Download embolism occurs with increasing frequency requiring

Management
of
Peripheral
Arterial Embolism
M. A. Hamza, M.D., F.I.C.A.
M. M. Souka, M.D.
and
M. M. Agha, M.D.
ALEXANDRIA, EGYPT
Abstract
This study included one hundred patients with peripheral arterial embolism.
The average age was 45 years with predominence of female over male patients
(3:2). The source of emboli was found to be the left side of the heart in 90% of
patients. Rheumatic heart disease was the primary cardiopathy in 70% of the
cases. Eight percent of the patients were presented more than 24 hours after the
onset of symptoms and embolectomy was carried out in 77% of cases. The purpose of this study is to clarify the magnitude of the problem as to the etiology,
different clinical presentations and the operative results after embolectomy using a Fogarty balloon catheter and its relation to time interval.
Introduction
Embolic obstruction of the main arteries has attracted the attention of both physicians and
surgeons since the time of William Harvey ( 1928) .’
Rheumatic heart disease is still considered a major problem in Egypt from the epidemiologic point of view and due to the increased longevity of our population, peripheral arterial
1
embolism occurs with increasing frequency requiring immediate and proper management.’
Surgical restoration of arterial continuity by removal of emboli, though one of the earliest
methods of arterial reconstruction, had been performed in many centers with disappointing
high mortality and morbidity, the latter attributed to the delay in interference and incomplete or
non-removal of the distal propagating thrombus (Shaw, 1960).3
Progress in the management of peripheral arterial embolism was achieved after discovery
of heparin by Howell and McLean in 1918 and its introduction into therapeutic use by Gra-
From the
Department of Surgery
and Internal Medicine, Alexandria
Faculty
of Medicine, Alexandria
152
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University, Egypt
153
foord in 1937.4 In addition, the development of a balloon catheter (1963) had its marvellous
effect on mortality after embolectomy.5’6
.
’
Materials and Methods
.
.
patients with peripheral arterial embolism were included in this study. Upon
admission, thorough histories and physical examinations were undertaken. Special attention
and evaluation of the heart was made by chest x-ray and electrocardiogram.
All cases were subjected to routine investigations, blood sugar level and serum cholesterol.
Fundus examinations were performed for all cases.
Most cases were managed operatively using a balloon catheter technique for arterial embolectomy. Conservative measures were used either solely, if operative intervention was not
feasible, or as an adjunct line in both pre-operative and post-operative periods. These included
measures to improve the cardiac disorder, anticoagulant therapy, vasodilators and local measures which would maintain the vitality of the ischemic limb and prevent complications.
Administration of heparin was started immediately following the diagnosis. Heparin was
given intravenously in a loading dose of 2 ml. ( 10.000 I . U . ) followed by a dose of 1 ml . (5 . 000
I. U . ) every four to six hours to maintain the coagulation at 2 to 2.5 times (15-17 min.) the
normal coagulation time. In addition, heparin was administered during the post-operative period by intermittent intra-venous injection in a dose of 1 ml. (5.000 I.U.) every four to six
One hundred
hours.
Oral anticoagulant therapy was initiated after three to four days and continued as long as
the patients were at risk. The average period in this study varied between three to six months.
In six cases, the extracted emboli were examined bacteriologically.
Results
The age distribution varied from 18 to 70 years with an average of 45 years. The maximum
age distribution was in the fourth decade. There were 60 females and 40 males, a ratio of 3:2.
The symptomatology of these patients was that of acute ischemia, however, frank gangrene
was encountered in 4 patients (4%). The degree of ischemia varied from just pain (sudden
onset), mild coldness and loss of sensation to frank gangrene in four patients (4 % ). Severe
pain and coldness were the main symptoms encountered in our study. The sources of emboli
ere illustrated in Table I. Cardio-arterial embolization was encountered in 90% of patients,
however, arterio-arterial embolization was only 10%. Rheumatic heart disease was the primary cardiopathy in 70 % of cass and atherosclerotic heart disease contributed to 18 % . Both
cardiopathies were associated with atrial fibrillation.
The sources of arterio-arterial embolization were an abdominal aortic aneurysm, femoral
artery aneurysm, post-stenotic dilatation of the subclavian artery and iliofemoral atherosclerosis. Femoral artery bifurcation was the common site of impact of these emboli. Two patients
presented with anterior compartment syndrome, one of them had been incorrectly treated for
deep vein thrombosis and the second for psychological monoplegia.
In the present stud, ninety-two patients were admitted for surgical intervention. Embolectomy alone was performed in 75 patients and in 2 patients, embolectomy combined with other
procedures, in the form of fasciotomy and sympathectomy (Table II) .. ~ -
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TABLE I
Sources
:
.
of peripheral arterial embolism
TABLE II
Surgical procedures applied
Functional limb salvage with intact peripheral pulsation was achieved in 47 patients (61 %)
and those with absent pulsation had been achieved in 24 patients (31 %). Only one patient ( %)
had limb salvage with residual disability (Table III) . The operative results in relation to time
interval is well illustrated in Table IV. It denotes that the time factor is now not considered an
obstacle for surgical intervention.
The conservative regimen had been followed in 11 patients, three of which developed
gangrene and required major amputation; four patients with arterio-arterial embolism; one
patient with resection of an abdominal aortic aneurysm and in the remaining 3 patients, femoral aneurysm were performed in order to prevent recurrence of embolism.
Post-operative local complications, i.e., hematoma and infection, were minimal.
Bacteriological examinations of six extracted emboli have shown that four emboli were
sterile, the remaining two had grown colonies of staphylococci.
’
’
’
Discussion
In our series, the maximum age was between 30 ad 40 years and the average was 35 years.
In Krause et al. , series ( 1966)’ the average age was 62.5 years and Darling ( 1967)g reported an
average of 63 years with extremes of 22 and 96 years.
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TABLE III
Results of embolectomy
Operative
TABLE IV
results related to time interval
The sex incidence varied with the cardiopathy, and in this series the predominence of
female patients was paralleled with the increase in the incidence of rheumatic heart disease as
an etiological factor of peripheral arterial embolism.
Haimovici ( 1970)9 reported an incidence of 78. 3 % females in the group of rheumatic heart
disease, while that with myocardial infarction 73.6% were males. Darling ( 1967)8 studied 260
patients with peripheral arterial embolism and found those patients with rheumatic heart disease and atrial fibrillation to be the source of the emboli, the average age being 54 years with
63 females and 30 males. In contrast, the average age of patients with acute myocardial infarction as the embolic source was 60 years with males outnumbering the females, 22 to 15.
In the Fogarty study* on peripheral arterial embolism in 300 patients, the source of emboli
was the left side of the heart in 281 cases of which 233 (77.6%) were associated with myocardial infarction and 48 patients (16%) had rheumatic heart disease. In 19 cases (6. 3 % ) the
source was atherosclerotic plaques.
In Egypt, rheumatic heart disease still constitutes a major epidemiologic problem and has a
marked contribution to the etiology of embolization than ischemic heart disease. In developed
countries, rheumatic heart disease is no longer as preponderant as before, due to better control
of fever and progress in valve-replacement surgery.
The site of impaction was found to be at the common femoral artery bifurcation in 70 cases,
thus in agreement with most published literature.&dquo; Aortic and iliac embolizations were the
least; the smaller arteries did not reveal to be prominent in most series, perhaps due to the fact
that at these sites, embolism is often silent
Less than 15 years ago, a serious proposal was that emboli which existed more than 12
hours should not be operated upon.13 It is now well established that such viewpoint to be
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The difficulties with late operations have been found to be due to inadequate removal of distal thrombi, however, such problems have been overcome by the use of the balloon catheter. Viability could be preserved in over 90% of patients operated upon, if such
operation is performed prior to the muscle becoming necrotic, regardless of whether the embolus originated 6 hours or 60 days earlier in the Fogarty’s series (1963).5
Our series reports one patient presented 4 days after embolization and another 15 days
later. Embolectomy had been performed successfully on these patients
As Cranely reported,’4 the judicious use of heparin is one of the factors which has eliminated the time interval as an inflexible criterion for success or failure of embolectomy. Therefore, while the elapsed time is a basic determination of the outcome, it should not be used as an
inflexible criterion for selecting patients for surgical treatment. As long as the limb is alive,
operations may be performed. The determination when a limb is acutely dead may not be easy.
In the absence of frank gangrene of the skin, helpful signs are loss of sensation, paralysis of the
leg and foot and rigormortis of the muscles.
erroneous.
Conclusions
The ultimate goal of embolectomy is to ensure a useful and functional extremity. The
presence of distal pulses after extraction is certainly desirable, but their absence does not in
any way signify a poor result from a functional stand point. 15 In our series, 61 % had restored
pulses following embolectomy, 31 % had functional limb salvage with absent pulses, 1 % had
limb salvage with residual disability and the total limb salvage after embolectomy is 93 % .
M. A. Hamza, M.D., F.I. C.A.
Assist. Prof. in Vascular Surg.,
Faculty of Medicine
Alexandria University
Alexandria, Egypt
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Quoted from: Kamal AH: Epidemiology of rheumatic
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