A Race Against Time: Contralateral Acute Limb Ischemia During Catheter‐Directed Thrombolysis for Peripheral In‐Stent Thrombosis—A Case Report
Vineet Madishetty, Abhinav Singh, Badal Sojitra, Alexander Yaylayan, Kevin Schneider, Merrill KrolickBackground
Acute limb ischemia (ALI) from peripheral in‐stent thrombosis is a vascular emergency requiring urgent revascularization. Catheter‐directed thrombolysis (CDT) is an established treatment option in selected patients, but development of contralateral ALI during active thrombolysis is rarely described.
Case Summary
A 70‐year‐old man with severe peripheral arterial disease, prior bilateral lower extremity stenting, coronary artery disease, diabetes mellitus, chronic kidney disease, and active tobacco use presented with acute left lower extremity pain, coolness, and absent pulses with preserved motor function most consistent with Rutherford Class IIa ALI. Imaging demonstrated extensive thrombosis involving previously placed left iliac and femoropopliteal stents. The patient underwent mechanical aspiration thrombectomy, balloon angioplasty, and left‐sided CDT. During ongoing thrombolytic therapy, he developed new right lower extremity discoloration and absent pulses with preserved motor and sensory function—also most consistent with Rutherford Class IIa ALI. Repeat angiography demonstrated restored left‐sided perfusion but new occlusion involving the right common femoral and superficial femoral arterial stents. Mechanical aspiration thrombectomy followed by right‐sided CDT restored bilateral limb perfusion.
Discussion
Contralateral ALI developing during CDT may have multifactorial causes, including underlying thrombotic susceptibility as well as local access or sheath‐related thrombosis. This case highlights the importance of bilateral vascular surveillance during thrombolytic therapy and prompt evaluation of new ischemic findings.