Emergent Thrombectomy for a Patient with Coronavirus Disease 2019 (COVID-19) / 日本心臓血管外科学会雑誌

A 76-year-old man presented with right leg numbness and general fatigue. The patient had no respiratory symptoms and negative PCR of COVID-19, but the lungs on CT scan revealed highly suspected COVID-19. The CT scan also showed occlusion from the right external iliac artery through below-knee arteries. Our surgical staff had personal protective equipment with powered air-purifying respirators and performed emergent surgical thrombectomy with the Fogarty balloon catheter. A few days after the operation, we found that the patient's antibody for COVID-19 was positive. The patient received anticoagulation and the postoperative course was uneventful. It is desirable to have more novel and precise knowledge of thrombosis in patients with COVID-19.

A Case of Acute Arterial Occlusion of the Lower Extremity Caused by Huge Vegetation of Prosthetic Valve Endocarditis / 日本心臓血管外科学会雑誌

A 79-year-old woman with prosthetic valve endocarditis (PVE) on aortic position underwent re-aortic valve replacement. Although emergency operation was indicated due to huge vegetation over 20 mm in diameter attached to the prosthesis shown by preoperative transesophageal echocardiography, intraoperative transesophageal echocardiography showed disappearance of the vegetation. The prosthesis was carefully removed and replaced by a new bioprosthesis, though only small vegetation was observed on the removed prosthesis. Sudden blue toe 11 h after the operation and diminished pulse on right pedal artery suggested an acute arterial occlusion of a right lower extremity, requiring an emergency thrombectomy. Pathology diagnosed bacterial embolus with fresh thrombus that was considered apart from the prosthesis at the time of operation.

Prevention of myonephropathic metabolic syndrome after operation of acute arterial occlusion by continuous renal replacement therapy / 上海第二医科大学学报

Objective To study the effect of continuous renal replacement therapy(CRRT) in preventing myonephropathic metabolic syndrome(MNMS) after operation of acute arterial occlusion. Methods Twenty-four patients with acute arterial occlusion were divided randomly into 2 groups: CRRT group(n=11) and control group(n=13).The patients were treated with embolectomy or revascularization.In control group,we used conventional therapy such as anti-inflammation,expansion of blood capacity,anticoagulation,and correcting acidosis and electrolyte disorder.In CRRT group,patients were treated by continuous veno-venous hemofiltration(CVVH) with 6 h during operation and 24 h after operation. Results In control group,24 h after operation,the serum potassium,blood urea nitrogen(BUN),serum creatinine(SCr),and myoglobin(Mb) were significantly increased(P

Management of Acute Peripheral Arterial Occlusion

PURPOSE: Treatment modalities of acute limb ischemia have evolved over the last decades, but the morbidity and mortality of the disease still remains high. We performed a retrospective study to analyze the demographics, risk factors, and prognosis of this disease. METHOD: Our subjects included a total of 49 patients (55 limbs) with acute peripheral arterial occlusion who underwent operative procedures between September 1996 and August 2001 at Gil Medical Center. Cases with graft occlusion or blue toe syndrome were excluded. The SVS/ISCVS reporting standards was used. RESULT: Mean age was 64.2 years (range: 25~85) and male-to-female ratio was 1.7 : 1. Clinical categories of ischemia were classified as the following: Viable (I) in 10 cases, Marginally threatened (IIa) in 14, Immediately threatened (IIb) in 17, and Irreversible (III) in 8. There were 40 lower extremity and 8 upper extremity arterial occlusions, and 1 aortic occlusion. The causes of occlusion were thrombosis in 14 and embolism in 35. Thromboembolectomy was performed in 42 cases, bypass graft in 9, primary amputation in 7, thrombolysis in 1, and stent insertion in 1. The 30-day mortality rate was 8%, mainly due to reperfusion injury and underlying cardiopathy. The 30-day major amputation rate was 23.8%. CONCLUSION: An aggressive, prompt operative management is important in saving patients with acute arterial occlusion. Higher amputation rates were related to more severe categories of ischemia at initial presentation. Patient education along with early referral and intervention will possibly reduce the amputation rate.

Clinical Study of Acute Arterial Occlusion of Lower Extremities

PURPOSE: The major source of acute peripheral arterial occlusion has been embolization from the heart. However overall improvement in medical care have increased life spans, resulting in significant increase in the incidence of systemic atherosclerosis and thrombotic occlusion of peripheral vessels. Recently, occlusion from in situ thrombosis has surpassed occlusion from embolization as the major cause of acute arterial occlusion. The introduction of the balloon catheter technique in 1963 dramatically simplified the technical aspect of surgical therapy for acute arterial occlusion and it became the main modality of the therapy. Recently, numerous reports have documented increased identification of intraluminal defects after arterial surgery using angioscopy as compared with those using intraoperative arteriography, and for this reason, the use of intraluminal angioscopy has grown in popularity. METHODS: We analyzed clinical characteristics and treatment results in patients with acute arterial occlusion. The variables studied include location, etiology, time interval from occurrence of occlusion to performance of thromboembolectomy. RESULTS: There were 41 men and 4 women and most prevalent age group was in 7th decades. The causes of acute arterial occlusion were embolism in 21 cases (46.7%), thrombosis in 24 cases (53.3%). The primary source of embolism was heart in 20 cases as a result of ischemic heart disease (n=11, 52.4%) and atrial fibrillation (n=9, 42.9%). Two patients in embolic group died of cardiogenic shock and were in shorter duration group (<24 hours). Iliac arterial occlusion group was associated with highest amputation rate (23.1%). Amputation rates were 12.5% for thromboembolectomy performed within 24 hours of onset of symptoms, and 17.4% when performed after 48 hours. We used angioscopic technique in limited cases of 5 patients to detect residual thrombus, intimal flap and other intraluminal defects. CONCLUSION: To improve outcome, early diagnosis and early treatment are essential. Direct visualization of the arterial lumen with angioscopy during thromboembolectomy procedure would provide a more reliable method of assessing luminal morphologic characteristics than angiography alone.

Treatment of Acute Arterial Thromboembolism

BACKGROUND: Arterial emboli remain an important cause of acute arterial ischemia. Despite simplification of operative techniques, the substantial morbidity and mortality still associated with an acute embolus remain a challenge to the vascular surgeon. We wanted to know the adequate evaluation and treatment modality for this limb threatened condition, and to evaluate the results according to etiology, location, time interval before starting treatment, clinical conditions, and limb survival rate. MATERIAL AND METHODS: A retrospective review was conducted on 91 patients who treated for acute lower leg thromboembolism between Jan. 1992 and Dec. 1997. RESULTS: There were 73 men and 18 women and most prevalent age group was in the 5th and 6th decades (53.8%). Over all amputation rate was 25.3% and mortality rate was 5.5%. Cardiac problem was the most common etiologic factor. Associated diseases were cardiac problem (37.4%), hypertension (35.2%), cerebrovascular accident (17.6%), and diabetes (15.4%). Interval from attack to definite therapy, within 24 hours in 14 cases (15.4%), 1~3 days in 23 (25.3%), after 4 days in 54 (59.3%) were noted. The locations were aorta and iliac in 25.3%, femoral in 38.5%, popliteal in 19.8%, tibial in 4.4%, and 15.4% in graft site in other of frequency. Clinical categories were grade I in 9.9%, IIa in 40.7%, IIb in 30.8%, and III in 18.7%. According to Eagle's criteria, low risk group were 34 cases (37.4%), moderate risk group were 39 cases (42.9%), and high risk group were 18 cases (19.8%). Of the 91 patients, conservative treatment in 2 (2.2%), thrombolytic therapy in 33 (36.3%), thromboembolectomy in 56 (61.5%), bypass in 16 (17.6%), endarterectomy and vessel ligation were performed. The 1-month and 1-year limb salvage rates were 73.4% and 71.1%, respectively. Especially, salvage rates in the Department of Vascular Surgery were 84.9% and 83.7%, whereas that of Thoracic and Orthopedic Surgery were 44.4% and 33.0% (p=0.0001). CONCLUSIONS: Cardiac problem especially atrial fibrillation was the most common etiologic factor. Prompt balloon catheter embolectomy performed under local anesthesia is a safe, simple, and effective method of treatment and the preferred mode of management in the great majority of patients. Nonoperative management with thrombolytic agents or high-dose heparin therapy alone is occasionally indicated in highly selected patients. The prognosis of acute arterial thromboembolism of lower extremity can be improved by early detection, early adequate treatment, and the involvement of a qualified vascular surgeon.

Arterial Embolism of the Lower Extremity

Despite the fact that the balloon catheter has greatly improved the technique of embolectomy, limb loss and mortality rates still remain high in some patients. The natural clinical course of a peripheral arterial embolism depends upon the location of the occlusion, the completeness of the luminal obliteration, the extent of secondary thrombosis, and the degree of spontaneous restoration of the collateral circulation. Surgeons should get accustomed to managing this disease appropriately. We wanted to know how to analyze the factors of amputation and operative mortality in those patients. For this study, we selected 46 cases of arterial embolectomies due to arterial embolisms of the lower extremity which were performed at Korea University Hospital between 1990 to 1996. Among the 46 cases, 39 cases were male and 9 cases were female. The etiologies of arterial embolism were 28 due to atrial fibrillation, 9 due to valvular heart disease. In the interval to therapy, 1) there were 7 cases severe ischemia and 3 cases amputations in a group for whom the embolectomy was done within 48 hours in 34 cases. 2) there were 5 cases of severe ischemia and 2 cases of amputations in a group for whom embolectomy was done after 48 hours. Popliteal artery occlusions were associated with severe ischemia and high amputation rates of 42.9%, and 28.6%, respectively. There were 6 cases of collateral circulation in the preoperative angiogram, one amputation was performed. Collateral circulation was not shown in 32 cases, but amputation was performed in 4 cases. In conclusion, this study shows that the prognosis of arterial embolism of the lower extremity can be improved by early detection, an early embolectomy, and the involvement of a qualified vascular surgeon. For a late arterial embolectomy, i.e., one beyond 48 hours after onset, indications are that even if the operation is performed one or several days beyond the accepted operation time, complete or adequate restoration of arterial flow to the limb may be achieved.

Clinical Review of Acute Arterial Occlusive Disease in Lower Extremities

Despite various methods of treating acute lower limb ischemia, the reported mortality continues to be in the 10% to 30% range. To evaluate the results according to etiology, location, time interval before starting treatment of acute lower extremities occlusive lesion, this study was done for 38 patients with acute arterial occlusive disease. The causes of acute lower limb occlusion were embolism (n=18, 47.4%) and thrombosis (n=20, 52.6%). The mortality rate was 11.1% (2/18) in embolism and 10% (2/20) in thrombosis. All the patients with embolic occlusion were treated by thromboembolectomy with Fogarty catheter, and thrombotic occlusive lesion were treated by intraarterial thrombolytic therapy only (n=3), followed by corrective procedure such as PTA only for short iliac arterial lesion (n=1), PTA and stent for long iliac arterial lesion (n=5), bypass operation (n=5). The amputation rate was higher (p,24 hr, 7/20, 35.0%) than in shorter duration (<24 hr, 1/18, 5.6%), and in multiple lesion (7/13, 53.7%) than single lesion (1/25, 10.0%). Even though advanced therapeutic modality for acute lower limb occlusive disease, mortality is still high, and limb salvage is dependent on various factors such as status of patients, etiology and number of lesion site, time interval before starting treatment.

Acute Arterial Occlusion of the Left Lower Extremity during Prolonged Fasting

Acute arterial occlusion of the extremity may result from obstruction of an artery by embolism or by thrombosis in situ. This results in the sudden cessation of blood flow to an extremity. So immediate managements are required to prevent propagation of the clot and to restore blood flow to the ischemic extremity promptly. We report a case of a acute arterial occlusion which was developed during prolonged fasting. A 59-year-old male was transferred due to severe ischemic pain, coldness and loss of pulse in left lower extremity during fast. The arteriogram shows a complete obstruction of external iliac artery and non-visualization of femoral artery and popliteotibial artery in the left lower extremity. Selective intra-arterial urokinase thrombolytic therapy and percutaneous transluminal angioplasty resulted in recannulation of obstructed artery and relief of symptoms.

A Case of Percutaneous Aspiration Thromboembolectomy(PAT)

The two most common causes of acute arterial occlusion are embolism and thrombosis in sity. They are mainly originated from the cardiovascular sources. About 70-80 per cent of occlusions occur in the axial limb vessels. Therapeutic options include supportive measures, pharmacologic treatment, surgery, and non-operative interventions. There have been several successful case reports using percutaneous aspiration thromboembolectomy with the advent of new instruments and technical imprevement. We report a case of 70-year-old male with acute anterior wall myocardial infaction who experienced acute embolic arterial occlusion of the left popliteal artery from mural thrombus in the left ventricular apex. It wan managed successfully by percutaneous aspiration thromboembolectomy.