Idea Transcript
Vascular Surgery
MAY/JUNE 2000
VOLUME 34
NUMBER 3
Fogarty Balloon Catheter Injury Revisited: A Cause for Progressive Claudication A Case Report Jason C. Smith, MD Douglas C. Smith, MD Frank C. Taylor, MD and Jeffrey L. Ballard, MD* LOMA LINDA, CALIFORNIA
W.11
A 59-year-old competitive ballroom dancer presented with right thigh claudication upon strenuous exercise. Following a diagnostic arteriogram, she underwent aortoiliac reconstruction for an ulcerated and narrowed distal aorta and severely stenotic right common iliac artery. The procedure was complicated by acute graft thrombosis due to a heparininduced "white-clot" syndrome. Several passes were made with Fogarty balloon catheters through each iliac limb and from the femoral arteries down each lower extremity until normal pulses returned. The patient returned 3 months later with a 6-week history of severe disabling bilateral calf claudication. An arteriogram showed diffusely narrowed iliac, femoral, and popliteal arteries, bilaterally, compared to the generous caliber vessels seen 3 months earlier. A diagnosis of myointimal hyperplasia secondary to Fogarty balloon catheter injury was made.
From the Departments of Radiology and
*Surgery, Loma Linda University Medical Center, Loma Linda,
California. (02000 Westminster Publications, Inc., 708 Glen Cove Avenue, Glen Head, NY 11545, U.S.A.
251
Downloaded from ves.sagepub.com at PENNSYLVANIA STATE UNIV on May 11, 2016
Vascular Surgery May/June 2000
Introduction Balloon catheter thromboembolectomy was first introduced by Fogarty et al in 1963.1 It has subsequently been widely accepted as the therapy of choice for acute arterial thromboemboli. Although it is relatively safe, various complications have been described, such as arterial perforation, balloon rupture, arteriovenous fistula, pseudoaneurysm formation, and myointimal hyperplasia.2-8 We describe a patient who developed progressively symptomatic myointimal hyperplasia after surgical Fogarty thromboembolectomy. Case Report
A 59-year-old woman sought medical attention because of right thigh claudication, which became severe enough to prevent her from participating in competitive ballroom dancing. She had a history of mild hypertension and mild hypercholesterolemia for which she took medications. She had a 20 pack-year history of smoking but quit 18 years before her presentation. Physical examination demonstrated normal femoral, popliteal, and posterior tibial pulses, bilaterally; the left dorsalis pedis pulse was weakly palpable and the right dorsalis pedis pulse was not palpable. Resting ankle brachial indices were 0.96 (right) and 0.91 (left). However, stress ankle brachial indices were 0 on the right and 0.66 on the left. Arteriography was performed using low-osmolality contrast material and a heparinized saline flushing solution. It revealed a very irregular and ulcerated distal aorta, which was narrowed to an indeterminant degree (Figure 1). There was a 70% origin stenosis of the right common iliac artery (Figure 2A). The remaining lower extremity arteries were unremarkable and of generous caliber (Figure 2B, C). Resting systolic pressure gradients from the midinfrarenal aorta to the distal right and left common iliac arteries were 20 and 15 mmHg, respectively. Disabling symptoms in conjunction with severe aortoiliac occlusive disease prompted aortobiiliac reconstruction 3 days later with a 16 x 8 mm polytetrafluoroethylene (PTFE) graft. She was systemically heparinized just prior to clamping of the iliac arteries and aorta; it was reversed with protamine after the anastomoses were completed. Immediately after surgery, her posterior tibial pulses were normal to palpation. However, 3 hours later these pulses were noted to be absent.
Figure 1. Preoperative arteriogram. Oblique aortoiliac arteriogram demonstrates irregular, probably ulcerated stenosis of the distal abdominal aorta.
She was immediately returned to the operating room where the previous incision was reopened and the graft exposed. Although the aortic portion of the graft had an excellent pulse, both limbs of the graft were thrombosed. Upon opening the graft, white, granular, clot-like material was recovered, consistent with white clot from heparin-induced thrombocytopenia.9 Three passes down each graft limb into the lower extremities were made with a 4-F Fogarty balloon catheter. When no more thrombus was recovered, dextran was infused into each graft limb. Because the posterior tibial pulses were present by Doppler but not palpable, arteriotomies were made into each common femoral artery, and a 3F Fogarty catheter was passed distally, but no further material was recovered. Inflow and back bleeding were excellent. The posterior tibial pulses were once again normal to palpation. She was discharged 4 days later and instructed to take aspirin daily. She returned 3 months later with a 6-week history of progressively severe bilateral calf clau252
Downloaded from ves.sagepub.com at PENNSYLVANIA STATE UNIV on May 11, 2016
Smith Fogarty Balloon Catheter Injury
Figure 2. Preoperative arteriogram. A. Pelvic arteriogram shows severe stenosis of the right common iliac artery at its origin (20 mmHg aortoiliac systolic gradient at rest). B. The superficial femoral arteries and deep femoral arteries are widely patent with no evidence of disease. C. The popliteal arteries and trifurcation vessels are patent bilaterally.
palpation, compared to her immediate postoperative examination. Arteriography revealed an unremarkable aortoiliac bifurcation graft except for a mild kink of the right limb. However, there was uniformly reduced caliber of the
dication, which prevented her from competitive dancing. She had no lower extremity rest pain or ulceration. Physical examination demonstrated femoral, popliteal, and posterior tibial pulses that were somewhat reduced to 253
Downloaded from ves.sagepub.com at PENNSYLVANIA STATE UNIV on May 11, 2016
Vascular Surgery May/June 2000
bilateral external iliac, common femoral, superficial femoral, and popliteal arteries. This was particularly pronounced in the superficial femoral arteries (Figure 3A-C) and was in marked contrast to the generous caliber arteries seen angiographically 3 months earlier. Interestingly, the internal iliac and deep femoral arteries,
which were not cannulated with a Fogarty balloon, were normal caliber, bilaterally. Both peroneal arteries were occluded proximally, but the anterior and posterior tibial arteries were patent, bilaterally. A diagnosis was made of myointimal hyperplasia secondary to a Fogarty balloon catheter
Figure 3. Arteriogram 3 month postoperative. The aortoiliac bifurcated graft has a slight kink in its proximal right limb. Markedly diminished caliber of the external iliac, superficial femoral, and popliteal arteries has developed in the 3-month interval (B, C). The internal iliac and deep femoral arteries, however, retained their normal caliber (A, B). 254 Downloaded from ves.sagepub.com at PENNSYLVANIA STATE UNIV on May 11, 2016
Smith Fogarty Balloon Catheter Injury
injury. She was placed on a regimen of pentoxifylline and aspirin and instructed in an exercise program. On routine follow-up 6 months later, she was improved but was still unable to resume competitive dancing. Her resting ankle brachial indices were 0.73 (right) and 0.77 (left).
Discussion Fogarty catheter thromboembolectomy is commonly used for treatment of acute thromboembolic arterial events. It is generally considered to be a safe procedure. In a series of 1,000 patients gathered over 6 years, an estimated 1% complication rate was reported,5 a rate similar to that found in another series of 600 patients.8 Although uncommon, a number of problems have been described. In 1976 Schweitzer et al10 reviewed the literature and classified complications from Fogarty balloon catheters into four main categories: (1) Immediate (the most common complication)-arterial perforation by the catheter tip (25% of all injuries), ruptured artery by the inflated balloon, and intimal disruption; (2) late-arteriovenous fistula and pseudoaneurysm, (3) embolic-plaques and balloons (fragments or complete); and (4) miscellaneous. Typically, the acute injuries are detected in the operating room. However, the more chronic injuries may go undetected for weeks, months, and even years, making the correlation with the original balloon catheter injury challenging.11 To our knowledge, a total of 10 patients with delayed myointimal hyperplasia secondary to Fogarty catheter-induced damage are reported in the literature; eight patients in surgical journals,5,7,12 and two in a radiologic journal.6 In the earliest description, marked reduction in arterial caliber 2 months following balloon thromboembolectomy occurred in the brachial artery in one patient and in the superficial femoral artery in another.5 Histology in both cases showed marked myointimal proliferation and nonspecific vasculitis. It was theorized that intimal wrinkling caused by the advancing Fogarty balloon, especially over atherosclerotic plaques, may have disrupted the intima. The role of the mechanical forces of catheter manipulation and intimal damage has been studied extensively. In 1981 it was proposed that typical Fogarty balloon catheter procedures likely produce significant intimal injury with every withdrawal and that further injury to the media
could lead to myointimal hyperplasia.13 With use of an in vivo model in 18 dogs, lateral wall pressures and shear forces created by the Fogarty catheter were measured and histologic specimens from the carotid and femoral arteries examined.14 It was found that at a force of about 60 gm (a generally accepted value for the force generated by a typical embolectomy procedure), significant, but reversible, intimal damage occurred. Histologic specimens showed denuded intima with platelet coating at 2 days following a 60 gm force, followed by hypercellularity of the intima anol increased ribosomal activity in the media by 7 days. However, by 180 days the arteries had returned to normal appearance. It was shown that a 200 gm force led to persistent histologic changes in the internal elastic membrane of the endothelium at 6 months follow-up. Investigators have found that these changes are partially mediated by released factors from activated platelets that induce proliferation of smooth muscle cells with migration through the internal elastic membrane.15 Several authors have alluded to technical factors that increase myointimal hyperplasia. With a canine model, it was demonstrated that increased shear force and increased number of withdrawal attempts correlated with increased circumferential extent of myointimal hyperplasia.16 Optimal Fogarty balloon catheter use includes passing the smallest possible catheter, beginning withdrawal of the catheter before the balloon is fully inflated to reduce friction, moving the catheter slowly and steadily, not forcing the catheter against resistance, and minimizing the number of passes.11 The onset of symptoms secondary to myointimal hyperplasia varied from 6 weeks to 4 months following the Fogarty balloon injury in the 10 patients previously reported.5-7,12 In our case, the patient began experiencing significant claudication 6 weeks postprocedure. Diffusely and concentrically narrowed arteries in the distribution of the passage of the Fogarty catheters (sparing the internal iliac and deep femoral arteries) are consistent with the accepted pathophysiology of myointimal hyperplasia. The diagnosis was made on the bases of clinical history and radiographic findings.
Conclusion We have presented a case of progressive claudication in a patient following thromboembolectomy using a Fogarty balloon catheter. Although these 255
Downloaded from ves.sagepub.com at PENNSYLVANIA STATE UNIV on May 11, 2016
Vascular Surgery May/June 2000
procedures are relatively safe, various complications may occur, such as delayed myointimal hyperplasia. The etiology appears to be traumatic denudement of intima with possible media disruption. This leads to release of platelet-activated factors that cause proliferation of smooth muscle with subsequent progressive narrowing of the arterial lumen. The diagnosis of Fogarty-induced myointimal hyperplasia is aided by understanding
its pathophysiology and recognizing its characteristic clinical course and angiographic appearance. Jason C. Smith, MD Department of Radiology Loma Linda University Medical Center 11234 Anderson Street 2605 Schuman Pavilion Loma Linda, CA 92354
References 9. Perler BA: Review of hypercoagulability syndromes: What the interventionalist needs to know. J Vasc Intervent Radiol 2:183-193, 1991. 10. Schweitzer DL, Aguam AS, Wilder JR: Complications encountered during arterial embolectomy with the Fogarty balloon catheter: Report of a case and review of the literature. Vasc Surg 10:144-156, 1976. 11. Dobrin PB: Mechanisms and prevention of arterial injuries caused by balloon embolectomy. Surgery 106:457-466, 1989. 12. Chidi CC, DePalma RG: Atherogenic potential of the embolectomy catheter. Surgery 83:549-557, 1978. 13. Dobrin PB: Balloon embolectomy catheters in small arteries. I. Lateral wall pressures and shear forces. Surgery 90:177-185, 1981. 14. Jorgensen RA, Dobrin PB: Balloon embolectomy catheters in small arteries. IV. Correlation of shear forces with histologic injury. Surgery 93:798-808, 1983. 15. Ross R: The pathogenesis of atherosclerosis: An update. N Engl J Med 314:488-497, 1986. 16. Schwarcz TH, Dobrin PB, Mrkvicka R, et al: Early myointimal hyperplasia after balloon catheter embolectomy: Effect of shear forces and multiple withdrawals. J Vasc Surg 7:495-499, 1988.
1. Fogarty TJ, Cranley JJ, Krause RJ, et al: A method for extraction of arterial emboli and thrombi. Surg Gynecol Obstet 116:241-244, 1963. 2. Fogarty TJ, Cranley JJ: Catheter technic for arterial embolectomy. Ann Surg 61:325-330, 1965. 3. Hogg GR, MacDougall JT: An accident of embolectomy associated with the use of the Fogarty catheter. Surgery 61:716-718, 1967.
4. Lord RSA, Ehrenfeld WK, Wylie EJ: Arterial injury from the Fogarty catheter. Med J Aust 2:70-71, 1968. 5. Foster JH, Carter iW, Graham CP Jr, et al: Arterial injuries secondary to the use of the Fogarty catheter. Ann Surg 171:971-978, 1970. 6. Greenwood LH, Hallett JW Jr, Yrizarry JM, et al: Diffuse arterial narrowing after thromboembolectomy with the Fogarty balloon catheter. Am J Roentgenol 142:141-142, 1984. 7. Bowles CR, Olcott C IV, Pakter RL, et al: Diffuse arterial narrowing as a result of intimal proliferation: A delayed complication of embolectomy with the Fogarty balloon catheter. J Vasc Surg 7:487-494, 1988. 8. Albrechtsson U, Einarsson E, Tylen U: Complications secondary to thrombectomy with the Fogarty balloon catheter. Cardiovasc Intervent Radiol 4:14-16, 1981.
with significant claudication who underwent surgery with implantation of an aortoiliac polytetrafluoroethylene graft. This patient developed thrombosis of the iliac limbs of the graft immediately after surgery with what appears to be heparin-induced antibodies-associated clot. She was returned to the operating room where she
DISCUSSION
Philip B. Dobrin, MD, PhD Columbia, Missouri Dr. Smith and colleagues have nicely documented the case of a 59-year-old woman patient 256
Downloaded from ves.sagepub.com at PENNSYLVANIA STATE UNIV on May 11, 2016