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PubMed1984

Peripheral arterial emboli.

One hundred eleven patients with 130 emboli treated in nonteaching private hospitals have been evaluated with respect to cause, mortality rate, and amputation rate. For surgically treated patients with balloon embolectomy, the mortality rate was 13.7 percent overall, with a limb salvage rate of 94.5 percent. The operative mortality was 8.3 percent. The mortality for late embolectomy was 3 percent with a limb salvage rate of 100 percent. The most critical factor in predicting mortality was age of the patient, with a significantly higher mortality in patients of advanced years. In this series, a prolonged duration of embolus before embolectomy did not have an adverse effect on the mortality rate.

Aged↗
PubMed1991

Fulminant pulmonary embolism: symptoms, diagnostics, operative technique, and results.

Fulminant pulmonary embolism associated with cardiac arrest has an extremely high mortality. The feasibility of pulmonary embolectomy initiated during resuscitation is still under discussion. Between January 1975 and January 1991, pulmonary embolectomy was performed in 27 patients, 21 to 79 years old. The diagnosis was established primarily by clinical findings in 18 patients, by angiography and ventilation-perfusion mismatch in 4 patients, and by transesophageal echocardiography in 1 patient seen recently. Eleven patients did not require resuscitation (group 1); 5 patients had to be resuscitated and underwent operation after circulation was reestablished without need of further cardiac massage (group 2); and 11 patients were connected to extracorporeal circulation devices during cardiopulmonary resuscitation (30 to 210 minutes) (group 3). Embolectomy was performed using extracorporeal circulation with the heart beating (n = 2) or fibrillating (n = 15) or using cardioplegia (n = 10). Fifteen patients received a caval clip or ligature at the end of the procedure. Twelve patients died early postoperatively; the mortality rates were 36%, 60%, and 45% for groups 1, 2, and 3, respectively. Eight patients died of right heart failure, and 2 patients each died of brain death and sepsis. Of the surviving patients, only 1 showed ischemic brain damage. Mean stay in the intensive care unit was 5.1, 7.0, and 9.75 days for groups 1, 2, and 3, respectively. There were no recurrent embolisms during the 15-year follow-up (mean follow-up, 4.6 years). This experience demonstrates that even with subtotal obstruction of the pulmonary arteries, effective cardiopulmonary resuscitation with maintenance of uncompromised brain function is possible.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiopulmonary Resuscitation↗
PubMed1993

Thrombolysis in acute lower limb ischaemia.

For the past three decades balloon embolectomy has been the treatment of choice for acute lower limb occlusion. However, although usually successful in emboli, results are often disappointing in thrombotic atherosclerotic vessels. Attempted dissolution of the clot is accordingly attractive, and has theoretically been possible since the introduction of streptokinase in 1933. This was initially used intravenously, with variable success rates, although intraarterial administration is currently the method of choice. Later thrombolytic drugs such as tissue plasminogen activator, urokinase and anistreplase have been introduced. Lysis time has also been increased by using pharmaco-mechanical methods of administration such as pulsed spray catheters, which could increase the usefulness of thrombolysis in patients with rapidly progressive neurological signs where currently surgical embolectomy would be advocated. Several newer drugs with theoretical advantages over older drugs such as single-chain urokinase-type plasminogen activator or K1K2PU are currently undergoing trials. The role of thrombolysis as an adjunct to surgical embolectomy is also promising, though again requires further trials. There is still no consensus as to which patients are best suited to thrombolysis, nor an optimum drug or method of administration. However, there seems no doubt that thrombolysis will be increasingly used in the management of peripheral limb ischaemia, though requiring a team approach between surgeons, radiologists and haematologists.

Acute Disease↗
PubMed1977

Surgical management of chronic pulmonary embolism.

The clinical course of most patients with pulmonary embolism is one of gradual resolution with re-establishment of flow in the pulmonary arteries. In a small but definite group of patients, the emboli do not resolve and a state of chronic pulmonary embolism ensues. The primary thrombotic process in the systemic venous system may persist, and in some instances may be unrecognized. Such patients experience recurrent showers of emboli which may ultimately occlude a large part of the pulmonary arterial circulation with development of severe respiratory insufficiency. Six patients with this syndrome are described, and in each there was a history of dyspnea, cyanoiss, and exercise intolerance associated with a low arterial PO2, right ventricular hypertrophy, and pulmonary hypertension. Pulmonary scans and arteriograms demonstrated that more than half of the major pulmonary arteries were occluded and, in addition, smaller vessels were also obstructed. Pulmonary embolectomy was performed in each patient. Five of the 6 obtained a highly gratifying response, including relief of the dyspnea and cyanosis, an increase in arterial PO2, and a decrease in pulmonary arterial pressure. In each of the five in whom improvement occurred, the back-bleeding from the pulmonary artery at the time of embolectomy was quite good. In the sixth patient, the back-bleeding was very poor, and despite embolectomy, the vessel thrombosed postoperatively with no improvement in the patient's clinical course. Follow-up studies in these patients range up to 8 years with demonstration of continued patency of the pulmonary arteries as well as continued improvement in clinical symptoms and in the arterial PO2.

Adult↗
PubMed1991

Delayed presentation and treatment of popliteal artery embolism.

In the course of reviewing a 10-year experience with popliteal artery embolism (PAE), two distinct patterns of clinical presentation were identified. In addition to those patients presenting with typical acute (symptom duration less than 7 days) arterial ischemia, a second group was identified who presented with more chronic symptoms. The present study was conducted to contrast the clinical factors and treatment of these two temporal patterns of presentation with PAE. Sixty PAEs in 58 patients were documented by the combination of angiography and/or exploration of the popliteal artery. Acute presentation (AP) was seen in 41 (68%) of these and delayed presentation (DP) was noted in 19 (32%) patients. Delayed presentation patients typically presented with a history of sudden onset of claudication or rest pain and a median symptom duration of 30 days. Eighty per cent of AP patients presented with immediately threatened limbs. Angiography was generally diagnostic of chronic popliteal embolism. In the acute group, 90% were treated with embolectomy alone, while 20% of the DP group required bypass grafting. However in two thirds of the DP group, embolectomy alone performed through a direct popliteal approach was possible. Current results with overall limb salvage (92%) and mortality (7%) represents a substantial improvement compared to the authors' previous experience with PAE. The current study suggests that as many as one third of patients with popliteal artery embolism may present in delayed fashion with chronic symptoms. Furthermore most of these patients can be treated with direct popliteal embolectomy alone with favorable results.

Amputation, Surgical↗
PubMed1995

Intraoperative digital subtraction angiography after thromboembolectomy: preliminary experience.

PURPOSE: To evaluate the potential influence of intraoperative digital subtraction angiography (DSA) on surgical strategy after balloon thromboembolectomy for acute lower limb ischemia. METHODS: Thirty-six consecutive patients with critical limb ischemia were treated with balloon catheter thromboembolectomy assessed by intraoperative digital subtraction angiography. The need for further intervention was determined by the surgeon based on the DSA information. Primary completion DSAs were made in every procedure; subsequent completion DSAs were performed after reinterventions at the discretion of the surgeon. RESULTS: Initial treatment in this patient group consisted of 14 embolectomies and 26 thrombectomies. From the completion DSAs of these 40 procedures, a reintervention was judged necessary in 27 (68%). Of these 27 reinterventions, 17 underwent a secondary DSA; evidence supporting a third intervention was found in 11 (64%). Overall, a total of 69 DSAs were performed in these patients. Mortality was 22% (8 patients); 38% (5) in embolectomy patients and 13% (3) in the thrombectomy cohort. Eighty-eight percent of the embolectomy survivors had an uneventful recovery, while only 25% of the thrombectomy survivors experienced an uncomplicated follow-up. In one quarter of the surviving thrombectomy patients, a surgical revascularization resulted in limb salvage; in 45%, a major amputation was the outcome. CONCLUSIONS: In this study, the completeness of balloon catheter thromboembolectomy was assessed by intraoperative DSA. As a result, 68% of the procedures required one or more reinterventions for residual lesions. Intraoperative DSA is a simple and quick technique that may be a promising adjunct to intraoperative balloon thromboembolectomy.

Angiography, Digital Subtraction↗
PubMed2001

[Experience of four cases of postoperative pulmonary embolism requiring surgical treatment].

Four patients underwent a pulmonary embolectomy using cardiopulmonary bypass for acute pulmonary embolism which had occurred after various operations. In two cases, dehydration due to either diabetes insipidus or ileus had existed. In two cases, pulmonary embolism suddenly occurred in our hospital. In the remainder, the disease occurred in the previous hospitals and its diagnosis was established on the 6th and 7th postoperative days, respectively. In massive pulmonary embolism, echocardiography and/or enhanced chest CT are useful for prompt and noninvasive diagnosis. Thrombolytic therapy was performed in only one case before surgical embolectomy, which was not effective. Three patients were discharged without any postoperative complications, but one requiring preoperative external cardiac massage died of multiple organ failure 9 days after operation. Acute pulmonary embolism is one of the fatal postoperative complications. Recognition of this entity, and prompt diagnosis and treatment are essential for managing the fatal disease. Even in the early postoperative period, embolectomy using cardiopulmonary bypass is a safe and effective treatment.

Acute Disease↗
PubMedDate not supplied

[Embolism in healthy arteries].

The authors present a series of 64 patients with arterial embolism in healthy arteries. 53 of these patients underwent one or several embolectomies, using a Fogarty catheter. Although arterial embolism has a poor prognosis owing to the constitutional background (15 p. 100 mortality and 12 p. 100 amputations), this is mainly due to the age of the patient. The severity of the initial attack and the delay between embolism and embolectomy seem to be the main factors in prognosis. Massive ischemia causes severe symptoms in these fragile patients and an early cure is necessary to compensate this disturbance. Heparin perfusion, whilst awaiting surgical treatment, is essential. Embolectomy by Fogarty's catheter may be carried out under local anesthesia; this remains the essential measure and has greatly improved the prognosis of this disease which used to be fatal in almost 60 p. 100 of cases, even in healthy arteries.

Adolescent↗
PubMed2003

[Surgical treatment of acute embolism of the upper extremity].

OBJECTIVE: To study the methods of surgical treatment and the prognosis of acute embolism of the upper extremity. METHODS: Balloon catheter embolectomy through the brachial artery was performed in 18 patients with acute embolism of the upper extremity. RESULTS: Both the pulse of the radial and ulnar artery could be palpated in 8 patients, either the pulse of the radial or ulner artery could be palpated in 9 patients. The temperature of the upper extremity was increased in the patient whose embolectomy was performed in the 6th day after onset of the illness. Three patients died postoperatively. CONCLUSIONS: Embolectomy through the brachial artery is an effective method to treat acute embolism of the upper extremity. Elderly and heart and pulmonary diseases are the high risk factors for postoperative death.

Acute Disease↗
PubMed2004

Results of surgical treatment for peripheral arterial occlusive disease in women.

BACKGROUND: The incidence and prevalence of peripheral arterial occlusive disease (PAOD) in women is more prevalent than generally appreciated, and the results of surgical treatment are not certain. The purpose of this study was to investigate the result of surgical treatment of PAOD in female patients in our service. METHODS: Medical records of female patients undergoing surgical treatment for PAOD in Taipei Veteran General Hospital from January 1, 1997 to July 31, 1998 were reviewed retrospectively. The clinical variables were evaluated, including age, smoking, diabetes mellitus, hypertension, renal function, coexistent coronary disease, history of stroke, Fontaine stages, surgical procedures and results. RESULTS: There were 20 female patients undergoing surgical treatment for PAOD during the study period, aged from 57 to 91 years, with an average of 73.7 +/- 2.2. Four patients presented with rest pain. Twelve patients presented with gangrene of lower limbs. Ten patients underwent bypass surgery. Three patients received embolectomy. One patient underwent below knee amputation after femoro-popliteal bypass. One patient underwent below knee amputation after embolectomy. Five patients underwent above knee amputation without bypass surgery or embolectomy. Four patients (20%) died after surgery. CONCLUSIONS: The female patients of PAOD presented with severe symptoms and advanced Fontaine stages. The delay in diagnosis and referral resulted in an unsatisfying outcome of surgical treatment. An aggressive approach in diagnosis and referral is necessary for better results.

Aged↗
PubMed1992

[Clinical profile and treatment of acute pulmonary embolism].

The clinical profiles of 15 patients with acute pulmonary embolism (APE) were analysed. The most common symptoms of APE were tachypnea and tachycardia with sudden onset. Both PO2 and PCO2 had decreased in almost all patients (mean PO2: 50 mmHg, PCO2: 30 mmHg). Chest roentgenogram (X-P) revealed hyperlucency of the lung field, prominence of proximal pulmonary artery and cardiac enlargement. ECG showed SI QIII TIII and ST-T changes in half of the cases. These changes, however, disappeared within 4 days in most patients. Lung scan and digital subtraction pulmonary angiography were useful for the diagnosis. Sixty percent of patients recovered only by medical therapy, and embolectomy was performed in only two patients. Fifty-three percent of patients were, however, considered to be candidates for the embolectomy, and half of them died because of ineffective medical therapy. From these results we concluded that the combination of severe hypoxemia and hypocapnia with abnormal chest X-P can be used for a diagnostic or therapeutic decision. If a patient has those findings, pulmonary angiography is recommended together with thrombolytic therapy. If a large embolus is detected, embolectomy is mandatory. The need for surgical therapy for APE is greater than we had imagined.

Acute Disease↗
PubMed1990

Peripheral arterial embolism: a prospective study of 40 consecutive cases.

A prospective study was made of 40 consecutive patients who presented with peripheral arterial embolism to the Vascular Surgical Service in UKM. Atrial fibrillation was the most common source of the embolus. Twelve patients did not present until the affected limb(s) were in established gangrene. Thirty-two embolectomies were performed on 25 patients. Only 10 of these patients were discharged well with their limbs intact. Four patients required amputation because embolectomy did not restore viability of the limbs. Eleven patients died following embolectomy. The overall mortality for arterial embolism was 50%. Among the survival (n = 20), only 11 patients were discharged with their limbs intact. The cause of the poor result was related to the delay in definitive treatment and the poor general state of the patients. It was concluded that the prognosis for arterial embolism was very poor. This result needs to be improved and recommendations are made to achieve this.

Adult↗
PubMed1990

[The therapeutic procedure in thromboembolism of the pulmonary artery].

Clinical symptomatology, ECG, roentgenography, echocardiography, blood biochemistry, angiopulmonography with manometry of the pulmonary artery and right heart compartments were used to diagnose in 14 patients (age: 25-65 years) massive and submassive pulmonary artery thromboembolism. The angiopulmonographic index exceeded 18 points. Treatment included embolectomy, medical therapy (heparine, indirect anticoagulants), thrombolytic agents (celiase) and symptomatic therapy. The results of medical treatment were good in 80% of patients. Good results in embolectomy were observed in 77.7%. The authors formulate absolute and relative indications to urgent embolectomy in conditions of artificial circulation.

Adult↗
PubMed1988

[Surgical tactics in acute mesenteric artery occlusion].

Operations were performed on 52 patients for acute mesenteric embolism, between 1980 and 1988. The average age of 48 of them was 75.8 +/- 7.3 years. Only four patients were below 60 years of age. Only exploratory laparotomy was possible in 20 cases, and all of these patients died. Six of eight patients (75 per cent) did not survive embolectomy from the superior mesenteric artery. Seven of twelve patients (58 per of eleven patients (27 per cent) died after embolectomy and resection of subtotal parts of the small intestine. Death occurred also to one patient with acute iliaco-mesenteric bypass. Hence, total mortality of all 52 patients amounted to 71.1 per cent. The mortality rate for 32 patients with attempted restitutional surgery amounted to 53.1 per cent, exploratory laparotomy unconsidered. This was certainly attributable to 73 per cent of survivors of embolectomy combined with removal of somewhat extended intestinal sections. Follow-up checks in short intervals of serum lactate have proved to provide reliable diagnostic parameters and means for postoperative appraisal with a view to making an informed estimate of changes of a second-look operation for acute intestinal ischaemia. The lactate mean value for mesenteric embolism was 8.88 +/- 4.43 mmol/l. However, lactate values were normal, between 1 mmol/l and 2 mmol/l, in acute abdominal processes with non-ischaemic causes and in cases of ischaemia of extremities.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute Disease↗
PubMed1986

Panvenography and pulmonary angiography in the diagnosis of deep venous thrombosis and pulmonary thromboembolism.

In summary, high-quality pulmonary angiography remains the most accurate and reliable means of diagnosing pulmonary embolism. It can be performed with relative safety, and the inherent mortality risks with pulmonary angiography (in the range of 0.2 to 0.5 per cent in active angiography laboratories) must be weighed against the significant risks incurred with inaccurate diagnosis obtained without pulmonary arteriography. Pulmonary arteriography and transvenous catheter embolectomy can be of great benefit in sudden cardiovascular collapse due to massive pulmonary embolism. Transvenous catheter embolectomy has survival rates at least as good as those of open embolectomy, and it has the advantage that it can be performed in any hospital with angiographic facilities and trained personnel, thus allowing more expeditious management of massive pulmonary embolism in hospitals that do not have cardiopulmonary bypass capabilities.

Acute Disease↗
PubMed1987

[Features of treatment tactics in emboli in an artery with impaired blood flow].

Results of surgical treatment of 203 embolisms in arteries of the extremities, including 127 embolisms in intact arteries, and 76 embolisms in atherosclerotic ones, are reported. Post-embolectomy regression of mild ischemia is shown to be unrelated to the condition of the artery. Severe ischemia in atherosclerotic arteries does not benefit from embolectomy alone; it must be supplemented by reconstructive surgery. Removing chronic obstruction to the main flow improved the success rate from 44 to 70%, as compared to embolectomy alone.

Arteriosclerosis↗
PubMed1985

Recent experience with arterial embolism of the limbs in a vascular unit.

A 5 1/2-year experience of 147 patients with arterial embolism of the limbs is reported. The mean age was 66.9 years, range 24-90 years and the male to female ratio was 1.07 to 1. Two distinct types of embolic episode with very different clinical consequences were recognised. Type I (64%) in which large emboli occluded the proximal arteries of the lower limb. They were usually treated by embolectomy and were followed by death or permanent disability in 63% of patients. Type II (36%) in which small emboli occluded the arterial supply of the upper limb or the arteries of the distal lower limb. Embolectomy was performed in only 60% of cases. Death was unusual and disability occurred largely as a consequence of non-surgical management. After occlusion of the aorta, iliac or femoral arteries embolectomy is necessary to save both life and limb while after embolism of the arm or distal lower limb it is essential for the preservation of function.

Adult↗
PubMed1984

Embolism of the popliteal artery.

The experience with popliteal arterial embolism at the Massachusetts General Hospital was surveyed, and the results of therapy prior and after the introduction of the balloon-tipped embolectomy catheter were compared. During the 17 year period from January of 1964 to January 1981, 67 popliteal emboli were diagnosed. Nonsurgical management was successful in salvaging 11 of 13 extremities in ten patients with one death. Surgical embolectomy was performed upon 54 extremities in 48 patients with 40 limbs salvaged and 11 deaths. Although the percentage of patients undergoing surgical therapy for popliteal emboli has dramatically increased since the introduction of embolectomy catheters, no improvement in limb salvage or in patient survival has resulted. In fact, the limb salvage rate has declined. Nonsurgical management in appropriately chosen patients is clearly successful. The results of this survey emphasize the necessity of early diagnosis and treatment as well as selective patient management. Recommendations for a therapeutic approach to popliteal emboli are presented which hopefully will improve the results.

Aged↗