Paclitaxel
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Type 1 Kounis syndrome: case report A 79-year-old woman developed type 1 Kounis syndrome following treatment with paclitaxel to improve patency of the site of treatment[route, time to reaction onset not stated]. The woman presented with rest pain afflicting her right leg on a 6-month background of progressively worsening claudication. She had a medical history of chronic airway disease, dyslipidemia, osteoporosis and hypertension. She had been receiving atorvastatin, irbesartan, hydrochlorothiazide, clopidogrel and aspirin. She underwent angioplasty of a stenosed left external iliac artery (EIA) and an occluded left superficial femoral artery (SFA) with two Ranger drug-coated balloons (DCBs) with paclitaxel coating 2 months previously. At the current presentation, she was note to have right SFA occlusion with a reduced ankle-brachial pressure index of 0.49. Thus, she underwent SFA angioplasty and stent procedure under unspecified local anesthetic and sedation. An ’up and over approach’ was performed with a retrograde puncture of the left common femoral artery (CFA) and a 6F Brite tip sheath into the right CFA was placed. She also received heparin. The lesion was predilated with a 3 x 200mm conventional Armada balloon followed by a 5 x 150mm conventional Armada balloon taken down from the 6F sheath. Residual dissection of the mid-SFA was treated with a Supera bare-metal stent. A 5 x 150mm Ranger DCB with paclitaxel coating 2.0 µg/mm2 was deployed across the distal SFA and popliteal artery to improve patency of the site of treatment. Subsequently, on inflation of the DCB, she became abruptly and haemodynamically unstable with hypotension and tachycardia with warm peripheries and flushed skin changes. Cardiac telemetry showed ST elevation. Then, the DCB was deflated and removed. Subsequently, the woman was promptly intubated and ventilated. She was noted to have bronchospasm with reduced airway compliance. She received adrenaline with crystalloid resuscitation. She underwent urinary catheter and right radial arterial line placement. The left groin sheath was removed for closure. Eventually, the vital parameters and resolution of the cardiorespiratory and ECG abnormalities normalised. Then, she was extubated and transferred to the coronary care unit and treated with heparin empirically and regular dual-antiplatelet therapy. Serial troponin levels at time 0 hour, 4 hours, 12 hours, and 24 hours following the event were 199 ng/dL, 67 ng/dL, 66 ng/dL, and 59 ng/L, respectively. Serial tryptase results at time 0 hour, 4 hours, 12 hours, and 24 hours following the event were 37.9 µg/L, 25.6 µg/dL, 8.5 µg/dL and 5.2 µg/L, respectively. A good clinical recovery with a marked improvement in her symptoms over 24 hours. Palpable pedal pulses were noted. Repeat arterial duplex imaging after 48 hours following the event showed a patent SFA with an ABPI of 0.96. She was able to mobilise at her baseline and was discharged on her regular dual-antiplatelet therapy. Then, for further investigation, she was referred to a specialist
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