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On the basis of an experimental study (44 dogs) and examination of 250 patients with arterial embolism the authors give grounds for a complex of intensive spasmolytic therapy eliminating the arterial spasm and stimulating collateral circulation which allows wider indications for embolectomy in later terms.
The authors review two homogenous groups of patients subjected to surgical embolectomy, one group receiving standard anticoagulant therapy before and after surgery, and the other not receiving that treatment regularly or at all. The results obtained in the two groups indicate that anticoagulant therapy plays a role of no mean order in the prevention of postoperative relapses.
The Fogarty embolectomy catheter has been found useful in minimizing blood loss in large surgical procedures about the hip and pelvis. Its utility lies in the ability to achieve temporary intraluminal occlusion of the common iliac artery while the proposed surgical procedure is being carried out. The technique of instrumentation is simple, rapid, and can be carried out using no special instruments other than the catheter itself. The instrumentation adds little, if any, additional time to the surgical procedure, and in fact may significantly shorten it by achieving earlier definitive hemostasis. Fogarty catheters, a part of the regular armamentarium of vascular surgeons, are readily available at most institutions.
The purpose of this report is to describe the evolution of an embolectomy-thrombectomy catheter (ETC) injury over a six week period. Carotid arteries and jugular veins in six adult dogs were subjected to ETC withdrawals at a standard velocity and balloon size. Vascular segments were excised as early as one hour and as late as six weeks. The specimens were prepared for light, scanning electron and transmission electron microscopic examination. In early specimens, arteries and veins showed endothelial denudation followed by regeneration. In later specimens, the arteries showed progressive disruption of the internal elastic lamina and marked subendothelial proliferation (arteriosclerosis). By the sixth week the artery's intima was equal in thickness to the media. The veins showed only regenerating endothelium without alterations of the subendothelium. Exposure of canine vasculature to ETC procedures caused pronounced transmural damage in the arteries and only endothelial alterations in the veins.
A series of 130 consecutive patients operated on for peripheral arterial embolism in 152 extremities and the longterm results of surgery are presented. The source of embolism was identifiable in 82 percent of the cases, atrial fibrillation being the source in 37 percent and myocardial infarction in 24 percent. Microscopy of the embolus permitted the diagnosis bronchogenic carcinoma in five patients. Echocardiography resulted in surgical correction in one younger patient with left atrial myxoma. Fourteen percent of the patients died after embolectomy. The initial limb salvage rate was 77 percent, and had fallen to 39 percent at the time of follow-up. The cause of this fall in salvage rate was not amputations, but excessive high mortality in the patient group compared to the normal population. The cumulative survival rate was thus 69, 39 and 21 percent, one, five, and 10 years after operation. Death was primarily due to the patients' underlying cardiovascular disease.
Victims of gunshot wounds may be noted to have bullets overlying the cardiac silhouette on roentgenogram. Direct cardiac penetration, bullet embolus to the heart, and missile proximity to the heart are all possibilities which must be differentiated. An unusual case of bullet embolism is presented in which thoracotomy was initially performed to rule out direct cardiac penetration. At the time of exploration, an intracardiac bullet embolus was fortuitously palpated and trapped within the apex of the right ventricle. Right ventriculotomy and embolectomy without cardiopulmonary bypass were performed to prevent retrograde or distal migration.
Balloon embolectomy catheters were studied in 3 mm dog carotid arteries to compare liquid-filled balloons with gas-filled balloons. Balloons were filled with syringes containing 1 cc fluid (1F), 1 cc gas (1G), and 50 cc gas (50G). Results showed that lateral wall pressures (LWPs) were precisely controlled with fluid-filled balloons but were poorly controlled with gas-filled balloons because gas-filled balloons exhibited spontaneous changes in diameter and LWP. Also, when Edwards 4F balloons were filled in clinically satisfactory criteria, out of direct vision, the following LWPs (in millimeters of mercury) were obtained: 54.4 +/- 8 with 1F, 95.2 +/- 13.8 with 1G, and 216 +/- 19.8 with 50G following balloon inflation; 28.1 +/- 5.7 with 1F and 34.2 +/- 7.1 with 1G following balloon deflation. Balloons filled with 50G collapsed completely during balloon deflation. Statistically lower (P less than 0.05) LWPs were obtained with fluid-filled balloons versus gas-filled balloons and with deflation versus inflation. Gas-filled balloons produced slightly lower shear forces than did fluid-filled balloons (P less than 0.05), but only through regions of stenosis and only at low LWPs-namely 25 and 75 mm Hg LWP. Gas-filled balloons produced no reduction in shear force at higher LWPs. It was concluded that fluid-filled balloons are preferable to gas-filled balloons for use in the operating room because fluid-filled balloons provide lower LWPs greater surgeon control, and only slightly increased shear forces. With both fluid-filled and gas-filled balloons, lower LWPs can be achieved by distending balloons to apparently satisfactory levels and then deflating them to slightly lower levels.
A case of successful superior mesenteric artery embolectomy with bowel resection is reported. Superior mesenteric artery embolization must be strongly suspected in a patient with atrial fibrillation, presenting sudden abdominal pain and an unremarkable examination. Extensive use of abdominal angiography is strongly recommended, since successful results depend on early diagnosis. This "second look" procedure may be limited, on the basis of careful clinical observation. Should any doubt persist regarding bowel viability, a duodenoenteric anastomosis is recommended.
Balloon embolectomy catheters were studied in 2 to 3 mm canine arteries in vitro to evaluate the determinants of lateral wall pressure (LWP), balloon-artery shear force, and shear stress. LWP was determined by examination of the pressure-diameter curve of each artery and identification of the diameter at each level of infected volume. The following results were obtained: (1) LWP was determined by balloon diameter and was poorly related to balloon pressure. (2) When balloons were filled to clinical criteria, mean LWPs of 50 to 10 mm Hg for 24 Shiley catheters and 62 +/- 11 mm Hg for 24 Edwards catheters were recorded. (3) Shear forces increased directly with LWP. (4) In most cases, shear forces at any LWP were not significantly different for Edwards and Shiley catheters. (5) Shear forces had a high initial component and a lower dynamic component; the latter component was decreased slightly by increasing withdrawal velocity. (6) Shear forces were lower (P less than 0.05) with small catheters than with larger catheters, i.e., 3F less than 4F less than 5F. (7) Shear stresses were at least 84 times greater than the critical stress for the intima. These data suggest the following clinical guidelines: (1) Every effort should be made to achieve the low LWP since this strongly influences shear force. (2) The smallest effective catheter should be used. (3) Negligible benefit may be gained if catheters are withdrawn at moderate velocities.
One hundred and twenty-two patients with 135 arterial emboli, 31 of whom had had a recent myocardial infarction, were seen during a 12 year period. Six patients died after embolectomy, resulting in a 19 per cent in-hospital mortality, and in five patients, amputation was required. The median time from infarction to embolization was 14 days. Length of follow-up period after operation ranged from four to 73 months, with a mean of 36 months. Life table analysis of patients alive 30 days after operation revealed a cumulative five year survival rate of only 26 per cent, recurrent myocardial infarction being responsible for 60 per cent of the deaths. This is in contrast with an approximate 60 to 70 per cent five year survival rate reported in the literature for patients having an infarction only. Although the immediate mortality was greater than that for patients with arterial emboli without infarction, an aggressive approach directed toward limb salvage is urged in these patients, as manifested by the 84 per cent salvage rate in this series.
Three cases of massive pulmonary embolism are described in order to illustrate the indications for open pulmonary embolectomy with temporary cardiopulmonary bypass. Surgical treatment is mandatory in the presence of shock with systemic arterial hypotension below 90 mm Hg, arterial hypoxaemia more than 50 per cent as demonstrated by pulmonary arteriography, and pulmonary mean pressure exceeding 30 mm Hg. Additionally the prognosis of the underlying disease should be considered. The specific problems related to anesthesia are associated with the severe shock and its concomitant excessive acid base disturbances both of them being refractory to medical treatment.
Although acute mesenteric ischemia causing bowel necrosis, a surgical emergency, has been diagnosed with increasing frequency today, it remains as lethal as it ever was, with a mortality rate of 70% to 80%. The high mortality rate can be attributed to delayed diagnosis and the presence of underlying disease. Earlier and more liberal use of angiography in patients with high suspicion of acute mesenteric ischemia is mandatory. We report here to a patient, presenting with acute abdomen and bloody stools, who was highly suspected to have superior mesenteric arterial occlusion. He received emergent angiography and successful embolectomy without bowel resection and second-look operation. The post-operative course was rather smooth. An aggressive surgical approach must be considered, and the second-look procedure should be used when the bowel viability is questionable at the first operation. Postoperative anticoagulation therapy should be given when indicated.
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