Upper limb ischemia resulting from arterial thromboembolism.

Acute ischemia of the upper limb is commonly caused by trauma and embolic arterial occlusion. However, primary atherosclerotic thrombosis is found infrequently and concern regarding its incidence, recognition, and treatment prompted a review of our clinical experience. Of 36 patients with acute ischemia of the upper limb, 17 (47.2 per cent) had embolic occlusion, 9 (25 per cent) iatrogenic thrombosis in the brachial artery, and 10 (27.8 per cent) primary arterial thrombosis. Of the total group, noncardiac arterial emboli (two patients) and primary atherosclerotic thrombosis (six patients) accounted for 8 of 36 (22.2 per cent) ischemic limbs. Including 2 additional patients who had atherosclerotic thrombosis associated with trauma, the total number represented 10 of 36 (27.8 per cent). An aggressive approach to the undiagnosed patient with acute ischemia of the upper limb is warranted, including the use of arteriography in most cases. In patients with iatrogenic thrombosis in the brachial artery, we believe that the routine use of intraoperative arteriograms may improve the operative results.     

The surgical management of acute limb ischaemia due to native vessel occlusion.

OBJECTIVES: Data from the STILE study have indicated that for patients with subacute limb ischaemia due to native vessel occlusion, surgery is both more effective, and durable than thrombolysis. The purpose of this study was to evaluate the outcome of an aggressive surgical approach in patients presenting with acute limb-threatening ischaemia. DESIGN: Details of patients presenting with salvageable acute limb ischaemia due to native artery occlusion over a 6-year period in a University hospital vascular unit setting were obtained from the vascular audit and the outcome of the surgical management of these patients was analysed. RESULTS: One hundred and seventy-four consecutive patients underwent surgery for acute native vessel limb ischaemia (76% lower, 24% upper limb). Fogarty thrombectomy or embolectomy was initially performed in 153 (89%) patients. Of these, 37 (24%) immediately underwent a further procedure: 28 (18%) had on-table thrombolysis and 14 (9%) underwent vascular reconstruction. Twenty-six patients (15%) underwent further limb salvage surgery within 30 days. Life table analysis demonstrated a limb salvage rate of 88% and 76% at 30 days and 2 years, respectively. Patient survival was 75% and 48% at the same time intervals. CONCLUSIONS: These results demonstrate that a role for aggressive surgical intervention still exists, resulting in high limb salvage rates.     

Intraoperative intra-arterial urokinase therapy after failed embolectomy in acute lower limb ischemia

BACKGROUND: Aim of this study is to evaluate the use of intraoperative intra-arterial urokinase infusion (IIUI) in overcoming residual thrombi after thromboembolectomy in acute lower limb ischemia. METHODS: Design: retrospective study over a 3-year period. Setting: University affiliated hospital. Patients: 21 patients with acute lower limb ischemia who underwent IIUI after embolectomy (18 transfemoral, 3 transpopliteal) had failed to achieve adequate distal perfusion. Postoperatively, all patients were maintained on full dose heparinization. Main outcome measurements: complete or partial clot lysis on post-IIUI angiography; restoration of pedal pulses and a viable leg at discharge. RESULTS: Angiographically, complete and partial lysis was demonstrated in 14 and 3 patients, respectively. Two patients with prolonged ischemia required fasciotomy. One of these eventually had an amputation. Altogether, limb amputations (1 above knee, 2 below knee) were necessary in 3 patients. The angiographic appearance of lysis correlated well with the restoration of pedal pulses and/or limb viability. One patient died of myocardial infarction 3 days after the procedure. Postoperatively, there were 5 (24%) wound hematomas of which 1 required surgical exploration. Over a mean follow-up period of 8 months (range 1-16), limb salvage was sustained in the 17 patients with successful angiographic lysis. CONCLUSIONS: IIUI is an effective therapeutic adjunct to failed embolectomy in acute lower limb ischemia. Use of this procedure is recommended as part of the routine management in such cases.     

Preoperative assessment of the risk for cardiac death following thrombo-embolectomy for acute lower limb ischaemia.

Cardiac monitoring and the selective use of initial non-operative management is reported to reduce the high mortality rate in patients with acute lower limb ischaemia. Early estimation, prior to selection of initial therapy, of the risk for intraoperative or postoperative cardiac death following thrombo-embolectomy is therefore important. The aim of this prospective multi-centre study was to develop a simple and clinically useful index for assessment of the risk of post-operative cardiac death. Patients judged to need thrombo-embolectomy for acute lower limb ischaemia were evaluated on admission for routine clinical, cardiac and limb ischaemia parameters that could be related to cardiac function and these parameters compared to postoperative cardiac outcome. Sixteen per cent of the 117 patients died from intraoperative or postoperative cardiac complications. Analysis revealed five admission parameters that significantly and independently predicted a high risk for cardiac death: mean arterial blood pressure below 90 mmHg, clinical sign(s) of cardiac decompensation, ischaemia affecting the thigh, haemoglobin concentration exceeding 140 gl-1, and a history of a myocardial infarction in the previous 4 weeks. Definition of risk points for each risk factor allowed a simple classification of each patient into one of three significantly different cardiac risk classes with cardiac death rates of 6 +/- 3%, 27 +/- 8% and 75 +/- 16%, respectively. More than two thirds of the patients belonged to the low risk group. The described risk index provides a tool for preoperative assessment of the cardiac death risk associated with early thrombo-embolectomy in patients with acute lower limb ischaemia.     

Colour-coded duplex imaging and dependent Doppler ultrasonography in the assessment of cruropedal vessels

BACKGROUND: It has been suggested that ultrasonography could replace diagnostic arteriography in the assessment of patients who present with leg ischaemia. This study investigated a group of consecutive patients who had femorodistal bypass and who were assessed before operation with colour-coded duplex and dependent Doppler insonation alone. METHODS: Thirty-seven consecutive patients with critical lower limb ischaemia underwent surgical exploration with a view to femorodistal bypass. Results of preoperative colour-coded duplex and dependent Doppler insonation were compared with intraoperative arteriograms and surgical findings. RESULTS: There was very good agreement between colour-coded duplex imaging and dependent Doppler insonation with intraoperative angiography and surgical findings in the prediction of the optimal run-off vessel (kappa = 1.0) and the site of the distal anastomosis (kappa = 0.85; 95 per cent confidence interval 0.71-1.0). There was also very good agreement between dependent Doppler insonation and intraoperative arteriography (kappa = 1.0) in predicting pedal arch patency and the predominant feeding vessel. CONCLUSION: Assessment of leg arteries before femorodistal bypass can be performed accurately with non-invasive colour-coded duplex imaging and dependent Doppler insonation alone, thus obviating the need for preoperative arteriography.     

Subintimal Angioplasty as a Treatment of Femoropopliteal Artery Occlusions

OBJECTIVES: to report the results of subintimal PTA of femoropopliteal occlusions above the knee. DESIGN: a retrospective study. PATIENTS: in the period from January 1997 to January 2002, 109 patients were submitted to 124 interventions. The indication for treatment was intermittent claudication in 78 cases and critical ischaemia in 46. METHODS: all cases of subintimal angioplasty were prospectively registered. A review of all cases treated with subintimal PTA for above-knee femoropopliteal occlusions were done. Primary assisted haemodynamic patency rate was calculated on intention to treat basis and for successfully treated cases. Comparison of patency with respect to comorbidities, indication, runoff and occlusion length was done with univariate and multivariate analysis (Cox' regression). RESULTS: technical success rate was 90%. Primary assisted patency rates at 6, 12 and 18 months were 43, 37 and 31% calculated on basis of intention to treat and 48, 42 and 35% for successfully treated cases. Diabetes mellitus and critical ischaemia were found to be independent risk factors for re-occlusion. CONCLUSION: subintimal angioplasty is an alternative to open surgery for patients with femoropopliteal occlusions and intermittent claudication. The treatment is relatively atraumatic, complications are rare and in most cases treated with endovascular techniques. Patency rates are low. In cases of critical ischaemia, time can be important for outcome with respect to limb salvage. We therefore find that the poor patency rates of subintimal angioplasty of femoropopliteal occlusions contraindicate its use in the treatment of critical ischaemia with exception of cases unsuitable for surgical treatment.     

Endovascular recanalization of subclavian artery occlusions

Percutaneous balloon angioplasty for subclavian stenosis achieves satisfactory procedural success rates except for total occlusion. Seven lesions in six consecutive patients who underwent stenting for subclavian total occlusion were reviewed to evaluate the feasibility and efficacy of endovascular stenting. Six lesions were treated using Palmaz stents, and one with the combination of a Palmaz and a SMART stent. Procedural success (residual stenosis < 30%) was achieved for all lesions. The only neurological complication was an embolism in a branch of the posterior cerebral artery, which resulted in homonymous hemianopsia. Follow-up angiography over 6 months after the stenting for five lesions found one in-stent re-occlusion and one ostial restenosis due to elastic recoil. No patient had any new or recurrent symptoms except for recurrent upper limb ischemia due to the case of in-stent re-occlusion during the clinical follow-up period of 1 to 52 months (mean 16.6 months). This complication was resolved by a second treatment. Our limited experience suggests that stenting can redilate even cases of angiographical total occlusion of the proximal segment of the subclavian artery.     

The results of completion angiography after acute lower limb thromboembolectomy.

The results of completion angiography after acute thromboembolectomy with a Fogarty balloon catheter were evaluated. There were 62 patients (median age 72 years, range 44-92 years) and completion angiograms were made in 44 of them (71%). Incomplete runoff was demonstrated in 26 patients (59%) and rethromboembolectomy or vascular reconstruction was made in 18 cases (41%) under the same anaesthesia, while additional vascular surgery was technically impossible in 8 patients (18%). Supplementary surgery resulted in radiological improvement in 56% of operated cases. Reocclusion rate after 6 months was 50% in patients without patent tibials compared to 15% in patients with two or three patent tibial arteries (P less than 0.05). Eighteen patients had no completion angiograms after thromboembolectomy and 5 (28%) required early reoperation due to ischaemia. Completion angiograms are advocated in all cases of acute thromboembolectomy before the patient leaves the operating table.     

Intraoperative fibrinolytic therapy: an adjunct to catheter thromboembolectomy

This article describes our initial experience with intraoperative infusion of the fibrinolytic agent streptokinase. Five patients with various complications of atherosclerosis manifested by limb-threatening ischemia were treated by balloon-catheter thromboembolectomy followed by intra-arterial streptokinase infusion. In each patient viability of the involved extremity was questionable after removal of all thrombus accessible to the balloon catheter. Fibrinolytic therapy was used when operative arteriography showed residual thrombus distal to the popliteal artery. All patients were systemically heparinized during the operation, and three patients were maintained on anticoagulants during the initial postoperative period. A streptokinase solution containing 750 U/ml was infused intra-arterially proximal to the residual thrombus. The total dosage ranged from 20,000 to 100,000 units per patient. This treatment was considered successful in all five patients, as documented by return of palpable pulses, audible Doppler flow signals where none was present prior to infusion, and operative arteriography. There were no complications related to intraoperative streptokinase infusion. We conclude that intraoperative fibrinolytic therapy is a safe adjunct to catheter thromboembolectomy. The observed improvement in limb perfusion can be attributed to lysis of thrombus in the distal arteries that could not be retrieved with the balloon catheter. Laboratory studies are in progress to establish precise indications for intraoperative streptokinase and to determine the most effective dosage and rate of administration.     

Increased limb salvage. Distal tibial/peroneal artery thrombectomy/embolectomy in acute lower extremity ischemia

Fifty-five acutely ischemic lower extremities, in 35 patients, which remained ischemic after standard thrombectomy/embolectomy techniques were further treated with distal tibial/peroneal thrombectomy/embolectomy by ankle level arteriotomy to increase limb salvage. A total of 84 infrapopliteal arteries were explored and thromboembolectomy performed in 79. The precipitating ischemic event was arterial embolus in 38 per cent, arterial thrombus in 60 per cent, and trauma in 2 per cent of the cases. There were 16 female and 19 male patients. Additional bypass grafting was used in 18 per cent of extremities. The limb salvage rate was 91 per cent in this select "tibial/peroneal" group. This technique salvaged 50 limbs that otherwise would have required major amputation. The addition of this technique changed the potential limb salvage rate from 76 per cent of the entire 199 lower extremities treated during this period to an actual limb salvage rate of 97 per cent. Operative mortality was 16 per cent in this selected group with an overall mortality of 6 per cent for all patients with acutely ischemic lower limbs. A mean patient follow-up of 32 months (range 12 to 72 months) identified only three late amputations, demonstrating that distal tibial/peroneal thrombectomy/embolectomy is a durable procedure. It is a technically easy means of promoting limb salvage in the acutely ischemic limb which either 1) remains ischemic after standard transinguinal iliofemoral thromboembolectomy, or 2) is secondary to infrapopliteal artery occlusion. It allows successful thromboembolectomy of acutely occluded infrapopliteal arteries without distal popliteal arteriotomy. These techniques should be within the armamentarium of all surgeons dealing with acute lower extremity ischemia.     

Intraoperative fibrinolytic therapy for salvage of limbs with acute arterial ischemia: An adjunct to thromboembolectomy

The purpose of this prospective study was to determine the value of intraoperative intra-arterial fibrinolytic therapy (IIFT) in patients with acute arterial ischemia as an adjunct to mechanical thromboembolectomy. Sixty-six femoropopliteal or distal acute arterial occlusions were assessed by means of arteriography and Doppler imaging pre- and postoperatively. Two groups of patients were compared: one (n=35) in which mechanical thromboembolectomy was applied as the single technique and another (n=31) in which 250,000 IU of urokinase diluted in 250 ml of normal saline solution was instilled at the end of mechanical thromboembolectomy over a 30-minute period with the arterial inflow occluded. Candidates for IIFT were selected according to a nonrandomized method. Intraoperative arteriography showed residual thrombus in 20 (30.3%) patients and unsuspected arterial lesions in 23 (34.8%). Thrombosis recurrence was associated with residual thrombus (p<0.001) and amputation (p<0.001). The ankle/brachial index increased significantly (p<0.05) in the patients who received IIFT (0.88±0.03) in comparison with those who underwent mechanical thromboembolectomy (0.75±0.05). Although the percentages of distal revascularization and amputation did not differ significantly between the two groups, quantitatively the results were better in the IIFT group (80.65% success and 9.68% failure) compared to the mechanical thromboembolectomy group (60% success and 22.86% failure). There was no bleeding due to IIFT. Significant variables in our study were diabetes (p<0.05), the time period of 12 to 24 hours before the surgery (p<0.05), and the severity of the ischemia in association with rest pain (p<0.05). Based on the results of intraoperative arteriography, we conclude that IIFT is a safe and effective adjunct to mechanical thromboembolectomy when an inaccessible thrombus cannot be removed from a distal vessel.     

Hepatische Ischämie bei der Whipple-Operation Kasuistik einer selten notwendigen Revascularisation

With the performance of a partial duodenopancreatectomy, the collateral vascular bed between the coeliac trunk and the superior mesenteric artery is reduced. Normally, this does not lead to ischaemia of the upper abdominal organs. However, we present the rare case of a patient in whom a Whipple resection in combination with a hyploplastic coeliac trunk led to hepatic and splenal ischaemia and aorto-hepatic bypass grafting. The indication for preoperative arteriography is in discussion, since variations or alteration of the upper abdominal vessels are known to be common but manifest organ ischaemia during resection is a rare complication. Patients with signs of general arteriosclerosis or those in whom upper abdominal resection has been performed previously may benefit from angiography. In other cases a test occlusion before vessel ligation is considered to be suitable in assessing the need for vascular surgical intervention.     

Intraoperative intraarterielle Thrombolysetherapie als Ergänzung von Gefäßrekonstruktionen bei amputationsbedrohender Extremitätenischämie

Purpose: Since its introduction in the 1980s, intraoperative thrombolysis in peripheral arterial occlusion as an additional procedure has been shown to be attractive and effective in reducing limb loss in severe lower-limb ischemia. Although the results are promising additional intraoperative intra-arterial thrombolysis has not been widely used according to the few papers published with approximately 300 patients that have been published from 1985 until now. Are vascular surgeons not acquainted with the intraoperative use of streptokinase, urokinase or tissue plasminogen activator (rt-PA)? We report our own experience, comparing our results with the data available in the literature. Patients and methods: Thirty patients (16 men, 14 women, mean age 71 years) with severe limb-threatening ischemia were treated with operative thromboembolectomy, local thrombendarterectomy or bypass-grafting and, simultaneously, with additional intraoperative thrombolysis. After clot removal or a revascularization procedure and after documentation by angiography, the procedure was accomplished by intra-arterial instillation of rt-PA (mean dose 10.5 mg Actilyse). Perioperatively, patients received systemic anticoagulation with heparin. Results: All but two combined revascularizations resulted in clinical and angiographically documentated restoration of perfusion to the affected limb. Four (13%) major amputations and two (7%) repeat operations due to bleeding complications were necessary during the 30-day postoperative period. Three (10%) patients died postoperatively, but not due to bleeding or operative complications. Conclusion: Intraoperative intra-arterial thrombolytic therapy with rt-PA is an attractive adjunct to catheter thromboembolectomy or to a revascularization procedure in limbthreatening ischemia. Salvage of the limb seems to be increased. We conclude that thrombolysis is effective and safe.     

Intra-operative arteriography in arterial embolectomy

In a retrospective study, 154 embolectomies in 135 patients with acute arterial occlusion were reviewed and the value of intraoperative arteriography studied. Included in the study were 69 embolectomies of the femoro-popliteal artery in 64 patients, and in 40 (58%) intra-operative arteriography was performed. Of these, 20 were done because of difficulty in passing the Fogarty catheter and/or absent backflow and 20 as a routine procedure where there was easy passage of the catheter and good backflow. In 29 embolectomies (42%) intra-operative arteriography was not performed because some surgeons, doubting the benefit of routine arteriography, did not use it. In 23 cases (58%) intra-operative arteriography led to an extension of the operation. Six out of 20 routine arteriograms (30%) showed incomplete clearance of the arterial tree, resulting in further embolectomy. The amputation rate was 17%, however in the group where routine arteriography was performed it was zero and significantly less than in the non-arteriogram group (23%). The use of intra-operative arteriography in arterial embolectomy surgery is recommended.     

Thrombolytic therapy in the management of acute limb ischaemia

Acute limb ischaemia poses a threat to both the limb and life of a patient. Until recently, attempted revascularization by thromboembolectomy or vascular reconstruction held the best chance of limb salvage. Thrombolytic techniques afford an alternative method of management for this condition and are effective in selected patients. Low-dose intra-arterial streptokinase is the most established method of thrombolysis, although the recently developed tissue plasminogen activator offers a promising alternative. Intra-arterial thrombolysis is not an easy option, being labour intensive and requiring close co-operation between surgeon and radiologist. Thrombolytic and surgical techniques are not mutually exclusive but are best used to complement each other. Ideally patients with acute limb ischaemia should be managed by surgeons with knowledge of, and access to, optimal current surgical and non-surgical techniques.     

Perimalleolar and pedal thromboembolectomy and bypasses to treat distal embolization during aortoiliac aneurysm repairs

OBJECTIVES: Lower extremity embolization occurs during aortoiliac aneurysm repair and may require major amputation when distal arteries are occluded. Because nonoperative treatments are often ineffective, we evaluated an aggressive operative approach. METHODS: In the past 11 years, we performed 328 endovascular and 350 open aortoiliac aneurysm repairs. Excluding cases of embolization to iliac, femoral, popliteal, and more proximal tibial vessels, which were treated in a standard fashion, foot ischemia severe enough to produce cadaveric, pregangrenous, or gangrenous skin changes occurred from more distal embolization after seven endovascular and three open aortoiliac aneurysm repairs. Six of these 10 patients underwent thromboembolectomies of both their dorsalis pedis and perimalleolar posterior tibial arteries < or =4 hours of their original operation. In the other four patients, treatment was delayed 7 to 10 days. Because of progressive foot ischemia, arteriography was performed. From these results, four bypasses (3 autologous vein, 1 polytetrafluoroethylene graft) were performed to the transverse metatarsal arch, dorsalis pedis, perimalleolar peroneal artery, or perimalleolar anterior tibial artery. RESULTS: Patency and limb-salvage rates for both thromboembolectomy and bypass procedures were 100% at a mean follow-up of 3.0 years (range, 5 months-8 years). CONCLUSIONS: Perimalleolar and foot artery thromboembolectomy and bypasses to arteries as distal as the metatarsal arch can be effective treatment for distal embolization from aortoiliac aneurysm repair. Even when cadaveric, pregangrenous, or gangrenous lesions are present, distal arteriography and operative treatment (thromboembolectomy or bypass) may be indicated to successfully salvage the foot.     

Acute ischaemia of the upper limb compared with acute lower limb ischaemia; a 5-year review

A series of 61 patients with acute upper limb ischaemia treated over a 5-year period is analysed and compared with patients presenting with acute lower limb ischaemia during the same period. The mean age was 74 years with a female to male ratio of 2.2:1. Eighty-two per cent were treated by operation. Three patients died and no survivors required a major or minor limb amputation, in contrast to a 5 per cent major limb amputation rate in patients with acute lower limb ischaemia. Mortality for upper limb ischaemia was 5 per cent compared with a 30 per cent mortality rate in patients with acute lower limb ischaemia in whom cardiopulmonary debility (New York Heart Association score 3-4) was significantly greater.     

Cardiac output in patients with acute lower limb ischaemia of presumed embolic origin--a predictor of severity and outcome?

Cardiodynamic studies using a non-invasive computerised thoracic electrical bioimpedance (TEB) equipment were performed in 35 patients presenting with acute lower limb ischaemia of presumed embolic origin, and in 36 age-matched control patients without emboli. Patients who presented with imminent gangrene were promptly operated upon, whereas those who had less severe ischaemia were treated initially with heparin only. In the former group, cardiac output and myocardial contractility were very low on admission, while systemic vascular resistance was high. Cardiac output was further decreased when measured immediately after revascularisation, whereas it had become normal 2 days later. In patients with less severe acute ischaemia, cardiac output and myocardial contractility values on admission were similar to those of control patients, and no changes were observed after 2 days of conservative treatment. Overall, cardiac output on admission was significantly related to the simultaneously observed severity of the limb ischaemia. A low cardiac output (less than 1.7 l/min m2) on admission was found to predict severe cardiac complications (60% mortality within 10 days), whereas clinical assessment of cardiac failure on admission was poorly related to outcome. We conclude that patients with acute lower limb ischaemia of presumed embolic origin often have unrecognised poor cardiac function, which is related to the severity of the limb ischaemia and to outcome. By routine non-invasive TEB cardiodynamic measurements, high risk patients can rapidly be identified and proper treatment regimes be instituted in each individual patient.     

Duplex scanning or arteriography for preoperative planning of lower limb revascularisation.

OBJECTIVE: to compare the accuracy of duplex and angiography for the planning of lower limb revascularisation. PATIENTS AND METHODS: Sixty limbs (82% with critical limb ischaemia) were assessed by means of duplex by one surgeon and by angiography by another in terms of the optimum inflow and outflow sites for arterial bypass. These data were then compared with the final operation performed which was used as the gold standard. Surgeons were blinded to the determinations of the other. RESULTS: surgical plans based on duplex scan and angiography were correct in 77% (40/52) and 79% (41/52), respectively and plans based on the one imaging modality was modified by the other in only 1 and 2 instances. The diagnostic agreement between duplex scanning and arteriography was excellent (Kappa value=0.94, 95% C.I. 0.89-0.98). CONCLUSIONS: the reliability of duplex scanning is comparable to digital angiography in the preoperative planning of lower extremity arterial reconstruction. However neither exam can be considered as the gold standard because intraoperative arteriography needs to be available in a significant number of infrapopliteal procedures.     

Peripheral arterial occlusion in acute promyelocytic leukemia.

A 16-year-old Caucasian teenager developed fatigue, abdominal pain, pneumonia, and subsequently acute vascular occlusion of the left superficial femoral artery. Vascular assessment and heparin therapy lead to bone marrow aspiration and a diagnosis of acute promyelocytic leukemia. Treatment with chemotherapy prevented loss of limb and avoided further vascular surgery. Young patients with acute vascular occlusion require an in-depth assessment including attention to hematological disorders. Clots obtained on thromboembolectomy should be sent for pathological assessment and not discarded, especially in an unusual-age patient for arterial embolus.