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Surgical management of atheroembolization
R R Keen1, W J McCarthy, P K Shireman
1Department of Surgery, Northwestern University Medical School, Chicago, IL, USA.
Insights
Surgical treatment of atheroembolism from the aorta or iliac arteries offers good outcomes. However, extensive suprarenal aortic thrombus presents a higher risk for mortality and limb loss.
Area of Science:
- Vascular Surgery
- Cardiovascular Disease
- Interventional Radiology
Background:
- Atheroembolization is a serious condition that can lead to limb loss or organ failure.
- Surgical outcomes for atheroembolization are not well-documented.
- This study presents the largest series of atheroembolization cases, focusing on disease patterns, surgical interventions, and patient outcomes.
Purpose of the Study:
- To analyze the patterns of disease in atheroembolization.
- To evaluate the effectiveness of surgical treatments for atheroembolization.
- To report the outcomes of surgical intervention for atheroembolization.
Main Methods:
- A prospective study of 100 patients (70 men, mean age 62) undergoing surgery for atheroemboli in the lower extremities, visceral organs, or upper extremities over 12 years.
- Atheroembolic source localization using computed tomography (CT) scanning, arteriography, duplex scanning, transesophageal echocardiography, and magnetic resonance imaging (MRI).
- Surgical correction methods included aortic bypass, endarterectomy with patch, infrainguinal bypass, extraanatomic reconstruction, graft revision, and upper extremity procedures.
Main Results:
- Occlusive aortoiliac disease and small aortic aneurysms were the most common sources of atheroemboli.
- Patients with extensive suprarenal aortic thrombus (12 patients) had significantly higher mortality rates (all 7 early deaths occurred in this group).
- Overall survival rates at 1, 3, and 5 years were 89%, 83%, and 73%, respectively. Postoperative complications included major leg amputations (9), toe amputations (10), and hemodialysis for renal involvement (10). Recurrent embolic events were infrequent (5/97) and primarily occurred early post-operatively, with a trend towards fewer recurrences in patients not on warfarin.
Conclusions:
- The aorta and iliac arteries are the primary sources of atheroemboli in surgically treated patients.
- CT scanning of the aorta is a valuable diagnostic tool for identifying the embolic source.
- Surgical elimination of the embolic source is associated with low mortality and limb loss rates, except in cases involving the suprarenal aorta.
Purpose:
Atheroembolization may cause limb loss or organ failure. Surgical outcome data are limited. We report the largest series of atheroembolization focusing on patterns of disease, surgical treatment and outcome.
Methods:
One hundred patients (70 men), mean age 62 +/- 11 years, operated on for lower extremity, visceral, or nonthoracic outlet upper extremity atheroemboli were identified prospectively and monitored over a 12-year period. The atheroembolic source was localized by use of a combination of computed tomography scanning (n = 55), arteriography (n = 93), duplex scanning (n = 25), transesophageal echocardiography (n = 6), and magnetic resonance imaging (n = 4). Occlusive aortoiliac disease (47 patients) and small aortic aneurysms (20 patients; mean aneurysm size 3.5 +/- 0.8 cm) were the most common source of atheroemboli. Imaging studies revealed 12 patients with extensive suprarenal aortic thrombus. Correction of the embolic source was achieved with aortic bypass (n = 52), aortoiliac endarterectomy and patch (n = 11), femoral or popliteal endarterectomy and patch (n = 11), infrainguinal bypass (n = 3), extraanatomic reconstruction (n = 6), graft revision (n = 3), upper extremity bypass (n = 11), or upper extremity endarterectomy and patch (n = 3).
Results:
All four deaths within 30 days and all seven deaths within the first 6 months after operation were among the 12 patients with suprarenal aortic thrombus. The cumulative survival probabilities for all patients at 1, 3, and 5 years were 89%, 83%, and 73%, respectively. After operation, nine patients required major leg amputations and 10 required toe amputations. Renal atheroemboli led to hemodialysis in 10 patients. Recurrent embolic events occurred in five of 97 patients monitored for a mean of 32 months. All five recurrences occurred in the first 8 months after operation. Three patients with recurrent emboli had suprarenal aortic disease, one of whom had undergone axillofemorofemoral bypass. Four of 15 patients receiving postoperative warfarin anticoagulation had development of recurrent embolism. Only one patient not receiving postoperative warfarin had a recurrent event (p < 0.05 by Fisher exact test).
Conclusion:
The atheroembolic source is the aorta or iliac arteries in two thirds of patients who underwent operation. Computed tomography scanning of the aorta is a useful diagnostic technique. The source of the emboli can be eliminated surgically with low mortality or limb loss rates except when the suprarenal aorta is involved.