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After the blue toe: prognosis of noncardiac arterial embolization in the lower extremities
K H Kvilekval1, J P Yunis, R A Mason
1Department of Surgery, University Hospital, State University of New York, Stony Brook 11794-8191.
Insights
Atheroembolic disease carries significant risks of mortality and recurrent embolization, particularly when originating above the diaphragm. Surgical intervention in select cases can reduce recurrence without increasing mortality.
Area of Science:
- Vascular Surgery
- Cardiology
- Radiology
Background:
- Atheroembolic disease, characterized by emboli originating from atherosclerotic plaques, poses a significant clinical challenge.
- Understanding the prognosis and risk factors associated with atheroemboli is crucial for effective patient management.
Purpose of the Study:
- To investigate the prognosis of atheroembolic disease affecting the viscera and lower extremities.
- To compare outcomes based on the location of the embolic source (supradiaphragmatic vs. subdiaphragmatic).
Main Methods:
- Retrospective review of 41 patients with atheroembolic disease.
- Analysis of mortality, recurrent embolization, and amputation rates.
- Comparison of outcomes between patients with supradiaphragmatic and subdiaphragmatic embolic sources.
- Evaluation of the impact of surgical intervention on recurrence rates.
Main Results:
- Overall mortality was 17% and recurrent embolization occurred in 15% of patients.
- Patients with supradiaphragmatic embolic sources had significantly higher mortality (60%) and recurrence rates (60%) compared to those with subdiaphragmatic sources (11% and 8%, respectively).
- Surgical intervention on the identified lesion in selected patients significantly reduced recurrent embolization (7% vs. 36%) without increasing mortality.
Conclusions:
- Atheroembolic disease has a substantial mortality and risk of recurrence, especially when the source is supradiaphragmatic.
- Surgical management in carefully selected patients can decrease the frequency of recurrent embolization and improve outcomes.
Purpose:
To better understand the prognosis of atheroembolic disease, we reviewed the outcomes of 41 patients with embolization to the viscera and lower extremities.
Methods And Results:
All cases involved emboli that originated from a radiographically identified proximal arterial source. There were 30 men and 11 women (mean age 65 years; mean follow-up time 2 years), and all had been first treated for this condition within the past 6 years. The overall mortality rate was 17% (7/41) and the rate of recurrent embolization 15% (6/41). To compare outcomes associated with supradiaphragmatic versus subdiaphragmatic disease, we defined two groups: group 1 comprised patients (n = 5) in whom the identified embolic source extended above the diaphragm, and group 2 comprised patients (n = 36) in whom the source remained below the diaphragm. The mortality rates in groups 1 and 2 were 60% (3/5) and 11% (4/36), respectively (p < 0.05). Recurrent embolization was also significantly higher in group 1 (60% vs 8%, p < 0.025). There were two amputations in group 1 and six in group 2 (p = not significant). Group 2 patients were then divided into two subgroups: those with limited disease (n = 19) in which the emboli had a single, radiographically identified source (i.e., aneurysm or single area of ulcerated plaque) and those with diffuse disease (n = 17) in which the emboli had multiple, radiographically identified potential sources. In the subgroup of patients with limited disease, no deaths or episodes of recurrent embolization occurred, whereas four deaths and three episodes of recurrent embolization occurred in the subgroup of patients with diffuse disease. The differences in these outcomes, however, were not statistically significant. Thirty selected patients (one from group 1 and 29 from group 2) underwent operation on or bypass of the imputed lesion. Only one (7%) of these 30 patients had recurrent embolization. In contrast, recurrent embolization was noted in four (36%) of the 11 patients who did not have an operation directed at the lesion (p < 0.025). No significant difference in mortality was found between patients who underwent operation and those who did not.
Conclusions:
Patients with atheroemboli have a substantial mortality rate and risk of recurrent embolization, especially if the disease process extends above the diaphragm; but in selected patients, operation may decrease the frequency of recurrence without increasing mortality.