Superficial femoral artery thrombosis as a cause for distal embolism in primary antiphospholipid syndrome

Abstract

Antiphospholipid syndrome is a diagnosis with the clinical manifestations of thromboses in the presence of an antiphospholipid antibody. A 25-year-old man with a history of deep venous thrombosis, pulmonary emboli, and myocardial infarction, and receiving long-term anticoagulation with warfarin, all due to primary antiphospholipid syndrome, presented with blue toe syndrome from a primary superficial femoral artery thrombus. He was anticoagulated with fondaparinux in addition to dipyridamole and aspirin perioperatively. The area of thrombus was resected and reconstructed using a cephalic vein interposition graft. This report reviews antiphospholipid syndrome and identifies potential questions and problems relating to a rare clinical presentation.

Surgical Interventions for Organ and Limb Ischemia Associated With Primary and Secondary Antiphospholipid Antibody Syndrome With Arterial Involvement

“…Although venous thrombosis and their long-term complications predominate in the APS literature, arterial involvement associated with ischemia of organs and limbs remains limited to small cohorts and case reports. 8,10,22 One of the largest series reported in the vascular surgery literature by Shortell et al 6 in 1992 includes 19 patients, 13 were females and the most common involvement was the cerebral circulation with 9 cases, followed by upper and lower extremities. Twelve procedures were performed in 9 patients, 1 patient underwent carotid endarterectomy, 1 carotid subclavian bypass, and these reconstructions according to the authors were patent in noninvasive studies at 1 and 16 months.…”

“…Despite technical success, the risk of recurrent thrombosis, thromboembolic events, restenosis of vessels, graft failure, and progression of the disease in these patients remain high even on optimal anticoagulation and commonly result in a high rate of limb loss in this relatively young population. 1,10 Although some authors state that an optimal anticoagulation postoperatively has shown to maintain a lower incidence in thrombosis recurrence which has led to the recommendation of lifelong anticoagulation therapy with an international normalized ratio (INR) target of 3.0 1 ; following arterial reconstructions, we have maintained an aggressive anticoagulation regime with an INR target range from 3.0 to 3.5 and antiplatelet therapy, and patients are clinically followed closely and monitored for possible hemorrhagic complications. With respect the conduits, we agree with Lauvao et al in the recommendation of the use of autogenous grafts when possible and a strict perioperative and long-term anticoagulation to prevent graft failure.…”

“…7 The deep veins of the lower limbs are the most commonly affected sites 8,9 ; on the other hand, the incidence of primary arterial involvement is unknown because no literature has differentiated between thromboembolic disease from the presence of underlying atherosclerotic disease in this particular group of patients. 10 According to the literature reports, the most affected arteries are the coronary circulation followed by the visceral vessel district, renal, retinal, and peripheral arteries, 2 and according to Toffon et al, there are only 5 cases of aortic thrombosis reported in patients with APS. 8 Antiphospholipid antibody syndrome associated with limb or organ ischemia is rarely encountered and recognized in a vascular surgery practice, and little has been written regarding its therapeutic approach and clinical outcomes.…”

The usefulness of Duplex Doppler ultrasound in the angiological and dermatological diagnosis of patients with blue toe syndrome

“…The proposed surgical procedures include a wide spectrum of vascular surgical techniques: unblocking, segmental ligation, excision of the affected segment, with a consequent by-pass procedure. The type of the procedure depends upon the nature of the location and extent of the primary lesion [ 10 , 18 ]. In recent years endovascular procedures have been more often recommended as an alternative procedure for open surgeries.…”

“…It is generally acknowledged that antithrombotic therapy with heparin or oral medications is of limited efficacy in the reduction of microembolism. Repeated embolic episodes are frequently observed despite adequate antithrombotic therapy [ 10 , 18 ]. Nonetheless, it may significantly reduce and shorten the duration of clinical symptoms, which we successfully took advantage of in our patients.…”