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PubMed1982

[Peripheral vascular surgery in the high-risk patient].

In peripheral vascular surgery a patient not infrequently becomes a high-risk case on account of local causes (morphological, haemodynamic), especially during long operations. Hence, low-risk procedures like partial or palliative operations, including extraanatomical procedures, and appropriate anaesthesiological methods are very important. This report includes several possibilities of peripheral arterial reconstruction, as well as a review of experience gained in 37 axillo(bi)femoral and 54 cross-over bypasses, 41 closed retrograde TEA's of the iliac region, 30 transluminal dilatations, 580 embolectomies, 257 reconstructions of the deep femoral artery and 19 in situ vein bypasses (Hall). The distribution of extraanatomical procedures in a high-risk and a local or angiological-morphological situation showed that after one year only 50% of high-risk patients were still alive compared with 85% of the latter group. Local anaesthesia was very suitable for embolectomies, whilst for other indications we prefer spinal and peridural or combined regional and general anaesthesia, with the proviso that the patient is in the hands of a skilled anaesthesiologist.

Amputation, Surgical↗

PubMed1978

Renal artery embolism: diagnosis and treatment.

A 59-year-old woman presented with flank pain, atrial fibrillation and a nonfunctioning left kidney. A diagnosis of renal artery embolism was made and she was treated successfully by embolectomy. A review of the literature reaffirms the role of embolectomy, even in cases with delayed diagnosis.

Embolism↗

PubMedDate not supplied

Cardiogenic embolism of the upper extremity.

Arterial embolism of the upper extremity is not as rare and especially not as benign in all instances as was considered in the past. Postembolic ischemic changes or frank gangrene of fingers or hand may occur in a substantial percentage of patients. This paper will attempt to update the current concepts of this problem. The clinical data and the methods for evaluation of the degree of viability of the hand or forearm will be reviewed. Arteriography is recommended more liberally than in the past. Arterial embolectomy usually performed under local anesthesia is widely applicable in view of the simplicity, safety and effectiveness of the balloon catheter technique. The overall results based on a compilation from six reports indicate that complete circulatory restoration occurred in 55% and salvage without a return of wrist pulses in 24%. Gangrene occurred in 9.3% and mortality in 11.8%. In general, mortality following embolectomy is primarily related to the gravity of the cardiopathy and least to the surgical procedure.

Aged↗

PubMed1982

[Reno-caval thrombosis complicated by massive pulmonary embolism. Diagnostic and therapeutic problems].

The authors report on a case of thrombosis of vena cava and renal vein associated with a nephrotic syndrome and complicated by a massive pulmonary embolism. Under emergency conditions, it was impossible to diagnose preoperatively a renal tumor, which is the most common cause of renal and vena caval obstruction or a thrombosis of the vena cava. Surgical treatment was carried out only because there were no arteriographic signs of renal neoplasm, and because thrombolytic treatment was contra indicated in a patient with greatly reduced vital capacity. Embolectomy was performed under cardiopulmonary by pass. The patient made a good recovery. Results of routine cardiac and pulmonary tests were normal after two months. Embolectomy must always be associated with as interruption of the vena cava, whose different forms are discussed. Partial interruptions using a De Weese clamp seems to be better tolerated than ligation.

Diagnosis, Differential↗

PubMed1981

[Diagnosis and treatment of acute obstructions of the superior mesenteric artery].

The author describes 13 patients with thrombosis (4) and embolism (9) of the superior mesenteric artery. Operations were performed in all the patients. Embolectomy or thrombectomy was fulfilled in 11 of 13 patients (in 8 patients it was associated with resection of the intestine). Embolectomy when fulfilled within 12 hours from the beginning of the disease results as a rule in the recovery of blood circulation.

Acute Disease↗

PubMed1994

Massive acute pulmonary embolism in protein S deficiency--a case report.

A young man with a history of deep vein thrombosis and pulmonary embolism 11 years ago presented again with acute pulmonary embolism and was treated initially with intravenous heparin at our institution. Five days later he had another massive bout of pulmonary embolism causing hypotension. Pulmonary angiography confirmed the presence of thrombi in both pulmonary arteries, with complete obstruction of the left pulmonary artery. He was treated successfully by emergency pulmonary embolectomy. Blood investigations later confirmed the diagnosis of protein S deficiency and he was started on warfarin therapy for life. Massive pulmonary embolism should be treated aggressively. Thrombolytic therapy accelerates clot lysis, reduces pulmonary pressures, restores pulmonary capillary volume and reverses right heart failure faster than heparin alone. There is also a trend towards decreased mortality with thrombolysis. In the presence of shock, the patient should be resuscitated and if facilities for emergency embolectomy are available, surgery is a viable alternative to thrombolysis, especially if the clot burden is massive. In young patients with recurrent venous thromboembolism in the absence of obvious predisposing factors, it is important to exclude inherited plasma protein deficiencies of protein S, protein C, antithrombin III, plasminogen and fibrinogen.

Acute Disease↗

PubMedDate not supplied

[Temporary caval filters. Our experience. Preliminary analysis of 24 cases].

The AA. utilized temporary vena cava filters (16 Filcard and 8 Lysofilters) in 24 patients affected by deep venous thrombosis (DVT) of the lower limbs for the prevention of primary and recurrent pulmonary embolism (PE). The diagnosis of thromboembolic disease was always achieved by means of Ultrasounds (echo-color doppler) and was punctually confirmed by a retrograde cavagram during the insertion of the device. 19 patients presented large free-floating thrombi at inferior caval, iliac or common femoral vein level whereas 5 patients presented thrombi mostly of occlusive aspect. There was clinical or scintigraphic evidence of PE in 6 of the patients enrolled. 20 patients, without contraindications, were treated by fibrinolysis (F) with Urokinase (2-10 days) whereas 4 patients underwent surgical thrombectomy (T) because of short time relation with surgical intervention or trauma. All of them were protected by temporary vena cava filters and heparinized. All the filters were removed within 10 days. The results were considered "very good" (complete regression of floating thrombi) in 16 cases (14 F + 2 T), "good" (nearly complete regression of floating thrombi) in 3 cases (2 F + 1 T) and "poor" (unchanged) in the remaining 5 cases (4 F + 1 T). We didn't observe any new case or relapse of PE in the whole group and, furtherly, in 2 cases (1 F and 1 T) we demonstrated the capture of big emboli by the filter's basket. These clots were subsequently dissolved by fibrinolysis. To achieve the diagnosis of thromboembolic disease the following methods were used: 1--Screening: echo-color doppler of lower limbs extended to iliac and inferiora cava veins for detection of DVT and echocardio-color doppler for the detection of cardiac signs of PE. 2--DIAGNOSIS: pulmonary scintigram, retrograde cavogram and, rarely, angioCT scan. 3--FOLLOW-UP: echo-color doppler of lower limbs and pulmonary scintigram. The percutaneous insertion sites were the basilic vein (Filcard) and the right jugular vein (Lysofilter). Left jugular vein was used in 1 case with a big thyroid goitre. In the present experience we had no accidents during filters introduction or removal and no thrombosis at the insertion site (1 case of phlebitis of basilic vein). Indications and effectiveness: our results seem to be favorable to the use of inferior vena cava temporary filters for primary and recurrent pulmonary embolism prevention in the cases with floating thrombi both on fibrinolysis and embolectomy. In the cases of occlusive thrombotic diseases they proved to be effective to prevent PE during surgical embolectomy.(ABSTRACT TRUNCATED AT 400 WORDS)

Adolescent↗

PubMed1993

Diagnostic approaches and surgical treatment of deep venous thrombosis and pulmonary embolism.

Diagnostic approaches for thromboembolism include Doppler probe examination, impedance plethysmography, phleborheography, radio-labeled fibrinogen scanning, magnetic resonance imaging, duplex imaging, and venography. The two primary diagnostic approaches for pulmonary embolism include ventilation/perfusion lung scanning and pulmonary arteriography. Surgical options available for venous thromboembolism are generally limited to those condition in which limb viability is threatened from acute iliofemoral thrombosis. Vena caval interruption, performed in patients with a contraindication to anticoagulation, a complication during anticoagulant therapy, and recurrent pulmonary embolism in the presence of adequate anticoagulation (among other indications) is best accomplished with the Greenfield filter. Surgical approaches for pulmonary embolism, limited to patients with massive embolism with hypotension, include catheter pulmonary embolectomy and open pulmonary embolectomy.

Humans↗

PubMed1993

[Thrombolytic therapy of pulmonary embolism--a therapeutic alternative?].

The spontaneous prognosis of pulmonary embolism is mainly dependent on the degree of pulmonary artery obstruction. As for the cause of spontaneous lysis, submassive pulmonary embolism generally will be survived with complete restitution of the pulmonary artery trunk. On the other hand, the hallmark of massive pulmonary embolism is a tremendously high early mortality. In the decision for thrombolysis in patients with pulmonary embolism, major attention must therefore be paid to the severity of pulmonary obstruction. Up to now, neither a reduction in mortality nor in secondary morbidity by thrombolysis has convincingly been shown in patients with submassive pulmonary emboli. In the rare cases with submassive pulmonary emboli, when one still tends to decide in favor of thrombolysis, beyond the thrombus obstructing the pulmonary artery, the thrombus identified as the source of the emboli should also be attacked. In these patients, careful attention has to be paid to the contraindications of thrombolysis, and low-dose continuous infusion regimens like the ones used in deep venous thrombosis should be selected. In patients with massive and life-threatening pulmonary embolism, however, thrombolysis has the potential to save lives and, therefore, must be judged in a different way. In spite of their high frequency, for the critical prognosis of these patients only minor attention must be paid to the contraindications of thrombolysis. In these critically ill patients, high-dose intravenous, brief duration infusions of the thrombolytics therefore can be considered as the best option. The far lower cost (about one-tenth) and the comparable success rates with embolectomy makes thrombolysis the regimen of choice, especially when embolectomy is not readily available.

Angiography↗

PubMed1977

Artery embolism of the upper limbs.

This report consists of an analysis of 256 consecutive patients with a total of 260 arterial emboli to the upper limbs treated in the Spasokukotsky Surgical Department of the Second Moscow Pirogov Medical Institute during the 35 year period from 1939 through 1974. Cardiac diseases were the causes of embolism in 92.58 percent of these patients. Mild ischemia of the limbs was revealed only in 33.82 percent of the patients. Severe ischemia accompanied by significant restriction or full absence of active movements in the joints of affected extremities was observed in 55.94 percent of the patients. Acute ischemia with a muscular edema and partial or total contracture was observed in 9.88 percent of the patients. Forty-seven patients were treated conservatively. Arteriectomy was performed in three patients. Embolectomy was carried out on 206 patients, 101 of whom were operated on by means of the approach outside the cubital fossa and 105 by means of the antecubital approach. The best results were obtained when embolectomy was performed with the use of the Fogarty catheter by means of the antecubital approach. This method achieved full restoration of circulation in 91.59 percent of our patients. The mortality rate was approximately equal in all groups of patients. The over-all hospital mortality rate was 21.1 percent. Recurrent embolism of cerebral and mesenteric arteries was the main cause of death. Fatal postischemic complications led to the death of two patients who were operated on with a total ischemic contracture of a limb. Autopsy revealed a pulmonary microembolism in one case and a myoglobinuric nephrosis in the other.

Aged↗

PubMedDate not supplied

[Acute ischemia of the lower limbs].

One hundred nineteen patients operated upon for acute ischemia of the lower limbs have been retrospectively reviewed, in order to evaluate the influence of the condition on outcome, and the patterns of treatment. Fifty six per cent of the patients were males and 42% females, 68.4% had an history of aorto-iliac obstructive disease; 51.2% of the ischemias were due to arterial thrombosis and 48.8% to embolism, in 12.5% of the cases etiology was unknown. Thrombosis were more frequent in younger patients' population (mean age 59.8 years) compared to embolism (mean age 69 years), even if the mean age of patients bearing an ischemia of embolic type has risen, in the last 10 years: 62.1% were due to atrial fibrillation and 50% occurred on pathologic arteries, patients with arterial obstructive disease presented a higher incidence of arrest of embolic material at the common femoral artery bifurcation. Women's mean age was significantly higher then that of men (70.9 vs. 59 yrs.). Embolism was more frequent in women than in men (64 vs 42.2), whereas thrombosis was more frequent in men than women (57.8 vs 36%). There were more deaths in women than men (30.8 vs 20.8%), but more amputations in men than women (37.3 vs 17.3%). Embolism of arterial origin include 15.2% of all acute ischemias and 31% of all embolisms, and their site of origin is often unknown, particularly when it is located in the thoracic aorta, which mandate a complete arteriography and eventually a CT-Scan of the thorax and the abdomen. A lower limb phlebitis, associated with an acute ischemia mandates the search of a patent foramen ovale, and an heparin induced thrombocytopenia. Surgical treatment is directed towards obstruction removal (embolectomy, by-pass) and towards the treatment of the causative agent (aortic endarterectomy, caval filter, anticoagulants). Post-operative thrombolysis may be beneficial in case of distal residual thrombus after embolectomy. An higher mortality rate has been observed in acute ischemias due to embolism rather than thrombosis (31 vs 19.6%) and more major amputations in thrombosis than in embolism (37.7 vs 17.2%). Overall mortality rate has been of 25%, with an amputation rate of 28%. Present results have been compared with those of the literature, both agree on some changes over the last 20 years, concerning the incidence of different mechanisms of acute ischemias and their prognosis.

Acute Disease↗

PubMed1997

Right heart pulmonary embolism in transit: a review of therapeutic considerations.

Two patients with pulmonary emboli and right heart masses detected on echocardiography are described. One patient underwent successful surgical embolectomy and the other was successfully treated with intravenous thrombolysis. Both were alive and well at six months' follow-up. The presence of a right heart clot in the setting of pulmonary emboli carries a very high mortality rate and warrants urgent therapy, which may include anticoagulation, thrombolysis or surgical embolectomy. Because limited information is available, therapy must be individualized based on patient characteristics, clot location and local expertise. The pertinent literature is reviewed and relevant issues in decision making are discussed.

Aged↗

PubMed1997

Paradoxical embolism and aortic occlusion: a case report.

This is the case report of a 45-year-old woman who sustained a left popliteal artery embolism. Ten days after popliteal embolectomy, she developed sudden occlusion of the distal aorta. She required a bifemoral embolectomy. Transesophageal echocardiogram demonstrated an atrial septal aneurysm and a septal defect with a right to left shunt. A venogram showed deep venous thrombosis in the right leg as the potential source of the embolism. Paradoxical embolization should be considered when ever an unexplained arterial occlusion occurs, especially in younger patients.

Acute Disease↗

PubMed1977

[Surgical aspects in arterial occlusion (author's transl)].

Acute arterial occlusion was found to be the most frequent emergency (10%) among vascular patients of the Department of Surgery of the University of Düsseldorf. Rheumatic heart diseases receded as etiological factors whereas atherosklerotic obstructive diseases exhibited a clear increasing tendency. Operation is urgent if acute ischemia is present. The best method is represented by embolectomy by means of the Fogarty-catheter, if it is performed within the first 6 to 12 hours after or vascular occlusion. Angiography is only indicated if ischemia is not complete or if the cartoid artery or great visceral arteries are involved. In cases of incomplete occlusion embolectomy may be successful even after days and weeks. Mortality after these operations is found to be 18 to 20%, the rate of amputation being 9%. The final results of operative results are better in arterial embolism than in arterial thrombosis.

Arterial Occlusive Diseases↗

PubMed1997

Perioperative pulmonary tumor embolus: a case report.

A 64-year-old white female underwent an elective exploratory laparotomy, right radical nephrectomy, and excision of a vena cava tumor for renal cell carcinoma. Preoperatively, the patient was diagnosed with a right kidney mass that was invading the right renal artery and vena cava. The patient had received a general endotracheal anesthetic consisting of O2, N2O, forane, fentanyl, pentothal, vecuronium, and hydromorphone. The right nephrectomy was completed by the urologist without incident. Following the nephrectomy, the right renal artery and vein were dissected, and the vena cava was exposed. When a temporary clamp was placed on the vena cava, there was a sudden onset of tachycardia, right bundle branch block with (transient) inversion of the QRS complex, hypotension, decreased end-tidal CO2 and decreased O2 saturation, and increased pulmonary inspiratory pressures that did not resolve when the clamp was removed. The diagnosis of tumor embolus was made and the incision was closed. As arrangements were made to transfer the patient to a nearby hospital with facilities to perform cardiopulmonary bypass and pulmonary embolectomy, the patient was supported with 100% oxygen, intermittent boluses of epinephrine, sodium bicarbonate, and titrated inotropic infusions (dopamine, dobutamine, and epinephrine). Successful embolectomy was accomplished. The patient was discharged on postoperative day 9 in good condition.

Anesthesia, General↗

PubMed1976

Pulmonary embolism: surgery in a hyperbaric chamber.

A 20-year-old man with a known history of thrombophlebitis experienced massive pulmonary embolism with hypoxia and shock. Embolectomy was performed with hyperbaric oxygenation for cardiopulmonary support. Ligation of the inferior vena cava was required postoperatively to prevent further embolism. Hyperbaric oxygenation is an effective method of cardiopulmonary support for pulmonary embolectomy.

Adult↗

PubMed1995

Acute limb ischemia due to malignant arterial embolism from a metastatic germ cell tumor.

Arterial tumor embolization is a rare but serious complication of neoplastic disease. The majority of these tumors are associated with primary or secondary lung malignancies, originating from pulmonary vein metastasis or from an atrial mass. Malignant germ cell tumors primarily disseminate to the retroperitoneal lymph nodes and lung, and to the brain and liver later in the course of the disease. A germ cell tumor metastasis embolizing to the iliac-femoral arterial system has not yet been reported. We report a metastatic embolism in a patient with disseminated embryonal cell carcinoma causing acute limb ischemia, managed by surgical embolectomy. The sudden development of limb ischemia in a patient with a germ cell tumor should alert the physician to the possibility of tumor embolism.

Echocardiography↗

PubMed1996

[Surgical therapy of acute mesenteric ischemia].

Between 1972 and 1993 a total of 90 patients were operated on for acute mesenteric ischemia at Hanover Medical School, Department of Abdominal- and Transplantation Surgery. As causes of mesenteric ischemia, arterial embolism (23%), arterial thrombosis (30%), venous thrombosis (33%), and non-occlusive disease (14%) were differentiated. The overall hospital mortality was 66%. The hospital mortality after venous thrombosis was 37%, significantly lower than after arterial (79%) and functional (83%) types of mesenteric ischemia. Besides the pathogenesis of mesenteric infarction, a multivariate analysis revealed age and presence of peritonitis and intestinal perforation to be independent prognostic factors of hospital lethality. Patients with venous thrombosis had a mean age of 48 years and were significantly younger than the remaining patients who had an average age of over 60 years. Surgical procedures comprised solitary bowel resection (60%), isolated embolectomy and/or thrombectomy (10%), a combination of embolectomy/thrombectomy and bowel resection (4%), and exploratory laparotomy only (21%). Vascular reconstruction was associated with a significantly better survival rate than bowel resection only. While hospital mortality was dependent on the type of mesenteric ischemia, long-term survival after exclusion of hospital deaths proved independent of the original pathogenesis. Of the patients who survived the acute attack of mesenteric ischemia, 70% were alive 2 years later and 50% 5 years later. The survival probability of these patients was not determined by recurrence of mesenteric ischemia, but was mainly related to their cardiovascular comorbidity and a high incidence and prevalence of malignancies.

Adult↗