Immediate heparinisation and surgery in the management of saddle embolism

Twenty-six patients (age range 40-88 years) with saddle embolism, representing 11% of cases of peripheral embolism, were treated during an 8-year period. A proven intra-cardiac source, including atrial fibrillation and post-infarction mural thrombosis, was observed in 22 cases (85%). The ambiguities in the clinical presentation of saddle embolism were sometimes responsible for delayed recognition. On confirmation of the diagnosis an IV heparin regime was immediately commenced followed by surgery. Our practice of initiating treatment of saddle embolism with immediate systemic heparin infusion resembles that of Blaisdell et al. In contrast, we also advocate a policy of early surgical intervention. Bilateral trans-femoral explorations were undertaken in 21 cases and direct aorto-iliac procedures in five cases. Recurrent embolism occurred in 27% of cases despite postoperative anticoagulant therapy. An overall limb salvage rate of 88.5% was recorded. The postoperative mortality of 30% was accounted for by primary cardiac disease and multiple organ failure. The influence of multiple and recurrent embolism and cardiac instability on the eventual outcome is signifcant. A policy of early systemic heparin therapy and surgery in the management of saddle embolism, enhances limb survival and prevents renal failure.