Challenging endovascular treatment for the patient with chronic limb threatening ischemia due to antiphospholipid syndrome


      Vascular surgery for chronic limb threatening ischemia (CLTI) in patients with antiphospholipid syndrome (APS) has a poor outcome with a high rate of postoperative thrombotic complications. However, there is little data regarding outcomes of endovascular treatment (EVT). This manuscript reports an interesting case of APS with CLTI in which timely EVT and continuous anticoagulant therapy not only prevented amputation but also thrombotic events over a long period of time. A 41-year-old man with CLTI in the left lower limb was seen and examined. Contrast-enhanced computed tomography revealed thrombotic occlusion in both iliac arteries and the left popliteal artery. Activated partial thromboplastin time was prolonged, and anti-β2 glycoprotein I antibodies and lupus anticoagulants were present. After starting antithrombotic therapy with warfarin, EVT was performed using self-expandable stents in both iliac arterial lesions, and a marked reduction in limb ischemia was observed. Furthermore, the patient was free from thrombotic events for six years until a change in the anticoagulant led to stent thrombosis. This case suggests that EVT using stents along with continuous antithrombotic therapy with warfarin in patients with APS and CLTI could be very effective for immediate relief of ischemia and long-term reduction in thrombotic events.
      <Learning objective: APS is a rare but important cause of CLTI, and outcomes in patients with APS who receive vascular surgery for CLTI are poor because of a high rate of postoperative thrombotic complications. EVT using a stent can be a useful option if it is coupled with sustained antithrombotic therapy using a vitamin K antagonist, namely warfarin. In addition, administering direct oral anticoagulants as anticoagulant therapy following EVT in APS patients should be very carefully considered.>


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