|Year : 2015 | Volume
| Issue : 4 | Page : 148-151
Early Intervention is an Important Factor in Reducing Mortality and Morbidity After Embolectomy/thrombectomy for Acute Limb Ischemia
Vikas Deep Goyal
Department of Cardiothoracic and Vascular Surgery, Dr. RPGMC, Kangra, Tanda, Himachal Pradesh, India
|Date of Web Publication||13-Apr-2016|
Vikas Deep Goyal
Department of Cardiothoracic and Vascular Surgery, Dr. RPGMC, Kangra, Tanda, Himachal Pradesh
Source of Support: None, Conflict of Interest: None
Background: Retrospective analysis of risk factors associated with acute limb ischemia, the role of early intervention and patient selection in reducing mortality and morbidity after embolectomy and results of surgical treatment.
Patients and Methods: From December 2011 to November 2013, 10 patients underwent embolectomy for acute limb ischemia at Dr. Rajendra Prasad Government Medical College Kangra at Tanda (H.P). Their mean age, sex, symptomatology, associated diseases, surgical technique, operative mortality, amputation, and incidence of renal dysfunction have been evaluated.
Results: Ten patients underwent embolectomy for acute limb ischemia. The mean age of the patients in the study was 51.4 ± 8.8 years and mean hospital stay was 10.5 ± 7.78 days. There was no operative mortality and one patient required amputation. Three patients had renal dysfunction, but they recovered with conservative management.
Conclusion: This study highlights that early intervention and patient selection are very important factors in minimizing mortality and morbidity after embolectomy. Right femoral and popliteal arteries are the most common peripheral sites of embolus arising from the heart and great vessels.
Keywords: Acute limb ischemia, early intervention, embolectomy, patient selection, prevention of complications
|How to cite this article:|
Goyal VD. Early Intervention is an Important Factor in Reducing Mortality and Morbidity After Embolectomy/thrombectomy for Acute Limb Ischemia. Indian J Vasc Endovasc Surg 2015;2:148-51
|How to cite this URL:|
Goyal VD. Early Intervention is an Important Factor in Reducing Mortality and Morbidity After Embolectomy/thrombectomy for Acute Limb Ischemia. Indian J Vasc Endovasc Surg [serial online] 2015 [cited 2020 Sep 28];2:148-51. Available from: http://www.indjvascsurg.org/text.asp?2015/2/4/148/180117
| Introduction|| |
The aim of this study was analysis of risk factors associated with acute limb ischemia, the role of early intervention and patient selection on mortality and morbidity and results of surgical treatment. Important causes of acute thromboembolism leading to limb ischemia are emboli arising from (1) heart due to valvular heart disease, endocarditis, atrial fibrillation, cardiac myxoma, myocardial infarction, and ventricular aneurysms, (2) aortic aneurysms, (3) atherosclerosis in the vessels and thrombus formation, (4) trauma/compression of the artery and subsequent thrombus formation.
Options in the management of acute thromboemboslism causing limb ischemia are surgical embolectomy, percutaneous suction devices, catheter-directed thrombolysis and thrombolysis with anticoagulation. Surgical embolectomy is the gold standard, and other techniques are compared to it for efficacy. Ideally, patients with acute limb ischemia should undergo revascularization within 6 h to get the maximum benefit and least complications, however, in clinical practice many patients present late and in those cases the success rate of the procedure decreases and complications increase.
Arterial embolectomy/thrombectomy is a common procedure done worldwide and is also not a very demanding procedure technically, but is associated with high complication rate including mortality. , Complications associated with the procedure include amputation of the limb, hemorrhage, renal failure, multi-organ dysfunction, sepsis, and mortality. Patient selection is a very important factor to decrease the mortality and morbidity rates associated with the procedure. Not all patients with acute limb ischemia are suitable for reperfusion; those patients with nonviable limbs should undergo amputation.
Reperfusion of the ischemic limb , leads to metabolic acidosis, toxemia, myoglobinuria, and systemic spread of infection and their severity increases with increase in the time between onset of ischemia and reperfusion.
| Patients and Methods|| |
From December 2011 to November 2013, 10 patients underwent embolectomy for acute limb ischemia. The total number of vascular procedures/interventions performed during this period were 77 of which 10 patients (12.98%) underwent arterial embolectomy. Their demographic data, preoperative, intraoperative, and postoperative characteristics are shown in [Table 1], [Table 2], [Table 3] and [Table 4]. All the procedures were done in an emergency.
Patients with following indications were selected:
- Symptomatic acute limb ischemia of <72 h duration
- Involved muscles in the limb having, at least, Grade 1 power or more and the presence of sensations of crude touch and pain in the involved part of the limb.
Following patients were not included in the study:
- Patients with acute limb ischemia with features of fully developed gangrene
- Patients with acute limb ischemia with features of complete motor and sensory loss in the involved limb along with skin changes
- Patients with acute limb ischemia with delayed presentation of more than 72 h with any of the above features
- Patients requiring a vascular bypass, end to end graft or interposition graft were not included in the study.
All the procedures done in this study were unilateral and involved one limb only. As all the cases were done in an emergency, patients were taken for surgery on the basis of clinical evaluation. Our protocol for acute limb ischemia was to get an electrocardiogram and chest roentgenogram, blood samples for routine blood investigations, blood group, cross match and shift the patient to the operating room as early as possible. Further blood investigations if required were sent from the operating room itself. Drugs with nephrotoxic side effects such as nonsteroidal anti-inflammatory drugs, amikacin, gentamicin, sulbactum or clavulinic acid combinations were not used.
All patients who underwent femoral embolectomy the surgical technique and steps were similar. Patients of femoral embolectomy were operated under femoral block using bupivacaine 0.25% supplemented with local anesthesia with xylocaine 2%. ECG and noninvasive blood pressure monitoring, large bore intravenous cannula for fluids and Foley's catheter for urine output measurement was done in all cases. Mild sedation with midazolam (2 mg bolus) and analgesia with fentanyl 2 μg/kg was used to relieve anxiety and pain. Vertical groin incision centered over femoral artery below inguinal ligament was used in all the cases, common femoral artery along with superficial femoral artery and profunda femoris artery were dissected and looped with cotton umbilical tapes. After heparinization in a dose of 1 mg/kg, vascular clamps and bull dog clamps were applied proximally and distally on the common femoral artery along with superficial femoral artery and profunda femoris artery. A transverse arteriotomy was done in the common femoral artery and Fogarty catheters of number 3, 4, 5 were used for extraction of clots proximally and distally, arteriotomy was repaired with polypropylene suture 6'0'. As soon as the arteriotomy was closed sodium bicarbonate was given in a dose of 25-50 ml depending upon the acidosis, along with frusemide in a dose of 20 mg or more was given to maintain urine output. Hemostasis and standard closure were done. Distal pulsations were always checked before shifting the patient from the operating room and color doppler was also used if the pulsations were feeble or absent.
Patients of brachial embolectomy were operated under supraclavicular block using bupivacaine 0.25% supplemented with local anesthesia with xylocaine 2%. Brachial artery was exposed using vertical incision above elbow through medial approach. Apart from exposure of the brachial vessel and the supraclavicular block, all the steps were similar to as described for femoral embolectomy.
Patients of popliteal embolectomy were operated under general anesthesia or combined epidural and spinal anesthesia. Patients of popliteal artery embolectomy were cases of trauma with compression and thombosis of the popliteal artery from fractured segments of tibia and fibula. After fixation of a fracture by the orthopedic team, patients were turned into prone position. A vertical incision was given in the popliteal fossa centered over the popliteal artery and extended into the posterior aspect of the calf as required, popliteal artery was dissected, and any kinks or compression were relieved, and embolectomy/thrombectomy of the popliteal artery was done in a similar way as described for femoral artery. One patient required skin grafting after 5 days as skin approximation was not possible.
Apart from monitoring of vital parameters, avoidance of nephrotoxic drugs, maintenance of urine output with adequate fluid and diuretics was very important to prevent oliguria, hyperkalemia, and fluid retention. Cases of atrial fibrillation were managed with digoxin or beta-blockers depending upon associated hypotension or hypertension, respectively. Our postoperative regimen consisted of antibiotics (ceftriaxone/cefuroxime + ofloxacin), analgesics (tramadol with or without acetaminophen), heparin 5000 units 8 hourly for 3 days and overlap with warfarin and clopidogrel. The limb was kept in a propped up position to prevent edema formation. Renal function tests were carefully monitored. The patient were mobilized on 3 rd or 4 th postoperative day or later depending upon the condition.
Data is reported as mean ± standard deviation and in percentage. Software used for analysis of data is Microsoft Excel.
| Results|| |
Total 10 patients underwent embolectomy out of this 7 patient underwent femoral embolectomy. Embolism was the cause in 60% of patients. The ratio of male to female in the study was 4:1. The mean age of the patients was 51.4 ± 8.8 years and mean hospital stay was 10.5 ± 7.78 days. There was no operative mortality and one patient required amputation. Three patients developed renal dysfunction but recovered with conservative management. Most patients had palpable pulsations in the operated limb at the time of discharge (80%). In two patients, distal pulsations were not palpable after embolectomy, one of patient required amputation; the second patient was relieved from symptoms and evaluation with color Doppler revealed adequate flow. The absence of pulsations in the second case was due to diffuse distal disease in the native vessels. Most of the patients were in follow-up for 3 months thereafter follow-up was irregular for many patients.
| Discussion|| |
Early intervention is the most important factor for favorable outcome in cases of acute limb ischemia. Judicious patient selection is required on the part of treating surgeon and his team to decide whether the patient is a candidate for embolectomy/thrombectomy or amputation. Doing revascularization in an already gangrenous limb can lead to multiorgan failure, sepsis, and mortality.
Mortality rates for embolectomy in recent studies from literature ,,,, varies from 8% to 25%, and amputation rates vary from 7% to 28%. The mortality and amputation rates in our study are 0% and 10% respectively. Significant difference in operative mortality and amputation rates in this study from those reported in literature could be due to the following reasons: (1) Early intervention (2) judicious patient selection (3) avoidance of anesthesia-related complications as most of the case were done in regional blocks (70%) supplemented with local anesthesia (4) all the cases were operated by a consultant rather than trainee surgeons (5) strict preoperative, intraoperative and postoperative management according to departmental protocol (6) avoidance of nephrotoxic drugs and maintenance of adequate urine output.
Fagundes et al.  have evaluated risk factors associated with increased mortality and morbidity, and they reported that (1) reperfusion injury was a risk factor for death but not amputation and (2) ischemia time longer than 24 h was associated with increased mortality and amputation. Güler et al.  recommended fasciotomy along with embolectomy for delayed presentation of acute limb ischemia.
There are studies in the literature on a comparison between thrombolysis and embolectomy for acute limb ischemia. Ouriel et al.  have concluded that intra-arterial urokinase decreases the need for open surgery with similar mortality and amputation rates though hemorrhagic complications were more. Van den Berg  studied intra-arterial thrombolysis and concluded that it is complimentary to embolectomy.
Main drawbacks of this study are a lesser number of patients.
| Conclusion|| |
This study highlights that early intervention is a very important factor in minimizing mortality and morbidity rates after embolectomy.
Right femoral and popliteal arteries are the most common peripheral sites of embolus arising from the heart and great vessels. Males are more commonly affected than females, and atrial fibrillation is the most common cause.
Avoidance of nephrotoxic drugs and maintenance of adequate urine output is of utmost importance to prevent acute renal failure and its complications.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Yangni-Angate H, Adoubi A, Adoh Adoh M, Yapobi Y, Coulibaly AO. Acute nontraumatic limb ischemia. West Afr J Med 2006;25:101-4.
Henke PK. Contemporary management of acute limb ischemia: Factors associated with amputation and in-hospital mortality. Semin Vasc Surg 2009;22:34-40.
Szijártó A, Turóczi Z, Szabó J, Kaliszky P, Gyurkovics E, Arányi P, et al.
Rapidly progressing fatal reperfusion syndrome caused by acute critical ischemia of the lower limb. Cardiovasc Pathol 2013;22:493-500.
Beyersdorf F, Schlensak C. Controlled reperfusion after acute and persistent limb ischemia. Semin Vasc Surg 2009;22:52-7.
Aune S, Trippestad A. Operative mortality and long-term survival of patients operated on for acute lower limb ischaemia. Eur J Vasc Endovasc Surg 1998;15:143-6.
Ender Topal A, Nesimi Eren M, Celik Y. Management of non-traumatic acute limb ischemia and predictors of outcome in 270 thrombembolectomy cases. Int Angiol 2011;30:172-80.
Manojlovic V, Popovic V, Nikolic D, Milosevic D, Pasternak J, Kacanski M. Analysis of associated diseases in patients with acute critical lower limb ischemia. Med Pregl 2013;66:41-5.
Illuminati G, Bertagni A, Calio FG, Ciulli A, Guglielmi R, Vietri F, et al.
Acute ischemia of the lower limbs. Riv Eur Sci Med Farmacol 1996;18:19-27.
Iyem H, Eren MN. Should embolectomy be performed in late acute lower extremity arterial occlusions? Vasc Health Risk Manag 2009;5:621-6.
Fagundes C, Fuchs FD, Fagundes A, Poerschke RA, Vacaro MZ. Prognostic factors for amputation or death in patients submitted to vascular surgery for acute limb ischemia. Vasc Health Risk Manag 2005;1:345-9.
Güler A, Sahin MA, Karabacak K, Küçükaslan N, Yokusoglu M, Tatar H. Accompanying embolectomy and closed fasciotomy in the same session for the delayed arterial thromboembolic occlusions in lower extremity. Anadolu Kardiyol Derg 2009;9:407-10.
Ouriel K, Veith FJ, Sasahara AA. A comparison of recombinant urokinase with vascular surgery as initial treatment for acute arterial occlusion of the legs. Thrombolysis or peripheral arterial surgery (TOPAS) investigators. N Engl J Med 1998;338:1105-11.
van den Berg JC. Thrombolysis for acute arterial occlusion. J Vasc Surg 2010;52:512-5.
[Table 1], [Table 2], [Table 3], [Table 4]