Contrast Extravasation through a Gore-Tex Graft_ A Sequela of Low

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 Contrast                            Extravasation                             through a Gore-Tex   Graft:                                                                        A
 Sequela                             of Low-Dose                             Streptokinase  Therapy
 Neal          H. Rosner’            and     Peter    E.            2

          Within     the   last     few    years,    low-dose   intraarterial       streptoki-          gangrenous               changes   of the      right   first   and        second
                                                                                                                                                                               A right          toes.
nase infusion        has proven         an extremely         useful therapy        for                  femoroanterior             tibial autologous      vein bypass graft was performed
acute arterial occlusion         [1 -3]. Contrast       extravasation       through                     an attempt     to salvage the limb. The proximal       part of the vein graft
                                                                                                        was anastomosed          in an end-to-end     fashion to the stump of the
the interstices     of knitted Dacron grafts has been documented
                                                                                                        occluded    Gore-Tex     graft. The distal end of the vein graft was anas-
during    streptokinase         infusion     [4]. Contrast          extravasation
                                                                                                        tomosed to the anterior tibial artery. The patient underwent amputa-
through a Gore-Tex           graft (polytetrafluorethylene,            W. L. Gore                       tion of the first and second toes, did well in the immediate        postoper-
& Assoc.)       has been           ently    reported       [5]. We describe          a                  ative period, and was subsequently         discharged.
similar case of asymptomatic              contrast      extravasation       through                         Three weeks      after surgery,    he was readmitted      after 1 day of
the proximal      stump of a Gore-Tex            graft.                                                 absent pulses in the vein graft. Arteriography         showed occlusion of
                                                                                                        the proximal area of the Gore-Tex graft stump and occlusion              of the
                                                                                                         vein    graft   (fig.     1 A). A 6 French      selective     arterial      catheter           was    intro-
Case Report                                                                                              duced      via a contralateralapproach  and positioned    into the thrombus
                                                                                                         within   the proximal  aspect   of the Gore-Tex    graft stump. Fibrinolytic
          A 67-year-old       diabetic     man had a long history       of severe    peripheral          therapy was instituted     at a dosage rate of 5000 U streptokinase/hr.
vascular           disease.       One year before admission,        he underwent         a right             Within 6 hr of the start of streptokinase        therapy, a pulse was
femoropopliteal               Gore-Tex    bypass graft, which occluded          after several            palpable in the vein graft. However, after 1 2 hr of therapy, the pulse
months. During                the first of two subsequent   admissions,         he had early             was no longer palpable.              A bedside arteriogram                demonstrated               a large

    Fig. 1 -A, Right extemal iliac angiogram. Occlusion of proximal part of                             valve and partially obstructs saphenous    area of bypass graft. C, Mild extrava-
Gore-Tex graft stump    cl saphenous    bypass graft. B, Portable arteriogram.                          sation (arrow) from medial wall of graft stump.
Large thrombus (arrow) within distal Gore-Tex graft stump. Stump acts as ball

      Received May 31 . 1983; accepted after revision May 4, 1984.
      I Department of Radiology, St. James Hospital, 1423 Chicago Rd., Chicago Heights. IL 6041 1 . Address reprint requests to N. H. Rosner.
      2 Department of Radiology, University of Chicago Hospital and Clinics, Chicago, IL 60637.

AJR         143:633-684,       September      1984 0361-803X/84/1433-0633           C American     Roentgen     Ray Society
634                                                                                    ROSNER        AND     DORIS                                             AJR:143, September      1984

thrombus within the graft stump, immediately above the proximal                                           A possible      explanation     for contrast     extravasation       in this
anastomosis of the vein graft (fig. 1B). The vein graft was otherwise                                  case may be the multiple           surgical manipulations         undertaken
patent to the level of its distal anastomosis to the anterior tibial artery.                           during the limb salvage procedure,           specifically    the femoroan-
Thus,        it seems    the thrombus         within     the Gore-Tex        graft    stump   was
                                                                                                       tenor tibial vein graft. Surgical manipulation              may have corn-
acting       as a ball   valve.   The   catheter       was   then   pulled   back     about   1 cm
                                                                                                       promised      the integrity    of the Gore-Tex        graft. An additional
and a repeat arteriogram,  immediately  after repositioning,                              revealed
                                                                                                       possibility   is leaking of the suture line at the anastomotic             site
thrombosis  of the vein graft and contrast    extravasation                              from the
medial wall of the Gore-Tex               graft stump (fig. 1C).                                       between     the Gore-Tex       stump and the proximal aspect of the
      About      2 hr after repositioning,         a pulse     in the vein graft       was again       venous bypass graft.
palpable. Streptokinase     infusion was terminated after 34 hr. A final
bedside arteriogram,     before catheter removal, confirmed     clot lysis
and patency of the vein graft. There was improved warmth, color,
and capillary filling in the right foot. The patient denied pain at the
site of contrast extravasation;    there was neither evidence of swelling                                  1 . Dotter CT, ROsch J, Seaman AJ. Selective clot lysis with low-
nor      induration.                                                                                           dose streptokinase.     Radiology 1974;i 11:31-37
                                                                                                           2. Katzen BT, van Breda A. Low-dose streptokinase                 in the treat-
                                                                                                              ment of arterial occlusions. AJR 1981;i 36: 1 1 71 -1 i 78
Discussion                                                                                                 3. Totty WMG, Gilula LA, McClennan              BL, Parveen IA, Sherman L.
                                                                                                              Low-dose    intra-vascular      fibrinolytic   therapy. Radiology     1982;
    Contrast extravasation     through knitted Dacron graft mate-                                              i43;59-69
rial has been well documented         by Rabe et al. [4]. The pres-                                        4. Rabe F, Becker       G, Richmond B. Contrast      extravasation    through
ence of contrast      extravasation     through  a Gore-Tex   graft                                            Dacron grafts.     AJR  1982;1 38:917-920
stump is unexpected,       because this material does not depend                                           5. Becker       G, Holden R, Rabe F. Contrast         extravasation       from a
on       preclotting       to assure         the   absence          of leaks         in vascular              Gore-Tex       graft:   a complication   of thrombolytic    therapy.      AJR
procedures.                                                                                                    194;573-574

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