CASE PRESENTATION – PATIENT 2:
A 66-year old female was scheduled for an elective endovascular coiling
of her right posterior communicating artery aneurysm in the
interventional radiology suite. This was an incidental finding during
investigation of recurrent headaches. Her medical history included
emphysema, ischaemic heart disease, dyslipidaemia, hypertension and
osteoporosis. She was a current smoker with a 40-pack year history.
After induction of anaesthesia, a 20G arterial catheter (Arterial Leader
Cath (PE), Vygon Ref 115.090, 3Fr- L.8 cm-0.9 mm-24 ml/min) was inserted
in the left radial artery using the Seldinger technique. The first
attempt was successful and the arterial catheter was introduced without
resistance. Blood could be withdrawn and a normal pulse tracing was
shown on the monitor. The coiling proceeded uneventfully without any
complications. There were no intra- or post-operative issues with the
arterial catheter, and it was removed in the recovery area prior to
transfer to the ward.
The following day, the patient noted a gradual discoloration and reduced
sensation in her left index, third and fourth digits. On examination,
reduced temperature and sensation was noted with intact radial
pulsation. Motor power was normal. An ultrasound scan of her left upper
limb demonstrated patent left brachial and ulnar arteries, and greater
than 50% stenosis of the left radial artery. The patient experienced
progressive purple-bluish discoloration of the left index finger with
increasing tenderness. After consultation with vascular surgery, she
received a loading dose of 5,000 IU of intravenous Heparin and 100mcg of
Iloprost. She continued on their respective infusions (dosing as per
local guidelines) as well as oral dual anti-platelet therapies, Aspirin
75mg and Clopidogrel 75mg, once daily. Topical Glyceryl Trinitrate
ointment was applied to the affected fingers for analgesic and
vasodilatory purposes. Complete resolution of her symptoms was observed
after eight days of treatment and she was discharged for follow up in
vascular outpatient service.