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 Blood could be withdrawn and a normal pulse tracing was shown on the monitor.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.