N e lso n W o lo ske r, S e rg io K u zn ie c, A lva ro G a u d e n cio , L u is R ica rd o A m a ra l S a lle s, R u b e n R o so ky,
R ica rd o A u n , P e d ro P u e ch -L e a o
A r te r ia l e m b o le c to m y in lo w e r lim b s
General Hospital of the College of Medicine of the University of Siio Paulo - Siio Paulo, Brazil
A rte ria l e m b o lis m s in th e lo w e r lim b s o c c u r fre q u e n tly , a n d a re o f g re a t in te re s t to th e v a s c u la r s u rg e o n . T h e a u th o rs s tu d ie d 1 5 9 c a s e s o f a rte ria l e m b o lis m s in lo w e r lim b s fro m J a n u a ry 1 9 9 1 to J u ly 1 9 9 3 . A g e s v a rie d fro m 1 2 to 9 8 , w ith a m e a n o f 5 8 . E ig h ty p a tie n ts w e re m a le a n d 7 8 w e re fe m a le . In m o s t c a s e s , e tio lo g y o f th e e m b o lu s w a s w e ll-e s ta b lis h e d , a n d m a in ly c a u s e d (7 8 p e rc e n t) b y a tria l fib rilla tio n . O c c lu s io n w a s m o s t fre q u e n t in th e fe m o ra l a rte ry (5 3 .4 p e rc e n t). A ll p a tie n ts p re s e n te d s e v e re lo w e r lim b is c h e m ia , b u t n o t g a n g re n e , o n a d m is s io n . T h e d u ra tio n o f is c h e m ia , b e tw e e n th e o n s e t o f s y m p to m s a n d th e lib e ra tio n o f a rte ria l flo w , w a s in m o s t p a tie n ts (6 7 .9 p e rc e n t) le s s th a n 2 4 h o u rs . A ll p a tie n ts w e re s u b m itte d to lo w e r lim b e m b o le c to m y w ith th e F o g a rty c a th e te r, o f w h ic h 7 0 .9 p e rc e n t w e re d o n e th ro u g h th e fe m o ra l a rte ry . F a s c io to m y w a s p e rfo rm e d o n 4 8 p a tie n ts d u e to a c o m p a rtim e n ta l s y n d ro m e . N in e te e n p a tie n ts d ie d im m e d ia te ly a fte r o p e ra tio n ; 6 8 .4 p e rc e n t d u e to h e a rt fa ilu re . T w e n ty -th re e (1 6 .4 p e rc e n t) o f th e 1 4 0 s u rv iv in g p a tie n ts (1 5 0 o p e ra te d lim b s ) w e re s u b m itte d to a m p u ta tio n s a fte r th e o c c lu s io n o f a rte ry b ra n c h e s , w h ic h h a d u n d e rg o n e e m b o le c to m ie s . O n e h u n d re d a n d tw e n ty -s e v e n lim b s (8 4 .6 p e rc e n t) w e re p re s e rv e d in 1 1 7 p a tie n ts (8 3 .5 p e rc e n t). E le v e n c a s e s (7 .3 p e rc e n t) re q u ire d re p e a te d s u rg e ry w ith th e F o g a rty c a th e te r. T h e p a tie n ts w ith m u s c le te n d e rn e s s , p a ra ly s is , o r is c h e m ia la s tin g lo n g e r th a n 2 4 h o u rs h a d w o rs e re s u lts in re la tio n to th e p re s e rv a tio n o f th e lim b (p < 0 .0 5 ). W e c o n c lu d e th a t p a tie n ts w h o p re s e n t lo w e r lim b e m b o lis m s , a re in g o o d c lin ic a l c o n d itio n , a n d w h o d o n o t h a v e a n y n e c ro s is in th e lim b s , h a v e g o o d o u tc o m e s a s to lim b p re s e rv a tio n , a lo n g w ith lo w c o m p lic a tio n ra te s , a fte r e m b o le c to m y w ith th e F o g a rty c a th e te r. lim b p re s e rv a tio n w a s s ig n ific a n tly h ig h e r in p a tie n ts w h o d id n o t p re s e n t m u s c le te n d e rn e s s , a n d w h o h a d n o rm a l m o to r a c tiv ity a n d a is c h e m ia d u ra tio n o f le s s th a n 2 4 h o u rs .
U N IT E R M S : F e m o ra l a rte ry . V a s c u la r s u rg e ry . E m b o le c to m y .
IN T R O D U C T IO N
A r t e r i a l e m b o l i s m s i n t h e l o w e r l i m b s o c c u r
f r e q u e n t l y , a n d a r e o f g r e a t i n t e r e s t t o t h e v a s c u l a r s u r g e o n
s i n c e t h e o u t c o m e m a y i n v o l v e g a n g r e n e , d e a t h , o r
p e r m a n e n t i m p a i r m e n t .I
-3 O u r s t u d y w a s b a s e d o n 1 5 9
p a t i e n t s w i t h a r t e r i a l e m b o l i s m s i n t h e l o w e r l i m b s t r e a t e d
f r o m J a n u a r y
1 9 9 1
t o J u n e1 9 9 3
i n t h e e m e r g e n c y r o o mo f t h e G e n e r a l H o s p i t a l o f t h e C o l l e g e o f M e d i c i n e o f t h e
U n i v e r s i t y o f S a o P a u l o ( U H C M U S P ) . O u r g o a l w a s t o
A d re s s fo r c o rre s p o n d e n c e : N e lso n W o lo ske r
R u a E sp e ria ,3 0 -Ja rd im P a u lista S a o P a u lo /S P - B ra sil- C E P 0 1 4 3 3 -0 6 0
s t u d y t h e s u r g i c a l t r e a t m e n t o f l o w e r I i m b e m b o l i s m s , a n d
t o e v a l u a t e w h e t h e r m u s c l e t e n d e r n e s s a n d t h e d e g r e e o f
m o t o r . i n v o l v e m e n t a r e p r e d i c t i v e f a c t o r s f o r l i m b
p r e s e r v a t i o n a n d o p e r a t i v e m o r t a l i t y .
M E T H O D S A N D P A T IE N T S
F r o m J a n u a r y
1 9 9 1
t o J u l y1 9 9 3 ,1 7 5
c a s e s o f a r t e r i a le m b o l i s m i n t h e l o w e r l i m b s o f 1 5 9 p a t i e n t s w e r e s u r g i c a l l y
t r e a t e d i n t h e e m e r g e n c y r o o m o f t h e U H C M U S P . T h e
c l i n i c a l p r e s e n t a t i o n s o f t h e a r t e r i a l e m b o l i s m s i n c l u d e d
s i g n s a n d s y m p t o m s o f a c u t e o c c l u s i o n s u c h a s : p a i n i n
t h e a f f e c t e d l i m b ; a b s e n c e o f p u l s e d i s t a l t o t h e o b s t r u c t i o n ;
p o o r t i s s u e p e r f u s i o n ( w h i c h w a s c h a r a c t e r i z e d b y p a l l o r ,
cyanosis and/or the lowering of temperature in comparison
to the other limb); paresis and paralysis (due to ischemic
lesion of the nerves as well as of the muscle groups);
paresth<?sia;hypoesthesia; or anesthesia of leg or foot. The
diagnosis of a arterial embolism was determined by the
absence of any previous symptoms in the limb with the
acute condition, associated with an embolic source (usually
cardiac), and was confirmed when the embolus was found
and removed.
Eighty-one patients were female and
78
were male,
with ages varying from 12 to
98
(mean age
=
58).
Seventy-three cases
(41.7
percent) showed right impairment,
70
cases (40 percent) showed left impairment, and
16
cases
(18.3
percent) showed bilateral impairment. The embolus
origin was not well-defined
in
26
percent of the cases;
atrial fibrillation
was the most common cause (Table
I).
Table 1
Distribution according to origin of emboli
Patients
TN=159
Etiology of embolism
N
%
Atrial Fibrilation
78
49
Congestive Heart Failure
9
5.7
Ventricular Extrasystole
7
4.4
Valvular Disease
7
4.4
Conduction Alterations
7
4.4
Endocarditis
5
3.2
Antecedent MI
4
2.5
Pericarditis
0.6
Not Defined
41
25.8
The obstruction level demonstrated by absence of
pulse is shown in Table 2.
Table 2
Distribution according to level of obstruction
Patients
TN=159
Level of Obstruction
N
0/0
Bilateral Femoral
16
10.1
Unilateral Femoral
69
43.3
Popliteal
56
35.2
Below the Popliteal Artery
19
11.4
The duration of ischemia, from the onset of symptoms
to the liberation of arterial flow, is shown in Table 3, ranged
from 1 to
96
hours (mean duration
=
31 hours).
Table 3
Distribution according to duration of ischemia
Patients
TN=,159
Question of Ischemia
N
%
0-6 hours
37
23.2
6-12 hours
39
24.5
12-24 hours
32
20.2
Above 24 hours
51
32.1
Statistical analyses were done using the Fisher test,
with' a critical value of 0.05
SURGICAL
PROCEDURES
All cases were treated as emergencies due to severe
ischemia.
Anesthesia
was administered
by medullar
blockage in all cases but 12, in which local anesthesia
with
lidocaine
infiltration
was used for
femoral
exploration, due to the patients' critical condition.
Revascularization
was performed
by a di rect
approach to the artery (most frequently
at the femoral
bifurcation - Table 4), fol1owecl by the removal of embolus
and secondary thrombi with a Fogarty catheter.
Table 4
Distribution according to surgical access
Surgeries
TN=179
Acess
N
%
Bilateral Femoral
12
13.4
Unilateral Femoral
103
57.5
Popliteal Below the Knee
36
20.2
Combined
8
8.9
A fasciotomy
of anterior
and posterior
muscle
compartments was performed on 48 limbs (27.4 percent)
by means of two extensive incisions which allowed for
WOLOSKER, N.; KUZNIEC, S.; GAUDENCIO, A.; SALLES, L.RA; ROSOKY, R.; AUN, R. & PUECH-LEAO, P. - Arterial embolectomy in lower limbs
th e e x p a n sio n
o f m u sc le v o lu m e w ith o u t re stric tio n
b y th e
fa sc ia a n d sk in .
T a b le 6R e la tio n b e tw e e n lim b p re s e rv a tio n a n d m u s c le te n d e rn e s s
N o rm a l P a re s is P a ra ly s is %
N u m b e r o f P a tie n ts 1 0 9 1 9 2 2 6 8 .4
lim b A m p u ta tio n 1 3 3 7 2 1 .0
M .A .- M o to r A c tiv ity 5 .3
5 .3
R E S U L T S
M .T .
C a u s e P re s e n t A b s e n t P re s e rv e d lim b 2 9 9 8 lim b A m p u ta tio n 1 1 1 2
T o ta l 4 0 1 1 0
M .T . - M u s c le T e n d e rn e s s
M .A .
n = 1 4 0 T a b le 7
R e la tio n b e tw e e n lim b p re s e rv a tio n a n d m o to r a c tiv ity
N 1 3
4
C a u s e H e a rt F a ilu re S e p s is
In te s tin a l N e c ro s is M e ta b o lic D is o rd e rs
E m b o le c to m y
re su lts
sh o u ld
b e re v ie w e d
u n d e r
th re e
a sp e c ts:
lim b
p re se rv a tio n
a n d
su rv iv a l
(P S );
lim b
a m p u ta tio n
a n d
su rv iv a l
(L S );
a n d th e d e a th
o f
th e p a tie n t
(D P ).
In th is stu d y ,
1 9 p a tie n ts
(1 2 .2 p e rc e n t)
d ie d , m o st
d u e to h e a rt c o m p lic a tio n s
(T a b le 5 ).
T a b le 5
D is trib u tio n a c c o rd in g to c a u s e o f d e a th D e a th s
n = 1 9
T a b le 8
R e la tio n b e tw e e n lim b p re s e rv a tio n a n d d u ra tio n o f is c h e m ia
A rte ria l
e m b o lism s
a re
a v e ry
fre q u e n t
c lin ic a l
m a n ife sta tio n
4-6o f c o m p lic a tio n s
fro m
o th e r d ise a se s.
A
c a rd ia c e m b o lic
so u rc e
w a s c o n firm e d
in 7 4 .2 p e rc e n t
o f
th e c a se s in th is stu d y . T h e e q u a l d istrib u tio n
o f g e n d e r
a n d a g e v a ria tio n
(1 2 -9 8
y e a rs, m e a n
=5 8 ) w e re sim i la r
to
w h a t
h a s
b e e n
re p o rte d
in
fo re ig n
a n d
n a tio n a l
lite ra tu re .7 .
xT h e c lin ic a l d ia g n o sis
o f a n e m b o lism
is n o t u su a lly
d iffic u lt, e sp e c ia lly
w h e n th e c a u sin g
fa c to r is e v id e n t.
In
In te stin a l
n e c ro sis
le a d in g
to d e a th
o c c u rre d
a fte r
m e se n te ric
e m b o lism .
S ix
o f th e se
p a tie n ts
sh o w e d
b ila te ra l
e m b o lism s.
A fte r
a n a ly z in g
th e tim e
o f isc h e m ia ,
p re se n c e
o f
m u sc le
te n d e rn e ss .•.a n d d e c re a se
in m o to r
a c tiv ity ,
w e
o b se rv e d
th a t
n o n e
o f th e se
fa c to rs
w e re
sig n ific a n tly
re sp o n sib le
fo r m o rta lity
(p > 0 .0 5 ).
T w e n ty -th re e
o f th e 1 4 0 o p e ra te d p a tie n ts (1 5 0 lim b s)
w e re su b m itte d
to a m p u ta tio n s
a fte r th e o c c lu sio n o f a rte ry
b ra n c h e s,
w h ic h h a d p re v io u sly
u n d e rg o n e
e m b o le c to m y .
T h re e o f th e se p a tie n ts p re se n te d
b ila te ra l e m b o lism s,
a n d
o n e lim b w a s p re se rv e d
in e a c h c a se .
O u t o f 1 1 7 p a tie n ts
(8 3 .5 p e rc e n t),
1 2 7 lim b s (8 4 .6
p e rc e n t)
w e re p re se rv e d .
R e o p e ra tio n
(w ith th e F o g a rty
c a th e te r)
w a s n e c e ssa ry
in e le v e n c a se s (7 .3 p e rc e n t). T h e
re su lts o f p a tie n ts
w ith m u sc le
te n d e rn e ss
w e re w o rse in
re la tio n to th e p re se rv a tio n
o f th e lim b (T a b le 6 )(p < 0 .0 5 ).
In p a tie n ts
w ith p a ra ly sis
d u e to isc h e m ia ,
re su lts
w e re
sig n ific a n tly
w o rse (p < 0 .0 5 ),
a s sh o w n in T a b le 7 .
P a tie n ts
w ith isc h e m ia ,
th a t h a d la ste d fo r m o re th a n
2 4 h o u rs,
h a d sig n ific a n tly
w o rse
o u tc o m e s
th a n th o se
w h o se isc h e m ia
h a d la ste d fo r le ss th a n 2 4 h o u rs. (p < 0 .0 5 )
(T a b le 8 ).
D u ra tio n o f Is c h e m ia (h o u rs )
0 -6
6 -1 2 1 2 -2 4 > 2 4
D IS C U S S IO N
P re s e rv e d lim b T o ta l
3 3 3 5
3 6 3 7
2 6 2 9
3 2 4 9
s a o P a u lo M e d ic a l J o u rn a l/R P M 1 1 4 (4 ): 1 2 2 6 -1 2 3 0 , 1 9 9 6 W O L O S K E A , N .; K U Z N IE C , S .; G A U D E N C IO , A .; S A L L E S , L .A .A .; A O S O K Y , A .;
all our cases, especially
in the presence
of heart disease,
w e discerned
that the em bolus origin w as not in the arterial
branches of the lim b, w hich allow ed the patient to undergo
surgery
w ithout
an arteriography,
avoiding
further delay
and possible
com plications.
W hen there is doubt as to the
diagnosis,
arteriography
is necessary
to ensure
the
appropriate
surgical
approach.
In m ost
cases
(74.2 percent),
there
w as
a heart
condition
w hich suggested
the origin of the em bolus. O ther
less frequent
causes
of low er
lim b em bolism s,
such as
aneurysm s,
plaques, and tum or em bolism s
lJ
w ere not found
am ong
our patients.
T he
41 (25.8
percent)
cases
w ith
unknow n causes coincide w ith other statistics.5L ow er
lim b
em bolism s
presented severe ischem ia in all cases, and could
have lead to irreversible
dam age
if not treated in tim e.
M ortality
rates vary from
10 to 30 percent,
Ill. I Iand
are
usually
due
to heart
cotnplications,lJ.12
m ortality
increases
tw ofold
in patients
m ore than
60
years old. O ur
cases show ed
a m ortality
rate of
12.25
percent, of w hich
84 percent
w ere m ore than 60 years old.
W e noticed that m uscle tenderness,
m otor im pairm ent
and duration
of ischem ia
did not interfere
significantly
w ith
surgically-related
m ortality.
T his
reinforces
that
m 0l1ality is due to heart conditions
(68.4
percent of deaths),
as opposed
to the severity of ischem ia
at adm ission.
T hus,
these w ere patients
w ith severe
heart disease
and a poor
prognosis
w ho presented
acute ischem ia
of the low er lim b
and w ere subm itted
to revascularization,
w hich increased
the risk of heart decom pensation.
C linical treatm ent w ith an appropriate
anticoagulation
should be adm inistered
to patients w ith m ild ischem ia w ho
present severe clinical conditions in w hich there is no further
risk of claudication
of the low er lim b.13
Surgical
em bolectom y
has long been a the treatm ent
of choice,4.6 even
before
1 9 6 3 ,w hen
routine
use of the
Fogartyi4
catheter
began.
T he
technical
sim plification
introduced
by this m ethod, and the use of a local anesthetic
for access to the fem oral
bifurcation,
allow ed
this surgery
to becom e
m ore frequent. 15
D ue
to poor
collateral
circulation,
the degree
of
ischem ia
in low er lim bs is alw ays
greaster
than in upper
lim bs. In our patients,
surgery
w as indicated
w hen there
w as a presence
of an em bolism
w ithout
any irreversible
trophic alteration; the duration and degree of ischem ia w ere
not considered.
Patients
subm itted
to surgery
show ed
good results.
L im b
am putation
occurred
in
16.4
percent
of the
surviving
patients.
W e confirm ed
that the best
results
occurred
in
patients
w ith
a shorter
duration
of
ischem ia.IO .14.16-IX
W e observed
that patients
w ith paralysis
and
tenderness
show ed
poor
results.
T his
finding
is
probably
related
to the fact that tenderness
is a clinical
sign of severe tissue ischem ia
in the lim b, thus indicating
a poor
prognosis
due
to
a greater
probability
of
irreversible
tissue
necrosis,
w hich
m ay
lead
to lim b
am putation
in spite of revascularization.
M otor
involvem ent
depends
only on perfusion
and
innervation.
T herefore,
finding this w ould indicate a better
prognosis
than tenderness,
since there is only a neurologic
alteration
and
no
necrosis
of
the
m uscle;
after
revascularization
the lim b
is preserved,
although
there
m ight be neurologic
sequelae.
T he inverse correlation
of duration
of ischem ia
and
lim b
preservation
em phasizes
the
need
to initiate
a
therapeutic
approach
i m m edi ately
upon
ad m iss ion.
Investigation
of the em bolic
source
should
be conducted
only
by clinical
observation
and
routine
preoperative
exam s.
A rteriography,
as in our report,
should
be used
only in selected cases w ith m ild ischem ia,
so as to identify
the etiology
of the
obstruction
and
allow
for better
preoperative
program ing.
In any identified
em bolic source,
long-term
anticoagulation
therapy
is recom m ended
to
prevent
any recurrence.
Ill.
llJ
C O N C L U S IO N
E m bolectom y
w ith the Fogarty catheter in low er lim b
em bolism s
has show n good rates of lim b preservation
and
a low incidence
of surgical com plications
in patients
w ho
are in good clinical condition
and show no sign of necrosis
in the lim bs. L im b preservation
is significantly
higher
in
patients w ho present no m uscle tenderness;
norm al m otor
activity;
and ischem ia
that has lasted less than
2 4hours.
W O L O S K E R , N .; K U Z N IE C , S .; G A U D E N C IO , A .; S A L L E S , L .R .A .; R O S O K Y , R .; A U N , R . & P U E C H - L E A O , P . - A r te r ia l e m b o le c to m y in lo w e r lim b s
RESUMO
As embolias arteriais de membros inferiores ocorrem com grande frequencia na popula<;ao em geral, correspondendo a importante area de interesse ao cirurgiao vascular. Os autores analisaram 159 casos de embolia arterial em membros inferiores, atendidos de janeiro de 1991 a julho de 1993. A idade variou entre 12 a 98 anos (media de 58 anos), 81 pacientes eram do sexo masculino e 78 do sexo feminino. A etiologia da embolia foi na grande maioria dos casos bem definida, sendo que a principal causa foi a fibrila<;ao atrial (78% ). A oclusao da arteria femoral foi a mais frequente (53,4% ). Todos os pacientes desta serie apresentavam isquemia grave de membro. Nenhum paciente estava com gang rena a admissao. A maioria dos pacientes apresentava tempo de isquemia entre 0 inicio do quadro e da libera<;ao do f1uxo arterial menor que 24 horas
(67,9% ). Todos os pacientes foram submetidos a embolectomia de membro inferior com cateter de Eogarty, 70,9% por acesso femoral. Empregou-se a fasciotomia em 48 pacientes devido a presen<;a de sind rome comportamental. Dezenove pacientes faleceram, no p6s-operat6rio imediato, a maioria deles por insuficiencia cardiaca (68,4% ). Dos 140 pacientes (150 membros) operados que sobreviveram, 23 (16,4% ) apresentaram perda de membro ap6s oclusao da arvore arterial previamente desobstruida pela embolectomia. Houve preserva<;ao de 127 membros (84,6% ) em 117 pacientes (83,5% ). Foi necessaria a reopera<;ao (nova passagem do cateter de fogarty) em onze casos (7,3% ). Os pacientes com empastamento muscular, plegia ou tempo de isquemia maior que 24 horas tiveram piores resultados quanto a preservayao de membro (p<0,05). Concluimos que em casos de embolia de membro inferior, apresentando-se 0paciente em boas condiyoes clfnicas e com 0membro sem necrose instalada, vale a pena a realiza<;ao da embolectomia com cateter de Fogarty, devido aos bons resultados quanto a preserva<;ao do membro e baixos indices de complica<;oes derivadas do procedimento cirurgico. A preserva<;ao de membro foi significativamente maior nos pacientes sem empastamento muscular, com tempo de isquemia menor que 24 horas e atividade motora normal.
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