The surgical management of acute limb ischaemia due to native vessel occlusion.
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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. (+info)
Massive pulmonary embolus in a 14 year old boy.
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Pulmonary embolus in children is rare. A case of massive pulmonary embolus, after surgery, in a child of 14 years is described. Accident and emergency doctors should be aware that pulmonary embolus can occur in children and exercise a high index of suspicion for the diagnosis in those patients with risk factors for the condition who present acutely with typical symptoms such as dyspnoea, chest pain, haemoptysis, or collapse. (+info)
Acute occlusion of popliteal and/or tibial arteries: the value of percutaneous treatment.
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OBJECTIVES: to describe early and mid-term results with a percutaneous therapeutic protocol including thromboaspiration, thrombolysis, and correction of the underlying lesion by PTA. METHODS: thirty-three consecutive selected patients with recent (<1 month) reversible acute ischaemia associated with popliteal and/or tibial occlusion were studied. The primary endpoints were technical success (defined as residual mural thrombus less than 20% of the lumen and the presence of at least one tibial artery on angiogram), patient survival and limb salvage at 1 and 12 months. Secondary endpoints included complications, primary, assisted primary and secondary patency determined by duplex scan at 1, 6 and 12 months. RESULTS: technical success was achieved in 27 patients (82%). Twenty patients were treated by thrombo- aspiration+/-thrombolysis only, and seven required additional PTA (26%). In six patients (18%), percutaneous techniques failed, and embolectomy was performed in two, bypass in one and major amputations in three (9%). For the entire series, the survival rate was 100% at 1 month and 94% at 1 year. The limb salvage rate was 91% at 1 month and 1 year. The cumulative primary patency, assisted primary patency and secondary patency rates were 81%, 81% and 86% respectively at 1 month and 66%, 72% and 77%, respectively, at 12 months. Early complications occurred in 10 patients (30%): five groin haematomas (15%), four compartment syndromes (12%) and one haemoglobinuria (3%). CONCLUSION: percutaneous techniques offer excellent early and mid-term results in selected patients presenting with acute ischaemia with popliteal and/or tibial arteries occlusion. (+info)
Occlusive arterial disease in HIV-infected patients: a preliminary report.
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OBJECTIVES: to preliminarily describe the clinical features and management of arterial occlusive disease in human immunodeficiency virus (HIV) infected patients. MATERIALS: twenty HIV positive patients with symptomatic large-vessel arterial occlusion treated by a tertiary vascular unit in a 3-year period. METHODS: retrospective review of clinical case records. RESULTS: patients were noted to be young (median age 37 years), with preponderance of males. Twelve patients had evidence of advanced HIV infection. All patients had critical ischaemia, involving the upper limbs in four and the lower limbs in 16. Coagulation abnormalities were noted in two cases. Operative intervention in 18 patients included revascularisation in seven. Thrombotic occlusion of normal-looking arteries was noted. Arterial biopsy revealed leucoIcytoclastic vasculitis indicative of HIV arteritis in three of five cases examined. CONCLUSIONS: initial experience with large-vessel occlusive disease in HIV positive patients suggests an underlying arteritic aetiology, with clinical and pathological features distinct from atherosclerosis. Further in-depth study is necessary to clarify the pathophysiological basis thereof. (+info)
Distal emboli as an unusual late complication of a thrombosed arteriovenous hemodialysis graft.
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The creation of an arteriovenous fistula for long-term hemodialysis access is one of the most commonly performed procedures in vascular and transplantation surgery. Prosthetic conduits are frequently prone to failure within their first year of construction, and after one or two revisions, they are left in their thrombosed state as permanent subcutaneous foreign bodies in the extremities. Conventional teaching has regarded these chronically thrombosed grafts to have a benign natural history, and their removal has been considered unnecessary. We describe an unusual late complication of distal thromboemboli from a chronically occluded arteriovenous graft that was implanted 10 years before and appeared as acute hand ischemia. (+info)
Two cases of primary pulmonary artery sarcoma resembling chronic thromboembolic disease features are presented. Tumour identification was achieved after pulmonarv thromboendarterectomy, which was indicated by documentation of a prothrombotic state in both patients. A doubtful history of pulmonary emboli or deep venous thrombosis should alert medical personnel to the possible presence of a primary pulmonary artery sarcoma. Advanced imaging methods such as gadolinium-enhanced magnetic resonance imaging could be useful in considering pulmonary thromboendarterectomy. If a tumour is detected, its surgical resection should be considered with caution, taking into account the poor survival results. Invasion of the adventitia or the right ventricle, as documented in the present cases, is unusual. As far as the present authors know, this is the first report of this kind of tumour and its coexistence with an activated protein C resistance state and type II heparin-induced thrombocytopenia. (+info)
The successful surgical treatment of a paradoxical embolus to the carotid bifurcation.
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Paradoxical embolism is a rare cause of ischemic stroke. We report the case of a 67-year-old man who had a saddle embolus to the carotid bifurcation successfully treated with emergency embolectomy. Transesophageal echocardiogram revealed a large patent foramen ovale and an easily demonstrable right-to-left shunt. Subsequent investigations revealed proximal deep venous thrombosis in the left femoral and popliteal veins and multiple pulmonary emboli. Long-term anticoagulation was instituted for the diagnosis of paradoxical embolism. The patient's recovery was uneventful, and he remained neurologically intact. A literature review emphasizes the role of transesophageal echocardiography and suggests that paradoxical embolism may be a more common cause of stroke than previously thought. (+info)
Surgical treatment of digital ischemia occurred after radial artery catheterization.
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Permanent ischemic injury of the hand after radial artery cannulation is rare, but several cases of thromboembolism after the cannulation leading to amputation of affected limb or digits have been reported. A 48-yr-old man undergoing spine surgery showed normal modified Allen's test and had no preoperative vascular disease. We inserted 20-G radial artery catheter for the continuous monitoring of the blood flow and serial blood sampling. There was no specific event during the operation and the catheter was removed immediately after the operation. The signs and symptoms of the circulatory impairment of the radial artery developed four days after the operation and aggravated thereafter. Through the angiographic study, we found the total occlusion of the radial artery and some of its branches. After an emergent surgical exploration of the radial artery for removal of the thrombus and vein graft for the defect of the artery on the 8th postoperative day, the ischemic signs and symptoms disappeared and the radial pulse was restored. (+info)