Case Report, Int J Cardiovasc Res Vol: 7 Issue: 1
Acute Arterial Occlusion after Treatment of Heart Failure
Rosaline Laboyrie and Daniel Eefting*
Department of Surgery, Haaglanden Medical Center, The Netherlands
*Corresponding Author : D. Eefting
vascular surgeon, Department of Surgery, Haaglanden Medical Center, Lijnbaan 32, 2512 VA, The Hague, The Netherlands
E-mail: [email protected]
Received: December 20, 2017 Accepted: January 09, 2018 Published: January 15, 2018
Citation: Laboyrie R, Eefting D (2018) Acute Arterial Occlusion After Treatment of Heart Failure. Int J Cardiovasc Res 7:1. doi: 10.4172/2324-8602.1000338
Arterial occlusion is a rare, serious complication in the treatment of acute decompensated heart failure with loop diuretics. A 66- year old male patient with acute decompensated heart failure was treated with loop diuretics after which occlusion of the left side of the patients’ aortic bifurcation prosthesis occurred. For acute leg ischemia a thrombectomy with a high mortality risk was performed after which perfusion of the leg increased and the clinical condition of the patient improved rapidly. Thus to improve the cardiac condition in a patient suffering from decompensated heart failure and acute arterial occlusion a multidisciplinary approach is necessary.
Keywords: Ischemia; Thrombectomy; Heart failure; Loop diuretics; Arterial occlusion
Acute decompensated heart failure is a life-threatening disease and a rapidly growing problem. Excess volume accumulation is one of the most common reasons for hospitalization. One of the key elements to achieve symptomatic improvement is treatment with loop diuretics . In this case report, a 66-year old man with acute decompensated heart failure is effectively treated with loop diuretics. This treatment was complicated by occlusion of the left side of the patients’ aortic bifurcation prosthesis and the patient decompensated again. We decided to perform a thrombectomy as a treatment for the arterial occlusion and indirectly as a treatment for the acute decompensated heart failure.
A 66-year-old man was referred to our non-academic teaching hospital with acute respiratory distress combined with an atrial flutter de novo of 170 bpm. His past medical history showed nicotin abuses, Bechterew disease, appendectomy, hypertrophic cardiomyopathy, renal failure (eGFR 55 ml/min/1.73m2), aortic bifurcation prosthesis in 2002 and a posterior inferior cerebellar arterial infarction for which he used dipyridamole and carbasalate calcium.
At the emergency department he was diagnosed with acute decompensated heart failure and an atrial flutter de novo for which he was treated with 80 mg furosemide intravenously and two times 150 mg cordarone. After the administration of the medication his diuresis increased, the respiratory distress diminished, his blood pressure reduced from 182/133 mm Hg to 111/62 mm Hg, and his heart rate returned to sinus rhythm. A transthoracic echocardiogram (TTE) showed an impaired left ventricular function and a hypertrophic left ventricle. The TTE showed no suspicion of a thrombus. Six hours after treatment with furosemide was started, the patient suffered from severe muscle cramps in his left lower leg, which was progressive despite treatment with paracetamol, inhibin and fentanyl. On physical examination the left lower leg was pale, cold, and the peripheral pulsations of the posterior tibial artery and anterior tibial artery were absent. There was a decreased sensibility of the left leg.
With an acceptable kidney function (eGFR 55 ml/min/1.73m2) and a stable pulmonary condition we decided to perform a computed tomography-angiography (CT-a) which revealed an occlusion of the left side of the aortic bifurcation prosthesis (Figure 1) and a stenosis of the superficial femoral artery.
After CT-a was accomplished the patient decompensated again. Because the critical ischemic limb seemed to be a maintaining factor of the decompensated heart failure we decided to perform an acute thrombectomy with a very high mortality risk according to his clinical condition to interrupt the vicious circle. After the intervention the patient was treated with intravenous heparin and monitored on the intensive care unit.
Directly after the surgery there was increased perfusion of the left lower leg and the clinical condition of the patient improved rapidly, and further cardiac analyses was possible. Additional cardiac analyses showed a stenosis and occlusion of the right coronary artery and left coronary artery, a thrombus in the left ventricle, and a large apical infarct for which the patient had an indication for lifelong treatment with oral anticoagulants and he will be treated with a coronary artery bypass grafting.
One of the key elements of the treatment of acute decompensated heart failure are loop diuretics. Use of an inappropriate low doses of loop diuretics can result in a remaining fluid retention and use of inappropriate high doses can lead to volume contraction, which can cause hypotension and renal failure [2,3].
The most common co-occurring chronic conditions among patients with heart failure, like hypertension, hyperlipidemia, and diabetes, are also high risk factors for developing peripheral arterial disease (PAD). Visa versa, patients with PAD have a significant increased risk for developing a stroke and myocardial infarct .
Research shows that a potential effect of treatment of decompensated heart failure with diuretics is impaired renal function. It is hypothesized that diuretics increase the intravascular hemoconcentration and thereby worsen the renal function . Another side effect of loop diuretics is decreased systolic pressure. When the patient also suffers from decreased arterial perfusion as a result of PAD the use of loop diuretics can potentially not only cause decrease of renal function but can also cause further decrease of peripheral tissue perfusion and thereby critical ischemia of limbs as seen in our case. In our case there was no increase of the intravascular hemoconcentration but there was a significant decrease in blood pressure which could have decreased the blood flow in de limb and thereby cause thrombosis.
A vicious circle can occur in which treatment of acute decompensated heart failure with loop diuretics can increase ischemia, with an inflammatory response, and thereby increase the workload of the heart which in turn worsens the condition of the decompensation. To interrupt the vicious circle treatment of the arterial occlusion or an acute amputation is necessary.
This case report describes the importance of a multidisciplinary approach to improve the cardiac condition of a patient suffering from decompensated heart failure and, as a complication of the treatment with loop diuretics, an acute arterial occlusion.
Informed Consent Statement
Written informed consent was obtained from the family of the patient for publication of this case report and accompanying images.
Conflicts of interest
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