Vascular Surgery

Case summary
A 68-year-old man with significant comorbidities (Ischaemic Heart Disease, hypertension dyslipidaemia and prior transient ischaemic attack) presented to the emergency department with left leg rest pain of three to four weeks duration. He had received superficial femoral artery (SFA)/popliteal stenting a year earlier for similar symptoms. 

Clinically, the patient had a ruborous Buerger’s-positive foot, suggesting chronicity with an acute-on-chronic component. He was assessed by the vascular registrar and admitted with a diagnosis of Rutherford 2a ischaemia. CT angiography revealed occlusion of the left SFA/popliteal stents, with thready triple-vessel run-off and chronic right SFA occlusion. A heparin infusion commenced. The following day, catheter-directed thrombolysis was initiated via right groin access with catheter placement across the left SFA/popliteal stents. A check angiogram showed minimal thrombus clearance, so thrombolysis continued. 

On day 3, following discussion at the vascular/radiology multidisciplinary team (MDT) meeting, the plan was to consider surgical bypass if thrombolysis remained ineffective. Despite this, a repeat angiogram (showing minimal improvement) led to a decision to continue thrombolysis for another night.

Later that day, the patient was reviewed by the vascular registrar for new-onset tachycardia and severe (10/10) right-sided abdominal pain. The abdomen was soft on examination, an abdominal ultrasound was unremarkable, and the patient was noted to be more comfortable on subsequent review. Thrombolysis continued overnight with a plan to proceed to theatre the following day for further endovascular intervention +/- bypass.

By late afternoon on day 3, the patient was hypotensive (systolic blood pressure [SBP] approximately 100 mm Hg), tachycardic and oliguric. The vascular registrar was notified, analgesia provided, intravenous fluids increased and usual antihypertensives withheld. 

The registrar was again contacted two hours later regarding elevated ketones and oliguria. A 500 mL fluid bolus was administered, after which SBP fluctuated from 100–110 mm Hg. Urine output remained <30 mL/hr.

At 03:00 on day 4, the patient was found unresponsive. After prolonged resuscitation with multiple arrests, return of circulation was briefly achieved. Arterial blood gas showed Hb 67, raising concerns for intra-abdominal or retroperitoneal haemorrhage. Further arrests followed and the patient could not be revived. Presumed cause of death was reported as intracranial haemorrhage.

Discussion
Although thrombolysis was reasonable initially, the lack of significant angiographic improvement after 24 hours, combined with the chronic history, should have prompted early reconsideration.

Despite MDT recognition that thrombolysis was unlikely to be effective beyond this point, treatment continued into a third day. 

Concurrently, severe abdominal pain, signs of physiological deterioration (hypotension, tachycardia, oliguria) and a dramatic fall in haemoglobin emerged later that day. These features strongly suggested a bleeding complication, yet this possibility does not appear to have been fully appreciated. No CT imaging was obtained, and thrombolysis did not cease.

There appears to have been several missed opportunities for escalation in this patient’s care during the third day of thrombolysis. Multiple concerning clinical features developed, and while each symptom may have been explainable in isolation, the combination of these findings in the setting of ongoing thrombolysis should have prompted a more urgent and cohesive clinical response. Despite these warning signs, no cross-sectional imaging was performed and thrombolysis continued. 

The literature indicates that the risk of major bleeding complications increases with the duration of thrombolytic infusion, particularly beyond 24 – 48 hours. Prolonged infusion not only confers diminishing therapeutic returns in subacute or chronic occlusions, it also significantly increases bleeding risk. In this case, the decision to persist with thrombolysis, despite clear physiological deterioration and minimal angiographic improvement, likely contributed to the patient's demise.

Alternative strategies for managing acute-on-chronic limb ischaemia are now widely adopted, with many centres moving away from prolonged catheter-directed thrombolysis due to its recognised risks. Single-session approaches, such as endovascular mechanical or aspiration thrombectomy—often combined with a brief thrombolytic infusion—offer lower bleeding risk, improved patient comfort and reduced resource utilisation. These techniques allow prompt clearance of acute thrombus and simultaneous assessment of the underlying chronic disease. If unsuccessful, they enable timely progression to definitive intervention, such as bypass surgery. It would be reasonable to expect most vascular centres to have the equipment and expertise to employ these methods and it is unclear why one of these single-session methods was not considered for this patient.

Clinical lessons
• Chronicity must be recognised early. A three-to-four-week history and poor response to thrombolysis should prompt early transition to alternative strategies.
• Prolonged thrombolysis increases risk. Bleeding complications rise significantly beyond 24–48 hours. 
• Clinical deterioration during thrombolysis should prompt immediate reassessment. One should assume a complication of therapy until proven otherwise.
• Single-session techniques should be preferred over prolonged thrombolysis. 
• MDT plans should be followed. Deviation from agreed plans should only occur with robust clinical justification and re-evaluation.