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Pradhan S, Gresa K, Röing Genannt Nölke JP, Trappe HJ. Blue toe syndrome caused by emboli from anomalous left atrial septal pouch thrombus: a case report. Thromb J 2020; 18:13. [PMID: 32699533 PMCID: PMC7370423 DOI: 10.1186/s12959-020-00226-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 06/15/2020] [Indexed: 12/28/2022] Open
Abstract
Background Left atrial septal pouches (LASPs) are a relatively newly described but common anatomical cardiac variant thought to be associated with atrial fibrillation (AF) and cardio-embolic stroke. Blue toe syndrome (BTS) describes ischemic changes in the toes due to microembolisation of the digital arteries. Establishing the etiology of BTS is vital so that the underlying cause can be treated. Here we describe the first case of BTS arising due to emboli from LASP thrombus arising on a background of new-onset AF. Case presentation A 65-year-old man presented with a two-day history of progressive painful swelling and bluish-purple discoloration of the second and fourth toes of his left foot and new-onset AF. Tests for hypercoagulability disorders were negative. Duplex ultrasound and CT angiography excluded deep venous thrombosis and an absence of embolus, thrombus, or occlusion in the arterial tree in the lower extremities bilaterally, so BTS was diagnosed. While transthoracic echocardiography and chest CT initially showed no cardiac abnormalities or mural thrombus, subsequent transesophageal echocardiography revealed a LASP with an associated pedunculated thrombus. The affected toes were amputated due to wet gangrene, but the patient recovered well with thrombus resolution after anticoagulation. Conclusion The presence of a LASP in the absence of any other identifiable cause of BTS should trigger careful investigation of the interatrial septum, preferably using a multimodality imaging approach. The possibility that LASPs may not merely be an innocent bystander but a causative mechanism for peripheral ischemia must be considered.
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Affiliation(s)
- Snehasis Pradhan
- Department of Cardiology and Angiology, Marien Hospital Herne, Ruhr- University of Bochum, Hoelkeskampring 40, 44625 Herne, Germany
| | - Kciku Gresa
- Department of Cardiology and Angiology, Marien Hospital Herne, Ruhr- University of Bochum, Hoelkeskampring 40, 44625 Herne, Germany
| | - Jan-Peter Röing Genannt Nölke
- Department of Cardiology and Angiology, Marien Hospital Herne, Ruhr- University of Bochum, Hoelkeskampring 40, 44625 Herne, Germany
| | - Hans-Joachim Trappe
- Department of Cardiology and Angiology, Marien Hospital Herne, Ruhr- University of Bochum, Hoelkeskampring 40, 44625 Herne, Germany
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2
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Kızıltan F, Benli ED, Yılmaz S, Kalender M, Gunaydin S. Association of arterial thromboembolism location with presence of nonvalvular atrial fibrillation. Vascular 2020; 28:325-328. [PMID: 32036773 DOI: 10.1177/1708538119881077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Since nonvalvular atrial fibrillation is persistent in nature, patients with chronic nonvalvular atrial fibrillation are at life-time risk for development of thromboembolic events. Several novel oral anticoagulants have entered the market and there has been a growing body of evidence regarding their efficacy in prevention of ischemic stroke and arterial thromboembolism. The present study sought to compare the baseline characteristics between patients presenting with upper and lower extremity arterial thromboembolism developed secondary to nonvalvular atrial fibrillation. METHODS This retrospective study was made up of patients presenting with acute upper or lower extremity arterial thromboembolism as the first presentation of atrial fibrillation. Patients were included if they had acute upper or lower critical limb ischemia symptoms lasting for less than one week. Patients in whom chronic peripheral artery disease was diagnosed were also excluded to prevent potential confounding. RESULTS Overall, 46.9% of patients presented with upper extremity arterial thromboembolism and 53.1% of patients presented with lower extremity arterial thromboembolism. None of the baseline characteristics showed significant difference between patients with upper and lower extremity arterial thrombosis. CONCLUSION It was observed that there was no significant difference in the incidence of extremity involvement of acute arterial thromboembolism occurring in patients with nonvalvular atrial fibrillation in our study, and we think that acute arterial thromboembolism must be taken into consideration as one of the first signs and symptoms of atrial fibrillation.
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Affiliation(s)
- Feryaz Kızıltan
- Department of Cardiovascular Surgery, Istanbul Okmeydani Education and Research Hospital, Istanbul, Turkey
| | - Emre Demir Benli
- Department of Cardiovascular Surgery, Derince Education and Research Hospital, Kocaeli, Turkey
| | - Seyhan Yılmaz
- Department of Cardiovascular Surgery, Çorlu Province Hospital, Tekirdağ, Turkey
| | - Mehmet Kalender
- Department of Cardiovascular Surgery, Derince Education and Research Hospital, Kocaeli, Turkey
| | - Serdar Gunaydin
- Department of Cardiovascular Surgery, Ankara Numune Education and Research Hospital, Ankara, Turkey
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3
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Emren SV, Ada F, Aldemir M, Tecer E, Çarşanba G, Çelik D, Çelik E, Onrat E. Is CHA 2DS 2-VASc Score Different in Patients with Non-valvular Atrial Fibrillation Suffering from Cerebral and Non-cerebral Thromboembolism?CHA 2DS 2-VASc Score in Thromboembolism. J Atr Fibrillation 2017; 10:1575. [PMID: 29250228 DOI: 10.4022/jafib.1575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 06/25/2017] [Accepted: 08/24/2017] [Indexed: 11/10/2022]
Abstract
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.
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Affiliation(s)
- Sadık Volkan Emren
- Afyonkarahisar State Hospital Department of Cardiology Afyonkarahisar/Turkey
| | - Fatih Ada
- Afyonkarahisar State Hospital Department of Cardiolovascular Surgery Afyonkarahisar/Turkey
| | - Mustafa Aldemir
- Afyon Kocatepe University Department of Cardiolovascular Surgery Afyonkarahisar/Turkey
| | - Evren Tecer
- Afyon Kocatepe University Department of Cardiolovascular Surgery Afyonkarahisar/Turkey
| | - Görkem Çarşanba
- Afyon Kocatepe University Department of Cardiolovascular Surgery Afyonkarahisar/Turkey
| | - Damla Çelik
- Afyonkarahisar State Hospital Department of Neurology Afyonkarahisar/Turkey
| | - Ersin Çelik
- Afyonkarahisar State Hospital Department of Cardiolovascular Surgery Afyonkarahisar/Turkey
| | - Ersel Onrat
- Afyon Kocatepe University Department of Cardiology Afyonkarahisar/Turkey
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4
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Landry GJ, Shukla R, Rahman A, Azarbal AF, Mitchell EL, Liem TK, Moneta GL. Demographic and echocardiographic predictors of anatomic site and outcomes of surgical interventions for cardiogenic limb emboli. Vasc Med 2016; 21:528-534. [PMID: 27807307 DOI: 10.1177/1358863x16666691] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We sought to determine if symptomatic cardiogenic limb emboli have a random distribution or if there are demographic or echocardiographic factors that predict site of embolization, limb salvage and mortality. Upper (UE) and lower extremity (LE) emboli were evaluated over a 16-year period (1996-2012). Demographic (age, gender, smoking, medical comorbidities) and echocardiographic data were analyzed to determine predictors of embolic site. All symptomatic patients underwent surgical revascularization. Limb salvage and mortality were compared with Kaplan-Meier analysis. A total of 161 patients with symptomatic cardiogenic emboli were identified: 56 UE and 105 LE. The female-to-male ratio for UE emboli (70%:30%) was significantly higher than for LE emboli (47%:53%, p=0.008). No other demographic factors were statistically different. Upper extremity patients were more likely to have atrial fibrillation (50% vs 29.8%, p=0.028), while LE patients had a higher percentage of aortic or mitral valvular disease or intracardiac thrombus (71.4% vs 52.5%, p=0.038). The 30-day limb salvage was higher for UE compared to LE (100% vs 88%, p=0.008). There was a trend toward higher 30-day mortality in the LE group (14% vs 5%, p=0.11). Survival at 1, 3, and 5 years were similar (UE: 62.2%, 44.2%, 35.3%; LE: 69.1%, 47.5%, 30.3%; p=ns). Upper extremity emboli are more frequent in women and patients with atrial fibrillation. Lower extremity emboli are more frequent in the presence of valvular disease or intracardiac thrombus, and are associated with increased 30-day limb loss and mortality. These findings suggest gender- and cardiac-specific differences in patterns of blood flow leading to preferential sites of peripheral embolization.
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Affiliation(s)
- Gregory J Landry
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Rakendu Shukla
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Auddri Rahman
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Amir F Azarbal
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Erica L Mitchell
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Timothy K Liem
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Gregory L Moneta
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
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Kim HK, Jung H, Cho J, Huh S, Lee JM, Kim YW. Therapeutic outcomes and thromboembolic events after treatment of acute arterial thromboembolism of the upper extremity. Ann Vasc Surg 2014; 29:303-10. [PMID: 25462546 DOI: 10.1016/j.avsg.2014.08.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2014] [Revised: 06/04/2014] [Accepted: 08/21/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND To investigate short- and long-term outcomes of patients with acute arterial thromboembolism of upper extremity, focusing on postoperative thromboembolic events by etiology. METHODS Hospital records of 53 patients (average age 70 years; males 49%) with acute arterial thromboembolism of upper extremity treated between June 1993 and December 2013 were retrospectively reviewed, evaluating patient characteristics and clinical outcomes, both short and long term. Subjects were stratified as those with (group I, 34) and without (group II, 19) atrial fibrillation as underlying cause. RESULTS Two patients received anticoagulation alone as conservative treatment. The remainder (n = 51) underwent surgical revascularization. Symptoms resolved in 51 patients (96%) except 2 patients with postoperative reocclusion, and there was no need of amputation in all patients. Overall inpatient mortality was 5.6% (3/53). Patients of group I suffered most of the recurrent thromboembolic events (group I: 17 events, 14 patients; group II: 2 events, 2 patients) recorded during follow-up (mean duration 56.8 ± 62.2 months). Respective event-free survival rates at 1, 3, and 5 years differed significantly by group: 77%, 44%, and 44% for group I; 100%, 100%, and 83% for group II (P = 0.004). Among 14 patients with recurrent embolic events in group I, half of the patients were not receiving anticoagulants; however, anticoagulant cessation was generally arbitrary. Overall survival rates at 1, 3, and 5 years were 82%, 69%, and 52% for group I and 84%, 78%, and 70% for group II (P = 0.21). CONCLUSIONS In this study, surgical treatment of acute arterial thromboembolism of upper extremity was largely successful. Especially in patients with atrial fibrillation, adequate long-term anticoagulation is indicated as prophylaxis, given the high rates of recurrent thromboembolic events.
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Affiliation(s)
- Hyung-Kee Kim
- Division of Vascular Surgery, Department of Surgery, Kyungpook National University School of Medicine, Daegu, South Korea
| | - Heekyung Jung
- Division of Vascular Surgery, Department of Surgery, Kyungpook National University School of Medicine, Daegu, South Korea
| | - Jayun Cho
- Division of Vascular Surgery, Department of Surgery, Kyungpook National University School of Medicine, Daegu, South Korea
| | - Seung Huh
- Division of Vascular Surgery, Department of Surgery, Kyungpook National University School of Medicine, Daegu, South Korea.
| | - Jong-Min Lee
- Department of Radiology, Kyungpook National University School of Medicine, Daegu, South Korea
| | - Young-Wook Kim
- Division of Vascular Surgery, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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6
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Cranial and non-cranial embolism: incidence in hospitalised patients in Germany. J Thromb Thrombolysis 2013; 36:369-74. [DOI: 10.1007/s11239-013-0873-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Heilmann C, Schmoor C, Siepe M, Schlensak C, Hoh A, Fraedrich G, Beyersdorf F. Controlled Reperfusion Versus Conventional Treatment of the Acutely Ischemic Limb. Circ Cardiovasc Interv 2013; 6:417-27. [DOI: 10.1161/circinterventions.112.000371] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Amputation rates and mortality in patients with severe acute limb ischemia remain high. The protective effect of controlled reperfusion (CR) on tissue damage because of local and systemic reperfusion injury is unclear.
Methods and Results—
A total of 174 patients from 14 centers were randomized between conventional treatment (CT) by thrombembolectomy and normal blood reperfusion and thrombembolectomy followed by CR. The primary end point was amputation-free survival (AFS) after 4 weeks (CT, 82.4%; CR, 82.6%). Secondary end points were AFS (CT, 62.4%; CR, 63.1%) and overall survival (CT, 71.6%; CR, 76.3%) after 1 year. Analysis of the prognostic effects of preoperative factors revealed a strong adverse effect of bilateral involvement on AFS. In the subgroup with unilateral ischemia (n=160), age >80 years and central localization of the occlusion had independent negative prognostic effects on AFS. In the per-protocol population of 104 patients with unilateral ischemia, treatment per protocol, and successful revascularization, amputation or death within 4 weeks occurred in only 8% as compared with 33% in patients not fulfilling these criteria. No differences between treatment groups CT and CR were found, neither overall nor in the per-protocol population nor in patient subgroups defined by other pre- and intraoperative factors.
Conclusions—
Similar AFS in patients with CT or with CR was observed in this large randomized multicenter trial.
Clinical Trial Registration—
URL:
http://www.drks.de
. Unique identifier: DRKS00000579.
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Affiliation(s)
- Claudia Heilmann
- From the Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany (C.H., M.S., C. Schlensak, F.B.); Clinical Trials Unit, University Medical Center Freiburg, Freiburg, Germany (C. Schmoor); and Department of Vascular Surgery, Medical University, Innsbruck, Austria (A.H., G.F.)
| | - Claudia Schmoor
- From the Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany (C.H., M.S., C. Schlensak, F.B.); Clinical Trials Unit, University Medical Center Freiburg, Freiburg, Germany (C. Schmoor); and Department of Vascular Surgery, Medical University, Innsbruck, Austria (A.H., G.F.)
| | - Matthias Siepe
- From the Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany (C.H., M.S., C. Schlensak, F.B.); Clinical Trials Unit, University Medical Center Freiburg, Freiburg, Germany (C. Schmoor); and Department of Vascular Surgery, Medical University, Innsbruck, Austria (A.H., G.F.)
| | - Christian Schlensak
- From the Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany (C.H., M.S., C. Schlensak, F.B.); Clinical Trials Unit, University Medical Center Freiburg, Freiburg, Germany (C. Schmoor); and Department of Vascular Surgery, Medical University, Innsbruck, Austria (A.H., G.F.)
| | - Andreas Hoh
- From the Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany (C.H., M.S., C. Schlensak, F.B.); Clinical Trials Unit, University Medical Center Freiburg, Freiburg, Germany (C. Schmoor); and Department of Vascular Surgery, Medical University, Innsbruck, Austria (A.H., G.F.)
| | - Gustav Fraedrich
- From the Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany (C.H., M.S., C. Schlensak, F.B.); Clinical Trials Unit, University Medical Center Freiburg, Freiburg, Germany (C. Schmoor); and Department of Vascular Surgery, Medical University, Innsbruck, Austria (A.H., G.F.)
| | - Friedhelm Beyersdorf
- From the Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany (C.H., M.S., C. Schlensak, F.B.); Clinical Trials Unit, University Medical Center Freiburg, Freiburg, Germany (C. Schmoor); and Department of Vascular Surgery, Medical University, Innsbruck, Austria (A.H., G.F.)
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8
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Santosa F, Nowak T, Moysidis T, Eickmeier F, Stallinger C, Luther B, Knut K. CHADS 2 and CHA 2DS 2Vasc-Score in Peripheral Systemic Embolism. J Atr Fibrillation 2013; 6:715. [PMID: 28496847 DOI: 10.4022/jafib.715] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Revised: 05/22/2013] [Accepted: 05/23/2013] [Indexed: 01/05/2023]
Abstract
Objectives: We analysed the characteristics of patients with an acute peripheral embolic event considering the possible use of the CHADS2-Score and the CHA2DS2Vasc-Score Patients and Methods: We retrospectively analyzed 163 cases of acute peripheral arterial embolism treated in the Department of Vascular Medicine of the HELIOS Klinik Krefeld, Germany, from 2008 to 2011. We retrospectively screened the medical form for information regarding atrail fibrillation (AF) and the risk factors necessary to calculate the CHADS2 and CHA2DS2vasc score. Results: Arterial hypertension and age > 75 years were the most frequent risk factors. Mean CHADS2 score was similar in males and females (2.3 ± 1.5 and 2.3 ± 1.4). 66% of the males and 63.3% of the females scored 2 and more points. Mean CHA2DS2Vasc score was 3.6 ± 2.0 in males and 4.6 ± 1.9 in females. 85.2% of the males and 95.4% of the females scored more than 2 points. In the medical forms AF was documented in 79 (48%) patients, of which 23 (43 %) were males and 56 (51%) females. Mean CHADS2 score and mean CHA2DS2Vasc score were slightly higher in those with AF compared to the total group, but not significantly different. The rate of patients with 2 and more points increased for both scores: CHADS2 score: males 82.6% and females 76.8%, CHA2DS2Vasc: males 100% and females 98.2%. Almost half of the patients with AF had had anticoagulation with phenprocoumon before (males 12 (52%), females 24 (43%), but only every 10th was within the therapeutic range (INR ≥2) Conclusion: The number of those with AF is high amongst patients with acute peripheral embolism. According to the CHADS2 and CHA2DS2Vasc score, most of these patients had an indication for oral anticoagulation independent form the embolic event.
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Affiliation(s)
| | | | | | - Frank Eickmeier
- Department of Diagnostic and Interventional Radiology, HELIOS Klinikum Krefeld, Germany
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9
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Abstract
Surgical and intensive care patients are at a heightened risk for arterial embolization due to pre-existing conditions such as age, hypercoagulability, cardiac abnormalities and atherosclerotic disease. Most arterial emboli are clots that originate in the heart and travel to distant vascular beds where they cause arterial occlusion, ischemia, and potentially infarction. Other emboli form on the surface of eroded arterial plaque or within its lipid core. Thromboemboli are large clots that dislodge from the surface of athesclerotic lesions and occlude distal arteries causing immediate ischemia. Atheroemboli, which originate from fracturing the lipid core tend to cause a process of organ dysfunction and systemic inflammation, termed cholesterol embolization syndrome. The presentation of arterial emboli depends on the arterial bed that is affected. The most common manifestations are strokes and acute lower limb ischemia. Less frequently, emboli target the upper extremities, mesenteric or renal arteries. Treatment involves rapid diagnosis, which may be aided by precise imaging studies and restoration of blood flow. The type of emboli, duration of presentation, and organ system affected determines the treatment course. Long-term therapy includes supportive medical care, identification of the source of embolism and prevention of additional emboli. Patients who experienced arterial embolism as a result of clots formed in the heart should be anticoagulated. Arterial emboli from atherosclerotic disease of the aorta or other large arteries should prompt treatment to reduce the risk for atherosclerotic progression, such as anti-platelet therapy and the use of statin drugs. The use of anticoagulation and surgical intervention to reduce the risk of arterial embolization from atherosclerotic lesions is still being studied.
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Affiliation(s)
- Michael R Lyaker
- Department of Anesthesiology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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10
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Andersen LV, Lip GYH, Lindholt JS, Frost L. Upper limb arterial thromboembolism: a systematic review on incidence, risk factors, and prognosis, including a meta-analysis of risk-modifying drugs. J Thromb Haemost 2013; 11:836-44. [PMID: 23433284 DOI: 10.1111/jth.12181] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Accepted: 02/15/2013] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The aim of this review is to focus on risk factors, risk-modifying drugs and prognosis for upper limb arterial thromboembolism, and the relationship between upper limb arterial thromboembolism and atrial fibrillation (AF). METHODS We searched MEDLINE for studies on the epidemiology of upper limb thromboembolism from 1965 to June 2012. We also searched for contemporary, phase III randomized trial data on systemic (non-stroke) thromboembolism comparing warfarin with new oral anticoagulants (OACs) in patients with atrial fibrillation published after the year 1999. RESULTS The incidence of upper limb thromboembolectomy was 3.3 per 100 000 person-years among men and 5.2 per 100 000 person-years among women; the risk of limb amputation, stroke and death after thromboembolectomy was increased. There was an increased risk of thromboembolectomy of the upper limb in patients with AF diagnosed with hypertension (hazard ratio [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). For those diagnosed with diabetes mellitus, the risk was non-significantly increased by 1.2-1.4. Females had a 1.8-fold (95% confidence interval [CI] 1.5-2.3) fold increased risk of thromboembolectomy as compared with men. The risk reduction for systemic embolism with new OACs as compared with warfarin in patients with AF is similar to that seen with warfarin (odds ratio 0.79, 95% CI 0.38-1.64). CONCLUSIONS Age, female sex, AF, hypertension, diabetes, myocardial infarction, heart failure and stroke are most common risk factors for thromboembolectomy of the upper limb. The availability of new OACs holds promise for reducing the risk of systemic thromboembolism, but specific data are still limited.
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Affiliation(s)
- L V Andersen
- Department of Clinical Pharmacology, Aarhus University Hospital, Aarhus, Denmark.
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11
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Piatkowski R, Kaplon-Cieslicka A, Scislo P, Kochanowski J, Karpinski G, Opolski G. Complication of acute myocardial infarction by systemic arterial embolism in the era of multimodality imaging. J Emerg Med 2013; 44:e85-e87. [PMID: 22209552 DOI: 10.1016/j.jemermed.2011.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2011] [Revised: 07/16/2011] [Accepted: 08/28/2011] [Indexed: 05/31/2023]
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12
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Griffin KJ, Rankine J, Kessel D, Berridge DC, Scott DJA. Compression of the dorsalis pedis artery: a novel cause of blue toe syndrome. Vascular 2012; 20:325-8. [DOI: 10.1258/vasc.2011.cr0323] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Blue toe syndrome (BTS) is an important vascular condition characterized by painful blue discoloration of one or more digits. It is frequently due to emboli and is important because of the risk of progressive ischemia and tissue loss. A 53-year-old male presented with recurrent episodes of painful blue discoloration and blistering of the skin of the right hallux. On examination, the patient was found to have a cool, blue-purple great toe; all peripheral pulses were present. The patient was investigated for coagulopathy and potential sources of emboli, but the only abnormality was significant stenosis of the dorsalis pedis artery due to extrinsic compression by the extensor hallucis brevis tendon. In the absence of any other embolic source or abnormality, we believe that this case presents a novel and potentially remediable cause of BTS and indicates the need for a careful search for an underlying lesion when common causes of BTS have been excluded.
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Affiliation(s)
- K J Griffin
- Leeds Vascular Institute, Leeds General Infirmary
| | - J Rankine
- Department of Radiology, Leeds General Infirmary, Leeds LS1 3EX, UK
| | - D Kessel
- Department of Radiology, Leeds General Infirmary, Leeds LS1 3EX, UK
| | - D C Berridge
- Leeds Vascular Institute, Leeds General Infirmary
| | - D J A Scott
- Leeds Vascular Institute, Leeds General Infirmary
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13
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Moon IS, Hwang JK, Kim JI. Recurrent upper extremity embolism due to a crutch-induced arterial injury: a different cause of upper extremity embolism. Ann Vasc Surg 2010; 24:554.e7-554.e12. [PMID: 20097518 DOI: 10.1016/j.avsg.2009.11.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Revised: 08/04/2009] [Accepted: 11/11/2009] [Indexed: 10/19/2022]
Abstract
Acute embolism of the upper extremity is a relatively infrequent event compared to the lower extremity, but it will affect the function of the limb involved and may occasionally lead to amputation. Most upper extremity emboli are of cardiac origin, with the remainder arising from subclavian aneurysm, occlusive disease, or iatrogenic causes. Rarely, crutch-induced repetitive trauma of an upper extremity can produce recurrent embolic events. Frequently, this process is initially diagnosed and treated as a brachial artery embolism; such a misdiagnosis is associated with recurrent embolism. We report herein two uncommon cases of axillobrachial arterial injuries secondary to crutch trauma as a source of recurrent emboli to an upper extremity.
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Affiliation(s)
- In Sung Moon
- Department of Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Seoul 137-040, Korea
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Lewis A, Kirk G, McKinley A, Blair PH, Harkin DW. The role of transthoracic echocardiography in embolic acute limb ischaemia. Ir J Med Sci 2009; 178:457-9. [DOI: 10.1007/s11845-009-0284-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2008] [Accepted: 01/14/2009] [Indexed: 10/21/2022]
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[Clinical and therapeutic characteristics of limb emboli]. Cir Esp 2008; 83:33-7. [PMID: 18208747 DOI: 10.1016/s0009-739x(08)70494-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
INTRODUCTION To treat an extremity embolus seems to be a simple and safe procedure. However, it is not exempt from potentially serious complications. We review our experience of treating acute peripheral arterial occlusion due to emboli. PATIENTS AND METHOD We retrospectively analyzed the data of 127 embolectomies performed during the last five years, in 120 extremities in 116 patients. The mean age of the patients was 80 years and 66% were female. All cases were presented as acute threatened limb ischemia grades IIA or IIB, and the mean evolution time was 27 hours. The patency, limb salvage and morbidity-mortality rates in the postoperative period and the salvage and survival rates in the follow-up were analyzed. RESULTS Of the embolectomies, 55% were femoral and 30% brachial. Although 90% of the cases improved, only 75% of them recovered distal pulses. In the postoperative period the patency, limb salvage, morbidity and mortality rates were 90%, 96%, 13% and 6.4%, respectively. The mean follow-up was 24 months. Up until this time, the patency and survival rates are 91% and 61%, respectively. The only factor related with an increase in the amputation rate was a clinical presentation, such as a threatened immediate ischemia. The factors related with an increase in survival rate were appropriate cardiological treatment and control, and long-term anticoagulation treatment. CONCLUSIONS Suffering an embolus of the extremities and its treatment causes considerable morbidity-mortality and limb amputation rates. The extremity salvage is associated with the clinical presentation at the time of the treatment. Long-term anticoagulation treatment and appropriate cardiological control increase the survival of these patients.
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