Please see supplemental content for abstract with figures.
Background: Although radial artery thrombosis following left-sided cardiac catheterization is a recognized complication, with an incidence reported anywhere from 1-10%, there are very few reports of recurrent brachial artery thrombosis and acute limb ischemia following such a procedure.
Case: 64-year-old female with past medical history of a previous CVA of unknown etiology with no residual deficits and hyperlipidemia who was initially admitted for management of a suspected NSTEMI. She was started on an IV Heparin infusion prior to undergoing a Left Heart Catheterization, which was normal, using right radial artery access. Within the next 24 hours, the patient developed ipsilateral brachial, radial, and ulnar artery thrombi, identified initially via ultrasound and confirmed intraoperatively. She was urgently taken to the operating room where a thrombectomy and angioplasty were performed. Unfortunately, these isolated thrombi continued to reoccur in her brachial, radial, and ulnar arteries despite adjustments in anticoagulation which had included a switch to argatroban as well as several intra-operative boluses of argatroban. Her ACT and aPTT remained persistently subtherapeutic. She underwent surgical thrombectomies over 4 consecutive days with removal of the recurrent thrombi.
Decision-Making: Hematology was consulted and labs were sent to work-up possible antiphospholipid or anticardiolipin syndrome in addition to vasculitis. Given concerns for these processes and the patient’s critical condition at the time, a shared-decision was made to trial plasmapheresis. She was continued on argatroban and dual anti-platelet therapy was initiated as well. Ultimately, the patient required a total of six operations, including the initial left heart catheterization as well as a subsequent fasciotomy performed emergently for acute compartment syndrome. Following all of the aforementioned medical and surgical management, including a total 5-day course of empiric plasmapheresis, the patient slowly began to regain sensation and strength within her right hand, although not to her previous baseline, with the aid of Physical and Occupational Therapy. She was discharged on oral forms of argatroban and dual anti-platelet therapy with her limb intact following a total of 29 days in the hospital. Laboratory work-up for the aforementioned hematologic and autoimmune entities were all negative.
Discussion and Conclusions: Prompt recognition of Acute Limb Ischemia as well as coordinated evaluation, management, and intervention from multiple medical specialties can be limb-and-life-saving. While there was not a confirmed diagnosis of any specific underlying vasculitis or autoimmune process in this instance, empiric treatment with plasmapheresis did seem to have played a positive role in the patient’s recovery; although, it would be difficult accurately quantify its effectiveness relative to all of the interventions she received. Overall, further research into the pathophysiology of the development of arterial thrombi in the setting of recent vascular manipulation is needed to further guide management of these types of cases.