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Welcome to the April, 2013 edition of SciEP newsletter, providing monthly summaries of articles on science & education related topics of interest to scientist and professionals. The mission of our journals is to provide an open access forum for publishing new findings on issues pertinent to scientific and academic field. We also invite you to submit original research papers, review articles, short reports, or case studies are considered for publication in our Multidisciplinary Journals.

American Journal of Public Health Research
DOI: 10.12691/ajphr-1-1-3

The Implementation of a Tele-Homecare System with Service Oriented Architecture and HL7 Message Transmission Standard
Ching-Sung Wang

American Journal of Medical and Biological Research
DOI: 10.12691/ajmbr-1-1-2

The Influence of Ethanol on Pyruvate Kinases Activity in Vivo, in Vitro, in Silico
Lelevich Sergey Vladimirovich, Khrustalev Vladislav Victorovich, Barkovsky Eugene Victorovich, Shedogubova Tatyana Aleksandrovna

American Journal of Medical Sciences and Medicine
DOI: 10.12691/ajmsm-1-1-1

Clinical and Histological Features in Wegener Granulomatosis
Li Cavoli Gioacchino, Passantino Rita, Bono Luisa, Tortorici Calogera, Ferrantelli Angelo, Giammarresi Carlo, Rotolo Ugo

American Journal of Infectious Diseases and Microbiology
DOI: 10.12691/ajidm-1-1-2

The Curse of Lymphatic Filariasis: Would the Continual Use of Diethylcarbamazine Eliminate this Scourge in Papua New Guinea?
Anne Lanham, Lillian Mwanri

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American Journal of Medical Sciences and Medicine
American Journal of Medical and Biological Research
American Journal of Pharmacological Sciences
American Journal of Clinical Medicine Research
American Journal of Nursing Research
American Journal of Cancer Prevention
American Journal of Medicine Studies
American Journal of Infectious Diseases and Microbiology
American Journal of Cardiovascular Disease Research
American Journal of Biomedical Research
American Journal of Mechanical Engineering
American Journal of Microbiological Research
Journal of Preventive Medicine
American Journal of Food and Nutrition
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Journal of Cancer Research and Treatment
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A Case of Proximal Deep Vein Thrombosis Following Lower Limb Angioplasty

Chaozer Er*, Eunice Chua Shumin, Navin Kuthiah

Department of General Medicine, Tan Tock Seng Hospital, Singapore

Abstract: Peripheral arterial disease can be treated with angioplasty. Complications of percutaneous angioplasty include arterial occlusion, thromboembolism and arterial rupture. I report a case of lower limb proximal deep vein thrombosis (DVT) that developed 1 day after a peripheral arterial angioplasty via common femoral artery approach. My literature search failed to identify any previously reported cases. The incidence of DVT following coronary intervention via femoral artery catheterization was reported to be 0.05% but the incidence of DVT following peripheral angioplasty remains unknown. This case showed that DVT can happen after peripheral angioplasty and further studies should be conducted to document its incidence. This also raised the point if routine short course of anticoagulation is required after angioplasty of lower limb to prevent DVT.

Keywords: deep vein thrombosis, angioplasty

Citation: Chaozer Er, Eunice Chua Shumin, Navin Kuthiah, A Case of Proximal Deep Vein Thrombosis Following Lower Limb Angioplasty. American Journal of Medical Case Reports, 5 (2). 41-42. January 2017. doi:10.12691/ajmcr-5-2-5

1. Introduction

The incidence of deep vein thrombosis following lower limb angioplasty is unknown. My literature search failed to identify any previously reported cases. I report a case of lower limb proximal deep vein thrombosis that developed 1 day after a peripheral arterial angioplasty via common femoral artery approach.

2. Case Report

Mr. M is a 67-year-old Malay gentleman with significant past medical history of diabetes mellitus, dyslipidaemia, ischaemic heart disease with depressed ejection fraction and peripheral arterial disease. He had undergone percutaneous coronary intervention in 2014 and angioplasty of right lower limb in 2011.

He presented to us with 1-week history of left lower limb swelling that started 1 day after he underwent an angioplasty of his left lower limb. The angioplasty puncture point was the left common femoral artery.

The angiogram showed: 30% stenosis of superficial femoral artery, 80% stenosis of popliteal artery, 90% stenosis of anterior tibial artery, 60%-70% stenosis of tibio-peroneal trunk, 70% stenosis of peroneal artery, total occlusion of posterior tibial artery, dorsalis pedis artery and plantar arteries.

Angioplasty of superficial femoral artery, popliteal artery, tibio-peroneal trunk, peroneal artery and anterior peroneal artery was performed with satisfactory result. Angioplasty of posterior tibial artery was unsuccessful. Intra-arterial heparin of 2500 IU was given during angioplasty. No stent was deployed. Patient was advised to take clopidogrel and aspirin for 6 months after angioplasty followed by lifelong aspirin.

A venous Doppler ultrasound of his left lower limb showed thrombosis of left external iliac vein, common femoral vein and superficial femoral vein. The popliteal vein had normal flow.

Enoxaparin and warfarin were given to treat his deep vein thrombosis. The dual antiplatelet therapy was stopped. Enoxaparin was stopped after his INR (international normalised ratio) achieved therapeutic range of 2-3. He was discharged well with follow up appointment with our anticoagulation clinic and thrombosis physician.

3. Discussion

Peripheral artery disease (PAD) can be treated with revascularization via surgical bypass or endovascular therapy [1]. The optimal post-procedural care after endovascular therapy however is not well established [1]. The pharmacological therapy such as anti-platelet, lipid lowering drug and anti-hypertensive after endovascular treatment is important as stroke and ischemic heart disease are common in patients with PAD [1].

Having extrapolated from the anti-platelet therapy trials in percutaneous coronary intervention with the use of stent, it is believed that antiplatelet can maintain stent patency in peripheral arterial angioplasty [1]. There are no modern randomised trials studying the optimal anti-platelet therapy after peripheral percutaneous transluminal angioplasty (PTA) but long term aspirin therapy seems adequate after peripheral PTA [1]. If a stent is inserted during angioplasty of the upper or lower limbs, the common practice is lifelong aspirin therapy with at least 4 weeks of an additional thienopyridine anti-platelet therapy [1]. The American College of Chest Physicians (ACCP) 2012 guideline on antithrombotic therapy for PAD however recommends long term aspirin or clopidogrel therapy for patients undergoing PTA with or without stenting [2]. The ACCP 2012 guideline recommends single rather than dual anti-platelet therapy for patients undergoing PTA with stenting [2]. The guideline however mentioned that “Patients who place a high value on an uncertain reduction in the risk of limb loss and a relatively low value on avoiding a definite increased risk of bleeding are more likely to choose to use dual antiplatelet therapy.” [2]

Our patient was prescribed by the primary vascular surgeon 6 months of dual anti-platelet therapy (aspirin and clopidogrel) followed by indefinite aspirin therapy after the peripheral PTA. Mr. M claimed that he has been ambulating independently and has been compliant with the dual antiplatelet treatment after the angioplasty. Intra-arterial heparin was given during the angioplasty. It has been reported that peripheral arterial disease increases the risk of DVT [3]. Other contributing factors of venous thromboembolism following femoral artery catheterization include prolonged bed rest, immobility of a catheterized limb, groin compression and haematoma compressing the femoral vein [4]. These raised the question if short term prophylactic anticoagulation rather than antiplatelet or dual antiplatelet following angioplasty for peripheral arterial disease should be a routine practice.

The incidence of DVT following coronary intervention via femoral artery catheterization was reported to be 0.05% [4]. The true incidence may be higher as most events may not be clinically evident [4]. The incidence of DVT post angioplasty of lower limb is however unclear and my literature search failed to identify any previously reported cases. Our patient developed left lower limb swelling 1 day after the angioplasty but he only sought medical attention 1 week after the onset of symptom. This has led to delayed diagnosis of his proximal DVT.

One study showed that acute arterial lumen occlusion due to thrombosis (2%) was the most important complication of angioplasty [5]. Sub-intimal passage of the guide wire/catheter (2%) may also cause luminal compromise [5]. Other less important complications include arterial dissection following balloon dilatation (1%), distal emboli (1.5%) and rarely vessel wall rupture (0.4%) [5]. DVT was not reported to be one of the complications of PTA.

In conclusion, DVT can happen following lower limb PTA. Further studies are required to study its true incidence and to determine if prophylactic anticoagulation for a short period of time is required following lower limb angioplasty.

Acknowledgements

Nil.

Conflict of Interest

Nil.

References

[1]   | Sobieszczyk P, Eisenhauer A. Management of patients after endovascular interventions for peripheral artery disease. Circulation. 2013 Aug 13; 128(7): 749-57.

[2]  
Alonso-Coello P, Bellmunt S, McGorrian C, Anand SS, Guzman R, Criqui MH, Akl EA, Olav Vandvik P, Lansberg MG, Guyatt GH, Spencer FA; American College of Chest Physicians. Antithrombotic therapy in peripheral artery disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb; 141(2 Suppl):e669S-90S.

[3]   | Libertiny G, Hands L. Deep venous thrombosis in peripheral vascular disease, Br J Surg. 1999 Jul; 86(7):907-10.
[4]   | Min SY, Shin JH, Lee SW, et al., A Case of Deep Vein Thrombosis after Coronary Angiography in a Patient Using Antidepressants and Anxiolytics, Korean Circ J. 2013 Feb; 43(2):132-4.
[5]   | Gardiner GA Jr, Meyerovitz MF, Stokes KR, Clouse ME, Harrington DP, Bettmann MA. Complications of transluminal angioplasty. Radiology. 1986 Apr; 159(1): 201-8.