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PubMedDate not supplied

Peripheral arterial embolism: prevalence, outcome, and the role of echocardiography in management.

The aims of this study were to review the prevalence and outcome of all surgically treated upper and lower limb emboli presenting to one vascular unit in the last 3 years and to compare transthoracic with transesophageal echocardiography for defining the source of the embolus. All patients who underwent surgical embolectomy for acute limb ischemia from January 2001 to June 2004 were reviewed. Transthoracic and transesophageal echocardiography were carried out on a subset of consecutive unselected patients. Forty-two patients, with a mean age of 80 years, underwent surgical embolectomy from January 2001 to June 2004 (M/F 1:1.8): 27 for lower limb ischemia and 15 for upper limb ischemia. Two thirds of these patients were found to be in atrial fibrillation at presentation (n = 28), of whom less than a third were receiving anticoagulants or antiplatelet agents (n = 8). The mean hospital stay was 15 days with 36 patients (86%) being fully anticoagulated before discharge from hospital. The 30-day mortality rate was 11% (n = 3/27) with 5 patients requiring fasciotomies (12%) and 3 patients requiring an amputation of the lower limb (11%). Postoperatively, 34 patients (81%) had transthoracic echocardiography (TTE), which demonstrated a source or potential source for thrombus in 19 (56%). Fifteen patients (36%) had transesophageal echocardiography (TEE), which changed the subsequent management in 3 patients. All patients in whom TEE altered clinical management would have required this investigation if standard clinical guidelines were followed. TEE did not identify any additional patients with cardiac embolic sources that were not detected by TTE. Arterial limb emboli are still prevalent, but limb salvage and mortality rates appear to be improving. Despite clear guidelines on anticoagulation for patients in atrial fibrillation, many are not receiving appropriate treatment. Transthoracic echocardiography is a good screening tool for detecting a potential cardiac source for peripheral embolism, with transesophageal echocardiography being reserved for specific indications.

Aged, 80 and over↗
PubMed1999

Therapeutic efficacy of flavonoids in oedema following reperfusion on acutely ischaemic legs.

BACKGROUND: The aim of this study was to investigate the effect of a purified, micronised, flavonoid fraction (Daflon) in lower limb oedema developed after delayed embolectomy and successful reperfusion of acutely ischaemic legs. METHODS: Our series consisted of 19 patients with prolonged, acute ischaemia of the lower extremity caused by arterial embolism, who had undergone successful embolectomy. Patients were randomised into two groups; ten patients (group I) treated with flavonoids, were compared to nine given a placebo. Ankle and calf circumferences, venous capacitance and venous emptying time were measured preoperatively [T1], on the 2nd [T2], 5th [T3], 8th [T4] and 30th [T5] postoperative days. RESULTS: An increase of ankle and calf circumference up to 9% and 13.5% respectively, as compared with preoperative values was demonstrated. There was a reduction in oedema formation in patients with the Daflon group, which reached statistical significance only in the ankles (p=0.0276). Calf differences were statistically significant on the second and fifth postoperative days (p<0.05). Venous haemodynamics were considerably improved by Daflon (p<0.001). CONCLUSIONS: Daflon 500 mg had an inhibitory effect on moderate oedema developed after revascularisation of an ischaemic limb.

Aged↗
PubMed1995

Massive pulmonary embolism. Diagnostic and therapeutic strategies.

Massive PE is a devastating clinical entity often undiscovered until autopsy. Acute right ventricular failure may progress to death within minutes to hours after the embolic event and prompt diagnostic and therapeutic intervention are imperative. The diagnosis heavily relies on clinical suspicion together with ventilation-perfusion scanning. Echocardiography may have a role in select patients to aid in the recognition of PE with right ventricular failure and to guide therapy. Clinical instability may hinder the diagnostic evaluation and delay therapeutic intervention. Oxygen is administered and, when necessary, intubation and mechanical ventilation are undertaken. In the setting of hypotension supportive therapy includes vasoactive medications, such as norepinephrine. Intravenous fluids should be administered cautiously. Therapeutic options aimed directly at reducing the embolic burden include systemic thrombolytic therapy, surgical embolectomy, and the use of intrapulmonary arterial catheter techniques. In the absence of contraindications, thrombolytic therapy should be strongly considered in hypotensive patients. Surgical embolectomy for acute PE is controversial, but this modality appears to have a role in select patients. Various intrapulmonary arterial catheter techniques, with or without low-dose thrombolytic therapy, have been used successfully to reduce the embolic burden, although no particular technique appears to have clear advantages over others. Placement of an inferior vena caval filter may prevent additional, potentially fatal emboli and appears appropriate in select patients with massive emboli.

Algorithms↗
PubMed1994

[Occlusion of the distal aorta].

Between 1984 and 1992, 79 patients were operated for occlusion of the infrarenal abdominal aorta. 12/79 (15%) of the patients underwent emergency procedure for an acute Leriche syndrome. 67/79 (85%) of the patients with a chronic occlusion were treated electively. The surgical management includes in our series in 57/79 (72%) cases aortoiliac or aortofemoral prosthetic bypass, in 11/79 (14%) cases aortoiliac endarterectomy, in 6/79 (8%) cases embolectomy and in 5/79 (6%) extraanatomical axillofemoral bypass. For chronic total occlusion of the aorta the most common procedure was prosthetic bypass in anatomical position. For emergency cases embolectomy was performed in 42%. Early morbidity rate was 26% (21/79). The most frequent complications were thromboembolic events in 7 patients, myocardial infarction in 4 patients and renal insufficiency in 4 cases. The 30-day mortality 2.5% (2/79); the cause in both cases myocardial infarction. For atherosclerotic occlusive disease of the infrarenal abdominal aorta the prosthetic bypass is the first-choice surgical procedure. For embolic occlusions and for risk patients other less burdening procedures are available.

Adult↗
PubMedDate not supplied

Surgical treatment of massive pulmonary embolism.

Surgical treatment of massive pulmonary embolism (PE) is usually performed in cases of contraindications to fibrinolysis (trauma and/or recent surgery). Additional indications for the embolectomy are either clinical (shock low cardiac output, cardiac arrest) or angiographic (occlusion of more than 80% of pulmonary arterial bed). Due to the emergency setting, PE is often diagnosed only on a clinical basis (10-30% of the cases). Embolectomy is usually performed using cardio-pulmonary bypass (CPB). Trendelenburg procedure can be indicated in desperate situations. No general agreement exists concerning the role of interruption of the inferior vena cava (IVC), in order to prevent PE recurrence. Usually, interruption of the IVC is performed in cases of contraindications to anticoagulant therapy or in presence of recurrence despite anticoagulation. Operative mortality ranges from 40 to 70%; there are no differences between the two surgical techniques and the major risk factor for death is the preoperative clinical status (shock, and/or cardiac arrest). Anticoagulant therapy affords a low incidence of recurrence.

Cardiopulmonary Bypass↗
PubMed1998

Elective or emergent interventional radiology through introducer sheath inserted during emergent vascular surgery for critical ischemia.

During performance of embolectomy or thrombectomy one often encounters arterial stenoses. These may be treated by adjunctive intraoperative angioplasty during the operation or delayed percutaneous angioplasty (PTA) may be performed in the interventional radiology department. Delayed PTA may have to wait until the wound has healed, and during this time there is a risk of re-occlusion. It may often be desirable to perform the radiologic intervention at a later time than the thrombo-embolectomy for logistic reasons. The vascular surgeon and interventional radiologist may perform best when working in the environment that they are accustomed to. Also, measurement of vascular diameters, and selection of proper balloon and stent sizes can usually be performed most accurately with the equipment that is available in the X-ray department. We treated selected patients who underwent thromboembolectomy or thrombendarterectomy in the groin for critical ischemia, and who also had clinically important proximal or distal stenoses, in the following way: an arterial sheath was inserted through the wound and the patients were transferred to the interventional radiology laboratory where they underwent PTA. A continuous over and over suture with 3 bites of a 6-0 polypropylene suture in the arteriotomy for the sheath appeared to be the best way to secure hemostasis. The wound was closed around this suture and the arterial sheath. After removal of the sheath slight traction was applied to the polypropylene suture and maintained for 1-2 days by application of a hemostat at skin level. The technique is illustrated with a case report.

Aged↗
PubMed1976

Arterial occlusion secondary to methylmethacrylate use.

We are reporting a new complication of the use of methylmethacrylate, namely occlusion of the iliac artery with embolization. We believe that the occlusion is related to trauma to the intima by the heat of polymerization created by methylmethacrylate, with resultant thrombosis. In view of the initial failure of embolectomy alone, we suggest direct attack on the involved artery with prosthetic replacement, and management of the distal embolus by embolectomy with Fogarty catheters.

Embolism↗
PubMed1984

Treatment of renal artery embolism.

Renal artery embolectomy was performed on four patients. There was no operative mortality. Four of the five affected kidneys were salvaged. The most common initial symptom was flank pain. The literature from 1970 to 1982 was reviewed to determine the current operative mortality (11%) and frequency of kidney salvage (67% to 90%) with surgery or anticoagulation. Newer treatment modalities, including intraarterially injected low-dose streptokinase and percutaneous transluminal angioplasty, have also proved useful. The addition of these newer methods, combined with the fact that kidneys can frequently be salvaged after prolonged periods of acute renal artery occlusion, led to the development of a clinical algorithm for treatment. With this algorithm, surgical embolectomy was reserved for patients with total renal parenchymal compromise caused by emboli, whose conditions failed to respond to less invasive treatment modes.

Adult↗
PubMed1991

Myointimal hyperplasia as a result of balloon-catheter thromboembolectomy.

The balloon-tipped embolectomy catheter is widely utilized in the treatment of arterial thromboemboli, significantly improving mortality and limb salvage rates. However, early and late complications related to catheter-tip injury and balloon trauma continue to occur and compromise the results of surgical intervention. Myointimal hyperplasia is an example of an unusual late complication induced by balloon-related arterial wall trauma. Myointimal hyperplasia is a commonly recognized healing response of the arterial wall to endothelial injury but is rarely reported after balloon-catheter thromboembolectomy. The extensive nature of the injury increases the incidence of limb loss. The pathophysiologic nature of this process is reviewed, and pertinent structural details such as intimal thickening and disruption of the internal elastic lamina are presented. The pathogenesis of myointimal hyperplasia suggests guidelines for catheter use during embolectomy that may further reduce the incidence of this unusual complication.

Adult↗
PubMed1984

Surgical approaches to thromboembolism.

Management of angiographically confirmed pulmonary thromboembolism in 313 patients has been based on a physiological classification system. Patients in shock (Class IV) are managed either by catheter embolectomy (26 patients) with 27 per cent mortality rate or by open embolectomy during active resuscitation (6 patients) with a 33 per cent mortality rate. High-risk patients with transient hypotension (Class III) are managed by anticoagulation and filter insertion. The most common indication for filter placement is a contra-indication to anticoagulation (37 per cent). Filter placement was infrarenal in 268 patients (86 per cent) and intentionally suprarenal in 19 patients (6 per cent). Misplacement has occurred into the iliac veins, renal veins and the heart but has not been seen since the guide wire technique for insertion was developed. The 30 day mortality for patients receiving filters was 14 per cent and due to other disorders. Only one death was suspected from recurrent embolism. One hundred and thirteen venacavagrams at intervals up to 99 months in 110 patients showed long-term patency in 97 per cent. Recurrent embolism was seen in five patients (2 per cent) but caused no deaths.

Aged↗
PubMed1987

Selective conservative and routine early operative treatment in acute limb ischaemia.

Arterial thrombo-embolectomy is often unsuccessful in those patients with acute limb ischaemia that have peripheral arteriosclerosis. During this study, conservative heparin treatment and, when needed, delayed surgery was employed in acute limb ischaemia when the ischaemia was less severe as judged by assessment of distal motor and sensory functions, regardless of the presumed aetiology of the acute ischaemia. The results are compared with those during a preceding period, when the routine treatment was emergency thrombo-embolectomy. The emergency operation rate was reduced to 49 per cent. There were overall fewer deaths with gangrene (8 per cent versus 18 per cent). In acute arterial thrombosis, more good results were obtained (76 per cent versus 47 per cent), whereas results were unchanged in embolic cases despite the reduced emergency operation rate. This study suggests that the choice of initial treatment of patients with acute limb ischaemia may be based on the severity of the ischaemia, and that patients with less severe acute ischaemia benefit from initial conservative heparin treatment.

Acute Disease↗
PubMed1990

Superior mesenteric artery embolism: eighty-two cases.

Eighty-two consecutive patients with superior mesenteric artery embolism were treated between 1966 and 1988. Abdominal pain was atypical or absent in 19 (23%) patients. Except for two instances of intraoperative embolism, emergency mesenteric arteriography was diagnostic in all cases. Seventeen patients were treated medically either because the site of embolism was peripheral, or because there were no life-threatening signs. Sixty-five patients underwent surgery, 31 for mesenteric infarction, and 34 for acute mesenteric ischemia without intestinal necrosis. Surgical treatment included 34 isolated embolectomies, 20 embolectomies associated with intestinal resection, two short segmental resections for limited necrosis of the small intestine, and nine exploratory laparotomies. Of the 34 patients operated on for acute mesenteric ischemia, 12 (35%) died. Of the 31 remaining patients operated on for intestinal infarction, 21 (68%) (p less than 0.05) died. The mean duration of ischemia before operation was 13 hours 20 +/- 6 min and 21 hours 24 +/- 24 min, respectively (p less than 0.05). Two patients (12%) receiving medical treatment died. This study confirms that survival is directly related to early diagnosis based on emergency mesenteric arteriography. Treatment is determined by clinical and roentgenographic criteria. Medical treatment is indicated in certain circumstances.

Acute Disease↗
PubMedDate not supplied

Right atrial thrombi: percutaneous mechanical thrombectomy.

The current therapeutic options for right atrial thrombi-surgical embolectomy and thrombolysis-are associated with high mortality and such patients often have contraindications to these therapeutic options. The purpose of this study was to evaluate the feasibility of endovascular right atrial embolectomy. Two patients with contraindications to thrombolysis and surgery were treated by a femoral approach. A catheter was placed in the right atrium, under fluoroscopic control, and a basket device was used to trap the thrombus. The location and extent of the thrombus was established before the procedure by transesophageal echocardiography (TEE) and the procedure was performed with TEE and fluoroscopy. Thrombi were withdrawn in the basket into the inferior vena cava (IVC) and a filter was inserted by a jugular approach and positioned in the IVC, just above the thrombi. The basket was removed leaving the thrombus below the filter. One patient died immediately after the procedure. In conclusion, endovascular extraction of right atrial thrombi may represent a potential therapeutic alternative, particularly in patients with contraindications to thrombolysis and surgery.

Aged↗
PubMed2001

Acute and Chronic Pulmonary Emboli.

Under most circumstances, the goal of treatment of pulmonary embolism is the prevention of recurrent embolic events, achieved through conventional anticoagulant therapy with unfractionated heparin or a low molecular weight heparin, followed by warfarin therapy for a minimum of 6 months. When acute pulmonary embolism is associated with significant right ventricular dysfunction or systemic hypotension, more aggressive intervention may be warranted. Under these circumstances, potential interventions include thrombolytic therapy (either systemic or catheter-directed), placement of an inferior vena caval filter, catheter-based embolectomy, or surgical embolectomy. Chronic thromboembolic pulmonary hypertension may develop in a small minority of patients who survive an acute, massive embolic event or who have suffered recurrent thromboembolic events. Due to the fixed nature of the pulmonary vascular obstruction, vasodilator therapy has proven far less effective in chronic thromboembolic disease than it has in primary pulmonary hypertension and other secondary forms of pulmonary hypertension. Correction of hypoxemia and volume overload and the prevention of recurrent embolic events are essential. Definitive therapy, however, requires surgical intervention to remove the chronic thromboembolic obstruction and to restore patency of the pulmonary vascular bed.

Journal Article↗
PubMed2005

Pulmonary embolism: current treatment options.

The initial treatment of patients with acute pulmonary embolism has traditionally involved unfractionated heparin. Given the more predictable pharmacodynamic and pharmacokinetic properties of low molecular weight heparins, their simpler (fixed) dosing regimens, and few or no laboratory monitoring requirements, low molecular weight heparins are gradually replacing heparin for the initial treatment of most patients diagnosed with acute pulmonary embolism, except in very obese patients or patients with renal failure. Only selected patients with massive, life-threatening pulmonary embolism should be managed with intravenously administered thrombolytic drugs, surgical embolectomy, or catheter-based embolectomy. Likewise, inferior vena caval filter should be considered only in patients with an absolute contraindication to, or a documented failure of, anticoagulant therapy. New anticoagulants, such as ximelagatran, an oral direct thrombin inhibitor, or fondaparinux and idraparinux, selective factor X(a) inhibitors with an almost complete bioavailability after subcutaneous injection are promising alternatives, but these drugs have yet to find a place in the initial treatment of pulmonary embolism in standard day-to-day clinical practice. Long-term anticoagulation treatment is still provided by antivitamin K antagonists (eg, warfarin), which unfortunately have a narrow therapeutic window. Consequently, time-consuming monitoring is required to ensure the therapeutic anticoagulant effect. A target International Normalized Ratio (INR) of 2.5 (INR range: 2.0 to 3.0) is recommended for warfarin therapy. This treatment should be continued for at least 3 months for patients with a first episode of pulmonary embolism secondary to a transient (reversible) risk factor, or up to 6 to 12 months for patients with a first episode of idiopathic pulmonary embolism.

Journal Article↗
PubMed1979

Management of acute aortic occlusion.

Acute aortic occlusion is most often seen in elderly patients with advanced cardiac disease. The management of these patients has been facilitated by the use of extraanatomic bypass. Over the past 2 years, six patients aged 55 to 87 years presented to our medical center with acute aortic occlusion, three after major operative procedures. One patient had a thrombosed abdominal aortic aneurysm; in the other five patients differentiation between saddle embolus and thrombosis of the distal aorta was impossible. There was one operative death. Four of the other five patients underwent axillobifemoral bypass and one underwent aortofemoral thrombectomy. All survived, and none required amputation. Two of the three patients who underwent preoperative aortography developed transient renal failure postoperatively. Aortography is of little value in diagnosis and is probably contraindicated in acute aortic occlusion. Our recommendation for operative management includes (1) preparation of the patient for possible axillobifemoral bypass, (2) angiography of distal runoff via both femoral arteries, (3) attempt at bilateral aortofemoral embolectomy with Fogarty catheters, and (4) axillobifemoral bypass if embolectomy fails to restore normal pulsatile flow.

Acute Disease↗
PubMed1983

Value of postoperative heparin therapy in peripheral arterial thromboembolism.

The experience with 359 patients with arterial thromboembolism from 1963 to 1982 has been reported. Combined operative and anticoagulant therapy appears the most beneficial form of treatment. Treatment with heparin after catheter embolectomy was associated with a decrease in mortality (7.6 percent), number of amputations (5 percent), and recurrent emboli (6 percent). Serious wound complications occurred less frequently than anticipated (8 percent). We advocate prompt arteriography and revascularization procedures to ensure long-term limb function after initial embolectomy for salvage, if the result is less than optimal or expected. Postoperative heparin seems to buy time in marginal cases, enabling secondary operations to ensure a satisfactory outcome in most patients.

Adult↗
PubMed1990

Intravascular missile embolization in childhood: report of a case, literature review, and recommendations for management.

A collective review of 20 cases of missile embolization among children (1961 to 1988) is analyzed, one case added, and guidelines for diagnosis and management are outlined. Causative agents were bullets (14 patients), pellets (5), and fragments (2). Their trajectory was arterioarterial (11), venovenous (5), paradoxical (4), and mixed (1). Diagnosis was suspected when an exit wound was absent and the foreign body was traced on regional x-ray. Embolization was predominantly to the legs, with a tendency for the left (5 of 8 cases). Upper extremity emboli were exclusively to the right. Only one of five cardiac entries required closure to control bleeding compared with four of six aortic. Embolectomy was performed in 16 patients. The overall mortality rate was 9.5%. Factors predicting a favorable outcome are early presentation, diagnosis, and intervention; location of cardiovascular entry and embolus site; and presence of soft tissue tamponade at entry wound. Although embolectomy for cerebral, asymptomatic pulmonary arterial, and silent venous emboli is controversial, universal agreement prevails regarding removal of systemic arterial as well as venous emboli that are potentially problematic.

Aorta↗