Recurrent Calcium Emboli in a Patient with Aortic Stenosis: Second Visit
Ten months later, the patient returned with the same symptoms as on his first visit; however, their onset was slower. About a week prior the pain had begun in his left leg on walking and progressed to the point that he experienced severe pain in his left calf after taking only a few steps. Both limbs appeared to be of normal color and were similar, except that the dorsalis pedis pulse on the left was absent. The posterior tibial artery was palpable. Using a handheld Doppler, the posterior tibial artery could be heard very well, but the dorsalis pedis and anterior tibial arteries produced no signals. The patient was admitted to the hospital and an arteriogram was obtained. It showed a typical, localized, bullet-shaped mass in the popliteal artery and the anterior tibial artery at the site where the anterior tibial is normally visualized. A duplex scan was obtained. Calcium could be observed in the popliteal artery but not clearly enough to enable the diagnosis of embolus to be made without the corroborating arteriogram. my canadian pharmacy
The operative findings were as follows: The old incision was reopened and the popliteal artery exposed. On opening the artery, the findings were identical to those at the earlier operation. There was definite atheromatous material and fibrin which formed a plug at the origin of the anterior tibial artery (Fig 3). The mass was easily dissected free. When this was removed, the remainder of the artery appeared smooth, glistening and normal. A No. 4 Fogarty embolectomy catheter was passed distally in the posterior tibial artery.
Because the artery had been narrowed, a saphenous vein patch was inserted for a distance of 3 to 4 cm from the popliteal artery to the tibial peroneal trunk. An arteriogram was obtained and showed a patent arterial tree. The patient did well postoperatively. After this second episode, aortic valve replacement was recommended. Prior to valve replacement, coronary arteriography was performed. It was elected not to attempt to cross the aortic valve as the patient was considered to be at risk for embolization from the diseased aortic valve.
At operation, the coronary arteries were normal. The aortic valve was replaced by a Medtronic Hall prosthesis. The postoperative course was complicated by a large pericardial eflusion requiring drainage. After resolution of the effusion the patient did well. Pathologic examination of the patient s aortic valve revealed a fibrotic and calcified cardiac valve with foci of myxomatous degeneration. The valve was severely fragmented and the number of raphe could not be determined.
The incidence of calcium emboli from calcified aortic and mitral valves is not known with certainty, although autopsy studies suggest that they may be more common than previously appreciated. They are most commonly associated with rheumatic valvular disease. Patients are at risk during catheterization and for this reason, we elected not to cross the aortic valve. Emboli are also common at the time of surgery,® although there was no evidence that this occurred in the present case.
Our patient had a second major embolus ten months after his first. This suggests that patients with a first calcium embolus are at risk for recurrence. Autopsy studies also demonstrate that embolic events tend to be recurrent.* Furthermore, while working in experimental pathology in 1955, Whisnant demonstrated streamlining of flow, such that stainless steel bearings, injected into the carotid arterial system of the dog, repeatedly lodged in the same branch of the left middle cerebral artery. We suggest that patients with major calcium emboli be considered for valve replacement even if the degree of stenosis would not otherwise warrant valve replacement.
Figure 3. Calcium embolus and associated thrombus removed from the popliteal artery at the time of the second operation.