Surgical management for acute aortic dissection with organ ischemia

In a series of one hundred and one cases of surgical treatment for acute aortic dissection between January 1986 and September 1997, we evaluated 29 cases presenting with organ ischemia. These consisted of 23 cases of acute type A dissection (type A) and 6 cases of type B dissection (type B). Organ ischemia was diagnosed by (1) aortography, (2) a retrospective review of the history and (3) physical examination or laboratory data. The 23 surgical cases of acute type A dissection consisted of, coronary ischemia 8 cases, cerebral and spinal cord ischemia 9 cases, intestinal ischemia 3 cases, lower extremities ischemia 10 cases, and plural organs ischemia 8 cases. In the 6 cases of acute type B, we noted 4 intestinal ischemias and 2 lower extremities ischemias. The operative mortality rates when subdivided according to ischemic organ were: coronary ischemia 50%, cerebral and spinal cord ischemia 11%, intestinal ischemia type A 33%, type B 50%, and lower extremities ischemia type A 33%, type B 0%. The operative mortality rates, especially for patients presenting with acute myocardial infarction or intestinal ischemia, were relatively high. In cases of acute aortic dissection when organ ischemia occurred, we believed that it was necessary to perform early thoracic aortic repair and reconstruction of the ischemic organ.     

Ascending aorta to biaxillar and left femoral artery bypass

A 68-year-old man was admitted to our hospital because of ischemia in the upper and lower extremities with rest pain. Aortography revealed complete bilateral subclavian artery occlusion and left femoral artery occlusion. We planned simultaneous revascularization of upper and lower extremities. Ascending aorta to biaxillar and left femoral artery bypass was performed. The postoperative course was uneventful and he was discharged on the 18th day after operation. This procedure was useful for patient with upper and lower limb ischemia.     

急性上肢动脉栓塞的外科治疗

目的 探讨急性上肢动脉栓塞的合并疾病、栓塞部位、手术与非手术及治疗前缺血时间等因素与疗效的关系.方法 回顾1988年7月至2008年1月约20年问62例急性上肢动脉栓塞的临床资料,采用累加Logit回归模型分析数据,以年龄、性别、心功能情况、栓塞部位、手术与非手术治疗、缺血时间等为参数,分析这些因素与临床疗效的相关关系.结果 本组62例,男33例,女29例,年龄35～86岁,平均63.5岁,男女之间差异无统计学意义(P>0.05).62例中37例接受了Fogarty球囊导管取栓术,25例接受非手术治疗而给予溶栓、抗凝、祛聚治疗.其中55例(88.7%)的肢体缺血状态得到改善,截肢2例,死亡2例.累加Logit回归模型分析表明治疗开始时间、心功能情况、手术取栓对决定预后有统计学意义(P<0.01);而年龄、性别和栓塞部位对疗效无统计学意义(P>0.05).而非手术的25例中,23例缺血状态得到改善.结论 对于急性上肢动脉栓塞,8 h以内Forty导管取栓术是最有效的治疗方法 ,而对于无法耐受手术的高危患者,积极的药物治疗仍可能改善栓塞肢体的缺血状态.     

Arterial reconstruction in the upper extremities

Arterial reconstruction in the upper extremities is rare relative to the incidence of reconstruction in the lower extremities. Twenty-three patients who underwent vascular reconstruction in the upper extremities from 1985 to 2000 were retrospectively reviewed. Atherosclerosis was observed in only two subclavian arteries. The most common cause of occlusion was thromboembolism from the heart, which occurred often in the brachial artery and could be treated successfully with thrombectomy. Seven of eight bypass grafts, including three procedures below the elbow, remained patent during follow-up periods ranging from 2 to 9 years. Arterial reconstruction of the upper extremities differs from that in the lower extremities. Atherosclerosis is a rare cause of ischemia, and the etiology varies with the site of obstruction. Bypass surgery below the elbow is feasible and successful in selected patients. Ischemia of the upper extremity causes significant morbidity and should be treated aggressively whenever possible.     

Epidemiologie und Behandlung der PAVK und der akuten Extremitätenischämie in deutschen Krankenhäusern von 2005 bis 2012

Background

Due to the demographic changes an increase in peripheral arterial occlusive disease (PAOD) and acute ischemia of the extremities can be assumed. Simultaneously, the options for revascularization have been extended with the chance of a decreasing rate of amputation. It is unclear whether these developments can also be realized at a national level in Germany.

Material and methods

An analysis of the thoroughly categorized diagnosis data of hospital patients and the diagnosis-related groups (DRG) statistics of the Statistisches Bundesamt (StBA, Federal Statistical Office) from the years 2005 to 2012) was carried out. The numbers of cases, the incidence and mortality of chronic ischemia of the extremities and the main diagnoses (HD) 170 (atherosclerosis), E10.5–E14.5 (diabetes mellitus with peripheral vascular complications) and acute ischemia of the extremities (HD I74, arterial embolism and thrombosis) were analysed. All open and endovascular treatment modalities and major and minor amputations were assessed based on the DRG statistics of the StBA.

Results

The inhospital incidence of chronic and acute ischemia of the extremities increased from 199 to 241 and from 22 to 27 HDs per 100,000 inhabitants, respectively. The incidence of all cases of ischemia of the extremities showed a clear increase after the age of 70 years. The mortality associated with HD 170 has decreased since 2005 from 3.6?% to 2.7?%. The mortality over the age of 80 years is 5–10?%. The corresponding mortality associated with HD 174 was 9.7 % with an increase to 10-20 % in both sexes above 80 years old. The total number of all cases of peripheral balloon angioplasty increased from 73,000 in 2005 to approximately 130,000 in 2012. The number of peripheral bypass operations decreased from approximately 43,000 to 39,500 (?8.4 %). The number of cases of embolectomy and thrombectomy increased from approximately 38,000 to 60,000 and endovascular therapy of acute ischemia of the extremities increased from approximately 12,000 to 21,000. The number of major amputations could be reduced by 32 % since 2005.

Conclusion

The incidence of acute and chronic ischemia of the extremities is increasing. The mortality risk increases with age and is particularly high for acute ischemia of the extremities. Despite the increase in hospitalized cases with the threat of amputation due to ischemia, the number of major amputations has clearly decreased.     

Acute ischemia of the upper and lower limbs: Tailoring the treatment to the underlying etiology

Acute limb ischemia (ALI) can be a devastating clinical emergency with potentially limb- or life-threatening consequences. It is defined as a quickly developing or sudden decrease in limb perfusion producing new or worsening symptoms and signs, often threatening limb viability. ALI is commonly related to an acute arterial occlusion. Rarely, extensive venous occlusion can lead to upper and lower extremities ischemia (ie, phlegmasia). The incidence of acute peripheral arterial occlusion causing ALI is approximately 1.5 cases per 10,000 people per year. The clinical presentation depends on the etiology and whether the patient has underlying peripheral artery disease. Except for traumas, the most common etiologies are embolic or thrombotic events. Peripheral embolism, likely related to embolic heart disease, is the most common cause of acute upper extremity ischemia. However, an acute thrombotic event may occur in native arteries, at the site of a pre-existing atherosclerotic plaque, or as a failure of previous vascular interventions. The presence of an aneurysm may predispose to ALI for both embolic and thrombotic mechanisms. Immediate diagnosis, accurate assessment of limb viability, and prompt intervention, when needed, play important roles in salvaging the affected limb and preventing major amputation. Severity of symptoms is usually dependent on the amount of surrounding arterial collateralization, which may often reflect a pre-existing chronic vascular disease. For this reason, early recognition of the underlying etiology is crucial for choice of best management and definitely for treatment success. Any error in the initial evaluation may negatively affect the functional prognosis of the limb and endanger the patient's life. The aim of this article was to discuss diagnosis, etiology, pathophysiology, and treatment of patients with acute ischemia of the upper and lower limbs.     

Emergency small-sized stent placement following aortic true lumen obliteration of Stanford type B acute aortic dissection

Acute aortic obstruction induced by acute aortic dissection frequently causes life-threatening organ ischemia. Although early reperfusion of lower extremities, renal and mesenteric artery is necessary, surgical treatment such as graft replacement is invasive and may result in myonephropathic-metabolic syndrome (MNMS), which leads to loss of limb and life. We herein report a case of stent placement as a less invasive treatment for true lumen obliteration associated with Stanford type B aortic dissection in a patient with chronic renal failure on hemodialysis. Ten mm metallic stents were placed in the obliterated true lumen of the descending aorta in order to perfuse peripheral organs within 5 hours after occurrence. It relieved symptoms of visceral organ and leg ischemia. On the postoperative day 14, abdominal discomfort after meal, hypertension in the upper extremity and headache appeared. Chest and abdominal computed tomography (CT) revealed stenosis of the true lumen proximal to the stents. On the other hand, the diameter of the true lumen was inversely dilated distal to the stents. Bilateral axillo-femoral artery bypass was performed with relief of upper extremity hypertension and visceral organ ischemia. The patient otherwise had an uneventful course and was discharged on the postoperative day 37. Our experience suggests that emergency stent placement can provide an option that is less invasive, more effective and prompt treatment for patients with visceral organ and leg ischemia resulting from acute aortic dissection.     

慢性肢体缺血的外科治疗：附75例报告

目的：探讨慢性肢体缺血的外科治疗方法及效果。方法：回顾性分析6年间收治的慢性肢体缺血经外科治疗的75例（78条肢体）的临床资料，其中上肢7条，下肢71条。手术方式包括传统外科手术65例、介入手术4例及干细胞移植术6例。结果：术后63例（66条肢体）获随访2～56个月，1年内8例患者9条下肢（13.6%）截肢;55条肢体（83.3%）临床症状减轻或消失;肢体溃疡愈合或截肢平面降低2条（3.0％），总有效率86.3％。结论：根据病情选用适当的手术方式治疗慢性肢体缺血，可取得较满意的效果。     

Local hypothermia in the treatment of acute arterial occlusion of the extremities

An experimental and clinical investigation of the possibility to use local hypothermia of the extremity in the complex treatment of its acute ischemia was performed. It was established that the local hypothermia could considerably improve tissue viability in the process of the extremity ischemia at the expense of spasmolytic, hypocoagulative, anesthetic effects and inhibition of metabolism. A conclusion is made that the local hypothermia should be used in the clinic for the improvement of results of treatment of patients with acute arterial obstruction of the lower extremities complicated by severe ischemia.     

介入技术在下肢动脉取栓手术中的应用

目的应用介入技术,改进传统的下肢动脉取栓手术,降低手术后的再栓塞率、截肢率、死亡率。方法2004年9月至2008年12月,我科应用术中造影、导丝引导下置管、监视下拖栓、经皮血管腔内血管成形术（PTA）、支架植入等介入技术结合动脉取栓手术治疗急性下肢动脉阻塞24例,涉及24条下肢动脉。结果全组病例手术后再栓塞3例,无截肢,无死亡。结论取栓手术中应用介入技术后,明显降低术后再栓塞率,截肢率,死亡率。     

急性上肢动脉栓塞诊断和外科治疗

目的 回顾性总结肱动脉切开取栓术治疗急性上肢动脉栓塞的经验,讨论急性上肢动脉栓塞的诊断和治疗。方法 1995-2007年中山大学附属第一医院血管外科共诊治28例急性上肢动脉栓塞病人,全部采用肱动脉切开取栓术治疗,术后予以序贯性抗凝。 结果 术后27例上肢供血良好,可触及桡动脉搏动。上肢再栓塞1例,合并其他部位栓塞3例。术后死亡3例,死亡原因为心肌梗死和脑栓塞。 结论 肱动脉切开取栓术是治疗上肢急性动脉栓塞的手术方式。防止再栓塞和治疗原发病是降低病死率和预防截肢的关键。     

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??Diagnosis and surgical treatment of acute arterial embolism of upper extremities LI Song-qi, YE Cai-sheng, HU Zuo-jun, et al. Department of Vascular Surgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080,China Corresponding author:WANG Shen-ming, E-mail: shenmingwang@vip.sohu.com Abstract Objective To summary the experience of brachial arteriotomy with embolectomy to treat acute embolism of the upper extremities retrospectively and discuss the diagnosis and treatment of it. Methods From 1995 to 2007, 28 cases were performed brachial arteriotomy and were given sequential anticoagulants. Results After operation the upper extremities were salvaged in 27 cases??1 case accepted amputation, 1 case Re-embolism 2 times. 3 cases Re-embolism in other vessels and 3 cases died of cerebral embolism and acut myocardial infarction. Conclusion Brachial arteriotomy with embolectomy is an approach to treat acute embolism of upper extremities and how to prevent re-embolism and treat primary heart disease is the key to decrease mortality and amputation rate.     

手术联合腔内治疗合并动脉硬化的急性下肢动脉缺血23例临床观察

目的：探讨手术联合腔内的方法治疗合并动脉硬化狭窄的急性下肢动脉缺血高龄患者的技术要点及疗效。方法：回顾性分析2008年9月-2010年9月收治的23例（26肢）合并动脉硬化的下肢动脉缺血高龄患者DSA下行腔内联合手术治疗的临床资料和治疗效果。结果：26条肢体（23例）经双腔Fogarty导管取栓、动脉内膜剥脱术,并行相应球囊扩张加支架置入术,或辅助人工皿管旁路手术或／和自体静脉补片成形术,救治成功20例（87．0％）,截肢1例（4．3％）,死亡2例（8．7％）。结论：伴有全身动脉粥样硬化的大多数动脉缺血高龄患者,手术联合腔内的个体化治疗方案,有助于提高重建下肢动脉供血的救治率。     

Embolus of surgical adhesive to the extremities causing acute ischemia: report of two cases

We present 2 cases in which a surgical adhesive embolized to the extremities. In the first case an adhesive was successfully used in the repair of a DeBakey type I aortic dissection. The patient was seen 2 months postoperatively with acute lower extremity ischemia, and a large piece of adhesive was extracted from the iliac and femoral arteries at embolectomy. In the second case the adhesive was used to seal a pericardial patch during repair of a ventricular septal defect. This patient was seen 1 day postoperatively with acute arm ischemia, and the adhesive particle was extracted from the brachial artery during embolectomy.     

Beneficial effects of hypertonic mannitol in acute ischemia—reperfusion injuries in humans

Acute ischemia-reperfusion of extremities is characterized by edema, compartment syndrome and neuromuscular dysfunction. Intravenous hypertonic mannitol has been shown to be of benefit in several experimental models. The authors' 5-year experience with the use of hypertonic mannitol and the treatment of acute ischemia reperfusion injuries in humans has been reviewed. Some 186 patients with acute arterial occlusion following thromboembolism (149) and trauma (37) were treated. Hypertonic mannitol (25g intravenous bolus followed by 5–10g intravenous/h) was given perioperatively. Length of preoperative ischemia varied from 1 to 24 h. Some 57.5% of patients had preoperative neuromuscular dysfunction. Following revascularization, limb salvage was obtained in 97.7% of surviving patients and neuromuscular dysfunction improved in 89%. Overall, 15% required fasciotomy. The mortality rate was 3.2%. These data suggest that hypertonic mannitol may have some protective effect in acute ischemia-reperfusion injuries of human extremities. It may decrease the need for fasciotomy and minimize neuromuscular dysfunction.     

St. Anthony's fire: successful reversal of ergotamine-induced peripheral vasospasm by hydrostatic dilatation

A 60-year-old trauma victim developed severe ischemia of all four extremities following administration of heparin-dihydroergotamine as prophylaxis against deep venous thrombosis. Despite cessation of heparin-dihydroergotamine and infusion of intraarterial papaverine into the right femoral artery, both lower extremities progressed to frank gangrene and amputation (above-knee on the left and below-knee on the right). However, both ischemic upper extremities were salvaged following intraoperative hydrostatic dilatation with balloon catheters. Ergotism is an avoidable and potentially treatable cause of peripheral gangrene in the critically-ill patient.     

急性肢体动脉栓塞26例诊断与治疗

目的 探讨急性肢体动脉栓塞的诊断、治疗与预后。方法回顾性分析2002年5月至2005年7月大连大学附属中山医院血管外科收治的26例急性肢体动脉栓塞病人的病例资料，26例均急诊行动脉切开Fogarty导管取栓并配合药物治疗。结果无死亡病例，26条肢体均获保存，术后肢体变暖，24例病人肢体远端动脉搏动恢复。2例肢体远端动脉搏动未恢复。结论早期诊断、及时动脉切开Fogarty导管取栓，是保存缺血肢体的关键因素。     

急性下肢动脉缺血溶栓治疗的临床研究

目的 总结溶栓治疗对急性下肢动脉缺血的疗效及其安全性.方法 回顾性分析2009年1月～201 1年12月收治43例急性下肢动脉缺血患者的临床资料,均进行动脉腔内溶栓治疗,其中27例进行导管直接溶栓,6例导管直接溶栓前行血管内球囊扩张,7例导管直接溶栓后进行血管内球囊扩张和支架置入,溶栓前后均进行球囊扩张有3例.腔内溶栓治疗无效转而手术取栓13例.结果 30例(69.8％)患者血管再通及肢体保存,但其中1例因出血并发症死亡,发生脑梗死1例.8例(18.6％)截肢,均为移植物血栓形成.1例肢体坏死但未行截肢.4例溶栓无效但肢体未坏死而最终采取药物保守治疗.结论 溶栓治疗对急性下肢动脉缺血总体安全有效,可优先考虑,根据病情的需要采取综合治疗方案.     

Role of biochemical and radiological study methods in the evaluation of prognosis in acute ischemia of the limbs

Examined were 47 patients with acute ischemia of the extremities: 29--with favourable outcome, and 18-with the development of gangrene. Scintigraphy of the extremity with 99mTc-Sn-pyrophosphate was performed; urinary excretion of epinephrine and norepinephrine, DOPA and dopamine, and vanillylmandelic acid as well was studied; the content of ACTH, cortisol and cyclic adenosine monophosphate in the blood was defined. The use of radionuclide and biochemical methods of investigation permits to assess the degree of severity of the ischemic injury to the tissues of the extremities.     

Rare cause of acute ischemia of the right upper extremity: thrombosis of a retroesophageal subclavian artery

Thrombosis of a subclavian artery is an uncommon cause of acute upper extremity ischemia in the elderly. Malformations of the aortic arch system are also rare. The purpose of this report is to describe an unusual case involving acute ischemia of the right upper extremity due to extensive thrombosis of a retroesophageal right subclavian artery (RSA) in a 79-year-old woman. Despite delayed diagnosis of the underlying etiology, the patient was successfully treated by extensive thrombectomy of the arteries in the upper extremity and right subclavian-to-carotid artery transposition.