Purpose : To assess the efficacy of a new in situ thrombolysis method using a low-pressure micro-porous balloon catheter (MPBC) compared to a traditional in situ infusion (ISI) of a fibrinolytic agent in the treatment of acute limb ischemia. Methods : Between January 2010 and December 2011, 21 patients (14 men; mean age 64.6 years, range 40-92) treated for acute lower limb ischemia were prospectively enrolled in the study. Seven patients underwent in situ thrombolysis using the ISI method and 14 patients the MPBC method to deliver urokinase. The total urokinase dose injected and the length of stay in an intermediate care unit were compared between the groups. Results : Recanalization was successful in 90% of cases (6/7 patients in the ISI group; 13/14 patients in the MPBC group). The morbidity was 7% (1 pseudoaneurysm). The dose of urokinase needed was significantly lower (p<0.001) in the MPBC group (0.7±0.44 IU, range 0.15-1.6) vs. the ISI group (1.66±0.71 IU, range 0.2-2). The average length of stay in the intermediate care unit was significantly shorter in the MPBC group (1.2 vs. 3.9 days, p<0.002). The overall 6-month limb salvage rate after recanalization was 90% (83% for the ISI patients vs. 93% for the MPBC group). Conclusions : Intra-arterial thrombolysis using a balloon catheter is an effective method in the treatment of acute peripheral arterial occlusions. In the case of occlusion caused by embolism, primarily in very elderly patients, it may reduce the risk of hemorrhage. A randomized study on high-risk patients is needed to confirm these initial results.

Surgical and intensive care patients are at a heightened risk for arterial embolization due to pre-existing conditions such as age, hypercoagulability, cardiac abnormalities and atherosclerotic disease. Most arterial emboli are clots that originate in the heart and travel to distant vascular beds where they cause arterial occlusion, ischemia, and potentially infarction. Other emboli form on the surface of eroded arterial plaque or within its lipid core. Thromboemboli are large clots that dislodge from the surface of athesclerotic lesions and occlude distal arteries causing immediate ischemia. Atheroemboli, which originate from fracturing the lipid core tend to cause a process of organ dysfunction and systemic inflammation, termed cholesterol embolization syndrome. The presentation of arterial emboli depends on the arterial bed that is affected. The most common manifestations are strokes and acute lower limb ischemia. Less frequently, emboli target the upper extremities, mesenteric or renal arteries. Treatment involves rapid diagnosis, which may be aided by precise imaging studies and restoration of blood flow. The type of emboli, duration of presentation, and organ system affected determines the treatment course. Long-term therapy includes supportive medical care, identification of the source of embolism and prevention of additional emboli. Patients who experienced arterial embolism as a result of clots formed in the heart should be anticoagulated. Arterial emboli from atherosclerotic disease of the aorta or other large arteries should prompt treatment to reduce the risk for atherosclerotic progression, such as anti-platelet therapy and the use of statin drugs. The use of anticoagulation and surgical intervention to reduce the risk of arterial embolization from atherosclerotic lesions is still being studied.

History: A 32-year-old woman was admitted to the emergency department because of acute dyspnea and syncope. A few minutes before the onset of symptoms, she had self-administered an intravenous injection of one gram of heroin combined with grinded flunitrazepam tablets.Investigations: Signs of acute cor pulmonale were detected on transthoracic echocardiography despite lack of pulmonary embolism in computed tomography. It was assumed that microembolisms were the cause of acute pulmonary hypertension after intravenous injection of heroin and flunitrazepam.Treatment and course: Because of lack of thrombus in CT scan therapeutic anticoagulation with unfractionated heparin and oxygen insufflation was initiated resulting in rapid improvement of oxygen saturation and blood pressure. On the following day pulmonary pressure in transthoracic echocardiography was already decreased significantly. Without signs of deep venous thrombosis in duplex scan and only a marginal sub segmental perfusion deficit in ventilation-perfusion-scintigraphy therapeutic anticoagulation was recommended for three months.

Conclusion:

The most likely cause of micro embolisms in this case are particles of talc, which are often used to cut heroin, or the microcrystalline cellulose used in tablets. There have been reports of tissue necrosis due to arterial embolism/vasospasm by crystalloid or oily substances (embolia cutis medicamentosa) in the extremities after intraarterial injection of grinded flunitrazepam tablets. Therefore it seems plausible that intravenous application may cause a serve but transient deficit of perfusion in pulmonary circulation.

As the major hazard of percutaneous vertebroplasty (PV), cement extravasation into the venous system, systemic embolism, and spinal canal has been previously reported. However, to our knowledge, only one case of the arterial migration of cement has been previously reported that is directly associated with this technique without any symptom in the immediate post-intervention and in the follow-up period. An arterial embolus of cement occurred in a 46-year-old woman undergoing lumbar PV for breast cancer metastasis. Less than one hour later, the patient complained of severe pain and numbness in her left leg. A diagnosis of acute left leg ischemia due to the acute occlusion of the infrapopliteal arteries by the cement was made. Transluminal angioplasty (PTA) for the infrapopliteal arteries was recommended because there were diffuse and long vessel involvements, leaving no distal targets for bypass vascular surgery. The patient's postoperative course was uncomplicated; the extremity tenderness and mottled skin were improved. A follow-up ultrasound 2 months later revealed an acceptable distal flow in the arteries of the affected limb, and the patient remained asymptomatic (except for a mild leg pain on exertion) at the one-year follow-up examination. In conclusion, PTA may save the limb from amputation in case of peripheral arterial embolism caused by cement during PV.

A 43-year-old man presented to the emergency department with left leg claudication. CT angiogram confirmed an acute left leg arterial occlusion from a left ventricular thrombus. During intra-arterial thrombolysis, he developed severe abdominal pain and a CT angiogram confirmed an acute occlusive thromboembolism to his left renal artery. Prior to left renal artery intra-arterial embolectomy, temporary intra-arterial occlusion balloons were inflated within his (1) right renal artery to protect this kidney from acute embolism and (2) left iliac artery to protect his left leg from further clot burden. Following the left renal embolectomy, an angiogram demonstrated patent renal arteries, acute occlusion of the right common iliac artery and persistent clot in his left iliac/lower limb. These occlusions were retrieved by surgical embolectomy. Final angiogram demonstrated patent bilateral iliac/lower limb arteries. The patient was discharged on lifelong anticoagulation and remains asymptomatic with bilateral palpable distal pulses and normal serum creatine.

Acute critical lower limb ischemia refers to the state of severely impaired vitality of lower limbs due to acute occlusion of arterial blood vessel by a thrombus or emboli. Surgical revascularization in the first 6-12 hours after the onset of symptoms gives the best results. However, a high mortality rate and probability of limb loss make this problem more debatable, and can be related with associated diseases.This research included 95 patients who had been operated within the first 12 hours after the onset of symptoms of critical limb ischemia We collected the following data: age and sex of patients, etiology of limb ischemia, type of operation, associated diseases and outcome of treatment.Most of the patients were 70 to 80 years old, both sexes being equally represented. There was significantly more arterial embolism (70%) than thrombosis on the prior arterial lesion. Most of the embolizations were treated with Fogarty balloon catheter embolectomy (98%); however, a great number ofarterial thrombosis demanded more complex "inflow" and "outflow" ensuring procedures such as thromboendarterectomy and bypass (33%). The performed surgical procedures showed no statistical differences when final outcome was analyzed. Amputation had to be performed in about 3% of the patients and all of them were diabetics. Mortality rate in this research was 10.5% and 7/10 with this outcome had severe form of chronic myocardiopathy and metabolic decompensation.Acute critical lower limb ischemia should be treated surgically as soon as possible. Negative outcomes are associated with comorbidity and general condition of the patient.

Catheter-directed thrombolytic treatment in an alternative method of treatment compared to the surgery of acute lower limbs ischemia. A case of acute lower limb ischemia due to occlusion of the vascular by-pass treated with guided thrombolysis with the use of a high doses of rtPA administered in a short period of time. Restoration of patency (revascularization) was achieved, and simultaneously complication in the form of peripheral embolism was found. After performing angioplasty of arteries occluded with embolism, total vascular revascularization and finally a very good clinical result were achieved.

Hyperbaric oxygen (HBO2) is the inhalation of 100% oxygen at pressures > 1.4 times atmospheric pressure. Hyperbaric oxygen can be delivered in monoplace (single person) or multiplace (multi-person) chambers. Most clinical HBO2 exposures are between 2 and 2.4 atm abs for approximately 2 hours. Hyperbaric oxygen causes the blood and tissue oxygen levels to increase, reduces the volume of intravascular and tissue bubbles (to treat decompression sickness [DCS] and arterial gas embolism [AGE]), and accelerates wash-out of other gases, such as nitrogen or carbon monoxide (CO), which is important for DCS, AGE, and CO poisoning. Hyperbaric oxygen favorably modulates ischemia-reperfusion injury by transiently inhibiting neutrophil-endothelial interactions, which is important for patients with DCS, AGE, CO poisoning, and potentially other acute ischemic conditions. Because of enhanced oxygen delivery, HBO2 is used for acute crush injury, ischemic flaps and grafts, acute central retinal arterial occlusion, other acute arterial occlusions, and idiopathic sudden sensorineural hearing loss. Hyperbaric oxygen has antimicrobial effects and is offered for patients with limb- or life-threatening infections, such as clostridial gas gangrene and necrotizing fasciitis. The most common US indication for HBO2 is the treatment of ischemic wounds (eg, diabetic lower extremity wounds, late effects of radiation, and refractory osteomyelitis). In ischemic wounds, HBO2 can deliver sufficient oxygen to the nonhealing wound to stimulate angiogenesis and healing through multiple mechanisms, including increased collagen production, increased growth factor receptor numbers, upregulation of vascular endothelial growth factor, increased circulating endothelial progenitor cells, and improvement in neutrophil-mediated host defense. Clinical trials support efficacy of HBO2 for acute CO poisoning, diabetic lower extremity wounds, crush injury, and radiation necrosis. Most hyperbaric chambers are associated with wound care centers and may be hospital based or nonhospital based. We review some of the disorders treated with HBO2 that hospital-based clinicians may be asked to evaluate.

Heart injuries can be classified as penetrating and non-penetrating (blunt). Penetrating wounds are usually caused by stabbing with a piercing object, weapon or projectiles--missiles. The right atrium is damaged in most cases, because of its anatomical position--making the most of the anterior side of the heart. Morbidity caused by stabbing injuries to the heart is 20%-30%, while piercing wounds cause 30%-60% of deaths.. A 28-year-old patient was admitted to our clinic with acute ischemia of the extremities. Angiography revealed a bullet in the right common femoral artery, occluding it. The patient denied having any piercing or shooting wound to his leg, but he said that four years before he had been shot to his chest. Echocardiography revealed an atrial septal defect of secondary type. An event reconstruction revealed that, four years after shooting, the bullet was displaced from the heart to the right common femoral artery.This case report is unique because of the rare type of injury, time that passed from the injury, the way bullet entered the artery (via atrial septal defect) and especially the success of both surgical procedures (embolectomy and repair of atrial septal defect).