Pérez-Riveros Erika D, Cardona-Montes Cesar A, Zapata-Álvarez Carlos A, Sotelo-Hernández Wendy L, Bastidas-Goyes Alirio R
Clínica Universidad de la Sábana, Chía, Colombia.
J Med Case Rep. 2019 Aug 5;13(1):242. doi: 10.1186/s13256-019-2168-7.
Medullary ischemia secondary to surgical procedures of the infrarenal aorta is an infrequent and mostly devastating complication of this procedure, and its nonspecific clinical presentation makes it difficult to promptly diagnose. Prevention measures for this complication are not yet clear; therefore, the need for anticoagulant and/or antiplatelet therapy is discussed.
This paper reports a case of a 69-year-old Hispanic man presenting with sudden pain and signs of ischemia on his left lower extremity 8 weeks after endovascular repair with endoprosthesis of an infrarenal aorta and left iliac aneurysm. The patient was admitted to the emergency room, where an extensive arterial thrombosis compromising the right iliac and femoral arteries was diagnosed. Dual anticoagulation and antiplatelet therapies were initiated, and therapeutic ranges were achieved. Nonetheless, the patient presented medullary ischemia by microembolization diagnosed by contrast-enhanced magnetic resonance imaging, with unsatisfactory evolution of an intracranial hemorrhagic event without documented excessive anticoagulation. The patient developed permanent pure motor deficit of his lower extremities, absence of sphincter control, and mild cognitive impairment.
This is a complex and extremely rare case. It is important to continue with clinical investigations that give more clarity about the onset of anticoagulation, antiplatelet therapy, and management of dual schemes to decrease the risk of complications in this type of surgical procedure.
肾下腹主动脉手术继发的髓质缺血是该手术罕见且大多具有毁灭性的并发症，其非特异性临床表现使其难以迅速诊断。该并发症的预防措施尚不明确；因此，对抗凝和/或抗血小板治疗的必要性进行了讨论。
本文报告了一例69岁的西班牙裔男性病例，该患者在肾下腹主动脉和左髂动脉瘤腔内修复并植入血管内假体8周后，出现左下肢突然疼痛和缺血迹象。患者被收入急诊室，诊断为广泛的动脉血栓形成，累及右髂动脉和股动脉。开始进行双重抗凝和抗血小板治疗，并达到了治疗范围。尽管如此，患者通过对比增强磁共振成像诊断为微栓塞导致的髓质缺血，颅内出血事件进展不佳，且无抗凝过度的记录。患者出现了下肢永久性纯运动功能障碍、括约肌控制丧失和轻度认知障碍。
这是一个复杂且极其罕见的病例。继续进行临床研究很重要，这些研究能更清楚地阐明抗凝、抗血小板治疗的起始以及双重方案的管理，以降低此类手术并发症的风险。
