Arterial embolism: a 44 year perspective

Percutaneous mechanical thrombectomy using the Rotarex®S device for the treatment of acute lower limb artery embolism: A retrospective single-center, single-arm study

Objective

Acute limb embolism (ALE) is a challenging, highly morbid, and frequently fatal vascular emergency. Percutaneous mechanical thrombectomy (PMT) devices are an alternative treatment to restore perfusion by removing emboli in the limb arterial system. We evaluated the outcomes of treatment of ALE patients using PMT devices in our center.

Methods

A retrospective review of ALE patients treated with Rotarex S (Straub Medical) at a single institution from 2018 to 2022 was performed. The primary outcome was technical success, defined as complete recanalization of the occluded segment with satisfactory outflow and good capillary filling of the distal parts of the foot without any major or obstructing residual emboli or thrombi either in the treated segment or in the outflow tract without the need for additional catheter-directed thrombolysis (CDT) or conversion to open surgery. Embolized segments treated, treatment outcomes, and perioperative complications were reviewed.

Results

A total of 17 ALE patients (29% men, 71% women; mean age, 73 years) underwent PMT procedures. The femoral arteries and popliteal arteries are the most commonly treated vessels, with both present in 59% of the patients. The technical success rate was 100%, but the majority of cases (82%) had concurrent percutaneous transluminal angioplasty or stent grafting, and two patients were treated with urokinase during the operation. There was one thrombotic recurrence that required amputation. There were no 30-day deaths. Complications included extravasation after PMT (two), intraoperative embolization of the outflow tract (one), access site hematoma (one), target artery thrombosis (one), and acute kidney injury (one). There were no severe bleeding complications.

Conclusions

The Rotarex S device has a satisfactory success rate, although complementary use of various adjunctive techniques is frequently required. It seems to be a moderately effective tool for treating ALE to avoid CDT or open surgery. The device appears safe, with low risks of amputation and mortality rates, but special attention should be given to the potential for extravasation and distal embolism.

A floating mural thrombus in the ascending aorta can cause multiorgan infarction

A man in his 50s with sudden-onset left-sided subcostal pain was diagnosed with splenic infarction by thoracoabdominal CT with contrast enhancement, which also revealed a mural thrombus in the thoracoabdominal aorta, raising the possibility of aortic dissection. The electrocardiographic findings were normal and transthoracic echocardiography did not detect thrombus in the heart. Antihypertensive medication was administered on admission, and anticoagulation therapy was started after he developed left renal infarction and occlusion of the superior mesenteric artery. Nevertheless, he subsequently sustained an acute cerebral infarction. Transoesophageal echocardiography revealed an abnormal floating structure in the ascending aorta, which was surgically removed and finally diagnosed as an organising thrombus. Although most of the causes of multiorgan infarction are cardiogenic, floating mural thrombus can also be a cause. Anticoagulation therapy may be necessary for patients with recurring severe embolisms even when aortic dissection has not been completely ruled out.

Pharmacomechanical Thrombectomy for Acute Limb Threatening Lower Extremity Arterial Thrombosis Secondary to COVID-19

Purpose The aim of this study was to report the clinical effectiveness and safety of pharmacomechanical thrombectomy (PMT) for acute limb threatening lower extremity arterial thrombosis secondary to coronavirus disease 2019 (COVID-19).

Methods In this retrospective study, the clinical and imaging records of six patients (6 men, mean age 56 years) with COVID-19-related lower extremity arterial thrombosis and treated with PMT using the Angio-Jet device were reviewed. Patients presented with symptoms of acute pain in the affected limb, pallor, pulselessness, paresthesia, or paralysis. Thrombosis involved below knee arteries in all patients, and above knee arteries in three patients. Reteplase 18 mg was infused into the thrombus using the power pulse mode on the Angio-Jet device. This was followed by rheolytic thrombectomy and then, intra-arterial infusion of urokinase 100,000 IU/hour for 5 hours. All patients received systemic intravenous heparin. Technical success, clinical success, and complications of PMT were analyzed.

Results The mean thrombectomy duration was 190.83 ± 99.18 seconds. Adjuvant balloon angioplasty was performed in two patients. The mean hospital stay was 7.67 ± 4.50 days. PMT was technically successful in all (100%) patients. Five patients had excellent clinical outcome with at least one palpable pulse and no tissue loss. One patient required minor amputation. One patient developed self-limiting retroperitoneal hematoma.

Conclusion In our series, PMT with supplemental intra-arterial urokinase infusion was highly successful in treating acute peripheral arterial thrombosis secondary to COVID-19.

Acute Upper Extremity Ischemia Due to Cardioembolism From Undiagnosed Atrial Fibrillation

The current study presents a case of right upper extremity ischemia secondary to cardioembolism in an elderly female with active and previously undiagnosed atrial fibrillation. The patient had no past medical history of any chronic cardiac disease or significant cardiac events. Computed tomographic angiography (CTA) was not performed due to her allergy to contrast material. A non-contrast computed tomography (CT) revealed mild atherosclerotic calcification of the right brachiocephalic artery; however, dissection or mural thrombus of the inflow vessels could not be ruled out. In evaluating a patient with acute ischemia of the upper limb, it is essential to obtain a complete history, including allergies, and be prepared to use alternative techniques for assessing arteries, if necessary. Routine cardiac function testing should also be prioritized in all elderly individuals, even those with no previous history of cardiovascular disease or symptoms.

Clinical Clues for the Current Diagnosis of Acute Lower Limb Ischemia: A Contemporary Case Series

BACKGROUND

Acute lower limb ischemia (ALI) is a limb and life-threatening condition whose treatment largely depends on the underlying cause. The clinical distinction between the main causes may have changed over the years because of changes in the epidemiology of this syndrome. The objective of this study was to determine the clinical pattern associated with the main causes of ALI in a contemporary series of cases.

METHODS

We retrospectively reviewed all consecutive ALI cases admitted to a tertiary hospital between 2007 and 2019. ALI secondary to other conditions than embolism or NAT were excluded. The association between clinical variables and the ALI cause was assessed with multiple logistic regressions and the discriminative power of the resulting clinical predictive scores with the area under the ROC curve.

RESULTS

The study group included 243 patients (mean age 77.2 years; 52.7% male), of which 140 (57.6%) were caused by an arterial embolism and 103 (42.4%) by a NAT. Among these latter, 78 (75.7%) were related to an atherosclerotic NAT and 25 (24.3%) to a complicated popliteal aneurysm. Independent risk factors associated with embolism included atrial fibrillation (OR 10.26, 95% CI 5.1 - 20.67) or female gender (OR 5.44, 95% CI 2.76 - 10.71), but not the severity of the episode or the presence of contralateral pulses. Those related to a NAT included a previous symptomatic peripheral arterial disease (OR 2.68, 95% CI 1.35 - 5.35) and seeking consultation more than 24 hours after the beginning of symptoms (OR 2.57, 95% CI 1.32 - 5), but not a higher rate of other vascular risk factors. Among patients with NAT, previous intermittent claudication (OR 8.34, 95% CI 2.42 - 28.72) and >24 hs delay of arrival of the patient (OR 4.78, 95% CI 1.48 - 15.43) were more frequent among those related to an atherosclerotic NAT, whereas higher hemoglobin levels (OR 1.60, 95% CI 1.21 - 2.11) and non-significantly the history of tobacco smoking (OR 2.95, 95% CI 0.84 - 10.36) among those with a popliteal aneurysm-related NAT. The discriminative power of the two clinical models resulting from these predictive variables for differentiating embolism from NAT and atherosclerosis-related NAT from popliteal aneurysm-related NAT was excellent (0.86 and 0.85, respectively).

CONCLUSION

Certain clinical features appear to be no longer useful in the distinction between embolism and NAT, while others may help in the differential diagnosis between atherosclerotic and popliteal aneurysm-related NAT. Surgeons must be aware of possible changes in the presentation of ALI because time constraints are frequent and clinical data remain essential.

Early experience with arterial thromboembolic complications in patients with COVID-19

BACKGROUND

Little is known about the arterial complications and hypercoagulability associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We sought to characterize our experience with arterial thromboembolic complications in patients with hospitalized for coronavirus disease 2019 (COVID-19).

METHODS

All patients admitted from March 1 to April 20, 2020, and who underwent carotid, upper, lower and aortoiliac arterial duplex, computed tomography angiogram or magnetic resonance angiography for suspected arterial thrombosis were included. A retrospective case control study design was used to identify, characterize and evaluate potential risk factors for arterial thromboembolic disease in SARS-CoV-2 positive patients. Demographics, characteristics, and laboratory values were abstracted and analyzed.

RESULTS

During the study period, 424 patients underwent 499 arterial duplex, computed tomography angiogram, or magnetic resonance angiography imaging studies with an overall 9.4% positive rate for arterial thromboembolism. Of the 40 patients with arterial thromboembolism, 25 (62.5%) were SARS-CoV-2 negative or admitted for unrelated reasons and 15 (37.5%) were SARS-CoV-2 positive. The odds ratio for arterial thrombosis in COVID-19 was 3.37 (95% confidence interval, 1.68-6.78; P = .001). Although not statistically significant, in patients with arterial thromboembolism, patients who were SARS-CoV-2 positive compared with those testing negative or not tested tended to be male (66.7% vs 40.0%; P = .191), have a less frequent history of former or active smoking (42.9% vs 68.0%; P = .233) and have a higher white blood cell count (14.5 vs 9.9; P = .208). Although the SARS-CoV-2 positive patients trended toward a higher the neutrophil-to-lymphocyte ratio (8.9 vs 4.1; P = .134), creatinine phosphokinase level (359.0 vs 144.5; P = .667), C-reactive protein level (24.2 vs 13.8; P = .627), lactate dehydrogenase level (576.5 vs 338.0; P = .313), and ferritin level (974.0 vs 412.0; P = .47), these differences did not reach statistical significance. Patients with arterial thromboembolic complications and SARS-CoV-2 positive when compared with SARS-CoV-2 negative or admitted for unrelated reasons were younger (64 vs 70 years; P = .027), had a significantly higher body mass index (32.6 vs 25.5; P = .012), a higher d-dimer at the time of imaging (17.3 vs 1.8; P = .038), a higher average in hospital d-dimer (8.5 vs 2.0; P = .038), a greater distribution of patients with clot in the aortoiliac location (5 vs 1; P = .040), less prior use of any antiplatelet medication (21.4% vs 62.5%; P = .035), and a higher mortality rate (40.0% vs 8.0%; P = .041). Treatment of arterial thromboembolic disease in COVID-19 positive patients included open thromboembolectomy in six patients (40%), anticoagulation alone in four (26.7%), and five (33.3%) did not require or their overall illness severity precluded additional treatment.

CONCLUSIONS

Patients with SARS-CoV-2 are at risk for acute arterial thromboembolic complications despite a lack of conventional risk factors. A hyperinflammatory state may be responsible for this phenomenon with a preponderance for aortoiliac involvement. These findings provide an early characterization of arterial thromboembolic disease in SARS-CoV-2 patients.

Management and clinical outcome of concomitant pulmonary embolism and paradoxical saddle aortic arch embolism

A 65-year-old man presented in a peri-arrest situation after collapse, he was found hypoxic with ischaemic arms. CT imaging showed massive bilateral pulmonary embolisms (PEs) and an aortic arch embolus extending from brachiocephalic trunk to left subclavian artery. Following intravenous thrombolysis, repeat imaging revealed that the aortic embolus had migrated distally into both axillary arteries and had occluded the right carotid from origin to skull base. Bilateral upper limb embolectomies were carried out from the brachial arteries together with forearm fasciotomies. Left hemianopia related to a right middle cerebral artery territory infarct was managed conservatively; forearm fasciotomy wounds were primarily closed and the patient was discharged on lifelong anticoagulation. A transoesophageal echocardiogram revealed a patent foramen ovale. This case demonstrates a very unusual presentation of concomitant PE and paradoxical saddle aortic arch embolism. A multidisciplinary approach has resulted in an excellent clinical outcome for this complex patient.

[Revascularization delay and complications in acute upper limb ischemia]

INTRODUCTION

Acute upper limb ischemia is a medical and surgical emergency. Studies that have reported revascularization results in acute upper limb ischemia are rare. For this reason, the revascularization delay has remained poorly defined. The purpose of this study was to evaluate surgery results of acute upper limb ischemia related to revascularization delay.

METHODS

We report a retrospective study of patients operated for acute upper limb ischemia between 2008 and 2016. Patients with thrombotic, traumatic or iatrogenic ischemia were excluded from this study. Patients were divided into two groups (those operated before 12hours and those operated after 12hours). A statistical analysis was performed to compare surgery results between the two groups in terms of limb salvage rate and neurological sequelae rate.

RESULTS

Our population consisted of 138 patients. The average age was 69 [31,92]. There were 90 women and 48 men. The mean revascularization delay was 20hours [2,240]. Seventy-six patients were operated on before 12hours and 62 patients after 12hours. At one month, the mortality was 1.4% and the morbidity was 5.7%. The overall limb salvage rate was 86.9% and the overall neurologic sequelae rate was 31.8%. Statistical analysis showed that there was no significant difference between patients operated before or after 12hours in terms of limb salvage (86.8% versus 87%, P=0.258). However, there was a statistically significant difference in terms of neurological sequelae in favor of patients operated after 12hours (15.7% versus 51.6%, P=0.012).

CONCLUSION

Revascularization of acute embolic upper limb ischemia is often associated with good results even if performed late. Beyond 12hours of ischemia, amputation rate is not significantly higher, however, the rate of neurological sequelae can be high.

Aortic Mural Thrombus in the Non-atherosclerotic Aorta of Patients with Multiple Hypercoagulable Factors

An aortic mural thrombus (AMT) on a non-atherosclerotic wall is a rare but important cause of arterial thromboembolism. We herein report two cases of AMT in the thoracic aorta. Both showed multiple hypercoagulable factors (case 1: protein S deficiency and positive finding of anti-cardiolipin antibody; case 2: protein C deficiency, gastric cancer, and cisplatin-based chemotherapy) and were successfully treated with anticoagulation. Hypercoagulable states, including malignancy, can influence the formation of AMT; therefore, the accurate assessment of a hypercoagulable condition is necessary when we encounter patients with AMT.

Initial and intermediate-term treatment of the phantom thrombus (primary non-occlusive mural thrombus on normal arteries)

An embolic event originating from thrombus on an otherwise un-diseased or minimally diseased proximal artery (Phantom Thrombus) is a rare but significant clinical challenge. All patients from a single center with an imaging defined luminal thrombus with a focal mural attachment site on an artery were evaluated retrospectively. We excluded all patients with underlying anatomic abnormalities of the vessel at the attachment site. Six patients with a mean age of 62.5 years were identified over a 2.5-year period. All patients had completed treatment for or had a current diagnosis of malignancy and none were on antiplatelets or other anticoagulants. Four thrombi originated in the aorta proximal to the renal arteries and one originated distal. One thrombus was found in the common carotid artery and one was in an arterialized vein graft. Mean follow-up was 22 months. None of the patients underwent removal or exclusion of the embolic source. With systemic anticoagulation, four of the phantom thrombi were resolved on imaging within 8 weeks, one resolved after 72 weeks. One phantom thrombus reoccurred after 6 months on reduced anticoagulant dosing. There was one acute and one death in follow-up (26 months). One patient required a partial foot amputation secondary to tissue necrosis from the initial thromboembolic event. Arterial thrombi forming on otherwise normal vessels are a distinct clinical entity. In patients with a phantom thrombus, a strategy of therapeutic anticoagulation for management of the embolic source seems to be safe and effective over both the short and intermediate-term.

Point-of-Care Ultrasound Facilitated Detection of Femoral Occlusive Septic Emboli During Mitral Valve Surgery: A Case Report

Acute lower extremity ischemia from septic emboli is a surgical emergency. Timely diagnosis and management are critical to improve patient outcome. However, traditional diagnostic modalities such as intraoperative angiogram are time-consuming, require special equipment and personnel, and introduce contrast exposure for critically ill patients. There are limited reports of utilization of point-of-care ultrasound to detect peripheral septic emboli. We present a case where femoral occlusive septic emboli were identified by point-of-care ultrasound after mitral valve replacement. This facilitated early surgical embolectomy and limb salvage. We suggest that perioperative point-of-care ultrasonography should be used as a first-line screening test in patients with acute lower extremity ischemia.

Is CHA2DS2-VASc Score Different in Patients with Non-valvular Atrial Fibrillation Suffering from Cerebral and Non-cerebral Thromboembolism?CHA2DS2-VASc Score in Thromboembolism

Background

Thromboembolic complication is directly related to CHA₂DS₂-VASc score in patients with non-valvular atrial fibrillation (NVAF). In this study we compared the CHA₂DS₂-VASc score and in-hospital mortality between NVAF patients with non-cerebral thromboembolism and those with stroke.

Methods

We retrospectively reviewed medical records of 213 patients with NVAF who experienced stroke and 115 patients with NVAF who experienced non-cerebral thromboembolism between 2010 and 2015. In all patients, CHA₂DS₂-VASc score before the event was calculated.

Results

The mean CHA₂DS₂-VASc score was similar in patients with stroke (4.52±1.66) and those with non-cerebral thromboembolism (4.29±2.02) (p=0.196). In-hospital mortality rate was similar between the groups (19% vs. 17%, p=0.756). The rates of coronary artery disease (52% vs. 38%, p=0.014), prior transient ischemic attack (16% vs. 5%, p=0.001), and prior non-cerebral thromboembolism (18% vs. 3%, p<0.001) were higher in patients with non-cerebral thromboembolism. Warfarin (55% vs. 14% p<0.001) and antiplatelet use (56% vs. 40%, p=0.004) was more common in the non-cerebral embolism group, while non-vitamin K antagonist oral anticoagulant (NOAC) use was more common in the stroke group (15% vs. 7% p=0.026).

Conclusion

The patients with stroke had similar CHA₂DS₂-VASc score and in-hospital mortality compared to patients with non-cerebral thromboembolism.

Early Thrombosuction and Tirofiban Use in Knee and Below-Knee Arterial Thrombosis

BACKGROUND Acute limb ischemia (ALI) is a clinical entity with a high rate of morbidity and mortality. Despite advances and variety of its management, there is still no criterion standard treatment. The goal of this study was to evaluate the effect of tirofiban use on the early and 6-month prognosis of patients with knee and below-knee arterial thrombosis who were treated with percutaneous thrombosuction (PT) within 24 h. MATERIAL AND METHODS Data of consecutive ALI patients who were diagnosed with popliteal and infra-popliteal arterial thrombosis and underwent PT procedure within 24 h between January 2010 and September 2015 were evaluated retrospectively. Patients were separated into 2 groups according to tirofiban usage. RESULTS A total of 105 patients (mean age 67±16; 53% men) were included in the study. Atrial fibrillation (n 64, 61%) and hypertension (n 60, 57%) were the most frequent comorbidities in patients with thromboembolic events. A significantly higher rate of distal embolization (6% vs. 16%; p=0.01) and slow-flow (17% vs. 30%; p<0.01) developed in patients who were not treated with tirofiban after the PT procedure. Although major and minor bleeding were more frequent in the tirofiban group, only the rate minor bleeding was statistically significant (29% vs. 9%, p=0.001). Reverse embolic event ratio was similar in both groups. Although there was a higher rate of amputation in patients not treated with tirofiban, the difference was not significant. CONCLUSIONS Adding tirofiban to PT reduces angiographic thromboembolic complications. Usage of tirofiban in patients prone to thromboembolic events may be useful for improving success of the PT procedure, with a reasonable bleeding ratio.

Differences Between Acute Nontraumatic Upper and Lower Extremity Ischemia

The aim of this study was to analyze the differences in natural perioperative history and risk factors in patients with acute upper and lower extremity ischemia. According to the national vascular registry (FINNVASC) for the period January 1991-November 1992, 599 patients were treated in Finland for acute extremity ischemia. Ninety (15%) patients were treated for acute upper limb ischemia and 509 (85%) for acute lower limb ischemia. Upper extremity ischemia was more common in women (P < 0.05). Patients with acute upper limb ischemia were older, 77.1 versus 73.2 years (P < 0.001). The embolus/thrombosis ratio in patients with acute upper extremity ischemia was 90/10% as against 62.5/37.5% in patients with acute lower extremity ischemia (P < 0.001). Smoking was more common in patients with acute lower extremity ischemia (P < 0.05). No other difference was noted in risk factors between the upper and lower extremity groups. No amputation of an upper limb was done. Mortality after acute upper extremity ischemia was 5.6% and after acute lower extremity ischemia 12.8% (P=0.07). The authors conclude that acute upper limb ischemia was most often caused by embolism and these patients were more often older and women as compared with patients with acute lower limb ischemia. Upper limb ischemia was also more common in the right upper limb. No upper limb amputation was done; however, mortality among these patients was not significantly lower.

Sources of Delay in the Acute Limb Ischemia Patient Pathway

BACKGROUND

Acute limb ischemia (ALI) continues to pose a significant challenge to clinicians and is associated with an unacceptably high rate of morbidity and mortality. Despite its time critical nature, little is known regarding the delays encountered during the patient pathway. The aim of this study was to identify sources of delay in the patient pathway at our institution.

METHODS

Sixty-seven cases of ALI of the lower extremities from 66 patients, who had presented to our center between May 2003 and April 2014, were identified for retrospective analysis. Data were retrieved from the patient records, discharge summaries and hospital laboratory, emergency department and radiology databases.

RESULTS

Median time from onset of symptom to arrival at our institution was 11.35 hr (interquartile range [IQR] 6.27-72). Median cumulative time taken from arrival to vascular team review was 40 min (22.5-120), to imaging being performed was 4.75 hr (2.42-17.25), and to intervention being performed was 10.2 hr (4-31). There were significantly longer delays to presentation in those transferred from inpatient beds as compared with those transferred from the emergency department of other hospitals (66 hr [10.3-98] vs. 8 hr [5.6-14.9], P = 0.007). In total, 84.6% of patients underwent preoperative arterial imaging. Time taken from arrival to diagnostic arterial imaging was significantly longer in patients presenting out-of-ours (15 hr [6.5-20.75]) as compared with patients presenting in-hours (3.5 hr [2-6.5], P = 0.014) or during the weekend (2 hr [2-3], P = 0.022). Time from presentation to intervention was significantly shorter in patients presenting over the weekend (3.9 hr [2.6-5.1]) as compared with those presenting in-hours (14.2 hr [6.2-29], P = 0.006) and out-of-hours (16 hr [10-33], P = 0.021). Out-of-hours, a significant portion of the delay, was attributable to imaging (median time to imaging 15 hr).

CONCLUSIONS

This study demonstrates the systematic nature of delays in the patient pathway from onset of symptoms to treatment. Several factors including time to patient presentation and time to imaging and delays in timely transfer to an appropriate facility contribute to this. Strategies need to be deployed to reduce time to revascularization.

Acute bilateral lower extremity arterial occlusion without risk factors or embolic source

Acute arterial occlusion is an emergency condition that, if untreated, can lead to serious complications and potential limb amputation. Risk factors for acute arterial occlusion include aortic atherosclerosis, arterial trauma, recent myocardial infarction, and atrial fibrillation. We present a patient with no history of peripheral vascular disease who presented to the emergency department with severe bilateral leg pain. Computed tomography angiography was performed showing bilateral acute arterial occlusions. Emergent vascular surgery was performed to remove the thrombus and establish perfusion in order to prevent bilateral lower leg amputation.

Extracranial Systemic Embolic Events in Patients With Nonvalvular Atrial Fibrillation

Background—

Nonvalvular atrial fibrillation is a major cause of thromboembolic events. In comparison with atrial fibrillation–related stroke, extracranial systemic embolic events (SEEs) remain poorly defined.

Methods and Results—

All suspected SEEs reported among 37 973 participants of 4 large contemporary randomized clinical trials of anticoagulation in atrial fibrillation were independently readjudicated for clinical and objective evidence of sudden loss of perfusion of a limb or organ. Over 91 746 patient-years of follow-up, 221 SEEs occurred in 219 subjects. The SEE incidence was 0.24 of 100 and stroke incidence was 1.92 of 100 patient-years. In comparison with patients with stroke, those with SEE were more often female (56% versus 47%; P =0.01) and had comparable mean age (73.1±8.5 versus 73.5±8.8 years; P =0.57) and mean CHADS 2 scores (2.4±1.3 versus 2.5±1.2; P =0.33). SEEs more frequently involved the lower extremity (58%) than visceral-mesenteric (31%) or upper extremity (10%). SEE-related care involved clinic assessment alone in 5%, 30% were hospitalized without procedures, 60% underwent endovascular or surgical intervention, and 5% underwent amputation. Within 30 days, 54% of patients recovered fully, 20% survived with deficits, and 25% died. Thirty-day mortality was greater after visceral-mesenteric than lower- or upper-extremity SEE (55%, 17%, and 9%, respectively, P ≤0.0001). The relative risk of death throughout follow-up was 4.33 (95% confidence interval, 3.29–5.70) after SEE versus 6.79 (95% confidence interval, 6.22–7.41) after stroke in comparison with patients without either event.

Conclusions—

SEE constituted 11.5% of clinically recognized thromboembolic events in patients with atrial fibrillation and was associated with high morbidity and mortality. SEE mortality was comparable to that of ischemic stroke and varied by anatomic site.

Upper Limb Ischemia: Clinical Experiences of Acute and Chronic Upper Limb Ischemia in a Single Center

BACKGROUND

Upper limb ischemia is less common than lower limb ischemia, and relatively few cases have been reported. This paper reviews the epidemiology, etiology, and clinical characteristics of upper limb ischemia and analyzes the factors affecting functional sequelae after treatment.

METHODS

The records of 35 patients with acute and chronic upper limb ischemia who underwent treatment from January 2007 to December 2012 were retrospectively reviewed.

RESULTS

The median age was 55.03 years, and the number of male patients was 24 (68.6%). The most common etiology was embolism of cardiac origin, followed by thrombosis with secondary trauma, and the brachial artery was the most common location for a lesion causing obstruction. Computed tomography angiography was the first-line diagnostic tool in our center. Twenty-eight operations were performed, and conservative therapy was implemented in seven cases. Five deaths (14.3%) occurred during follow-up. Twenty patients (57.1%) complained of functional sequelae after treatment. Functional sequelae were found to be more likely in patients with a longer duration of symptoms (odds ratio, 1.251; p=0.046) and higher lactate dehydrogenase (LDH) levels (odds ratio, 1.001; p=0.031).

CONCLUSION

An increased duration of symptoms and higher initial serum LDH levels were associated with the more frequent occurrence of functional sequelae. The prognosis of upper limb ischemia is associated with prompt and proper treatment and can also be predicted by initial serum LDH levels.

Acute embolic occlusion of the right common iliac artery after revision total hip arthroplasty treated with catheter-directed thrombolysis and balloon angioplasty: A case report

METHODS

A 63-year-old woman with atrial fibrillation presented clinical symptoms and signs of acute ischemia in the right lower extremity on the 17th postoperative day after revision total hip arthroplasty of the left hip for aseptic loosening of femoral component. Aspirin was discontinued 7 days before surgery. Both computed tomography angiography and digital subtraction angiography demonstrated complete occlusion of the right common iliac artery. An emergency catheter-directed thrombolysis with urokinase combined with balloon angioplasty was performed to obtain complete patency of the right common iliac artery.

RESULTS

The patient received anticoagulation and antiplatelet therapy postoperatively and was fine at the 2-year follow-up.

CONCLUSIONS

This case demonstrated that catheter-directed thrombolysis combined with balloon angioplasty could be an efficacious, minimally invasive approach for the treatment of acute embolic occlusion of the common iliac artery. Preoperative anticoagulation for patients undergoing total hip arthroplasty with long-term use of aspirin for atrial fibrillation needs further investigation.

Digital Gangrene an Unusual Presentation of Takayasu's Arteritis

Context:

Takayasu arteritis (TA) is a chronic inflammatory disease involving large vessels like aorta and its major branches. It presents to clinician with features of arm claudication, stroke, asymmetrical pulse, or asymmetrical blood pressure in both limbs. Digital gangrene may be occurred secondary to various systemic diseases like diabetes, thrombophilic states, vascular embolism, and medium and small vessel vasculitis or infections. Through evaluation to diagnose the exact etiology and timely intervention is needed to prevent progression of the gangrene which at the time can be life-threatening. Digital gangrene as an initial presentation in TA is very rare. In medical literature, there are only few case reports have been reported.

Case Report:

We are reporting a case of a 26-year-old female patient presented with right little finger and index finger gangrene, ultimately diagnosed as TA and responded dramatically to treatment.

Conclusion:

Though rare, TA should be taken in the differential diagnosis for work up in a case of digital gangrene and it necessitates more studies in this field to uncover the exact pathophysiology for such presentation.

Acute Limb Ischemia

Acute limb ischemia is a vascular event presenting with sudden decrease in limb perfusion (of <14 days' duration) that threatens limb viability. Acute thrombosis of the native artery or graft makes up the bulk of etiopathogenesis. Prompt revascularization is the cornerstone of management of acute limb ischemia in limbs that have not undergone irreversible tissue and nerve damage. Amputation is performed in patients with irreversible tissue and nerve damage.

Acute limb ischemia: surgical thromboembolectomy and the clinical course of arterial revascularization at ankle

Surgical thromboembolectomy for acute limb ischemia using Fogarty catheter is basically a blind procedure. Therefore, the complete removal of thromboemboli in all calf arteries is difficult even if completion angiography or radiological intervention is performed. The purpose of this study is to identify whether limb salvage could be achieved if at least one ankle artery was revascularized by surgical thromboembolectomy. We also observed the effectiveness of below-knee popliteal approach. Over 1 year, surgical thromboembolectomy via below-knee popliteal artery was performed on 18 acutely ischemic limbs in 14 consecutive patients. All patients were diagnosed based on clinical symptoms and computed tomography (CT) angiography. Surgical thromboembolectomy was terminated when a pulse was detected by a handheld vascular Doppler device in at least one ankle artery after closing the arteriotomy. Patients were observed during postoperative anticoagulation therapy. Of the 14 patients, 1 died and 1 underwent amputation due to the already necrotized lesion in the foot. After 1 week of anticoagulation therapy, two or more arterial pulses were detected at the ankles in all 15 limbs from the remaining 12 patients. During the 6 to 18 months of follow-up, all 15 limbs were salvaged successfully. In acute limb ischemia, successful limb salvage could be achieved by the revascularization of at least one ankle artery by surgical thromboembolectomy with concomitant anticoagulation therapy. Below-knee popliteal approach is an effective method and is worth for further study compared with other approaches.

Twenty-Year Analysis of Trends in the Incidence and In-Hospital Mortality for Lower-Extremity Arterial Thromboembolism

Background—

Epidemiology data for lower-extremity arterial thromboembolism (LET) are limited and may result from either acute limb ischemia or an acute exacerbation of critical limb ischemia. Given marked changes in both diagnosis and therapy over the last 2 decades, we hypothesized that this time period would have witnessed reductions in both the incidence and in-hospital mortality of LET.

Methods and Results—

Data from 1988 through 2007 from the National Hospital Discharge Survey were analyzed. All admissions for patients with LET were extracted, and the respective International Classification of Diseases, Ninth Revision, Clinical Modification codes were internally validated for both LET and acute limb ischemia. Descriptive statistics were used. The validity of the codes was good for identifying LET cases but poor for identifying acute limb ischemia cases because many of these acute presentations were attributable to critical limb ischemia. Over the 20-year span, there were 1.76 million cases of LET. The incidence of LET decreased significantly from 42.4 per 100 000 persons between 1988 and 1997 to 23.3 per 100 000 persons between 1998 and 2007. The in-hospital mortality for LET decreased significantly from 8.28% between 1988 and 1997 to 6.34% between 1998 and 2007, and male patients achieved greater mortality reduction compared with female patients. Treatments for acute limb ischemia showed decreasing use of surgical bypass and amputation and increasing rates of catheter-based thrombolysis.

Conclusions—

Over the 20-year study period, there have been significant reductions in both LET incidence and in-hospital mortality. Unfortunately, LET admissions extracted from an administrative database comprise a diverse group of individuals, including those with acute and chronic forms of limb ischemia and iatrogenic arterial injury, limiting the true assessment of ALI incidence.

Atrial fibrillation and upper limb thromboembolectomy: a national cohort study

BACKGROUND

The risk factors associated with, and the incidence of systemic embolism in patients with atrial fibrillation (AF) are poorly understood.

OBJECTIVES

We studied the association between AF and upper limb thromboembolectomy involving brachial, ulnar or radial artery in a national cohort study that included all individuals aged 40-99 years with incident AF.

METHODS

Data were retrieved from the Danish National Vascular Registry, the National Registry of Patients, the Danish Civil Registration System and Statistics Denmark.

RESULTS

In total, 131,476 patients (68,042 men and 63,434 women) with AF without previous thromboembolectomy in the upper limb were registered. In the study cohort, 130 men underwent upper limb thromboembolectomy over 220,890 person-years of observation, whilst 275 women underwent thromboembolectomy over 197,777 patient-years. The incidence per 100,000 person-years was 58.9 (95% CI, 49.2-69.8) for men and 139.1 (95% CI, 123.1-156.5) for women. The relative risk of thromboembolectomy among patients with AF compared to the background population was 7.5 (95% CI, 6.3-8.9) for men, and 9.3 (95% CI, 8.3-10.5) for women. Women with AF had a relative thromboembolectomy risk of 1.8 (95% CI, 1.5-2.3) compared to men with AF. Among patients with AF, history of hypertension (HR 2.2-2.9), myocardial infarction (HR 2.9-3.9), heart failure (HR 1.6-1.9) and stroke (HR 2.2-3.8) were significantly associated with increased risk of thromboembolectomy in both men and women.

CONCLUSIONS

AF substantially increases the risk of upper limb thromboembolectomy. This risk is higher with increasing age, female gender, and associated with hypertension, myocardial infarction, heart failure and stroke.

Multiple thromboembolism with multiple causes in a 69-year-old woman: a case report

Introduction

Aggressive, recurrent embolisms require accurate etiologic diagnosis. We describe the case of a 69-year-old Italian Caucasian woman with recurrent arterial embolisms in whom several sources and triggers of thrombosis were detected.

Case presentation

The patient, a 69-year-old Italian Caucasian woman, presented with a systemic embolism that was initially attributed to atrial fibrillation. The recurrence of embolisms despite anti-thrombotic therapy prompted a re-evaluation of the clinical presentation. New potential causes of thrombosis emerged in this patient, including thrombocytosis associated with the JAK2 V617F mutation and the very rare mural thrombosis of the descending aorta. A mural thrombus in the pulmonary artery was detected contiguous with the aortic mural thrombosis, raising the possibility of a clinically silent ductus Botalli as the initiating event. The patient was treated with warfarin, aspirin, hydroxyurea, and surgery.

Conclusions

The diagnosis was achieved via systematic use of imaging procedures and reconsideration of blood tests performed to explore the diagnosis of thrombosis. This allowed a deeper and more detailed analysis of the case beyond the conventional approach, which would have aimed to identify one cause for the condition at hand, in this case, atrial fibrillation. The broader approach that we used resulted in the diagnosis of multiple embolisms from multiple sites and multiple causes.

Update experience of surgery for acute limb ischaemia in a district general hospital - are we getting any better?

INTRODUCTION

The aims of this study were to audit results of a 10-year experience of surgery for acute limb ischaemia (ALI) in terms of limb salvage and mortality rates, and to compare results with a historical published series from our unit.

PATIENTS AND METHODS

All emergency operations performed during the period 1993-2003 were identified from theatre registers and patient notes reviewed to determine indications for, and outcome of, surgery. Data were compared to a similar cohort who underwent surgery from 1980 to 1990.

RESULTS

There was a 33% increase in workload from 87 to 116 patients between the two time periods. The number of patients with idiopathic ALI reduced (24% versus 4%; P < 0.05), and there were fewer smokers (71% versus 39%; P < 0.05) and a greater number of claudicants (17% versus 35%; P < 0.05) in those treated from 1993-2003. Latterly, more patients underwent pre-operative heparinisation (33% versus 80%; P < 0.05), received prophylactic antibiotics (14% versus 63%; P < 0.05), and had anaesthetic presence in theatre (46% versus 88%; P < 0.05). There was also a reduction in local anaesthetic procedures (80% versus 41%; P < 0.05). Despite increased pre-operative (15% versus 47%; P < 0.05) and on-table imaging (0% versus 16%; P < 0.05) technical success did not improve. Whilst complication rates were identical at 62%, there were fewer cardiovascular complications in the recent cohort. The 30-day mortality rate for embolectomy fell from 45% to 33%. Multivariate analysis revealed age > 70 years, prolonged symptom duration, ASA score > or = III, lack of prophylactic antibiotics, absence of an anaesthetist, and operations performed under local anaesthetic to be associated with increased risk of mortality. Factors adversely affecting limb salvage included prolonged duration from symptom onset to operation, and a history of claudication or smoking.

CONCLUSIONS

Despite improvements in pre- and peri-operative management, arterial embolectomy/thrombectomy remains a procedure with a high morbidity and mortality. Further attempts to improve outcome must be directed at early diagnosis and referral as delay from symptom onset to surgery is a major determinant of outcome.

Proper evaluation and management of acute embolic versus thrombotic limb ischemia

Acute limb ischemia is one of the most potentially devastating but treatable diseases faced by the vascular surgeon. It is crucial to identify the ischemic process early, as the outcomes of early intervention can lead to limb salvage, whereas late recognition places the patient at risk for limb loss and potential mortality. This article emphasizes the importance of properly evaluating the acutely ischemic extremity to ascertain whether the etiology is embolic or thrombotic. Appropriate treatment and management of the limb are determined by the underlying cause of the ischemia. The authors will review the clinical features, angiographic findings, and strategies for management for these similar but distinct etiologies: acute embolic versus thrombotic limb ischemia.

Peripheral arterial ischemia by a primary lung tumour invading left atrium

Peripheral arterial embolism from a malignant tumour is an uncommon manifestation of a neoplasm. Here, we present a case of acute upper limb ischemia due to an embolus originating from primary lung malignancy invading the left atrium.

Arterial embolectomy: a retrospective evaluation of 730 cases over 20 years

PURPOSE

We reviewed our experience of treating acute peripheral arterial occlusion to determine whether early diagnosis and treatment prevents loss of function of the vital organs caused by ischemia threatening the extremities.

METHODS

We retrospectively examined the records of 730 patients who underwent a collective total of 794 operations for peripheral arterial occlusion of the upper or lower extremities at Erzurum Numune Hospital between January 1984 and April 2004.

RESULTS

The patients ranged in age from 11 to 86 years old, with a mean age of 58.7 years for men and 64.3 years for women. The underlying cause of arterial embolism was atrial fibrillation in most (433; 59.3%) patients. Two hundred and eleven (28.9%) patients were admitted less than 6 h preoperatively, 104 (14.2%) were admitted 6-12 h preoperatively, 194 (26.5%) were admitted 12-24 h preoperatively, and 221 (30.2%) were admitted more than 24 h preoperatively. All of the patients underwent embolectomy and 64 revisions were done. The overall mortality rate was 3.69%.

CONCLUSIONS

The extremity preservation rate was related to the time delay between the onset of symptoms and surgical intervention.