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PubMed1996

[Controlled reperfusion of the extremities for preventing local and systemic damage after prolonged ischemia. An experimental study with the swine model].

Our previous studies in isolated rat hindlimbs using crystalloid perfusion solutions have shown that control of the initial reperfusion reduces postischemic complications. However, no experimental study has been undertaken to evaluate the concept of controlled limb reperfusion experimentally in an in-vivo blood-perfused model and to assess the local as well as systemic effects of normal blood reperfusion and controlled limb reperfusion. Of twenty pigs undergoing preparation of the infrarenal aorta and iliac arteries, six were observed for 7.5 hours and served as controls. Fourteen other pigs underwent 6 hours of complete infrarenal occlusion. Thereafter, embolectomy was stimulated in 8 pigs by removing the aortic clamp and establishing normal blood reperfusion at systemic pressure. In 6 other pigs, control of the composition of the reperfusate and control of the conditions of reperfusion was done during the first 30 min, followed by normal blood reperfusion. Six hours of infrarenal aortic occlusion lead to a severe decrease in high energy phosphates and muscle temperature and a slight increase in creating kinase (CK) and potassium in the systemic circulation. Normal blood reperfusion resulted in severe reperfusion injury: massive edema developed (80.6% vs. 76.6%, p < 0.0009), the tissue showed a marked decrease in oxygen consumption (7.3 +/- 1.1 vs. 14.3 +/- 2.5 mL )2/100 g/min, p < 0.02), glucose consumption (0.19 +/- 0.06 vs. 0.51 +/- 0.03 mg/100 g/min, p < 0.06), tissue ATP (18.3 +/- 1.9 vs. 36.1 +/- 0.9 mumol/g protein, p < 0.000001), total adenine nucleotides (26.3 +/- 2.6 vs. 45.8 +/- 1.5 mumol/g protein, p < 0.00001), muscle pH (5.9 +/- 0.1 vs. 7.3 +/- 0.1, p < 0.000006) and total calcium in the femoral vein (2. +/- 0.1 vs. 2.7 +/- 0.1 mmol/L, p < 0.002). Furthermore, a massive increase was seen in CK concentration (12,743 +/- 2,562 vs. 513 +/- 80 U/L, p < 0.0003), potassium (7.9 +/- 0.3 vs. 4.4 +/- 0.2 mmol/L, p < 0.000001) and muscle rigidity (60 +/- 11 vs. 122 +/- 1 degree, p < 0.00008). In sharp contrast, initial treatment of the ischemic skeletal muscle by controlled limb reperfusion resulted in normal water content (77.6 +/- 0.4 vs. 76.8 +/- 0.3%), oxygen consumption (13.2 +/- 1.6 vs. 14.9 +/- 3.2 mL O2/100 g/min), glucose consumption (0.58 +/- 0.18 vs. 0.46 +/- 0.11 mg/100 g/min), flow (5.4 +/- 1.1 vs. 4.6 +/- 4.6 +/- 0.5 mL/100 g/min) and muscle rigidity (106 +/- 4 vs. 122 +/- 1 degree). Furthermore, controlled limb reperfusion resulted in higher total adenine nucleotides content (78% vs. 57% of control), less tissue acidosis (6.6 +/- 0.2 vs. 5.9 +/- 0.1, p < 0.002), severely reduced CK release (2,618 +/- 702 vs. 12,743 +/- 2.562, p < 0.02) and potassium release (5.1 +/- 0.3 vs. 7.9 +/- 0.3 mmol/L, p < 0.0002) as compared to normal blood reperfusion. In conclusion this study shows that 6 hours of acute infrarenal aortic occlusion will result in a severe reperfusion injury (postischemic syndrome) if normal blood at systemic pressure is given in the initial reperfusion phase. In contrast, initial treatment of the ischemic skeletal muscle by controlled limb reperfusion reduces the metabolic, functional and biochemical alterations.

Animals↗
PubMed1996

[Anticoagulation after vascular surgery interventions].

Questionnaires regarding postoperative antiplatelet and anticoagulant therapy were answered by personal interviews with 35 German vascular surgeons. A 3/4 majority follow the recommendations of literature by anticoagulation after embolectomy in patients with persistent atrial fibrillation. Antiplatelet therapy is common in patients after thrombendarteriectomy and justified by improving the natural history of atherosclerotic disease. Considerable differences exist in postoperative therapy following peripheral bypass surgery. Controlled clinical trials are rare and present contradicting results. Prospective randomized multicenter studies are necessary.

Aged↗
PubMed1997

[Embolisms of the abdominal aortic bifurcation].

The authors evaluate in the submitted paper the results of surgical treatment of embolization into the bifurcation of the abdominal artery at the Second Surgical Clinic in Brno during 1990-1996. A total of 5 patients was involved whereby in all a cardiac cause of the embolization was obvious. The authors deal also with the time which has elapsed between the development of complaints and surgery, the type of anaesthesia, average length of operation. The operation is implemented concurrently by two teams as antero- and retrograde simultaneous bi-transfemoral embolectomy. The authors emphasize the importance of the metabolic condition of the patient as well as cardiac and renal functions before, during and after surgery. They consider the application of peroperative haemodialysis essential. During the postoperative period it is important to find the objective cause of the cardiac deficiency and treat it. Their results--a 40% mortality are comparable with those of other specialized departments. By comparison with a similar group treated at the same department twenty years previously the authors find a decline in the incidence of this disease and explain this phenomenon by an increased number of cardiosurgical operations in this area.

Aorta, Abdominal↗
PubMed1997

[Mobile thrombi of the right heart in pulmonary embolism].

Systematic transthoracic echocardiography in all cases of pulmonary embolism may demonstrate right heart thrombi. The results of this monocentric series of 28 consecutive cases observed between 1987 and 1996 were analysed. Twenty-four patients were in NYHA Class IV: thirteen were in cardiogenic shock. Echocardiographic signs of acute cor pulmonale were usually observed: 96.3% of patients had right ventricular dilatation, 85.2% paradoxical interventricular septal motion, 88.9% pulmonary hypertension. The thrombus was typical serpentine (27/28 cases) arising from the lower limb veins. Passage into the left heart chambers through a patent foramen ovale was observed in 3 cases. Pulmonary embolism was confirmed in all cases. This is an extreme therapeutic emergency and 13 patients (46.4%) died despite treatment: surgery (7/16), thrombolysis (2/5), heparin (3/4) or interventional radiology (1/3). After the acute phase, the prognosis was generally good, as demonstrated by the 100% survival rate at 28.6 +/- 25 months. This study confirms the gravity of mobile right heart thrombi in pulmonary embolism. The diagnosis is echocardiographic. No significant difference in mortality was observed between the different therapeutic approaches used in this series. The echocardiographic finding of these thrombi is a traditional indication for emergency surgical embolectomy. Thrombolysis is rapid and readily available and seems to provide promising results alone or before surgery. In patients with contraindications to thrombolysis, interventional radiology or simple heparin therapy may be proposed.

Adult↗
PubMed1993

Recent developments in the diagnosis, treatment, and prevention of pulmonary embolism.

The diagnosis of pulmonary embolism remains enigmatic. Points to look for are: (1) Ninety percent or more of patients with pulmonary embolism have known predisposing factors. (2) Eighty percent or more complain of dyspnea and exhibit hyperpnea (eg, respiratory rate > 20 breaths per minute). (3) Chest roentgenogram abnormalities occur in more than 80% of patients. (4) Seventy percent to 90% of patients complain of chest pain. (5) Either the pCO2 is low or the alveolar-arterial oxygen gradient is high in more than 95% of cases. (6) Twenty percent of patients have normal pO2. (7) Anxiety is present more often than not, and, if present, is no reason to dismiss the cause as "hyperventilation syndrome." Pulmonary arteriography is the "gold standard" for diagnosis, although the combination of ventilation/perfusion scan and noninvasive leg vein studies may decrease its use. An experimental test, the immunosorbent plasma D-dimer assay, seems a promising future screening tool if its reportedly high sensitivity is confirmed. Transthoracic or esophageal echocardiology, if immediately available, may have a place in assessing patients who present with cardiovascular collapse. Early and adequate heparinization coupled with the use of intravenous heparin protocols should lower future mortality rates. Food and Drug Administration approval of low-molecular-weight heparin and heparinoids may revolutionize the management of routine thromboembolism, as these substances are easier to use and less hazardous. A recent British study showed no advantage to anticoagulation beyond 4 weeks for patients with perioperative thrombophlebitis and no other risk factors. In selected cases, thrombolytic therapy, vena caval filters, and invasive embolectomy have been shown to decrease both short- and long-term mortality.

Clinical Trials as Topic↗
PubMed1983

Idiopathic multiple systemic aneurysms in a child.

A 3-year-old child had ischemia of the left-sided upper extremity secondary to embolic disease. Arteriography showed multiple idiopathic saccular aneurysms of the left subclavian artery. Coronary arteriograms were normal. Cerebral arteriography showed ectasia of the right common carotid artery, and abdominal aortography, aneurysms of the splenic and phrenic arteries. The patient underwent brachial artery embolectomy, proximal and distal aneurysm ligation, and placement of a carotid to axillary artery polytef bypass graft. Microscopic analysis indicated intimal proliferation, normal elastic tunica media vasorum, and no evidence of an inflammatory process. Electron microscopy showed no evidence of rickettsiae. The patient's clinical appearance was similar but not identical to that of Kawasaki disease, Takayasu's disease, or periarteritis nodosa. Workup of the patient and subsequent surgical exploration failed to demonstrate a definitive cause.

Aneurysm↗
PubMed1975

Routine intraoperative angiography. An essential adjunct in vascular surgery.

Intraoperative angiography was performed during a variety of 155 arterial reconstructive procedures including bypass, endarterectomy, embolectomy, thrombectomy, primary reconstruction, and angioplasty. In 27 or 17% of these cases, defects were identified that could be corrected. These included technical errors at the suture line, accumulation of platelet thrombus and atherosclerotic debris, or unrecognized lesions in the runoff. The likelihood of identifying such lesions is greatest in patients undergoing bypass surgery, particularly when the distal anastomosis involves one of the leg arteries. Routine use of intraoperative angiography as an adjunct to vascular surgery is justified and will help to obviate many early graft failures.

Aneurysm↗
PubMed1977

Paradoxical embolization. Case report and review of the literature.

A 32-year-old morbidly obese woman had bilateral subclavian artery embolism. After embolectomy, a right heart catheterization showed a patent foramen ovale and a right-to-left shunt. Pulmonary angiography revealed multiple pulmonary emboli. Bilateral lower extremity venography demonstrated left ileofemoral thrombi as the probable source. The patient was successfully treated with an inferior vena caval umbrella and anticoagulant drugs.

Adult↗
PubMed1981

Factors that affect the outcome of peripheral arterial embolization.

To find the factors that significantly affected prognosis in patients with peripheral arterial thromboembolism, we reviewed a 12-year experience at two hospitals. Sixty-one patients had 67 embolectomies. Operative treatment and management preserved the limbs in 75.8%. Mortality was 22.4%. Outcome was favorably affected when age was less than 60 years and when arteriosclerotic heart disease was absent, and was adversely affected when common femoral emboli were present and hematocrit level elevated. Duration of symptoms did not affect outcome. Our treatment of patients with peripheral embolism is based on the effect of certain intrinsic factors on the formation of distal thrombus. These factors may be more important than duration of symptoms. Immediate, complete heparinization is recommended to arrest thrombosis, and to allow both for proper emphasis on treatment on the often-associated cardiopathy and for attention to hydration and acid-base balance. This preoperative plan of therapy should produce maximal limb salvage with reduced operative mortality.

Adult↗
PubMed1983

Effects of hypoxia and hyperoxia on progression of intimal healing.

To assess the effect of changes in inspired oxygen concentration on intimal healing, the aorta was stripped by a single passage of an inflated embolectomy catheter in 34 rabbits. Each then was maintained in a controlled-atmosphere cage with a normobaric oxygen concentration of 14%, 21%, or 40% for up to ten days. Although after six months all animals showed nearly normal aortic healing, the progression of healing was considerably different. Hypoxia appears to result in prolonged platelet adherence, exaggerated medial proliferation, and aberrant migration. Hyperoxia appears to allow a more orderly intimalization. An aberrant healing process secondary to tissue hypoxia when combined with exacerbating factors may be important in producing the unfavorable result in vascular surgery.

Animals↗
PubMed1983

Paradoxical embolization with Ebstein's anomaly.

A 48-year-old woman with known Ebstein's anomaly had bilateral, lower-extremity arterial emboli after a total abdominal hysterectomy. She underwent embolectomy, placement of a Greenfield caval filter, subsequent tricuspid valve replacement, and closure of an atrial septal defect. Antemortem diagnosis of a paradoxical embolus is rare. To our knowledge, this is the first case associated with this congenital cardiac anomaly in a survivor.

Ebstein Anomaly↗
PubMed1984

Acute arterial thrombosis of the lower extremity. Its natural history contrasted with arterial embolism.

We compared a group of 52 patients with acute lower extremity ischemia secondary to arterial thrombosis with a series of 220 patients with peripheral embolism who were seen at the Massachusetts General Hospital, Boston, from 1967 through 1980. The conditions of patients with arterial thrombosis were misdiagnosed as acute embolism at a rate of 20%. Mortality in the patients with embolism was significantly higher. While patients with acute embolism were routinely treated with embolectomy, two thirds of the patients with thrombotic occlusion required surgery during their initial hospitalization for ongoing severe ischemia. More than half of these operations were carried out as emergency procedures. Limb salvage in surgically treated patients with arterial thrombosis was inferior to that seen with embolism. Early revascularization for acute thrombosis was carried out with a 30-day patency rate of 82%. While the mortality associated with acute thrombosis was significantly lower than that seen with peripheral embolism, the risk of major amputation was 35%. There should be no reluctance to proceed with indicated vascular reconstruction in the setting of acute limb ischemia secondary to arterial thrombosis.

Acute Disease↗
PubMed1986

Intraoperative streptokinase. An adjunct to mechanical thrombectomy in the management of acute ischemia.

Streptokinase was injected directly into the arterial tree following balloon-catheter embolectomy on 13 occasions to remove residual thrombus that could not be mechanically retrieved in 12 patients with imminent limb (ten patients) or kidney (two patients) necrosis. Effective lysis, confirmed by arteriography, pulse return, and increased ankle pressures, was achieved in 11 trials (85%). Bleeding complications, minor in three patients and severe in two patients, were ascribed to systemic lysis although other factors were contributory. One of five deaths was related to therapy. Six limbs were salvaged. The average total dose of streptokinase used, 110,000 units, was given in intermittent boluses of 25,000 to 50,000 units injected below a clamp placed to temporarily occlude distal circulation. Safe application of this technique requires intraoperative monitoring of coagulation parameters, aggressive replacement therapy, and prudent patient selection. This preliminary experience suggests that intraoperative lytic therapy (1) is an effective method for clearing thrombus not amenable to mechanical extraction and (2) may improve patency and tissue salvage.

Acute Disease↗
PubMed1987

Late results of peripheral vascular surgery in patients 80 years of age and older.

During a seven-year period, 114 patients 80 years of age and older underwent 119 peripheral arterial procedures. There were 26 elective aortic reconstructions, nine ruptured abdominal aortic aneurysm (AAA) repairs, 33 femoropopliteal bypasses, 13 femorotibial bypasses, 21 femoral embolectomies, and 17 miscellaneous procedures. Early mortality, morbidity, and Goldman cardiac risk factors were determined by chart review. All 48 survivors returned for current noninvasive vascular examination and life-style assessment. Perioperative mortality after elective AAA resection was 4.3%, vs 78% after ruptured AAA. Perioperative mortality after infrainguinal bypass was nil. Five-year survivals after elective aortic and infrainguinal reconstructions were 54% and 30%, respectively. Of 18 patients studied 19 to 68 months after infrainguinal bypass, limb salvage was achieved in 83% and graft patency in 76%. Thirty-one long-term survivors (65%) were living at home. Only seven patients (15%) were confined to a wheelchair or were bedridden, and 28 (58%) were fully ambulatory. Peripheral arterial reconstruction in patients 80 years of age and older can be performed safely with excellent long-term survival and quality of life.

Aged↗
PubMed1989

Routine intraoperative angioscopy in lower extremity revascularization.

The inability to see through blood remains the main obstacle to the widespread and routine use of angioscopy. Local irrigation with a balanced salt solution is presently the most widely used method to clear the blood. By applying basic principles of irrigation and using a unique, dedicated, irrigation pump, we found that routine angioscopy during lower extremity revascularization that yields consistent high-quality studies is feasible, clinically useful, and safe. Between May 1, 1987, and July 31, 1988, 136 intraoperative angioscopies were performed during 112 peripheral bypass procedures, 15 thrombectomies, 2 embolectomies, and 7 miscellaneous revascularization procedures. Mean total irrigation fluid used in the peripheral bypasses was 398 mL (range, 0 to 1400 mL). Good visual quality was obtained in more than 80% of angioscopies and the failure rate was only 1.8%. On the basis of the findings in 71 of the 136 angioscopies, 78 clinical or surgical decisions were made. No complications were directly attributable to the insertion of the angioscope or use of the pump.

Angiography↗
PubMed1990

Friedrich Trendelenburg and the surgical approach to massive pulmonary embolism.

A surgical approach to embolectomy from the pulmonary artery had been worked out in laboratory animals prior to 1908 by Friedrich Trendelenburg, professor of surgery and director of the University Surgical Clinic at Leipzig, Germany. His technique was based on limited opening of the left side of the chest directly over the common or undivided pulmonary artery and encircling the proximal aorta and pulmonary artery together through the transverse sinus of the pericardium. Both vessels were to be occluded by traction on the encircling band. Emboli were to be extracted through a small pulmonary arteriotomy, which then was to be controlled by a tangentially applied clamp, while occlusion of the great blood vessels was released. Unfortunately, during the first clinical trial of the technique, the patient died because of technical difficulties. Not until 1924 was a surviving patient described, by Trendelenburg's former trainee, Martin Kirschner.

Aged↗
PubMed1990

Transatrial interruption of the inferior vena cava.

Transatrial placement of a Greenfield filter at the time of cardiac surgery was performed on three patients with recent femoral venous thrombosis and unstable angina, and at the time of pulmonary embolectomy on four others. The filter carrier was passed through the right atrial cannulation site under fluoroscopic guidance into the inferior vena cava. A preliminary venacavogram was performed through the carrier or a previously placed angiographic catheter. Two complications were encountered: the first was misplacement of a filter in the right renal vein before routine venacavography was employed; the second was caudal displacement of a filter by a right atrial venous drainage cannula that projected into the inferior vena cava. The latter complication can be prevented by the use of a right atrial "sump" drain that does not protrude into the inferior vena cava.

Angina, Unstable↗
PubMed1998

A rare complication of coronary arteriography.

We describe a 66-year-old man with acute mesenteric ischemia and myocardial ischemia within 6 hr after coronary arteriography. He underwent successful emergency surgery with embolectomy of the mesenteric artery and coronary artery bypass grafting.

Aged↗