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Int J Angiol
DOI: 10.1055/s-0044-1779491
Case Report

Concurrent Chronic Limb Threatening Ischemia and Deep Vein Thrombosis of a Limb in Patient with Systemic Lupus Erythematosus: A Case Report

Achmad Hafiedz Azis Kartamihardja 
1   Department of Cardiology and Vascular Medicine, Universitas Padjadjaran, Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
,
Raymond Pranata 
1   Department of Cardiology and Vascular Medicine, Universitas Padjadjaran, Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
,
Margareta Ginanti Ratna Indraswari Suriyanto
1   Department of Cardiology and Vascular Medicine, Universitas Padjadjaran, Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
,
Badai Bhatara Tiksnadi
1   Department of Cardiology and Vascular Medicine, Universitas Padjadjaran, Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
,
Syarief Hidayat
1   Department of Cardiology and Vascular Medicine, Universitas Padjadjaran, Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
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Abstract

Concurrent thrombus formation in both the arterial and venous systems is rare and present as a diagnostic challenge in these cases; therefore, we must explore various possible etiologies and mechanisms. Herein, we report a case of concurrent chronic limb threatening ischemia (CLTI) and deep vein thrombosis (DVT) of a limb in a patient with systemic lupus erythematosus (SLE) and chronic heart failure who underwent laboratory examinations and multimodality imaging. A 37-year-old male presented with a complaint of pain and swelling of the lower left extremity since 21 days before admission. Echocardiography showed dilated all chambers with ejection fraction, moderate-to-severe pericardial effusion, and no intracardiac shunt. Doppler ultrasound of the lower extremities showed DVT at the left mid-femoral and popliteal vein, severe stenosis at the left dorsalis pedis artery, moderate stenosis of the left popliteal, anterior, and posterior tibial arteries, and soft tissue swelling in the tibial region. Computed tomography angiography showed significant stenosis of the left popliteal, anterior, and posterior tibial arteries. The patient was diagnosed with CLTI and DVT of the left inferior extremity, heart failure, SLE, and tuberculous meningitis on antituberculosis medication. Primary amputation was performed, and the patient was discharged uneventfully.

Concurrent CLTI and DVT in the same limb caused by SLE and heart failure is a rare condition. In this case, the probable causes were hypercoagulable state and vasculitis. Despite exhaustive attempts, the exact mechanism was not fully elucidated in this patient. However, we excluded other possible causes that require specific intervention, such as intracardiac shunt or phlegmasia cerulea dolens.

Keywords

chronic limb threatening ischemia - deep vein thrombosis - systemic lupus erythematosus - vascular - peripheral artery disease


Publication History

Article published online:
02 February 2024

© 2024. International College of Angiology. This article is published by Thieme.

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  • References

  • 1 Wilhelm AJ, Major AS. Accelerated atherosclerosis in SLE: mechanisms and prevention approaches. Int J Clin Rheumatol 2012; 7 (05) 527-539
    CrossrefPubMedGoogle Scholar
  • 2 Cassar K, Bachoo P, Ford I, Greaves M, Brittenden J. Markers of coagulation activation, endothelial stimulation and inflammation in patients with peripheral arterial disease. Eur J Vasc Endovasc Surg 2005; 29 (02) 171-176
    CrossrefPubMedGoogle Scholar
  • 3 Zamzam A, Syed MH, Rand ML. et al. Altered coagulation profile in peripheral artery disease patients. Vascular 2020; 28 (04) 368-377
    CrossrefPubMedGoogle Scholar
  • 4 Abunnaja S, Clyde M, Cuviello A, Brenes RA, Tripodi G. Concomitant deep venous thrombosis, femoral artery thrombosis, and pulmonary embolism after air travel. Case Rep Vasc Med 2014; 2014: 174147
    PubMedGoogle Scholar
  • 5 Emmi G, Silvestri E, Squatrito D. et al. Thrombosis in vasculitis: from pathogenesis to treatment. Thromb J 2015; 13 (01) 15
    CrossrefPubMedGoogle Scholar
  • 6 d'Audiffret A, Shenoy SS, Ricotta JJ, Dryjski M. The role of thrombolytic therapy in the management of paradoxical embolism. Cardiovasc Surg 1998; 6 (03) 302-306
    CrossrefPubMedGoogle Scholar
  • 7 Greenberg JW, Goff ZD, Mooser AC, Wittgen CM, Smeds MR. Acute limb ischemia secondary to patent foramen ovale-mediated paradoxical embolism: a case report and systematic review of the literature. Ann Vasc Surg 2020; 66: 668.e5-668.e10
    CrossrefPubMedGoogle Scholar
  • 8 Ren P, Li K, Lu X, Xie M. Diagnostic value of transthoracic echocardiography for patent foramen ovale: a meta-analysis. Ultrasound Med Biol 2013; 39 (10) 1743-1750
    CrossrefPubMedGoogle Scholar
  • 9 Stafford MB, Bagley JE, DiGiacinto D. Comparison of transthoracic echocardiography, transesophageal echocardiography, and transcranial Doppler in the detection of patent foramen ovale as the etiology for cryptogenic stroke. J Diagn Med Sonogr 2019; 35 (02) 127-133
    CrossrefPubMedGoogle Scholar
  • 10 Miriyala V, Awan MU, Faraj K, Nagra B. Traversing boundaries: thrombus in transit with paradoxical embolism. J Community Hosp Intern Med Perspect 2016; 6 (04) 31438
    CrossrefPubMedGoogle Scholar
  • 11 Meissner I, Whisnant JP, Khandheria BK. et al. Prevalence of potential risk factors for stroke assessed by transesophageal echocardiography and carotid ultrasonography: the SPARC study. Stroke Prevention: Assessment of Risk in a Community. Mayo Clin Proc 1999; 74 (09) 862-869
    CrossrefPubMedGoogle Scholar
  • 12 Hakman EN, Cowling KM. Paradoxical Embolism. In: StatPearls [Internet]. . Treasure Island (FL): StatPearls Publishing; 2023
    PubMedGoogle Scholar