engleski

Arterial thrombosis in a 19-years - old patient on CAPD

Acut critical left limb ischemia (grade III) in a 19-year old patient started 36 hours before hospitatal admisson. Previous medical history in a childhood, at age of three, segmental glomerulosclerosic and renal insufficiency occurred. Renal transplantation was performed at the age of six. Four years later CAPD was introduced because of graft rejection. Episode of peritonitis was successfully treated with antibiotic therapy a few weeks before arterial thrombosis. At admission the patient was hypotensive ( BP 85/60, HR 110/min), somnolent, presented with 5 P. According to angiografhy disclosing the left common iliac artery thrombosis the patient was referred to the sergeon who indicated high femoral amputation. Selective intraarterial fibrinolytic therapy with rt - PA as the salvage threathment was indicated with 10 mg intrathrombi bolus, continued with a high dose of rt-PA in the next 4 hours(5mg/h), followed by a reduced dose (1 mg/h) up to 40 hours. Repeated angiography found successful progressive reperfusion up to the foot. Low molecular heparin was initiated after finishing fibrinolytic therapy. Unfortunately, CT scan of the leg performed the next day because of limb swelling confirmed diffuse intramuscular hemorrhages mostly as a complication of late fibrinolytic therapy and reperfusion injury. Itwas treated conservatively at the beginning, but soon after the fasciotomy was done. Peroneal paresis was the only complication of extensive proximal ileofemoral arterial thrombosis and very late thrombolytic salvage.Later, familiar thrombophilia was confirmed - protein C deficiency in a grandmother who suffered venous thromboembolism, father who had pulmonary embolism, and the patient whose protein C level was decreased, about 20%. Homocystein level and von Willebrand factor were extremely high. Also, local mechanical injury of the iliac artery where metal clips were positioned, promoted vascular occlusion in syngergistic influence with thrombophilic disorders. This controversial case could encourage the angiologysts for intraarterial selective fibrinolytic therapy as a limb saving therapy.

thrombosis; CAPD; fibrinolysis

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