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PubMed1978

[Peripheral arterial embolism. Considerations on 101 cases (121 emboli)].

The treatment of 101 patients with peripheral arterial embolism between 1970 and 1976 is discussed. Embolectomy was performed 98 times in 78 cases, antigoagulant and fibrinolytic management was employed in 19 cases, and primary amputation was necessary in the remaining four subjects. The limb was saved in 70% of those operated, while secondary amputation proved necessary in 14%. Overall mortality (after embolectomy and amputation) was 22%. Lastly, the therapeutic protocol used is discussed, together with the various factors that still prejudice the results of embolectomy.

Adult↗
PubMed1996

Fluoroscopically assisted thromboembolectomy: an improved method for treating acute arterial occlusions.

We performed bilateral femoral artery dissections in a single 50 kg mongrel dog. Digital fluoroscopic arteriograms documented the luminal diameter of the left iliac and right superficial femoral arteries. Balloon thrombectomy catheter passage was performed through hemostatic sheaths by 12 surgeons. Embolectomy balloons were filled with radiographic contrast material and the balloon catheter diameter was compared with the underlying vessel diameter. The percentage of overdistention of the embolectomy balloon relative to the arterial wall was 23% +/- 5% in the iliac artery and 40% +/- 13% in the femoral artery. Over a 25-month period, we used fluoroscopically assisted thromboembolectomy to treat 21 patients with acute arterial or graft occlusions. As the balloon was gently withdrawn to extract intravascular thrombus, deformities of the compliant balloon profile caused by underlying arterial lesions were identified fluoroscopically and their locations recorded to facilitate further treatment. After initial clot removal in these 21 patients, 15 residual lesions were documented. Repeat thrombectomy (n = 8), balloon angioplasty (n = 3), and placement of intravascular stents (n = 4) eliminated all 15 lesions. Luminal continuity was successfully restored in all 21 of these patients, 10 of whom required distal open vascular reconstruction to correct existing outflow artery disease. Fluoroscopically assisted thromboembolectomy is a simple and safe method for treating acute arterial or graft occlusions in patients with diffuse arteriosclerosis. It minimizes arterial damage and blood loss during balloon thrombectomy and reduces the need for intravascular contrast agents. It also has the potential to facilitate accurate identification, localization, and treatment of significant underlying arterial lesions.

Adult↗
PubMed1998

Massive pulmonary embolism in late pregnancy.

PURPOSE: To describe the management problems presented by a case of acute massive pulmonary embolism in a labouring woman. CLINICAL FEATURES: A case of massive pulmonary embolism is described in a woman who presented in early labour at thirty-eight weeks gestation. Immediate management involved the administration of oxygen and intravenous heparin, and transfer to the regional cardiothoracic centre. Pulmonary angiography confirmed the diagnosis of massive pulmonary embolism, but attempts at percutaneous catheter disruption of the clot were of only temporary benefit. The patient subsequently underwent Caesarean section under general anaesthesia, followed minutes later (because of an abrupt deterioration in her condition) by surgical pulmonary embolectomy. The outcome was successful for both mother and child. CONCLUSION: In cases of acute massive pulmonary embolism presenting in late pregnancy and in labour, the risks and benefits of surgical embolectomy, pharmacological thrombolysis, or attempts at mechanical clot disruption have to be weighed on an individual basis. Management at the referral centre was facilitated by having cardiothoracic and obstetric facilities on the same site.

Acute Disease↗
PubMedDate not supplied

Saddle arterial embolus in a patient with Down syndrome.

We report acute thromboembolic events in a 14-year-old boy with Down syndrome and repaired atrioventricular septal defect. He presented with sudden onset of bilateral lower limb ischemia. Transesophageal echocardiography detected a thrombus in the right atrium. An arterial saddle embolus was removed following bilateral iliac embolectomy. Despite anticoagulation, he presented again with sudden bilateral lower limb ischemia and respiratory distress. Multiple pulmonary emboli and a thrombus in the right atrium were noted on imaging studies. An arterial embolus was removed from the abdominal aorta at the bifurcation. To our knowledge, this is the first report of a child or adolescent with a repaired congenital heart lesion and arterial embolism requiring embolectomy. This association and possible etiological factors are discussed.

Adolescent↗
PubMedDate not supplied

rt-PA thrombolysis in acute thromboembolic upper-extremity arterial occlusion.

PURPOSE: Retrospective analysis of the results of rt-PA thrombolysis in the treatment of acute thromboembolic occlusion of the upper limb. METHODS: Of 55 patients with demonstrated acute embolic arterial occlusion, rt-PA thrombolysis was performed on 40 occlusions in 38 patients (23 women with a mean age of 62 years, range 32-85 years; 15 men with a mean age of 65 years, range 32-92 years) according to the following design: 6 mg rt-PA/hr for 30 min, 3 mg rt-PA/hr for the next 30 min, 1 mg rt-PA/hr for 7 hr, and 0.4 mg rt-PA/hr until the end of lysis. Onset of symptoms varied from 1 to 14 days. Included were three isolated upper-arm occlusions, nine combined brachial and forearm occlusions, and 28 forearm and hand artery occlusions. RESULTS: The overall success rate was 55%. The lysis results for isolated upper arm, combined brachial and forearm occlusions, and forearm and hand artery occlusions were 100%, 66%, and 46%, respectively. In eight patients surgical embolectomy had to be performed after failed thrombolysis. No amputation was required in the follow-up period. No lethal complications occurred. CONCLUSIONS: Interventional rt-PA treatment of proximal upper-extremity arterial occlusions may be performed with comparable success rates to surgical embolectomy and without severe complications. For distal occlusions the results are inferior to the success rates obtained with surgery.

Acute Disease↗
PubMed1999

Primary aortic mural thrombus: presentation and treatment.

The clinical presentation of patients with acute lower-limb ischemia and primary aortic thrombus prompted this review. Following recognition of the first case in early 1994, relevant patients (n = 6) were kept in a database and were reviewed for presentation, treatment, and follow-up. The median age was 41 and five patients were male. Angiography, computed tomography, and/or magnetic resonance angiography demonstrated one or more aortic sessile or pedunculated thrombus(i) without associated atherosclerotic disease. In two cases, a retropancreatic intraaortic mural thrombus was associated with severe pancreatitis. All other cases presented with acute lower-limb emboli requiring limb salvage embolectomy. Because of significant patient illness, systemic anticoagulation was chosen acutely to prevent recurrent emboli. Interestingly, serial studies demonstrated aortic thrombus resolution. Failure to continue warfarin therapy resulted in recurrent problems (n = 1) unless the instigating event had resolved (n = 3). There were no deaths or amputations. We concluded that surgical embolectomy, when required, with subsequent anticoagulation, results in limb salvage and allows for eventual resolution of the primary aortic thrombus. Long-term anticoagulation is required unless the etiologic process resolves. The literature describes patients with atherosclerosis and overlying thrombus but fails to describe the approach to patients with primary thrombus formation.

Acute Disease↗
PubMed2004

Thrombectomy for acute internal carotid thrombosis: five thrombectomy devices compared.

OBJECTIVE: To test the safety and efficiency of commercially available thrombectomy catheters in clearing simulated internal carotid artery (ICA) thrombosis. DESIGN: Comparative in vitro study. MATERIALS AND METHODS: A model of the ICA was filled with human thrombus, the 'circle of Willis' back pressure was set at either 10 or 30 cm of water. Five thrombectomy devices (Hydrolyser, Clot Buster, Acolysis System, AngioJet and Fogarty embolectomy catheter) were compared for (i) efficiency at removing thrombus, (ii) pressure changes at the tip of each device, and (iii) distal embolisation by flow cytometry. RESULTS: Thrombus clearance was greatest with the AngioJet (median 95%, range 92-97%) and least with the Acolysis System (median 34%, range 12-50%). The Clot Buster and Hydrolyser were safest as they produced only negative tip pressures, the AngioJet and Balloon catheter produced positive and negative pressures risking distal embolisation. The Acolysis system produced no pressure change during use. Distal embolisation (of particles between 5 and 40 microm diameter) was greatest with the Fogarty balloon catheter at 10 cm water (P<0.05) and least with the Hydrolyser and Clot Buster. CONCLUSION: Balloon embolectomy for ICA thrombosis risks further embolic cerebral damage. The Hydrolyser and the Clot Buster show the greatest promise for ICA thrombectomy.

Acute Disease↗
PubMed2004

Embolus of surgical adhesive to the extremities causing acute ischemia: report of two cases.

We present 2 cases in which a surgical adhesive embolized to the extremities. In the first case an adhesive was successfully used in the repair of a DeBakey type I aortic dissection. The patient was seen 2 months postoperatively with acute lower extremity ischemia, and a large piece of adhesive was extracted from the iliac and femoral arteries at embolectomy. In the second case the adhesive was used to seal a pericardial patch during repair of a ventricular septal defect. This patient was seen 1 day postoperatively with acute arm ischemia, and the adhesive particle was extracted from the brachial artery during embolectomy.

Acute Disease↗
PubMed2002

Management of pulmonary embolism during acrylic vertebroplasty.

A 55-year-old man diagnosed with osteogenesis imperfecta had multiple pulmonary embolism from acrylic cement during vertebroplasty. The patient immediately developed respiratory distress, renal failure, and right cardiac failure. A computed tomographic scan showed the presence of cement in the right and left pulmonary arteries, and in both lungs. Cardiac and respiratory functions did not improve with medical treatment, therefore the patient underwent pulmonary artery embolectomy. Cement was easily removed from both pulmonary arteries. The patient quickly recovered from respiratory and cardiac failure. We believe pulmonary embolectomy is a reliable and effective procedure to treat this rare and dreadful complication of acrylic vertebroplasty.

Embolectomy↗
PubMed2003

Endovascular management of axillofemoral bypass graft stump syndrome.

OBJECTIVE: Upper extremity embolic complications of occluded axillofemoral bypass grafts are infrequent. However, traditional management of dissection of axillary anastomosis for removal of the stump can be challenging. We report two patients with critical upper extremity ischemia secondary to stump syndrome and its successful management with endovascular techniques. METHODS: One hundred fifty-two patients underwent axillofemoral bypass grafting over 10 years from 1991-2001. Two patients from this series had acute ischemia involving the ipsilateral upper extremity of occluded axillofemoral bypass graft. Duplex ultrasound scans revealed occlusion of the axillofemoral bypass graft and acute occlusion of ipsilateral upper extremity arteries. Both patients underwent brachial artery exploration and embolectomy. Completion angiograms revealed persistent axillofemoral bypass graft stump as the source of embolus. The stump was obliterated with a 10-mm/40-mm Wallgraft introduced through the same arteriotomy made for brachial embolectomy. Transesophageal echocardiography and magnetic resonance angiography of the arch and great vessels were performed to exclude other sources of origin for the embolus. RESULTS: Both patients remained symptom-free and with patent stent grafts, as seen on duplex scans at 3, 6, and 9 months of follow-up. CONCLUSIONS: Upper extremity embolism is a rare complication after occlusion of axillofemoral bypass grafts. The endovascular approach to obliterate the stump of occluded axillofemoral bypass grafts is minimally invasive and an effective alternative treatment of this rare condition.

Aged↗
PubMed2002

"Malignant" carotid artery dissection.

PURPOSE: Carotid artery dissection resulting in occlusion or severe narrowing and massive intracranial embolism can result in life-threatening hemispheric ischemia. Aggressive endovascular and microsurgical measures may be necessary to salvage life and minimize stroke morbidity in this extreme situation. PATIENTS AND METHODS: We have treated two middle-aged women who presented within an hour of spontaneous cervical internal carotid artery (ICA) dissection causing hemiplegia, forced head and eye deviation, and declining consciousness. The first patient had a carotid occlusion through which a catheter could not be passed, so intracranial thrombolysis was achieved through a microcatheter navigated through the posterior circulation. Surgical intimectomy and thrombectomy of the dissected ICA was then carried out using an intraoperative Fogarty arterial embolectomy catheter passed up the dissected ICA, followed by endovascular stenting of the reopened cervical ICA. The second patient underwent intracranial microsurgical embolectomy and, after an unsuccessful attempt of stenting the dissected and severely narrowed cervical ICA, surgical reopening again with a Fogarty catheter. Both patients suffered basal ganglionic infarcts but most of the middle cerebral artery territories were preserved and the patients made satisfactory recoveries. CONCLUSIONS: "Malignant" carotid artery dissection causing occlusion or near occlusion with intracranial embolism is an important cause of severe and life-threatening hemispheric ischemia. Treatment should include aggressive endovascular and microsurgical interventions when the hemisphere is at risk.

Carotid Artery, Internal, Dissection↗
PubMed2002

A rare cause of peripheral arterial embolism: ruptured cardiac hydatid cyst.

One of the important unfavorable events that occur during the course of the cardiac hydatid cyst is rupture of the cyst and embolism of the germinative membrane. Peripheral arterial embolism of this germinative membrane is uncommon but is a potential risk due to the nature of the disease. Ruptured cardiac hydatid cyst should be suspected in young patients who have a peripheral arterial embolism and come from sheep-raising areas and/or if they have a suspected embolectomy material resembling germinative membrane. Following the embolectomy and reconstruction of the circulation in the involved extremity, ruptured cardiac hydatid cyst should be diagnosed immediately and excision of the cardiac cyst should be performed as quickly as possible. In this case report, we present two patients who had lower extremity embolism originating from the ruptured cardiac hydatid cyst and were operated on for cardiac cyst excision.

Adult↗
PubMed2006

Acute mesenteric ischaemia, a highly lethal disease with a devastating outcome.

BACKGROUND: Acute mesenteric ischaemia remains a serious condition requiring emergency, surgical management. The mortality rate still remains high, due to the unspecific and delayed diagnosis and ranges from 59% to 100%. Purpose of our study is to present our experience in the management of the disease. PATIENTS AND METHODS: This is a retrospective study of 61 patients treated surgically for acute mesenteric ischaemia, between 1988 and 2004. All patients underwent a laparotomy. 75% of the patients were operated within the first 24 hours and the rest within 48 hours. RESULTS: Superior mesenteric artery embolism occurred in 36 (59%), thrombosis in 21 (34%) and superior mesenteric vein thrombosis in 4 (7%) cases. In 49 (80%) cases, embolectomy or thrombectomy of the superior mesenteric artery with resection of the necrotic segment of the bowel was performed. Twelve cases (20%) were considered inoperable because of massive bowel necrosis. According to our study mortality and morbidity rate amounts to 75% and 80% respectively. No significant difference in the mortality rate between patients with embolism (75%) and thrombosis (76%) was found. However a significant increase of mortality rate was observed when the surgical intervention became afterwards the first 24-hour period. (72% versus 87%). Patients who underwent embolectomy or thrombectomy with bowel resection presented an improved survival rate compared with patients that underwent only bowel resection. (p = 0.019) CONCLUSIONS: Acute mesenteric ischaemia has the characteristics of a highly lethal condition and only early recognition and appropriate treatment can reduce the potential for a devastating outcome. The reduction of time interval from the beginning of symptoms up to the treatment remains the main critical important factor.

Acute Disease↗
PubMed1998

Acute non-traumatic arm ischaemia.

BACKGROUND: Much attention has been paid to the management of acute leg ischaemia. Acute arm ischaemia is perceived as less of a problem because the risk of limb loss is lower. After conservative treatment up to half the patients have late symptoms, such as forearm claudication. METHODS: This study was a review of all published English language data on acute arm ischaemia. The entire Medline database was searched and other references were derived from the material perused. There were no randomized or controlled studies. RESULTS: The incidence of acute arm ischaemia is one-fifth that of acute leg ischaemia. Patients with arm ischaemia tended to be older with a mean age of 74 years compared with 70 years for acute leg ischaemia. Since the development of the embolectomy catheter, embolectomy can be performed in most patients under local anaesthetic. Collected outcome included successful restoration of the circulation in 65-94 per cent of patients and amputation in 0-18 per cent. The mortality rate ranged from 0 to 19 per cent, despite the use of local anaesthesia, mostly from associated cardiac disease. Management by a vascular specialist may be beneficial, particularly in complex cases. CONCLUSION: An active approach to the management of acute arm ischaemia is safe and effective and reduces the risk of late disabling symptoms.

Acute Disease↗
PubMed1996

Carbon dioxide elimination measures resolution of experimental pulmonary embolus in dogs.

Patients with severe pulmonary embolism can suffer progressive hypercapnia refractory to supramaximal mechanical ventilation, and may require open-thoracic or transvenous emergency embolectomy in addition to anticoagulation and/or thrombolysis. The functional recovery of gas exchange would be signaled by an increase in pulmonary CO2 elimination and decrease in CO2 retention; such data could guide the course of operative embolectomy. Accordingly, we studied five chloralose-urethane anesthetized, mechanically ventilated dogs with open thoraces in which the right pulmonary arteries (RPAs) were reversibly occluded with cloth snares. After waiting for steady state, we abruptly released the snare to restore RPA perfusion and experimentally simulate resolution of pulmonary embolism. For 70 min we serially measure the CO2 volume exhaled per breath (VCO2,br), arterial, mixed venous, and end-tidal PCO2 (PACO2, PVCO2, PETCO2), cardiac output (QT), and the alveolar dead space fraction (VDalv/VTalv = [PaCO2 - PETCO2/PaCO2). RPA reperfusion caused VCO2,br to significantly and abruptly increase from 8.9 +/- 2.7 to 11.6 +/- 3.6 mL; 70 min later VCO2,br had returned to baseline. PaCO2 and PVCO2 steadily decreased during 70 min of RPA reperfusion. PETCO2 increased from 25 +/- 5 to 33 +/- 5 mm Hg immediately after RPA reperfusion, as VDalv/VTalv decreased from 54% +/- 10% to 32% +/- 12%, but PETCO2 was still significantly greater than baseline at 70 min of RPA reperfusion. QT did not significantly change. We conclude that intraoperative measurement of VCO2,br should immediately detect and follow the resolution of CO2 retention in the lung and peripheral tissues after RPA reperfusion. PETCO2 could not detect the decrease of VCO2,br back to baseline because PETCO2 does not measure exhaled volume or the PCO2 waveform.

Animals↗
PubMed2001

Comparison of three mechanical thrombus removal devices in thrombosed canine iliac arteries.

PURPOSE: To assess and compare intimal and medial vascular damage caused by three mechanical wall-contact thrombectomy devices: Fogarty embolectomy catheter, Arrow-Trerotola peripheral thrombectomy device, and MTI-Castañeda over-the-wire brush. MATERIALS AND METHODS: Bilateral external iliac arteries of 15 canines were thrombosed before mechanical thrombolysis. Ten thrombosed arteries were randomly assigned to receive each device. Animals were sacrificed immediately, and histologic assessment of endothelial and medial damage in the vessels was performed. RESULTS: The vascular damage found with all devices extended into the tunica media. The Fogarty embolectomy catheter and the Arrow-Trerotola device caused significantly more damage than the Castañeda brush. CONCLUSION: All devices caused lesions extending into the media. Previous research has shown that the extent and depth of the vascular lesion may be contributing factors in promoting early atherosclerotic and accelerated hyperplastic intimal and medial changes. These findings warrant further study of these devices in an atherosclerotic model with longer follow-up.

Angiography↗
PubMed2005

Multimodal therapy for the treatment of severe ischemic stroke combining GPIIb/IIIa antagonists and angioplasty after failure of thrombolysis.

BACKGROUND AND PURPOSE: Intraarterial and intravenous thrombolysis are often ineffective for the treatment of acute ischemic stroke and are associated with a significant risk of intracranial hemorrhage (ICH). Multimodal rescue therapy combining mechanical disruption and platelet GPIIb/IIIa receptor antagonists may improve recanalization. METHODS: Patients who did not recanalize with thrombolysis were treated with GPIIb/IIIa antagonists, angioplasty, or an embolectomy device. Treatment was individualized based on vascular anatomy, stroke mechanism, patient status, and symptom duration. RESULTS: Twelve patients were treated within 3.8+/-2.2 hours. The mean National Institutes of Health Stroke Scale (NIHSS) score was 19.4+/-4.1. Six patients had carotid terminus occlusion, whereas 5 had middle cerebral artery and 1 had basilar artery occlusion. The average doses of intraarterial tPA and reteplase were 17.1+/-8.6 mg and 2+/-0.6 units, respectively. All patients received either an intravenous or intraarterial abciximab bolus (mean 11.8+/-5.8 mg) and heparin (mean 3278+/-1716U). Eleven were treated with angioplasty and 4 had mechanical embolectomy or stenting. Complete (8) or partial (3) recanalization was achieved in 11 cases. There was only one (8.3%) symptomatic hemorrhage. Patients had a favorable outcome at discharge (mean NIHSS 8.9+/-8.7) and 6 (50%) had an NIHSS < or =4 at discharge. CONCLUSIONS: Multimodal rescue therapy was effective at recanalizing occluded cerebral vessels that failed thrombolysis without an excess risk of ICH.

Aged↗
PubMed1999

Management of acute nontraumatic upper limb ischemia.

A retrospective review of all patients presenting to a tertiary referral center with acute nontraumatic upper limb ischemia between January 1992 and June 1997 was undertaken to examine the role of intraarterial thrombolysis in the management of such cases. Twenty-one patients were identified in the radiology and vascular surgery departments' registers. Twenty (95%) underwent angiography, demonstrating subclavian artery occlusion in four, axillary in two, brachial in 13, and one at the digital level. Intraarterial thrombolysis was attempted in 12 patients. There were three technical failures, all requiring embolectomy. Six had complete lysis and resolution of their symptoms. One patient had partial lysis but experienced no further rest pain. Thrombolysis was unsuccessful in two cases with one subsequently requiring embolectomy and the other surgical bypass. Three patients had surgical intervention as their primary procedure with two favorable outcomes and one ending in above-elbow amputation. Five patients were treated conservatively with heparin, resulting in three partial and two full recoveries. One patient experienced complete resolution of symptoms with an intravenous prostacyclin infusion. Both electrocardiograms (ECG) and echocardiograms (ECHO) were of limited diagnostic aid, and long-term warfarin anticoagulation was prescribed to all patients. There was no recurrence of upper limb ischemia at a median follow up of 18 months. Intraarterial thrombolysis is an effective first line treatment for acute nontraumatic upper limb ischemia in selected cases.

Acute Disease↗