Upper extremity arterial thromboembolism in ulcerative colitis
Georgios Tzavellas, MD, Spyridon Monastiriotis, MD, Angela Kokkosis, MD.
Stony Brook University Hospital, Stony Brook, NY, USA.
Objectives:
Peripheral arterial thromboembolic events (ATE) in the setting of ulcerative colitis flare is a very rare entity despite the well-described increased risk for venous thromboembolism(VTE). We report a patient with an ulcerative colitis flare and acute left upper extremity arterial thromboembolism.
Methods:
A 61- year-old female with a past medical history of ulcerative colitis (UC) was experiencing an uncontrolled flare for the past year. She presented with cyanosis of her left second finger, and progressively worsening paresthesias of her hand and forearm for one week, and no wrist pulses. She had no other remarkable medical history, family history and never smoked cigarettes. A CT angiogram was performed which showed abrupt occlusion of the brachial artery at the antecubital fossa on the left side. Additionally, there was nonocclusive acute thrombus occluding within the bilateral common iliac arteries without evidence of lower extremity ischemia. Left brachial artery thromboembolectomy was performed with successfully restoration of blood flow. During the hospitalization she was placed on therapeutic LMWH. Due to the ongoing UC flare, gastroenterology determined an effective medical regimen to control the flare, which included steroid therapy. Prior to discharge, the patient underwent left upper extremity duplex showing patent brachial, ulnar and radial arteries; and a complete hypercoagulable workup was otherwise negative. At one month follow up, the patient was doing well with no left upper extremity deficits and an aortoiliac duplex demonstrated resolution of bilateral common iliac artery thrombus.
Results:
Review of the literature reveals that patients with IBD (Ulcerative colitis or Crohn’s disease) are 3x more likely to have an ATE, and this risk is increased to 15x in the setting of acute flare. Female gender is another significant risk factor for development of ATE. The majority of the ATE events involved cerebral, coronary and mesenteric arteries, with fewer occurrences in the lower and upper extremities. Very few case reports regarding upper extremity arterial thromboembolism are available in the literature with the incidence being 0.04% among the IBD patients.
Conclusions:
Patients with inflammatory bowel disease have a significant risk for ATE, especially during acute flares. Despite the rarely reported occurrence, there should remain a high clinical suspicion, a meticulous evaluation, and aggressive management with a multidisciplinary approach to mitigate the morbidity and mortality in this population.
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