Rare complication of surgical intervention for acute limb ischemia: a case report

Abstract

Background. Complications of balloon catheter embolectomy for acute arterial occlusion are extremely rare and there is a lack of clear recommendations for its management. This report describes a case of peroneal artery (PA) pseudoaneurysm that developed after lower limb thrombembolectomy using Fogarty balloon catheter and was successfully treated by transluminal coil embolization. Case report. A 84-year-old female patient presented to the emergency department 5 hours after sudden onset of pain in the right lower extremity. She had a known history chronic atrial fibrillation, being on ongoing treatment with warfarin. Clinical examination discovered absent popliteal and plantar pulses and typical signs of acute limb ischemia. The hand-held Doppler revealed inaudible arterial and audible venous signals at the level of the right foot. Under spinal anesthesia the right common femoral artery was dissected and a 4F Fogarty embolectomy catheter was easily advanced down to the tibial arteries. The embolectomy was performed successfully with recovering of plantar pulses postoperatively. Four hours later clinical manifestations of the compartment syndrome were observed and “2-incision 4-compartments” fasciotomy was performed. Prolonged bleeding from fasciotomy wounds was noted after surgery, considered being caused by systemic heparinization. After transfusion of 3 units of red blood cells, one litter of plasma and several reapplications of bandage bleeding was controlled. After 3 days the fasciotomy wounds were sutured. Patient was discharged at 5-th postoperative day, anticoagulated with 20 mg of rivaroxaban. Eighteen days after discharge, she returned to the hospital with complaints to severe, permanent pain in right leg. Clinical examination noted extensive pulsation of the right calf with audible systolic bruit. Duplex ultrasound suggested a large pseudoaneurysm of the PA. Digital subtraction angiography confirmed a 55 mm large sacular pseudoaneurysm of the PA and patent tibial run-off. A microcatheter (Progreat®, Terumo) was percutaneously inserted into the right PA via ipsilateral antegrade femoral approach. Two detachable coils (Azur®, Terumo) were deployed distally to the aneurysm and 5 coils were released in the proximal PA and aneurysm sac. The complete occlusion of pseudoaneurysm was achieved. Postoperatively patient becomes symptom free and ultrasound confirmed absence of flow in pseudoaneurysm. Conclusions. Apart from the rarity of iatrogenic pseudoaneurysm of PA, this case highlights the risk of severe complications associated with relative simple procedure of balloon catheterembolectomy. Vascular imaging should be performed if patient demonstrates unusual postoperative evolution.