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PubMed2005

[Management of acute leg ischemia].

Nowadays acute limb ischemia (ALI) is still a tremendous complication that may compromise local or general prognosis. Every practician might be able to diagnose this situation in order to transfer in emergency the patient in a vascular unit. The main determinants of outcome of the leg are the severity of the ALI and a prompt treatment. The severity is evaluated according the SCV/ISCVS classification. Patients with a sensitive-motor neurologic deficit are at high risk; they require urgent therapy. The main causes are embolism and thrombosis. In case of classical presentation of embolism, immediate embolectomy will be done under local anesthetic. But this presentation is rare; often the picture is much more complex; the majority of ALI patients are elderly with atherosclerotic vessels. In such situation a team approach is mandatory to decide optimal management. The treatment may combine thrombolytic therapy or aspiration thrombectomy and percutaneous or surgical revascularisation. Finally, atrial fibrillation is now the most common cause of embolism, and appropriate anticoagulation would prevent this complication.

Acute Disease↗
PubMed2006

Management of acute lower limb ischemia following percutaneous arterial closure device application: our experience.

INTRODUCTION: The Authors report their experience in the management of acute lower limb ischemia following percutaneous arterial closure device application. PATIENT AND METHODS: Five patients required an emergency vascular operations for acute lower limb ischemia. The symptoms onset was < 1 hour in 1 case, 4-12 hours in 2 cases and > 24-36 hours in 2 cases. A preoperative angiography was performed in all the cases. A transfemoral embolectomy was carried out. Direct suture repair were performed in three cases, vein patch angioplasty was carried out in two cases. In one case, a common femoral artery endarterectomy was performed. RESULTS: No post-operative mortality and limb loss occurred. CONCLUSIONS: Acute lower limb ischemia due to closure devices required an extensive approach with reconstruction in high risk septic area. Angiography is mandatory for surgical strategies. We prefer direct suture repair and vein path angioplasty for vascular reconstruction.

Acute Disease↗
PubMedDate not supplied

[Acute nontraumatic limb ischemia].

Twenty four patients (18 males, 6 females, Mean age 50 years) with acute non traumatic limb ischemia were operated on in our institution. The ischemia has been observed after 24 hours in 15 patients (62,5 % versus 7 patients (37,5 %) within 24 hours. The arterial femoral was often (54,1 %) the site of occlusion. Embolism (29,2 %) and thrombosis (54,2 % were the cause of acute limb ischemia. All patients were treated by embolectomy or thrombectomy. The overall mortality was 29,2 % with a limb salvage rate of 45,8 % and secondary amputation rate of 29,2 %. According to our experience, the diagnosis of acute non traumatic limb ischemia is not instituted early and the rate of hospital mortality and morbidity remain high.

Acute Disease↗
PubMed1995

Outcome of surgical treatment in acute upper limb ischaemia.

During a 26 years' period, 547 thromboembolectomies were undertaken for acute limb ischaemia. The portion of upper limb ischaemia was 17.7% (97/547). The annual incidence of surgically treated acute upper limb ischaemia was 1.3 cases/100,000/year during the last 15 years of study period. There were 91 patients, 45 males and 46 females, ranging from 17 to 92 years with a median age of 73 years. Pulselessness (96), coldness (94), pain (85), paraesthesia (45) and dysfunction (45) of the affected limb were the main symptoms. The right upper limb was more often affected (59/38, P < 0.05). An embolus originating from the heart was the reason for the ischaemia in 71 cases, while in 11 cases the occlusion was caused by a local thrombosis. In 15 cases the origin of the embolus remained unsolved. In five cases an additional arterial reconstruction was needed to restore the circulation. Reembolectomy of the same limb was needed in five cases, and additionally in two patients, a third embolectomy was unavoidable. A secondary humeral amputation was necessary for one patient. Eleven patients (11.3%) died within 30 days and of these nine did so from recurrent embolism. The mortality was not related to the duration of the ischaemia, but rather to patients' general condition. During a mean follow-up time of 50 weeks a good functional result was achieved in 78 cases (80.4%). The clinical results in ischaemia caused by embolism are markedly better than those of local thrombosis (P < 0.001).

Acute Disease↗
PubMed1995

[Embolic episodes after treatment of atrial fibrillation in a patient with thyrotoxicosis].

Thyrotoxic artrial fibrillation is well known and occurs in 10-30% of all patients with thyrotoxicosis. The risk of systemic embolism has been found to be 10-40% in patients with thyrotoxic atrial fibrillation. We present a case of 53 year-old man, a healthy and active athlete, with atrial fibrillation and thyrotoxicosis. He was treated with a beta-blocking agent (sotalol) and sent home. Seven days later, he suffered systemic arterial emboli, one in the right arm and one in the left leg. After embolectomy the patient started anticoagulation and no further complications occurred. Previous studies are discussed, and the following conclusions made. When taken together the data suggest that the rate of embolism in patients with thyrotoxic atrial fibrillation exceeds that of non-thyrotoxic atrial fibrillation unassociated with rheumatic heart disease. The majority of clinically evident embolic events that occur in patients with thyrotoxic atrial fibrillation involve the central nervous system. The rate of embolic events appears to be greatest early in the course of thyrotoxic atrial fibrillation, but may persist for some weeks after conversion and may be particularly high in patients with associated heart failure. It is suggested that anticoagulation therapy should be considered in these patients.

Anticoagulants↗
PubMed1995

[Acute pulmonary embolism].

Pulmonary embolism is a frequent event, even today the diagnostic comes often too late or not at all. Symptoms, clinical results and additional examinations like ECG, echocardiography, scintigraphy and angiography permit the differentiation between small peripheral and massive central pulmonary embolism [PE], important for the therapeutic procedure. Patients with peripheral PE have to be heparinized, sometimes they can be treated at home. The acute massive PE represents an emergency situation, the patient must be hospitalized immediately. The goals of therapy in massive PE consist in a rapid reduction of the threatening load on the right ventricule by the embolism. If the patient is in cardiogenic shock, surgical embolectomy is indicated, without shock the immediate start of thrombolytic therapy must be considered.

Acute Disease↗
PubMed1995

[Acute occlusions of the aorta].

Acute occlusion of the aorta is a vascular emergency with high mortality, greater than 30% after revascularization, due to the extent of the ischaemic territory and the haemodynamic consequences. Over a period of 12 years, 34 patients (22 males, 12 females) underwent surgery for acute occlusion of the aorta. Acute bilateral ischaemia was present in 24, unilateral ischaemia in 6 and sub-acute ischaemia in 4. An embolus of cardiac origin was the cause in 13 cases, disease of the aorta itself in 11 cases and hypercoagulability in 10 including 7 due to allergy to heparin. The delay from onset of ischaemia to revascularization was 9 hours (mean). Revascularization was done by simple bifemoral embolectomy in 19 cases, by aortobifemoral bypass in 9 and by extra-anatomic bypass in 6 (3 supra-pubic, 3 axillo-bifemoral). Six patients (18%) died during the post-operative period. Delay to care had been greater than 12 hours in most of these patients. One or more post-operative complications occurred in 18 patients (53 p. 100) including repeated thrombosis, insufficient revascularization, ischaemic neuropathy. Long-term survival at 3 years was 30%. Prognosis might be improved by three elements: reducing the duration of ischaemia by rapid diagnosis and emergency revascularization, better control of metabolic disorders, screening for heparin allergy before thrombotic events occur.

Acute Disease↗
PubMed1995

[Surgical management of acute and chronic arterial occlusion].

Arterial occlusion may develop acutely and chronically, can affect any artery in the body. Surgical treatment of the disease is reasonable when definite symptoms occur. The forms of surgical treatment are: in acute arterial occlusion embolectomy or thrombectomy with Fogarty balloon catheter, under special circumstances in this group of patients we are compelled to use the typical surgical technique for chronic occlusion; the bypass and thrombendarteriectomy. Reconstructive operations are made most often on the lower extremities: thrombendarteriectomy or artificial prosthetic grafting on the aortoiliac section, autogenous saphenous vein bypass on the femoropopliteal section, and this is also the recommended procedure in the cases when the occlusive disease affects the crural arteries. Other operations in connection with occlusive arterial disease are lumbal and thoracal sympathectomy, fasciotomy and amputation at different levels. The recognition of occlusive disease on the extracranial carotid arteries are getting more and more common nowadays. The recommended operation in carotid occlusive disease is eversio endarteriectomy. Compared with the above the reconstructive operations of the mesenterial and renal arteries are rare. In the cases we do operate the operations are seldomly thrombendarteriectomies and more often bypasses with autogenous saphenous vein or artificial prosthetic grafts.

Acute Disease↗
PubMed1994

[Clinical aspects and diagnosis of arterial embolism of the upper extremity].

The upper limb embolus is rarely encountered (upper limb:lower limb emboli 1:4-5). Our problem was to determine in which way the paraclinical investigations influence the operation indication. In 1992, we have seen 10 consecutive patients with an upper limb embolus. The characteristics of our patient group are the advanced age and the cardiovascular morbidity. It was always possible to diagnose the emboli clinically. 7 duplex, 6 Dopplers and 2 angiographies were performed and have confirmed the clinical diagnosis and the clinically suspected localisation of the emboli. All the patients were operated in local anesthesy. An embolectomy with Fogarty catheter was done. After the operation, all our patients were asymptomatic. No amputation was done. We do think that when the clinic is clear enough to diagnose an embolus, no other investigations are necessary to the operation indication.

Aged↗
PubMed1994

[Damage to the vessel wall by the Fogarty balloon catheter].

Thromboembolectomy with the Fogarty balloon-catheter is a well-established surgical therapy for the treatment of acute ischemia with generally good results. However, arterial injuries caused by balloon embolectomy occur in up to 6%. The different types of injury are mentioned, the role of myointimal hyperplasia as a result of endothelial denudation is discussed. We conclude that after balloon-catheter thromboembolectomy an early angiographic control should be performed and repeated 3 months postoperatively.

Aged↗
PubMed1994

[Diagnosis and therapy of perioperative lung embolism].

Pulmonary embolism is a major cause of postoperative problems, accounting for 12-20% postoperative deaths. 0.1% to 0.4% of all hospitalised patients die due to acute pulmonary embolism. Thus, pulmonary embolism should be included in the differential diagnostic considerations. Blood gas analysis, ECG, chest roentgenography, scintigraphy, pulmonary arterial catheterisation, echocardiography, digital subtraction angiography, and angiography are important diagnostic tools. When pulmonary embolism is not life-threatening, heparinisation may be an adequate therapeutic approach. In the case of severe cardiovascular instability, recanalisation of the pulmonary arterial tree has to be achieved. Recent studies show that preceding surgery may not be an absolute contraindication to thrombolysis. Recommendations for thrombolytic therapy include the bolus administration of 250,000 U of urokinase followed by a continuous infusion of 40-60,000 U per hour. In an emergency situation, a bolus dose of 1-2,000,000 U may be administered. A neurosurgical operation in the preceding 10 days is still considered an absolute contraindication to thrombolysis. Patient outcome in the case of cardiopulmonary resuscitation for massive pulmonary embolism may be improved by the bolus application of 2-3,000,000 U of urokinase. In addition or alternatively, mechanical thrombus fragmentation via catheter or surgical embolectomy may be used in certain hospitals.

Angiography, Digital Subtraction↗
PubMed1993

[Mobile thrombus of the right heart and pulmonary embolism: diagnostic and therapeutic problems. Apropos of 12 cases].

The objectives of this report were to analyse clinical presentation, echocardiographic features and diagnostic and therapeutic problems posed by an unusual form of thrombo-embolic disease: mobile right heart thrombosis. Systematic echocardiography in 170 cases of severe pulmonary embolism identified mobile right thrombi in 12 cases. The auscultatory findings were abnormal in 6 cases, 3 showing signs of tricuspid obstruction. Two-dimensional echocardiography showed an extremely mobile right atrial mass, sometimes prolapsing across the tricuspid valve, which was variously spheric, ovoid or worm-like; dilatation of the right heart chambers and echocardiographic signs of cor pulmonale were observed in all cases. The differential diagnosis with other embolic masses of the right atrium and, above all, with well-developed Chiari networks, may be difficult and requires transoesophageal echocardiography. Pulmonary angiography is contra-indicated because of the risk of embolism. Embolectomy under cardiopulmonary bypass was carried out in 8 patients, immediately after echocardiography in 6 cases. The thrombus was recovered from the right atrium in 6 cases and from the pulmonary artery in 2 cases: there was one operative death. Medical treatment was administered to 3 inoperable patients. The clinical and echocardiographic outcome was good in 2 of these but the third patient died; autopsy revealed thrombi in the right atrium and pulmonary artery. One patient died before any treatment could be given and autopsy showed the thrombus in the pulmonary artery. These results confirm the extreme instability of this type of thrombus and the risk of death due to its embolism.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1993

Spontaneous bilateral renal artery occlusion associated with chronic atrial fibrillation.

Bilateral renal artery occlusion with resultant anuria is a rare entity usually seen following blunt abdominal trauma. We present a case of bilateral renal artery occlusion in a patient with chronic atrial fibrillation who had complete resolution of acute renal failure following embolectomy 30 hours later although complete occlusion was shown by arteriography. After inclusion of this case with 35 other reported cases a point biserial correlation coefficient was calculated for delay in treatment (hours) vs outcome (functional or nonfunctional kidney and survival or death). There was no correlation between these parameters. The statistical results from these combined data demonstrate that attempts at reestablishing blood flow should be made without strict adherence to previously reported critical time frames, which have no applicability based on the evidence presented here.

Acute Kidney Injury↗
PubMed1995

Treatment of venous thromboembolism.

This review provides meta-analytic data of studies aiming at improved treatment of deep vein thrombosis and pulmonary embolism. The introduction of low molecular weight heparin has considerably ameliorated the initial treatment of deep vein thrombosis, and should now be regarded as the treatment of choice for most patients with deep vein thrombosis. Oral anticoagulant treatment is presently considered safe and effective for the long-term treatment of venous thromboembolism, provided that the INR is maintained at 2.0-3.0. However, the optimal duration as well as the optimal intensity of anticoagulation have still to be determined. Patients with submassive pulmonary embolism should presently be treated with adjusted dose unfractionated heparin and coumarins. Studies determining the efficacy and safety of low molecular weight heparin in this condition deserve priority. Thrombolytic therapy should be restricted to patients with massive pulmonary embolism, unless safer methods of thrombolysis have been developed. Surgical embolectomy and catheter fragmentation of emboli seem alternative options but deserve further investigations.

Anticoagulants↗
PubMed1995

[Epidural anesthesia in vascular surgery in patients with chronic obstructive lung disease].

Epidural anaesthesia was determined in 29 patients with chronic obstructive pulmonary disease. Lidocaine 2% for vascular procedures such as embolectomy from the arteriae femoralis and arteriae poplitea was used as an anesthetic in 12 patients and 0.5% bupivacaine for aortobitemoral or femoropopliteal bypass in 17 patients. Thus possible complications in patients with obstructive chronic pulmonary disease were avoided as well as prolonged mechanical ventilation and endotracheal intubation. With the postoperative application of local anesthetic through a catheter into the epidural space, spontaneous breathing and good analgesia was achieved. Preoperatively all patients were administered bronchodilators, expetorants and they stopped smoking.

Anesthesia, Epidural↗
PubMed1996

[Treatment of severe pulmonary embolism].

Acute circulatory failure is the major complication of acute pulmonary embolism. It may be clinically silent, but sometimes leads to systemic hypotension, shock, or clinical manifestations of right ventricular failure. In these patients, oxygen, inotropic drugs, and fluid loading are indicated. Unless contra-indicated, thrombolytic therapy should be undertaken when clinical signs of circulatory failure occur. Surgical embolectomy is now undertaken in the very few patients not responding to maximal medical treatment. Vena cava interruption is not more often useful in massive pulmonary embolism than in non massive pulmonary embolism.

Anticoagulants↗
PubMed1995

[Pulmonary embolism and thrombi of the right heart].

In general, there are two types of right heart thrombi diagnosed by echocardiography: mobile and non-mobile thrombi, more often located in the atrium than in the ventricle and a potential source of pulmonary embolism. However, they differ in several points: clinical context, clinical and echocardiographic presentations, embolic potential, prognosis and treatment. The result of peripheral venous thrombosis, mobile thrombus it is usually diagnosed during echocardiographic investigation of pulmonary embolism. The appearances are often that of serpentine thrombus floating in the right heart chambers associated with signs of acute cor pulmonale. It is a marker of imminent and often fatal embolism as it completes a previous and usually severe pulmonary embolism; the mortality is over 40%. It is a contra-indication for pulmonary angiography because of the risk of embolism and a therapeutic emergency. Some groups advocate surgical embolectomy and others thrombolysis. Its precise frequency in the acute stage of pulmonary embolism and its treatment remain to be determined by a prospective, multicentre clinical trial. The adherent non-mobile thrombus is usually implanted on the free wall of the right atrium or the interatrial septum. Its formation, in situ, is due to stasis secondary to decompensated congenital or acquired cardiac disease or to the presence of an intracardiac foreign body such as a pacing wire. It is less likely to cause pulmonary embolism. It decreases or disappears with anticoagulant therapy and the outcome is usually good. The differential diagnosis between a mobile thrombus and a Chiari network, or between an adherent thrombus and a vegetation on a intracardiac pacing wire may be difficult and requires transoesophageal echocardiography. The investigation of pulmonary embolism requires systematic echocardiography, one of the objectives of which is to search for right sided thrombi.

Anticoagulants↗
PubMed1995

[Management of the venous pole in pulmonary embolism].

The prognosis of thromboembolic disease depends, to a large degree, on the deep venous thrombosis. It is located in the legs in nearly 80% of cases and proximal to the popliteal vein in one out of two patients. It is the cause of recurrence and at longer term, of post-thrombotic disease, the frequency of which contrasts with the rarity of chronic post-embolic cor pulmonale. The deep vein thrombosis is often neglected, either because it has no clinical expression or because the symptoms it causes regress rapidly with treatment. Venous ultrasonography by a skilled operator, a painless and easily repeated investigation, is the method of first intention. When the thrombus is not well visualised, it is necessary to complete the investigation with bilateral phlebocavography in free flow or with a computerised tomography scan if the vena cava is poorly seen. The treatment of the pulmonary embolism depends on its size, its tolerance, the embolic source and sites of embolism. Severe pulmonary embolism may require surgical embolectomy at the outset, during which inferior vena cava interruption should be systematic. When thrombolytic therapy is considered, the implantation of a temporary caval filter should be proposed, especially if the thrombus is "floating" or extends into the inferior vena cava. If pulmonary embolism is associated with a recent proximal venous thrombosis it would seem logical to propose surgical thrombectomy or thrombolysis, at least in young patients. Conversely, distal deep vein thrombosis only requires heparin therapy. Interruption of the inferior vena cava is essential when embolism complicates well-treated deep vein thrombosis or when the thrombosis becomes more extensive despite effective treatment. It is also advisable when pulmonary sequellae are severe, long-term anticoagulant therapy is contra-indicated or when the aetiology of the thromboembolism cannot be determined.

Embolectomy↗