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Nikizad H, Tsai D, Lookstein R, Hausman M. Catheter-Directed Thrombolysis for Acute Digit Ischemia in the Setting of Heterozygous Factor V Leiden Mutation: A Case Report and Review of Literature. JBJS Case Connect 2022; 12:01709767-202212000-00034. [PMID: 36417546 DOI: 10.2106/jbjs.cc.22.00437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 10/01/2022] [Indexed: 11/24/2022]
Abstract
CASE We are reporting the successful treatment of a patient with a heterozygous factor V Leiden mutation who presented with spontaneous thrombotic ischemia of ring and small fingers. Microcatheter-directed administration of thrombolytics at the level of common and proper digital arteries resulted in the salvage of the ring finger to the level of the distal tuft and the entirety of the small finger. CONCLUSION Heterozygous factor V Leiden mutation is an extremely unusual etiology for thrombotic digital ischemia. This case report emphasizes the importance of correct diagnosis, timely intervention, and thrombolytic therapy using microcatheters to optimize digital rescue.
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Affiliation(s)
- Hooman Nikizad
- Department of Orthopedic Surgery at Mount Sinai Health System, New York, New York
| | - David Tsai
- Department of Orthopedic Surgery at Mount Sinai Health System, New York, New York
| | - Robert Lookstein
- Department of Diagnostic, Molecular, and Interventional Radiology at Mount Sinai Health System, New York, New York
| | - Michael Hausman
- Department of Orthopedic Surgery at Mount Sinai Health System, New York, New York
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González‐Medina S, Nout‐Lomas YS, Landolt G. Unintentional intracarotid injections in the horse—15 cases (2010–2020). EQUINE VET EDUC 2022. [DOI: 10.1111/eve.13706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Sonia González‐Medina
- Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Science Colorado State University Fort Collins Colorado USA
| | - Yvette S. Nout‐Lomas
- Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Science Colorado State University Fort Collins Colorado USA
| | - Gabriele Landolt
- Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Science Colorado State University Fort Collins Colorado USA
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Maldarelli ME, Traver EC, Norcross G, Gann D, Kattakuzhy S, Welsh C, Schmalzle SA. Acute Limb Ischemia Caused by Inadvertent Arterial Drug Self-Injection: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e932903. [PMID: 34392302 PMCID: PMC8378779 DOI: 10.12659/ajcr.932903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND A predictable consequence of long-term injection drug use is the destruction of the native venous system; as a consequence, people who inject drugs may eventually move to injection into skin and subcutaneous tissue, wounds, muscles, and arteries. These practices put people who inject drugs at risk for injection-related soft-tissue infection, vascular damage, ischemia, and compartment syndrome, all of which have overlapping presenting symptoms. CASE REPORT A 35-year-old man who injects drugs presented with foot swelling and discoloration initially concerning for necrotizing fasciitis or compartment syndrome. After progression despite appropriate antimicrobial and surgical treatment for soft-tissue infection, he was diagnosed with arterial insufficiency and resultant distal ischemia. This diagnosis was discovered only after obtaining additional history of the patient's drug use practices. Just prior to his symptoms, he had unintentionally injected a formed thrombus into his dorsalis pedis artery. CONCLUSIONS Intra-arterial injection of drugs can cause ischemia through a variety of mechanisms, including direct vessel trauma, arterial spasm, toxicity from the drug of abuse or an adulterant, embolism of particulate matter, and as proposed here, direct injection of preformed thrombus. Medical providers should be aware of the steps of injection drug use and their associated risks so that they can ask appropriate questions to focus their differential diagnosis, increase their understanding of common or current local injection practices, and develop rapport with the patient. Patient education on safe injection techniques may also reduce the risk of serious complications.
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Affiliation(s)
| | - Edward Conan Traver
- Department of Infectious Diseases, University of Maryland Medical Center, Baltimore, MD, USA
| | - Gregory Norcross
- Department of Internal Medicine, University of Maryland Medical Center, Baltimore, MD, USA
| | - Donald Gann
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sarah Kattakuzhy
- Division of Clinical Care and Research, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Christopher Welsh
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sarah Ann Schmalzle
- Division of Clinical Care and Research, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA.,Division of Infectious Disease, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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Lokoff A, Maynes JT. The incidence, significance, and management of accidental intra-arterial injection: a narrative review. Can J Anaesth 2019; 66:576-592. [PMID: 30877587 DOI: 10.1007/s12630-019-01327-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 12/05/2018] [Accepted: 12/08/2018] [Indexed: 10/27/2022] Open
Abstract
This narrative review discusses the incidence, risk factors, mechanisms of injury, complications, and treatment regimens for accidental intra-arterial injection of medications. Despite awareness of the issue and the establishment of safety recommendations by national agencies, accidental iatrogenic intra-arterial injection of medications continues to occur. Most of these injuries are caused by accidental injection into an established arterial cannula or the inadvertent and unrecognized cannulation of an artery instead of a vein. Although many medications have been injected into arteries without significant consequence, a number of drugs are consistently associated with severe morbidity, including the need for amputation, making early incident recognition and treatment vital. Accidental intra-arterial injection of medications has also been increasingly reported in those who use illicit drugs, as these intravenous injection attempts can be misdirected into an artery. These reports have improved understanding of these injuries and possible treatment modalities. While the characteristics of injuries from illicit injections are diverse and the optimal treatment modalities are still uncertain, a regimen that includes anticoagulation and intra-arterial injection of thrombolytics and prostaglandins may improve outcomes. Steroids, vasodilators, and sympathetic blocks do not appear to influence amputation rates. Owing to the small and sporadic number of cases, no definitive clinical trial evidence exists, but the treatment modalities found to be useful in the illicit intra-arterial injection group may benefit treatment of similar iatrogenic injuries.
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Affiliation(s)
- Andrew Lokoff
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, ON, Canada. .,Department of Anesthesia, University of Toronto, Toronto, ON, Canada.
| | - Jason T Maynes
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, ON, Canada.,Department of Anesthesia, University of Toronto, Toronto, ON, Canada
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Bercovici N, Russomanno K, Santoro F, Scola C, Murphy M, Elaba Z. Cutaneous refractile foreign body microemboli with intravascular injection of oral medication. J Cutan Pathol 2018; 45:365-368. [DOI: 10.1111/cup.13125] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Revised: 01/25/2018] [Accepted: 02/06/2018] [Indexed: 11/28/2022]
Affiliation(s)
| | - Kristen Russomanno
- Department of Dermatology, University of Connecticut School of Medicine; Farmington Connecticut
| | - Frank Santoro
- Department of Pathology; Hartford Hospital; Hartford Connecticut
| | | | - Michael Murphy
- Department of Dermatology, University of Connecticut School of Medicine; Farmington Connecticut
| | - Zendee Elaba
- Department of Pathology; Hartford Hospital; Hartford Connecticut
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Wilson RM, Elmaraghi S, Rinker BD. Ischemic Hand Complications From Intra-Arterial Injection of Sublingual Buprenorphine/Naloxone Among Patients With Opioid Dependency. Hand (N Y) 2017; 12:507-511. [PMID: 28832211 PMCID: PMC5684922 DOI: 10.1177/1558944716672198] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Sublingual buprenorphine/naloxone, a common treatment for opioid dependence, is frequently abused by intravenous injection. Inadvertent intra-arterial injection of buprenorphine/naloxone can produce acute ischemic insult to the hand due to gelatin embolism. Our purpose was to review a series of these patients in order to describe the clinical entity, review the outcomes, and propose a rational treatment algorithm. METHODS Clinical records of all patients evaluated by the hand surgery team between 2011 and 2015 for ischemia of the hand after buprenorphine/naloxone injection were reviewed. Treatment, complications, and amount of tissue loss were recorded. Patients presenting within 48 hours of the injection were treated with intravenous heparin for 5 days, followed by oral aspirin and clopidogrel for 30 days. Those presenting after 48 hours were treated with aspirin and clopidogrel only. RESULTS Ten patients presented during the review period. Average follow-up time was 13 weeks. Eight had ischemia of the radial side of the hand, 1 of the ulnar side, and 1 had bilateral ischemia. Three patients were treated with intravenous heparin and 5 with oral agents. Two presented with dry gangrene and did not receive anticoagulation. All patients experienced tissue loss. There was no difference in outcome regardless of treatment. CONCLUSIONS With the increasing use of sublingual buprenorphine/naloxone in opioid dependency, ischemic hand injuries will be seen with greater frequency. Whereas outcomes did not vary with treatment modality in this series, further study is needed to determine the most effective treatment of these injuries.
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Abstract
BACKGROUND Acute upper limb ischemia (AULI) is an uncommon emergency warranting immediate evaluation and treatment. The role of nonsurgical therapies including endovascular techniques, thrombolytics, and anticoagulation remains undefined. The authors systematically reviewed the current literature on the nonsurgical treatment of acute ischemia of the upper extremity. METHODS A PubMed and Embase search was conducted, and articles were screened using predetermined criteria. Data collected included patient demographics, cause of upper limb ischemia, type of nonsurgical treatment used, treatment outcomes, and complications. Patients were divided into 4 treatment groups: catheter embolectomy, catheter-directed thrombolysis, endovascular stenting, and anticoagulation/medical therapy alone. RESULTS Twenty-three retrospective studies met the search criteria. Of 1326 reported occlusions, 92% (1221) were attributed to thromboembolic disease. The second most common cause was iatrogenic (1.5%). Overall limb salvage rates were excellent with catheter embolectomy (862 of 882 cases, 97.7%) and catheter-directed thrombolysis (110 of 114 cases, 96.5%). Limb salvage rates were also high with anticoagulation/medical therapy (158 of 165 cases, 95.8%), but poor functional outcomes were more often reported. CONCLUSIONS High-quality evidence to guide the nonsurgical treatment of AULI is lacking. Retrospective studies support the utility of catheter-based embolectomy and thrombolysis for distal ischemia. Whether a surgical or nonsurgical approach is taken, anticoagulation therapy remains a mainstay of both treatment and prevention of AULI. Because AULI patients often have underlying cardiac and/or systemic disease, a multidisciplinary approach is essential to minimize complications and prevent future occurrences.
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Affiliation(s)
| | | | - James P. Higgins
- Curtis National Hand Center, Baltimore, MD, USA,James P. Higgins, MD, c/o Anne Mattson, Curtis National Hand Center, MedStar Union Memorial Hospital, 3333 North Calvert St. JPB #200, Baltimore, MD 21218, USA.
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Iannuzzi NP, Higgins JP. Acute Arterial Thrombosis of the Hand. J Hand Surg Am 2015; 40:2099-106. [PMID: 26408378 DOI: 10.1016/j.jhsa.2015.04.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 04/08/2015] [Accepted: 04/10/2015] [Indexed: 02/08/2023]
Abstract
Arterial thrombosis of the hand occurs infrequently but may result in considerable morbidity and compromise of hand function. The hand surgeon may be called upon to direct management in cases of acute arterial thrombosis of the hand and should have an understanding of the available diagnostic tools and treatment modalities. This article discusses the vascular anatomy of the hand and clinical manifestations of arterial thrombosis. Differences between isolated thrombosis and diffuse intravascular injury are detailed, and treatment options for these conditions are described. Appropriate care often requires coordination with interventional radiologists or vascular surgeons. Outcomes after treatment of arterial thrombosis of the hand are variable, and prognosis may be related to whether isolated thrombosis or diffuse intravascular injury is present.
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Affiliation(s)
| | - James P Higgins
- Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD.
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Abstract
Distal arm and hand ischemia from vessel thrombosis or embolism remains a difficult clinical challenge. The causes of ischemia are variable and include connective tissue disease, embolism, atherosclerosis, and iatrogenic etiology. Although reports are limited, treatment with catheter-directed thrombolysis has favorable results in cases of acute thrombosis, with most patients (80%) demonstrating improvement. Digital amputation rates are less than 10% and the hand is often salvaged. Bleeding and access-site complications remain prevalent in patients undergoing intra-arterial thrombolysis. This review discusses etiology, treatment approaches, outcomes, and complications when thrombolytic therapy is used for distal arm and hand ischemia.
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Affiliation(s)
- Randall R De Martino
- Division of Vascular and Endovascular Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
| | - Steven L Moran
- Division of Plastic Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
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