Aortic saddle embolus in acute myocardial infarction

Reports on Therapy Aortic

Saddle

Embolus

Myocardial Successful Removal LAWRENCE

N A patient tion,

tion

with

embolic

is a feared

agree

that

a recent

occlusion complication.

embolectomy

is required

even

its attendant

presence

disease.

Recently

a

technic

has

described

which

extraction through

of an

infarction

of this recovering

and

three

balloon

under

arteriotomy

ful application risk patient

emboli

incision. from

bouts

severe

catheter

permits

local

simple

risks

of such

cardiac

been

bifurca-

All investigators

with

in the

infarc-

aortic

the

anesthesia The

technic a recent

successin a poor

myocardial

of ventricular

fibrilla-

tion jvill be described. CASE

REPORT

In 1962, a 46 year old white man \vas admitted to another hospital because of severe chest pain lasting The diagnosis of an acute myocardial for hours. infarction of the diaphragmatic wall was made. During his hospitalization no complications occurred, and he was discharged on anticoagulant therapy. He discontinued this medication in May 1965 because of his sense of well-being. Four weeks later, on June 6. crushing chest pain led to his rehospitalization. The diagnosis of a new anterolateral myocardial infarction was made and verified by typical electrocardiographic changes and elevation of levels of serum lactic dehydrogenase and glutamic oxalacetic transaminase. He was transferred to the Bronx Veterans Administration Hospital for follow-up care on July 23. The examination at that time revealed the blood pressure to be 165/l 00 mm. Hg and pulse 120 and regular. 7‘he lungs were clear. The heart was not enlarged. Auscultation revealed a sinus tachycardia as well as a protodiastolic gallop. An electrocardiogram was * From the Medical VOLUME 19, FEBRUARY 1967

and Surgical

Technic*

M.D. and FRANK ~\~~IGLIORF.LLI, M.D.

GOULD,

myocardial

of the

Infarction

by a Fogarty Catheter Bronx,

I

in Acute

New

York

compatible with diaphragmatic and anterolateral wall myocardial infarction (Fig. 1). Coumadin” was reinstituted shortly after admission. On July 27. severe chest pain developed, and shortly thereafter the patient was in cardiac arrest. Immediate resuscitative measures were instituted, and the diagnosis of ventricular fibrillation was determined electrocardiographically. A D.C. discharge of 250 watt-sec. from the Lown Cardioverter re-established a regular sinus Over the ensuing hour, t\vo recurrences of rhythm. ventricular fibrillation necessitated two more applications of D.C. discharge. Suppressive doses of quinidine prevented a further recurrence of this arrhythmia. The patient slowly recovered from this new complication. However, on August 4 he noted the sudden onset of pain in his buttocks and an inability to move his legs. Examination revealed absent femoral and popliteal pulses bilaterally. as well as marked coldness and paleness over both thighs and legs. The clinical diagnosis of a saddle embolus to the aortic bifurcation was made. Immediate surgery was deemed necessary, and the femoral triangle was anesthetized locally with xyloCaine. Both common femoral arteries were isolated and arteriotomies performed. Mimimal retrograde and antegrade bleeding was noted. Through the right common femoral arteriotomy the Fogart! embolectomy catheter was passed with ease up the right femoral artery and on into the aorta. The balloon was inflated and several large emboli \rere removed with each of three separate passages of the Good pulsatile flow was established on the catheter. right side. Similar passage was performed through the left common femoral artery. and again several large emboli were extracted. Good pulsatile flow was established on the left side. At this time the pulse of the right common femoral artery was again

Services of the Veterans 231

Administration

Hospital,

Bronx, N. Y.

232

Gould and Migliorelli noted

to be markedly

Fogarty

catheter

embolus

(Fig.

established

2 and

that the embolus

both

femorals

while

the

amelioration

and

v2

V3

V4

V5

V6

catheter

was

Walking

discharged

of pain

bounding was on

Oct.

sequence flow

patient

patient

another

was was

with

and

large

of

events bifurca-

present

the

motor

1, 1965,

power achieved

the

in

procedure

postoperatively.

gradually

in

experiencing an increase

tolerated

given

of the

patient

All slowly and, was

asymptomatic.

Electrocardiogram shows diaphragmatic anterolateral myocardial infarction.

shows embolectomy FIG. 2. Diagram above the aortic bifurcation.

heparin

remained

returned. when

The

of

was at the aortic

pulsatile

pulses

VI

This

good

well,

1.

3).

Finally,

progressive

and passage

productive

tion.

paresthesias.

FIG.

diminished,

was

and

placed

FIG. 3. Diagram shows removal of the clot through the femoral arteriotomy.

DISCUSSION

In arterial embolism the prognosis for the patient as well as the survival of the limb depends on the site of the occluded vessel. Most patients with an aortic saddle embolus will die if embolectomy is not performed successfully. However, occlusion of the more distal anterior or posterior tibia1 artery will not produce major gangrene in most patients.’ The mortality in patients with embolism is also related to the underlying disease. While the mortality is relatively small in patients with rheumatic heart disease, it increases considerably in those with myocardial infarction. Approximately 9 per cent of peripheral arterial emboli become arrested at the aortic biIn patients with recent myocardial furcation. infarction and mural thrombi, the possibility of using local anesthesia and approaching the embolus through the femoral arteries is certainly desirable in contrast to an abdominal procedure. Unfortunately, the available instruments and technics until recently did not always Also, the allow satisfactory removal of emboli. use of spinal or general anesthesia further increases the hazard of surgery in these poor risk patients. In 1963 Fogarty described an intravascular catheter, 80 cm. long, with an inflatable balloon at its distal tip. In its clinical application, an arteriotomy was made over the site of the embolus and the catheter was inserted and threaded The balloon was inflated as far as possible. with fluid, and the catheter was removed with the balloon still inflated, bringing with it the distal embolus and propagated thrombus. The pliability of the catheter avoided the possibility of dissection of plaques or arterial perforation. Chassin4 recently reported that successful embolectomy can be accomplished by this technic even after a delay of 3 to 21 days. In our critically ill patient, the extraction of THE AMERICAN JOURNAL OF CARDIOLOGY

Aortic

Saddle

emholi through the bilateral femoral arteriotThe paornies was accomplished with ease. tient not only survived the procedure but recovered the complete use of his legs. This technic in patients with severe cardiac disease is vastly superior to all previous technics deUnfortunately, in our previous exscribed. perience with such patients using the older methods, loss of life or limb was a common-place occurrence. Fogarty and Cranley,b using the balloon catheter, verified this impression in their The hospital morseries of 56 embolectomies. tality rate of 20 per cent and limb salvage rate of 96.4 per cent are far better than previous studies based on either conservative or surgical treatFogarty in his ment of peripheral embolism.2 series does not allude to any case of aortic saddle embolism complicating an acute myocardial However, in his experience with infarction. over 100 cases of peripheral arterial embolism, acute myocardial infarction represents the third Our case most common cause of embolism.6 demonstrates that this new method for extraction of arterial emboli is also admirably suited

VOLUME

19, FEBRUARY 1967

Embolus

233

for the poor risk patient ease.

with severe cardiac

dis-

SUMMARY

A patient is described who sustained an aortic saddle embolus after a myocardial infarction. The Fogarty embolectomy catheter successfully extracted the embolus, and arterial flow was completely restored. REFERENCES 1. HARDY, J. J. Surgery of the Aorta and its Branches. p. 243. Philadelphia, 1960. J. B. Lippincott Company. 2. HAIMOVICI,H. Peripheral arterial embolism. An&dogy, 1: 20, 1950. 3. FOGARTY, T. J., CRANLEY, J. J., KRAUSE, R. J., STRASSER,E. S. and HAFNER, C. D. A method for extraction of arterial emboli and thrombi. SW~. Gynec. G3 Obst., 116: 241, 1963. Improved management of acute 4. CHASSIN, J. L. embolism and thrombosis with an embolectomy catheter. J.rl.M.A., 194: 103, 1965. 5. FOGARTY, T. J. and CRANLEY, J. J. Catheter technique for arterial embolectomy. Ann. Surg., 161: 325, 1965. 6. FOCARTY, T. J Personal communication, March 3, 1966.