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PubMed2003

[Anesthetic management of massive endobronchial hemorrhage after pulmonary embolectomy].

We report a case of massive endobronchial hemorrhage after pulmonary embolectomy. A 63-year-old woman underwent emergency pulmonary embolectomy with cardiopulmonary bypass (CPB). During partial CPB, we found massive blood gushing out from the endotracheal tube. Approximately 2,000 ml of blood was aspirated in 10 minutes. To ensure adequate oxygenation, emergent percutaneous cardiopulmonary support system (PCPS) was started. After neutralization of heparin and the institution of 10 cmH2O of positive end-expiratory pressure, the bleeding diminished. Institution of PCPS allows performance of unhurried bronchoscopy to identify the actual bleeding point and to lavage the airway. In addition to this management, we administrated steroids and neutrophil elastase inhibitor to stabilize pulmonary capillary membrane. Without complications, the patient was extubated 2 days after operation and the following course was uneventful. Immediate institution of PEEP and pharmacological interventions to reduce pulmonary blood pressure were beneficial in arresting hemorrhage. The bleeding begins usually at the time of discontinuation of CPB. We should recognize the possible occurrence of endobronchial bleeding after pulmonary embolectomy and prepare to protect the airway and to maintain oxygenation and cardiac function.

Anesthesia↗
PubMed1995

[Unilateral pulmonary embolectomy without extracorporeal circulation. A report of a clinical case].

The surgical treatment of pulmonary embolectomy is currently indicated for acute massive obstruction of the pulmonary artery with severe haemodynamic failure and, as in this case, when medical treatment with anticoagulants or thrombolytic drugs is contraindicated. In this work, the Authors focus on the technique of unilateral pulmonary embolectomy through a median sternotomy; this approach allowed an easier and safer embolectomy without extracorporeal circulation.

Embolectomy↗
PubMed1994

An 11-year experience of arterial embolectomy in a district general hospital.

We present a retrospective audit of all arterial embolectomies performed at the East Glamorgan General Hospital over an 11-year period (1980-1990). Eighty-seven patients (47M:40F), mean age 67 years (50-90 years) underwent 95 embolectomies, an incidence consistent with previous studies. There were 17 upper and 71 lower limb emboli with a mean delay before diagnosis of 29 h (range 1-264 h). In 66% of cases the cause was atrial fibrillation; 33% received immediate heparinization and 14% prophylactic antibiotics. Surgery was performed by a consultant in 12 and registrars in 75 cases, and under local anaesthesia in 80% and general anaesthesia in 20%. There was no anaesthetist present in 54% of cases. Few pre- or peroperative arteriograms were performed. The 30-day mortality was 45%, with an amputation rate of 15% and an overall postoperative complication rate of 62% with little improvement in these figures over the last 10 years. Factors increasing mortality were: delay before diagnosis, grade of surgeon performing the operation, and inadequate inflow or outflow at operation. Factors found to affect limb salvage rate adversely were a history of intermittent claudication, although such a history was not recorded in many cases, and lack of immediate preoperative heparinization. Although embolectomy is considered a 'registrar operation', reviewing our results it can be seen that it is an uncommon operation, in our series eight or nine being performed annually. Sometimes inappropriate surgery is performed upon patients in whom severe systemic illness may contraindicate any form of surgical intervention.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMedDate not supplied

Emergency pulmonary embolectomy.

Pulmonary embolectomy maybe a life saving procedure in the unresponsive hypotensive patient following a massive pulmonary embolectomy despite optimal medical therapy. We report a successful pulmonary embolectomy in a 47 year old patient, three days post post coronary artery bypass grafting (CABG) and a new approach to the problem of caval filters in such patients. This case demonstrates the benefit of early surgery in this life threatening situation.

Embolectomy↗
PubMed1991

Risk factors for early lower limb loss after embolectomy for acute arterial occlusion: a population-based case-control study.

To identify risk factors for lower limb loss after arterial embolectomy a cohort of 1189 patients was studied. Detailed data were obtained for 165 patients who underwent a major amputation within 30 days of embolectomy and for 165 matched controls. The amputation risk was increased in patients with two or more myocardial infarctions (odds ratio (OR) 3.1, 95 per cent confidence interval (CI) 0.8-11.2), chronic ischaemia (OR 2.1, CI 0.9-4.9), long duration of symptoms (OR 4.3, CI 1.9-9.6, for greater than or equal to 25 h versus less than or equal to 6 h) or postoperative heart failure (OR 3.4, CI 1.8-6.5). Reduced risks were found in association with acute myocardial infarction (OR 0.3, CI 0.1-0.9) and postoperative anticoagulation treatment with warfarin (OR 0.3, CI 0.1-0.9). The independent prognostic value of chronic ischaemia and symptom duration, and the beneficial effect of postoperative anticoagulation gained additional support in multivariate analysis. We conclude that the risk of early amputation after arterial embolectomy or thrombectomy can be predicted by several clinical characteristics.

Acute Disease↗
PubMed1991

Pulmonary embolectomy: a 20-year experience at one center.

Between 1968 and 1988, 96 consecutive patients with acute massive pulmonary embolism underwent pulmonary embolectomy under cardiopulmonary bypass. The operative mortality rate was 37.5%. We analyzed 12 clinical and hemodynamic variables by univariate and multivariate analyses to assess the predictive factors of postoperative outcome. Multivariate analysis disclosed that cardiac arrest and associated cardiopulmonary disease were independent predictors of operative death. Long-term follow-up (range, 2 to 144 months; mean, 56 months) information was available for 55 of the 60 discharged patients: 6 had died, and 5 complained of persistent mild or severe exertional dyspnea (New York Heart Association class II). These results help assess the preoperative risk in patients undergoing pulmonary embolectomy. They also show that, in the few patients who do not benefit from optimal medical therapy, pulmonary embolectomy remains an acceptable procedure in view of the long-term results.

Adult↗
PubMed1992

Preoperative assessment of the risk for cardiac death following thrombo-embolectomy for acute lower limb ischaemia.

Cardiac monitoring and the selective use of initial non-operative management is reported to reduce the high mortality rate in patients with acute lower limb ischaemia. Early estimation, prior to selection of initial therapy, of the risk for intraoperative or postoperative cardiac death following thrombo-embolectomy is therefore important. The aim of this prospective multi-centre study was to develop a simple and clinically useful index for assessment of the risk of post-operative cardiac death. Patients judged to need thrombo-embolectomy for acute lower limb ischaemia were evaluated on admission for routine clinical, cardiac and limb ischaemia parameters that could be related to cardiac function and these parameters compared to postoperative cardiac outcome. Sixteen per cent of the 117 patients died from intraoperative or postoperative cardiac complications. Analysis revealed five admission parameters that significantly and independently predicted a high risk for cardiac death: mean arterial blood pressure below 90 mmHg, clinical sign(s) of cardiac decompensation, ischaemia affecting the thigh, haemoglobin concentration exceeding 140 gl-1, and a history of a myocardial infarction in the previous 4 weeks. Definition of risk points for each risk factor allowed a simple classification of each patient into one of three significantly different cardiac risk classes with cardiac death rates of 6 +/- 3%, 27 +/- 8% and 75 +/- 16%, respectively. More than two thirds of the patients belonged to the low risk group. The described risk index provides a tool for preoperative assessment of the cardiac death risk associated with early thrombo-embolectomy in patients with acute lower limb ischaemia.

Aged↗
PubMed1988

Beneficial effects of intra-arterial reserpine after upper-extremity embolectomy: a prospective randomised trial.

Persistent ischaemia occasionally follows technically-successful arterial embolectomy, and has generally been ascribed to small-vessel thrombosis in the distal vascular bed. Because of the possibility that distal vasospasm might be a contributory cause, we conducted a prospective randomised trial of vasodilator therapy in this setting. In 50 consecutive patients presenting with their first episode of upper-extremity arterial embolism, we compared the results of the intra-arterial instillation of 0.5 mg reserpine with those of saline alone following embolectomy. Among 29 patients receiving saline only, 13 (44.8%) suffered persistent or recurrent limb ischaemia requiring reoperation, while three (14.3%) of 21 patients receiving reserpine had continuing ischaemia (P = 0.02). Three patients in each group required a second re-operation; all three in the reserpine group were ultimately found to have a proximal axillo-subclavian artery stenosis as the cause for their persistent or recurrent limb ischaemia. Although its underlying pathophysiology remains obscure, peripheral vasospasm appears to accompany acute embolic arterial occlusion. Manoeuvres to prevent or reverse such distal vasoconstriction may be useful in avoiding persistent or recurrent ischaemia following arterial embolectomy.

Aged↗
PubMed1982

Pulmonary embolectomy for acute massive pulmonary embolism.

During the period from 1961 to 1981, 40 pulmonary embolectomies were performed in 39 patients who were in extremis at the time of initiation of cardiopulmonary bypass. In a 460-bed hospital with more than 17,000 acute admissions and 4,000 operations per year, this small number represents the few patients who are potentially salvageable by urgent embolectomy. Preoperative angiography was performed in 57% of the cases, and in another ten patients suspected of having pulmonary emboli, angiography prevented unnecessary thoracotomy. Despite their moribund condition, 43% of the embolectomy patients lived. Excluding two patients with tumor occlusion of the pulmonary arteries and three patients with chronic cor pulmonale from old pulmonary emboli, the survival rate was 50%. Ten patients died because of hypoxemia and hypotension prior to initiation of cardiopulmonary bypass, and seven died of myocardial depression of multiple etiologies. Portable cardiopulmonary bypass affords the possibility of survival in moribund patients with acute massive pulmonary embolism. Preoperative angiography is recommended to guide appropriate surgical management.

Cardiopulmonary Bypass↗
PubMed1975

Arterial embolectomy in the lower limbs.

A series of arterial embolectomies of the lower limb is reviewed, and the results are compared with those in a previous series reported from this hospital. There were 40 emboli in the 36 patients, with an operative mortality of 16% and a limb salvage rate of 85%. This represents a considerable improvement on the results reported from the first series and is attributed to the greater experience of surgeons with the Fogarty embolectomy catheter. However, there has been no decrease in the delay between the onset of symptoms and the embolectomy. If this aspect of management could be improved, then even better results should be obtained.

Aged↗
PubMed1978

Acute myocardial infarction and arterial embolectomy.

Emboli of a main artery cause serious complications in patients suffering from acute myocardial infarction, in whom the surgical risk is high. In order to save the limb, embolectomy is indicated and should be considered. Early diagnosis and prompt surgical intervention with the use of the Fogarty catheter simplify the embolectomy procedure and enable restoration of circulation to the ischaemic limb. Thirty-two embolectomies were performed in twenty-eight patients suffering from acute myocardial infarction. Patients with cardiac compensation survived the surgery and recovered. However 50% of the patients in whom acute myocardial infarction was accompanied with congestive heart failure and arrhythmias died. The cause of death was the underlying disease. Considering the severity of the acute myocardial infarction this group of patients represents the expected mortality.

Aged↗
PubMed1984

Percutaneous embolectomy by transcatheter aspiration. Work in progress.

Distal embolization occurred in 14 of 339 (4%) attempted percutaneous transluminal angioplasty (PTA) procedures, including five of 225 stenoses (2.2%) and nine of the 81 occlusions (11%) that were crossed successfully in 114 attempts (8%). Transcatheter embolectomy by aspiration through a nontapered large-bore catheter was technically successful in five of six attempts (83%), and was combined with successful PTA in three of five patients. In two patients in whom the clinical result of PTA was considered unsatisfactory, successful transcatheter embolectomy permitted an uncomplicated surgical by-pass procedure to be performed. If clinically significant embolization occurs during PTA, this procedure can be attempted prior to surgical embolectomy as an alternative to local fibrinolytic therapy.

Aged↗
PubMed1992

Percutaneous embolectomy: in vitro investigations of the self-expanding tulip sheath.

A self-expanding sheath with a tulip-shaped distal end was designed for performance of percutaneous embolectomy. Its ability to retrieve clots was tested in an in vitro flow model; results were compared with those obtained with a conventional 10-F sheath. Simulated embolectomy of clots weighing 0.1-1.5 g was performed with a 0.75-mL Fogarty balloon on a 4-F catheter. The clot material that embolized distally during the procedure was sampled and quantified. No effective embolectomy was performed via a conventional sheath. With the tulip sheath, however, complete clot removal was achieved unless the clot size exceeded the tulip volume. On the basis of results of in vitro testing, the tulip design is promising for use in several applications during percutaneous interventions.

Catheterization↗
PubMed1995

Percutaneous balloon embolectomy with a self-expanding tulip sheath: in vivo experiments.

PURPOSE: To test a self-expanding tulip-shaped sheath designed for percutaneous embolectomy in an in vivo animal experiment. MATERIALS AND METHODS: In nine sheep, a total of 23 percutaneous balloon embolectomies were performed with use of a self-expanding tulip sheath device with an outer diameter of 9- or 10-F when collapsed. A 10-F instrument was used in 11 cases, and a 9-F instrument was used in 12. Radiopaque emboli were pushed into the aorta via the left carotid or contralateral femoral artery with a 16-F introducer sheath. RESULTS: The embolus was captured in the tulip cage in all 23 cases. Retrieval of the embolus into the sheath was complete in 21 of 23 cases. In two cases, minor parts of the embolus dislodged from the sheath. Major embolism did not occur. In nine cases, the outer sheath had to be cleared of remaining clot particles with aspiration. CONCLUSION: The noncovered self-expanding tulip sheath is an effective and safe instrument for percutaneous embolectomy under in vivo conditions.

Animals↗
PubMedDate not supplied

Complications encountered during arterial embolectomy with the Fogarty balloon catheter.

The Fogarty arterial embolectomy catheter, while indispensible in the armamentarium of the vascular surgeon, is not entirely benign instrument. A case is desribed in which the balloon was lost in its entirety from the catheter and immediately retrieved using a second identical instrument. A comprehensive survey of the literature reveals that a variety of arterial injuries have occurred during the use of the Fogarty catheter. Each of the major ones is discussed in depth. Amongst the most serious are arterial perforation and rupture occasionally followed by loss of the involved extremity. All previously reported complications following use of the Fogarty catheter are tabulated and reviewed. Additionally, a formal classification of these complications is proposed. Since the time of its introduction in 1963 the Fogarty ballon-tipped catheter has become an indispensible tool in the armamentarium of the vascular surgeon. Its use for arterial embolectomy has been responsible for the salvage of many thousands of limbs. Over the course of the past decade, however, a number of complications referable to this instrument have appeared in the literature. These include perforation of vessels, intimal disruption and foreign body embolization amongst others. To our knowledge, however, there has been only one reported case of a balloon having been lost intra-arterially in toto without obvious cause. It is the purpose of this paper to present the second such case where the balloon, which had separated entirely from the catheter during the course of an arterial embolectomy, was later retrieved by passage of a second Fogarty catheter. In addition, a comprehensive review of the literature is undertaken, and all arterial complications reported to date summarized and tabulated.

Aneurysm↗
PubMedDate not supplied

Arterial embolectomy in lower limbs.

Arterial embolisms in the lower limbs occur frequently, and are of great interest to the vascular surgeon. The authors studied 159 cases of arterial embolisms in lower limbs from January 1991 to July 1993. Ages varied from 12 to 98, with a mean of 58. Eighty patients were male and 78 were female. In most cases, etiology of the embolus was well-established, and mainly caused (78 percent) by atrial fibrillation. Occlusion was most frequent in the femoral artery (53.4 percent). All patients presented severe lower limb ischemia, but not gangrene, on admission. The duration of ischemia, between the onset of symptoms and the liberation of arterial flow, was in most patients (67.9 percent) less than 24 hours. All patients were submitted to lower limb embolectomy with the Fogarty catheter, of which 70.9 percent were done through the femoral artery. Fasciotomy was performed on 48 patients due to a compartimental syndrome. Nineteen patients died immediately after operation; 68.4 percent due to heart failure. Twenty-three (16.4 percent) of the 140 surviving patients (150 operated limbs) were submitted to amputations after the occlusion of artery branches, which had undergone embolectomies. One hundred and twenty-seven limbs (84.6 percent) were preserved in 117 patients (83.5 percent). Eleven cases (7.3 percent) required repeated surgery with the Fogarty catheter. The patients with muscle tenderness, paralysis, or ischemia lasting longer than 24 hours had worse results in relation to the preservation of the limb (p < 0.05). We conclude that patients who present lower limb embolisms, are in good clinical condition, and who do not have any necrosis in the limbs, have good outcomes as to limb preservation, along with low complication rates, after embolectomy with the Fogarty catheter. Limb preservation was significantly higher in patients who did not present muscle tenderness, and who had normal motor activity and a ischemia duration of less than 24 hours.

Adolescent↗
PubMed1989

Emergency embolectomy in a patient with massive pulmonary embolism during second trimester pregnancy.

Emergency pulmonary embolectomy was performed successfully on a patient in her second trimester of pregnancy. The patient had severe right ventricular failure due to obstruction of 85% of the pulmonary arterial circulation. Three months after embolectomy she was delivered of a normal infant. The problem of significant but misinterpreted or overlooked clinical and electrocardiographic signs of pulmonary embolism is discussed. Thrombolytic therapy during pregnancy imposes considerable risk of bleeding with deleterious effects on both mother and fetus. In our opinion, emergency embolectomy during extracorporeal circulation is the best treatment in case of massive emboli during pregnancy.

Adult↗
PubMed1975

Technical considerations in arterial embolectomy.

The frequency of arterial embolism is high and seems to be increasing. The introduction of the Fogarty catheter for embolectomy has afforded a considerable simplification of the operative technique. Nevertheless the mortality and amputation rates are still substantially high. Early diagnosis and further improved technique for removal of the embolus may enhance limb salvage and reduce mortality rates. The present paper is a review of 10 years' experience concerning technical problems with embolectomy. The arteriotomy technique, the handling of the catheter, per- and postoperative management, and specific technical problems related to the embolic lodgement at different sites are discussed with the object of giving some hints on how to perform the embolectomy in a safe way and with best chances of a suscessful outcome.

Aorta↗