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Vascular disorders, leading to death in an elderly patient: case report A 68-year-old woman developed vascular disorders and died following a gelatin/thrombin injection [FLOSEAL Haemostatic Matrix] and subsequent treatment with alteplase [Actilyse]. Following a coronary angiography, the woman presented with a femoral artery pseudoaneurysm (FAP), and was treated with ultrasound-guided compression for 1 hour. She received anticoagulant therapy, together with percutaneous 500IU gelatin/thrombin injected into the pseudoaneurysm cavity. The pseudoaneurysm thrombosed, and a pedal pulse was confirmed by ultrasound. Thirty minutes later, she developed right foot pain, paraesthesia and the dorsalis pedis pulse was absent. Duplex imaging and angiography revealed distal popliteal artery thrombosis and ischaemia of the right leg. This was thought to be due to leakage of thrombin into the femoral artery. The woman underwent recanalisation of the popliteal and tibial arteries, and received a locoregional bolus of alteplase 2.5mg for fibrinolysis. Her foot was reperfused successfully. Five hours later, she developed hypotension and abdominal pain. Examination revealed a haematoma in the groin region. Tests revealed a haemoglobin level of 5.7 g/dL and an INR of 1.4. Ultrasonography revealed a massive haematoma of the right lateral and medial vastus muscles. CT findings were indicative of a massive intestinal ischaemia, with recurrence of the FAP and a large retroperitoneal haematoma. She underwent surgical repair of the femoral artery. Subsequently, a laparotomy with colon resection was performed due to a massive infarction; however, she died 2 hours after surgery. Author comment: "The acute critical ischemia of the right leg was probably due to leakage of thrombin into the femoral artery, resulting in thrombosis of the distal right popliteal artery. . . the use of fibrinolytic agents with concomitant thrombin-antithrombin III complex may have been responsible for recurrence of the previously thrombosed pseudoaneurysm and, subsequently, of the retroperitoneal hematoma." Gabrielli R, et al. Fatal complication after thrombin injection for postcatheterization femoral pseudoaneurysm. Thoracic and Cardiovascular Surgeon 59: 372-375, No. 6, Sep 2011. Available from: URL: http://dx.doi.org/10.1055/ 803062007 s-0030-1270837 - Italy

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