Acute limb ischemia on graft thrombosis and severe pancreatitis

A 64-year-old female patient was referred for Rutherford IIB acute leg ischemia due to limb graft thrombosis, complicating a severe Balthazar E pancreatitis with respiratory distress. 

Previous medical history included EVAR for AAA two years ago. She was stated ASA 4 by the anesthesiologist team due to her medical condition and risk factors (Obesity BMI 35; diabetes).

Due to her respiratory condition, anesthesiologists were reluctant to perform general anesthesia and mechanical ventilation.

Furthermore, hostile groins (obesity, previous open access, infectious risk) were good arguments for a percutaneous approach under local anesthesia.

As thrombus extended into CFA, a 7 Fr sheath was place via a retrograde ultrasound-guided puncture of the SFA. 

Penumbra Lightning™ 7 Fr device was used to remove thrombus inside the graft. 

After thrombus removal, a completion angio highlighted a proximal limb stenosis treated by placement of a covered stent (Bentley BeGratf 10 x 57 mm, then over inflated with a 12 mm balloon) (videos 2 and 3).

Second angio (video 4) showed persistant low flow in the SFA and proximal occlusion of PFA due to residual thrombus.

After complete removal using Penumbra, a normal blood flow was restored (video 5).
 

Arterial access was closed using a 6 F Angioseal

Then, patient was transferred to ICU and underwent several abdominal surgeries following her pancreatitis (necrosis removal, colectomy with temporary abdominal closure for second look).