Outcome of catheter-directed thrombolysis for lower extremity arterial bypass occlusion.
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OBJECTIVE: The purpose of this study was to determine the clinical outcome of patients undergoing catheter-directed thrombolysis (CDT) for lower extremity arterial bypass (LEAB) occlusion. METHODS: A retrospective review was performed of two university-based practices from 1988 to 2001. All patients with LEAB occlusion (<14 days by history) undergoing CDT as initial treatment were included. Technical success, complications, secondary patency, and limb salvage were examined. Additional analysis examined secondary procedures performed for residual lesions or failed CDT and the number of LEABs that were replaced or that became infected. RESULTS: One hundred four patients (77% male; mean age, 65 years) had 109 LEAB occlusions. CDT restored patency in 77%. Of the 25 LEABs that failed initial CDT, 15 underwent surgical thrombectomy/revision, four were replaced, and six underwent no further interventions. Of the 84 LEABs successfully lysed, 51 had residual lesions that underwent revision with interventional (n = 30) or surgical (n = 15) techniques or both (n = 6). Median hospital stay was 8 days with three periprocedural deaths. One quarter of CDT procedures had bleeding or thrombotic complications or both. The mean follow-up period was 45 months. Secondary patency rates on an intention-to-treat basis (attempted thrombolysis) were 32% and 19% at 1 and 5 years, respectively. After successful CDT, the 1-year secondary patency rate was comparable in LEABs with or without residual lesions (42% versus 45%). Overall, the limb salvage rates were 73% and 55% at 1 and 5 years, respectively. The survival rate was 56% at 5 years. Ten of the 54 LEABs (19%) that eventually failed after successful CDT had three or more reocclusive episodes. Seven LEABs (8.3%) salvaged with CDT eventually became infected from recurrent interventions; six of these necessitated major amputation. Twenty LEABs initially salvaged with CDT were replaced (four immediately and 16 after episodes of recurrent ischemia). Two patients died during hospitalization for treatment of recurrent ischemia. CONCLUSION: Despite relatively high initial technical success for LEAB thrombolysis, eventual failure is the rule rather than the exception. Recurrent LEAB occlusions lead to significant morbidity, including recurrent interventions, eventual graft infection/replacement, and limb loss. However, LEAB replacement has substantial problems associated with limited conduit, reoperative anatomy, and subsequent wound complications. We therefore advocate an initial attempt at CDT with liberal use of graft replacement for early and late failures or as an initial strategy in those with favorable remaining conduit. (+info)
Deep venous thrombosis during pregnancy and after delivery: indications for and results of thrombectomy.
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PURPOSE: Pregnancy and the puerperium are time periods of an increased risk for venous thromboembolism. An ideal treatment should lead to complete restoration of the venous lumen, elimination of the embolic source, and prevention of severe postphlebitic syndrome. Anticoagulation therapy with heparin or thrombectomy are treatment options. In the current literature, these options are discussed controversially. METHODS: From January 1982 to December 2001, 97 women underwent (93% transfemoral) thrombectomy and construction of an arteriovenous fistula (AVF) for deep venous thrombosis related to pregnancy. The clinical and coagulation parameters were evaluated. The AVF was ligated 3 to 6 months later. Follow-up with duplex ultrasound scan, photoplethysmography, and strain-gauge plethysmography was completed in 87 women. RESULTS: Surgery was performed without any maternal death or pulmonary embolization. A cesarean section was carried out during the same anesthesia in 11 cases. Thrombectomy was completed with construction of a temporary AVF in 90 patients (92.8%). One fetal death occurred in the recovery room for unknown reasons. In the early postoperative course, 16 patients (16.5%) underwent redo surgery for rethrombosis with or without the occlusion of the fistula. In 14 of these patients, the venous system remained patent thereafter. Fetal or neonatal death occurred in five cases 2 to 10 weeks after surgery, mainly because of abruption of the placenta probably from anticoagulation. Among 247 preoperatively occluded anatomic regions, 221 could be restored, and the secondary patency rate amounted to 89.5%. After a mean follow-up period of 6 years, 49 patients (56.3%) were seen without a postphlebitic syndrome, and only three patients (3.5%) had had a leg ulcer develop. CONCLUSION: In experienced hands, venous thrombectomy is a safe method to prevent pulmonary embolism and postphlebitic syndrome in women during pregnancy and the puerperium. The frequency of a severe postphlebitic syndrome after our surgical approach is lower than the rates published for anticoagulation treatment alone. (+info)
Surgery of popliteal artery aneurysms: a 12-year experience.
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BACKGROUND: Management of asymptomatic popliteal aneurysm is controversial, and the prognosis for acutely thrombosed aneurysm is notoriously poor. We evaluated the management and outcome for popliteal aneurysm. PATIENTS AND METHODS: A retrospective review of all patients with popliteal aneurysm between 1988 and 2000 was carried out. Fifty-two limbs were operated on in 41 patients. Data collected included findings at presentation, operative details, graft patency, limb salvage, complications, and 30-day mortality. RESULTS: Initial findings included acute ischemia (n = 14), no symptoms (n = 29), acute rupture (n = 2), chronic ischemia (n = 5), and symptoms of nerve or vein compressive (n = 2). All patients with symptomatic aneurysms and 22 patients with asymptomatic aneurysms (21 larger than 2 cm in diameter, 1 with thrombus at duplex ultrasound scanning) underwent surgery as first-line treatment. Of the 7 patients with asymptomatic aneurysm managed with surveillance with duplex ultrasound scanning, acute ischemia developed in three, 1 aneurysm ruptured, compressive symptoms developed in 1, and 2 remained asymptomatic but required surgery because of aneurysm enlargement (>2 cm). Of the 17 patients with acute ischemia, 13 had neurologic signs and underwent immediate thromboembolectomy (trifurcation alone in 8, ankle-level arteriotomy in 4) and bypass grafting (n = 12) or inlay grafting (n = 1), and the other 4 underwent intra-arterial thrombolysis initially. Of these 4 procedures, 2 were successful and had elective surgery; the other 2 required urgent surgery because of secondary distal embolism and failure of recanalization. Thirteen of the 17 grafts were to the crural vessels. Bypass grafting (medial approach) was used in 16 of the 17 patients with acute ischemia, all 5 patients with chronic ischemia, and the 8 patients with no symptoms. An inlay technique (posterior approach) was used in 16 patients with no symptoms, the 3 patients with symptoms of nerve or vein compression, and 1 patient with acute ischemia. The distal anastomoses were to the below-knee popliteal artery in 35 patients and the crural arteries in 15 patients, using autologous vein. Two of the patients with rupture underwent ligation alone, the other undergoing bypass grafting in addition. The overall 5-year primary patency rate was 69%, secondary patency rate was 87%, and limb salvage rate was 87%. Limb salvage was achieved in 14 of the 17 patients with acute ischemia. Patients with asymptomatic aneurysms had better secondary graft patency (100%) compared with symptomatic aneurysms (74%; P <.01). Acute ischemia, technique used, and crural artery grafts were not predictors of graft failure with either univariate or multivariate analysis. Symptomatic aneurysms were associated with more postoperative complications and greater 30-day mortality (4 of 28 vs 0 of 24). CONCLUSION: Thromboembolectomy followed by crural bypass grafting is an effective treatment for popliteal aneurysm with severe acute limb ischemia. Outcome is better with surgical management of asymptomatic popliteal aneurysm compared with symptomatic aneurysm. (+info)
Successful catheter interventional therapy for acute coronary syndrome secondary to kawasaki disease in young adults.
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Acute coronary syndrome occurred in 2 young adults who had a history of Kawasaki disease (KD), but few other coronary risk factors. The first patient was a 27-year-old male with acute myocardial infarction without stenosis detected by coronary arteriography 4 years earlier. Emergency coronary arteriography showed occlusion of the right coronary artery. Aspiration-thrombectomy and rescue balloon angioplasty were successfully performed. The second patient was a 32-year-old male with unstable angina. Right coronary arteriography showed total occlusion with severe calcification. Left coronary arteriography showed 99% stenosis at the proximal site of the circumflex artery, and a directional coronary atherectomy was performed. Histological examination of a specimen from this site revealed a lipid core, macrophages, and smooth muscle cells. Restenosis was not observed on follow-up coronary arteriography after 5-6 months in either case. The coronary stenosis in each case was probably caused by accelerated atherosclerosis at the site without aneurysm as it seemed to be 'normal' on arteriography. Conventional catheter intervention was effective treatment. The sequelae of KD should be recognized as independent coronary risk factors. (+info)
Thromboembolic events are potential complications of neurointerventional procedures. The mainstay of therapy for these complications is both supportive therapy and the use of fibrinolytic agents. In some cases, the occluding clot seems to be resistant to fibrinolytic or anti-platelet agents. We herein report our successful attempt at clot removal by using a microsnare to mechanically capture and remove a small resistant organized clot fragment that was occluding one of the post-trifurcation M2 divisions of a middle cerebral artery. This complication occurred during coil embolization of an ipsilateral posterior communicating aneurysm. (+info)
Surgical treatment of thoracoabdominal aortic mural and floating thrombi extending to infrarenal aorta.
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The case of a 49-year-old man with thoracoabdominal aortic mural and floating thrombi extending to the infrarenal aorta and occlusion of the common iliac artery is described. He had no factors promoting thrombosis, with a history of thrombectomy of the femoral artery. The thoracoabdominal aortic thrombi were successfully removed with a Forgaty catheter through a thoracotomy under simple aortic clamping and subsequent femoro-femoral cardiopulmonary bypass. Intravascular ultrasound performed through the femoral artery after thrombectomy revealed that little mural thrombi remained and that the celiac, superior mesenteric, and bilateral renal arteries were all patent. (+info)
Initial experience during balloon angioplasty assisted surgical thrombectomy for thrombosed hemodialysis grafts.
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BACKGROUND: Access failure in hemodialysis patients is commonly encountered by vascular surgeons. Researchers have reported various solutions for dealing with clotted grafts, including thrombectomy, thrombolysis, interposition grafting, angioplasty, or a combination of these methods. Surgical thrombectomy has been the standard procedure for dealing with thrombosed hemodialysis grafts in the cardiovascular department of Chang Gung Memorial Hospital. However, to correct associated stenotic lesions and improve the results of surgery, intraoperative balloon angioplasty has been applied in consecutive cases of dialysis graft failure since July 2001. METHODS: Initial experience with 13 consecutive intraoperative balloon angioplasties performed during a 2-month period was reviewed. Noncompliant high-pressure balloons were used for the procedures. Age, gender, graft age, and initial outcome were reviewed and analyzed. RESULTS: A success rate of 100% was achieved in the group that underwent thrombectomy plus intraoperative balloon angioplasty. Furthermore, the primary potency rates were 77% at 1 month, 62% at 3 months, and 38% at 6 months. CONCLUSIONS: We recommend intraoperative balloon angioplasty plus surgical thrombectomy as an effective method of salvaging thrombosed hemodialysis grafts. However, since these are the initial results for this kind of hybrid procedure from a single hospital, large-scale studies with long-term follow up are required. (+info)
Ischemic intestinal involvement in a patient with Buerger disease: case report and literature review.
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A 42-year-old Japanese man who had undergone amputation of the left leg below the knee because of Buerger disease required emergency thrombectomy 7 months later. He complained of acute abdominal pain after thrombectomy. At aortography the distal superior mesenteric artery and its branches were not well visualized. Emergency laparotomy was performed because of suspected intestinal ischemia, and the terminal ileum and cecum and part of the ascending colon were resected. In total, the patient underwent laparotomy four times. Histopathologic findings revealed that the arteries and veins of the resected small intestine were occluded with organized thrombi. Inflammatory cell infiltration was recognized mainly in the intima. These findings are compatible with Buerger disease. (+info)