collateral flow.
Left Common Iliac Artery was canulated with a 6F Judskin Right guiding catheter. We tried to cross the occlusion by using Progreat 130 cm micro catheter. We performed thrombo aspiration through the left Extrenal IliacArtery and tried to move the micro catheter forward the lesion but failed. After negotiation, we decided to perform PIAT with Alte plase and supported with standard drugs.
Two days later, the patient undergone another angiography. We reinserted the Progreat 130 cm micro catheter and perfomed another thrombo aspiriation. Then we performed wiring with Radio focus guide wire and tried to advance the wire through the occlusion. The guide wire successfully passed though distal of anterior tibialis artery (ATA). Trombo aspiration was performed from Common Iliac Artery to distal ATA. Unfortunately we cannot place any stent due to lack of peripheral artery stent available in our region. The final angiogram revealed successful revascularization from Common Iliac Artery to ATA with collateral flow in the distal of the limb. Patient was later moved to CCU and received anticoagulant, antiplatelet, and HF standard drugs.
The next day in CCU, the symptoms were improved with palpable left lower limb and disappearance of cyanosis. She was discharged from hospital 5 days later. Three days after discharged, patient came to clinic for control and we found improvement of symptoms, stronger distal pulse and lost of cyanosis. Patient was able to walk.
This case showed immediate intervention in ALI case significantly improve the chance of limb salvage.