A yound 40 year old female with known right sided cardio-myopathy on dual anti-platelets presented in December, 2006 with history of inability to walk and stand up, with rapidily increasing pain in both the lower limbs, since approx 18 hours prior to admission. Initial clinical examination showed evidence of vascular occlusion with absent peripheral pedal pulsation on both side with cold, clammy and pale lower extremitines and no sensation till the inguinal ligaments on both sides, even though she remained haemodynamically stable. An urgent peripheral Doppler study of the lower limbs revealed normal venous flow but serverly diminished arterial flow. Echocardiogram revealed dilated right vernticle and right atrium with good LV function (LVEF – 60%) and no regional wall motion abnormality or mural clots. Thereafter, early consultation with Dr. Ajay Kaul (Cardiovascular Surgeon) & Dr. Aurobindo Mukherjee (Neurologist) was sought and a 64 slice CT angiogram of abdominal aorta done the same eveing revealed totally occluded abdominal aorta below the origin of both renal arteries; internal and external iliac arteries are supplied by collaterals from the abdominal aorta and braches of superios mesenteric arteries. Based on this an early decision to administrer Urokinase was given as bolus followed by infusion in the recommended dose along with simultaneous unfractionated Heparin (UHF) infusion was started to prevent clot propatation. The Urokinase infusion was continued for 7 days, even though significant clinical improvement (with return of pedal pulsation) occurred within the first 24 hours.
A repeat CT-Abdominal Angiography, after 3 days, revealed almost total revascularization of terminal abdominal aorta with contract clearly visible on both iliac arteries; the left iliac circulation was clearly visible up to the tibial artery, while a short segment of occlusion still remained in right femoral artery (but with good collaterals) with delayed antegrade flow. Her remaining course in the hospital was basically unremarkable, except for a single episode of non-sustained ventricular tachycardia.
The patient was subsequently mobilized out of bed and with continued physiotherapy had good recovery. She was eventually discharges after 3 weeks on optimum oral anti-coagulation and antiplatelet therapy along with a low dose Beta Blocker.
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