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 Acute Arterial Occlusion

Keith Calligaro, M.D., David Drezner, M.D., Frank Veith, M.D.

Includes:

  • Acute Thrombotic Disease
  • Atheroembolic Disease
  • Thromboembolectomy Techniques
  • Thrombolysis: Percutaneous & Intraoperative
  • Systemic Complications of Reperfusion Injury
  • Compartment Syndrome

I . Anatomy and Pathophysiology

1. To understand the various causes of acute arterial thrombosis including chronic atherosclerosis, hypercoaguable conditions, catheters and medical devices, and drug injections.

2. To understand various sources of peripheral arterial emboli including the heart (and underlying factors including myocardial infarcts, valve disease, atrial fibrillation, intracardiac tumors), arterial aneurysms and ulcerative plaques.

3. To define the variable interval of acute arterial ischemia before irreversible changes of the muscle and peripheral nerves begin to occur.

4. To understand the reasons for the high morbidity and mortality associated with acute arterial occlusion even when treatable by simple, straightforward operations.

5. To understand impaired reflow phenomenon including cellular edema, vascular lumen narrowing, capillary occlusion, and oxygen derived radicals.

6. To understand ischemia-reperfusion syndrome and its' complications, including compartment syndrome, hyperkalemia, metabolic acidosis, myoglobinuria and renal insufficiency, and pulmonary insufficiency.

7. To understand the etiology and clinical presentation of "blue-toe syndrome".

8. To understand how the degree of arterial collateralization, in particular chronicity of underlying arterial disease and site of arterial occlusion in reference to major collaterals, affects severity and course of symptoms.

II . Diagnostic Evaluation

1. To understand the classic signs and symptoms of acute arterial insufficiency (pallor, decreased temperature, pulselessness, paraesthesias, paresis, pain) along with other more subtle findings such as poor venous filling.

2. To be able to recognize features of the viable, threatened and irreversibly ischemic extremity.

3. To correlate other systemic clinical findings with the likely cause of acute arterial occlusion including atrial fibrillation, claudication or a past history of unexplained previous arterial or venous clotting.

4. To understand the utility of doppler studies of peripheral arteries.

5. To understand the indications for preoperative arteriography in the setting of acute arterial occlusion.

6. To understand arteriographic findings suggestive of embolus or thrombus due to underlying arterial stenosis.

III. Treatment

1. To understand the role of heparin to prevent propagation of thrombus and protect the distal arterial tree.

2. To understand the benefits of mannitol for patients with advanced acute arterial occlusion.

3. To understand the importance of hydration and correcting electrolyte imbalances.

4. To understand the role of thrombolysis as the initial treatment of acute arterial occlusion and its role intraoperatively.

5. To understand the value of full preoperative arteriography in localizing the level of occlusion, the presence of other occlusions and stenoses, and suitable vessels for a bypass should it be needed.

6. To understand the importance of appropriate prepping and draping of the patient to gain access for possible venous conduits and appropriate inflow and outflow arteries.

7. To make correct decisions concerning the proper locations and type of arteriotomy depending on whether an embolus is the likely source of acute arterial occlusion or thrombus secondary to underlying chronic arterial stenosis.

8. To understand the proper technique when using thromboembolectomy catheters.

9. To understand the importance of completion arteriography.

10. To understand the indications for and technique of fasciotomy.

References

1. Jameson RL: The role of cellular swelling in the pathogenesis of organ ischemia. West J Med 1974;3:205.

2. Harman JW. The significance of local vascular phenomena in the production of ischemic necrosis in skeletal muscle. Am J Pathol 1948;24:625.

3. McCord JM. Oxygen-derived free radicals in post-ischemic tissue injury. N Engl J Med 1985;313:159.

4. Walker PM, Lindsay TF, Labbe R, et al. Salvage of skeletal muscle with free radical scavengers. J Vasc Surg 1987;5:68.

5. Perry MO, Shires GT III, Albert SA. Cellular changes with graded limb ischemia and reperfusion. J Vasc Surg 1984;1:536.

6. Elliott JP JR, Hageman JH, Szilagyi DE , et al. Arterial embolization: Problems of source, multiplicity, recurrence, and delayed treatment. Surgery 1980;88:833.

7. Fogarty TJ, Cranley JJ, Krause RJ, et al. A method for extraction of arterial emboli and thrombi. Surg Genecol Obstet 1963;116:241.

8. Abbott WM, Maloney RD , McCabe CC, et al. Arterial embolism. A 44 year perspective. Am J Surg 1982;143:460.

9. Thompson JE, Weston AS , Sigler L, et al. Arterial embolectomy after acute myocardial infarction. A study of 31 patients. Ann Surg 1970;171:979.

10. Haimovici, H, Moss CM, Veith FJ. Arterial embolectomy revisited. Surgery 1975;78:409.

11. Kempczinski RF. Lower extremity arterial embol from ulcerating atherosclerotic plaques. JAMA 1979;241:807.

12. Blaisdell FW, Steele M, Allen RE. Management of acute lower extremity arterial ischemia due to embolism and thrombosis. Surgery 1978;84:822.

13. Haimovici H. Muscular, renal and metabolic complications of acute arterial occlusions. Myonephropathic-metabolic syndrome. Surgery 1979;85:461.

14. Perry MO. Compartment syndromes and reperfusion injury. Surg Clin North Am 1988;68:853.

15. Gupta SK, Samson RH, Veith FJ. Embolectomy of the distal part of the popiteal artery. Surg Gynecol Obstet 1981;153:255.

Posted June 2010