- Email: [email protected]
A curette for embolectomy
A Curette
for Embolectomy
R. 0. HEIMBECKER, M.D., F.R.C.S. (C.) AND GORDONMURRAY, M.D., F.R.C.S. (C.), F.A.c.s., Toronto, Ontario, Canada From tbe Department of Surgery, University of Toronto and Toronto General Hospital, Toronto, Ontario, Canada.
TABLE RETROGRADE
ADDLE embohsm of the aorta is a highIy IethaI disease [r,2,4] in spite of the most skiIIed surgica1 management. The direct approach to the aorta through a Iarge abdomina1 incision is traumatic to a patient who is already criticaIIy iI1. Retrograde remova of such emboIi through a smaI1 exposure of the femora1 artery is a simpIe, rapid procedure, which in no way further jeopardizes the patient’s Iife. This approach has been difhcult in the past because of inadequate instruments [3,4]. A curette* for emboIectomy has been in continuous use in the Toronto Genera1 HospitaI for the past six years. (TabIe I.) EmboIi Iodged in the abdomina1 aorta or in the iIiac arteries have been readiIy removed with the patient under IocaI anaesthesia. The hazards of deep anaesthesia, and the Iong dissection of an abdomina1 exposure are avoided. The patient’s postoperative course is much easier. Anticoagulants can be given immediateIy after the operation with IittIe risk of wound haematoma. The curettes are designed with shafts Iong enough to reach from the femora1 arteriotomy we11 up into the abdomina1 aorta. (Fig. I.) A curette with a Ioop which wiI1 convenientIy enter the lumen is seIected. The proxima1 umbiIica1 tape is momentariIy relased so that the curette can be passed proximally. (Fig. 2.) When the cIot is feIt with the curette loop, the instrument is gently advanced and rotated so that a portion of cIot is engaged and then
(TORONTO
S
* ObtainabIe from J. F. Hartz Co., Toronto, Ontario, Canada. American
Journal
of Surgery,
Volume
99. June,
1960
918
AORTIC GENERAL
OR
I ILIAC
EMBOLECTOMY
HOSPITAL,
rg~pIg~g)* Outcome
Anaesthetic SW-
No. of Patients
cessful Operations
Died in Cardiac F&Ire
Died of Subsequent Cured Emboli (Cerebral or Multiple)
. 3
II
This method of removing arterial emboti has also been used by one of us (G. M.) in another group of twenty patients.
extracted. The cIot is removed piecemeal in this manner, unti1 the hydrostatic pressure proxima1 to the cIot suddenly forces out the Iast fragment with a dramatic gush. SaddIe emboli do not aIways require biIatera1 femora1 arteriotomy; however, both groins shouId be prepared for operation. The more ischaemic limb shouId be operated upon first, whereupon the other limb wiI1 often recover spontaneousIy. This is probabIy due to complete remova of the cIot from one side and reIief of associated spasm. The curettes are aIso useful in other types of arteria1 surgery. A stasis thrombus dista1 to a common femora1 embolus can frequentIy be removed by the smaI1 curette, as iIIustrated in the foIIowing case. This forty-five year old woman had had rheumatic fever as a chiId and was found to have mitraI stenosis folIowing a cerebral emboIus at the age of twenty. Congestive heart faiIure was controIIed with diffIcuIty by Digoxin,@ a low salt diet and diuretics.
A Curette
for EmboIectomy
FIG. I. Embolectomy curettes with end loops of varying size to fit the lumen of the artery conveniently. Shafts are long and IIexibIeso that they will conform to curves in the iliac artery system. Handles are placed in the same pIane of rota-
tion as the loops so that the position of the Ioop wiI1 always be known. These instruments are aIso useful for endarterectomy proceedures.
At operation no thrombus was found in the atrium, and a tight mitral stenosis was relieved. Two hours postoperativeIy a coId, white, anaesthetic right limb was noted, with absence of all arterial puIses incIuding femoraI and external iliac. Embolectomy was immediateIy performed with the patient under local anaesthesia. The common femoral artery was isoIated and found to be coIIapsed, with no pulsation. A curette which was passed proximally engaged a soft thrombus Iodged in the common iliac artery. This was removed piecemea1, with a dramatic return of pulses when the arteriotomy had been closed. The patient left the hospita1 with a perfectIy norma limb.
To have subjected this woman to Iaparotomy as well as mitraI commissurotomy on the same day wouId have been very traumatic. The small femoraI arteriotomy with the patient under IocaI anaesthesia was we11toIerated. Her postoperative course was in no way different from that of the usua1 patient who undergoes mitraI commissurotomy. COMMENTS
In the beginning it had been feared that such a bIind emboIectomy might prove incompIete; then cIot which had been Ieft behind wouId stimuIate secondary thrombus formation and further ischaemia. However, this has never
FIG. 2. Femoral arteriotomy with patient under IocaI anaesthesia. The curette is advanced retrograde toward the aortic bifurcation, unti1 the emboIus is engaged. It is then removed by degrees whiIe bleeding is controIIed by an umbilica1 tape about the artery.
9’9
Heimbecker occurred. Hydrostatic pressure in the aorta provides very adequate irrigation of the area, so that the Iast piece of emboIus is always ffushed out. It had aIso been feared that an emboIus which was being removed from a common iIiac artery might inadvertentIy be pushed across into the other common iliac artery, to render the other Iimb ischaemic. This has never occurred in our patients. It is probabIy important to extract the cIot gentIy, in a piecemea1 manner, if this compIication is to be avoided. SUMMARY
A curette for emboIectomy is described which has been in constant use in the Toronto Genera1 Hospital for six years.
and Murray SaddIe emboli of the aorta and emboIi of the iIiac arteries can be safeIy and adequateIy extracted by a smaI1 femora1 artery arteriotomy with the patient under IocaI anaesthesia. The surgica1 trauma of prolonged Iaparotomy with the patient under deep genera1 anaesthesia can be avoided. REFERENCES I. HAIMOVICI, H. PeripheraI
arterial emboIism; study of 330 unseIected cases of embolism of the extremities. Angiology, I : 20, 1950. 2. WARREN, R., LINTON, R. R. and SCANNELL, J. G. ArteriaI cmboIism; recent progress. Ann. Surg., 140: 31 I, 1954. 3. SCHUMACHER, H. B., JACOBSON, H. S. Ann.
Surg.,
145: 145, 1957. 4. DETAKATS, G. Vascular Surgery, pp. 318, 608. PhiIadeIphia, 1959. W. B. Saunders Co.
for Embolectomy
R. 0. HEIMBECKER, M.D., F.R.C.S. (C.) AND GORDONMURRAY, M.D., F.R.C.S. (C.), F.A.c.s., Toronto, Ontario, Canada From tbe Department of Surgery, University of Toronto and Toronto General Hospital, Toronto, Ontario, Canada.
TABLE RETROGRADE
ADDLE embohsm of the aorta is a highIy IethaI disease [r,2,4] in spite of the most skiIIed surgica1 management. The direct approach to the aorta through a Iarge abdomina1 incision is traumatic to a patient who is already criticaIIy iI1. Retrograde remova of such emboIi through a smaI1 exposure of the femora1 artery is a simpIe, rapid procedure, which in no way further jeopardizes the patient’s Iife. This approach has been difhcult in the past because of inadequate instruments [3,4]. A curette* for emboIectomy has been in continuous use in the Toronto Genera1 HospitaI for the past six years. (TabIe I.) EmboIi Iodged in the abdomina1 aorta or in the iIiac arteries have been readiIy removed with the patient under IocaI anaesthesia. The hazards of deep anaesthesia, and the Iong dissection of an abdomina1 exposure are avoided. The patient’s postoperative course is much easier. Anticoagulants can be given immediateIy after the operation with IittIe risk of wound haematoma. The curettes are designed with shafts Iong enough to reach from the femora1 arteriotomy we11 up into the abdomina1 aorta. (Fig. I.) A curette with a Ioop which wiI1 convenientIy enter the lumen is seIected. The proxima1 umbiIica1 tape is momentariIy relased so that the curette can be passed proximally. (Fig. 2.) When the cIot is feIt with the curette loop, the instrument is gently advanced and rotated so that a portion of cIot is engaged and then
(TORONTO
S
* ObtainabIe from J. F. Hartz Co., Toronto, Ontario, Canada. American
Journal
of Surgery,
Volume
99. June,
1960
918
AORTIC GENERAL
OR
I ILIAC
EMBOLECTOMY
HOSPITAL,
rg~pIg~g)* Outcome
Anaesthetic SW-
No. of Patients
cessful Operations
Died in Cardiac F&Ire
Died of Subsequent Cured Emboli (Cerebral or Multiple)
. 3
II
This method of removing arterial emboti has also been used by one of us (G. M.) in another group of twenty patients.
extracted. The cIot is removed piecemeal in this manner, unti1 the hydrostatic pressure proxima1 to the cIot suddenly forces out the Iast fragment with a dramatic gush. SaddIe emboli do not aIways require biIatera1 femora1 arteriotomy; however, both groins shouId be prepared for operation. The more ischaemic limb shouId be operated upon first, whereupon the other limb wiI1 often recover spontaneousIy. This is probabIy due to complete remova of the cIot from one side and reIief of associated spasm. The curettes are aIso useful in other types of arteria1 surgery. A stasis thrombus dista1 to a common femora1 embolus can frequentIy be removed by the smaI1 curette, as iIIustrated in the foIIowing case. This forty-five year old woman had had rheumatic fever as a chiId and was found to have mitraI stenosis folIowing a cerebral emboIus at the age of twenty. Congestive heart faiIure was controIIed with diffIcuIty by Digoxin,@ a low salt diet and diuretics.
A Curette
for EmboIectomy
FIG. I. Embolectomy curettes with end loops of varying size to fit the lumen of the artery conveniently. Shafts are long and IIexibIeso that they will conform to curves in the iliac artery system. Handles are placed in the same pIane of rota-
tion as the loops so that the position of the Ioop wiI1 always be known. These instruments are aIso useful for endarterectomy proceedures.
At operation no thrombus was found in the atrium, and a tight mitral stenosis was relieved. Two hours postoperativeIy a coId, white, anaesthetic right limb was noted, with absence of all arterial puIses incIuding femoraI and external iliac. Embolectomy was immediateIy performed with the patient under local anaesthesia. The common femoral artery was isoIated and found to be coIIapsed, with no pulsation. A curette which was passed proximally engaged a soft thrombus Iodged in the common iliac artery. This was removed piecemea1, with a dramatic return of pulses when the arteriotomy had been closed. The patient left the hospita1 with a perfectIy norma limb.
To have subjected this woman to Iaparotomy as well as mitraI commissurotomy on the same day wouId have been very traumatic. The small femoraI arteriotomy with the patient under IocaI anaesthesia was we11toIerated. Her postoperative course was in no way different from that of the usua1 patient who undergoes mitraI commissurotomy. COMMENTS
In the beginning it had been feared that such a bIind emboIectomy might prove incompIete; then cIot which had been Ieft behind wouId stimuIate secondary thrombus formation and further ischaemia. However, this has never
FIG. 2. Femoral arteriotomy with patient under IocaI anaesthesia. The curette is advanced retrograde toward the aortic bifurcation, unti1 the emboIus is engaged. It is then removed by degrees whiIe bleeding is controIIed by an umbilica1 tape about the artery.
9’9
Heimbecker occurred. Hydrostatic pressure in the aorta provides very adequate irrigation of the area, so that the Iast piece of emboIus is always ffushed out. It had aIso been feared that an emboIus which was being removed from a common iIiac artery might inadvertentIy be pushed across into the other common iliac artery, to render the other Iimb ischaemic. This has never occurred in our patients. It is probabIy important to extract the cIot gentIy, in a piecemea1 manner, if this compIication is to be avoided. SUMMARY
A curette for emboIectomy is described which has been in constant use in the Toronto Genera1 Hospital for six years.
and Murray SaddIe emboli of the aorta and emboIi of the iIiac arteries can be safeIy and adequateIy extracted by a smaI1 femora1 artery arteriotomy with the patient under IocaI anaesthesia. The surgica1 trauma of prolonged Iaparotomy with the patient under deep genera1 anaesthesia can be avoided. REFERENCES I. HAIMOVICI, H. PeripheraI
arterial emboIism; study of 330 unseIected cases of embolism of the extremities. Angiology, I : 20, 1950. 2. WARREN, R., LINTON, R. R. and SCANNELL, J. G. ArteriaI cmboIism; recent progress. Ann. Surg., 140: 31 I, 1954. 3. SCHUMACHER, H. B., JACOBSON, H. S. Ann.
Surg.,
145: 145, 1957. 4. DETAKATS, G. Vascular Surgery, pp. 318, 608. PhiIadeIphia, 1959. W. B. Saunders Co.