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Peripheral Arterial Emboli
Peripheral Arterial Emholi ALBERT G. MARTIN, M.D. *
IN THIS day of dramatic achievements in vascular surgery, a worthwhile accompaniment has been the revived interest in surgical treatment of emboli lodged in major peripheral arteries. While part of this revival of interest may be cyclical, it is directly stimulated by the occurrence of peripheral emboli following operations upon the heart and even more by the improved results in the treatment of arterial emboli. The surgical removal of arterial emboli now carries little or no risk to life or to the circulation of the parts involved and when done early brings with it a likely prospect of restoring function to the level enjoyed before the embolus occurred. While only femoral and brachial emboli are discussed here, it is felt that these expressions apply also to axillary, iliac, popliteal and' possibly aortic emboli. Statements made regarding risk must recognize that the disease which has been complicated by an embolus carries a high mortality of itself. Embolectomy does not add to the inherent mortality of the disease which the embolus complicates, nor does a properly performed embolectomy jeopardize circulation. It may be regarded as a worthwhile emergency operation in desperate circumstances where a life as well as an arm or a leg may be saved. While the source of a small proportion of emboli cannot be determined, they most frequently complicate auricular fibrillation or myocardial infarction. Part or all of a mural thrombus breaks loose and becomes the plug. Warren, Linton and Scannelll report the incidence of peripheral embolism complicating mitral surgery as 16 per cent and 30 per cent in those patients who had previously had embolism. Emboli lodge at arterial bifurcations. Embolism is followed by spasm of the involved arteries and the propagation of thrombi proximally and distally. The proximal thrombus is usually short; the distal one long. Emboli occur at all hours of the day and night. If they are given prompt attention, regarded as emergencies of hours, gratifying results may be expected. Embolectomy within six hours after onset has for years
* Assistant Clinical Professor of Surgery, Marquette University School of Medicine; Surgeon, St. Mary's Hospital; Associate Surgeon, Columbia and Milwaukee Hospitals, Milwaukee, Wisconsin. 1055
Albert G. Martin
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been regarded as the optimal time. As time passes, the development of propagating thrombi makes clearing of the vessel lumen more difficult. Time was when embolectomy was not considered after 24 hours. Even this situation has been improved by an aggressive surgical approach in patients who have been seen as late as two weeks after embolism. Success in late cases seems to be greatest in the largest vessels (aorta) and in patients who are on anticoagulant treatment. In the latter instances, propagating thrombi and adherence between embolus and vessel walls are minimized. The importance of early operation should still be emphasized; for within six or even ten hours good results can be obtained in most cases. Once gangrene has occurred, salvage of the extremity by embolectomy becomes most unlikely and amputation as a life-saving measure must be considered. Whether embolectomy, if successful, will result in relatively distal demarcation in cases of early gangrene is a question worth consideration in individual cases. A group of ten cases seen in private practice is presented. The number is small but the problems presented probably have been shared by many individual surgeons. Treatment and results in eight patients with femoral emboli, five of whom were operated upon and two patients with brachial emboli, both of whom were operated upon, are summarized in Table 1. Table 1 SUMMARY OF TEN CASES NUMBER
SITE OF EMBOLUS
TREATMENT
RESULT
3
Common femoral artery
Nonsurgical
2 deaths 1 thigh amputation
5
Common femoral artery
Embolectomy
4 full recoveries 1 amputation below knee
2
Brachial artery
Embolectomy
1 full recovery 1 death
Femoral and brachial arteries are the most common sites for lodgment of emboli and in this respect these cases follow the usual patterns. The severity of the two cases of brachial artery embolus is unusual. The patients not operated upon presented clinical pictures so similar to those who received operation that it seems proper to include them. The two who died were a man of 62 and a woman of 58 years. Both had arteriosclerotic heart disease with auricular fibrillation and both developed sudden occlusion of the right femoral artery presumably due to embolus. One patient was seen 12 hours, the other 24 hours after onset of symptoms. Operation was advised but refused by the patients and their families. Anticoagulants, antispasmodics and lumbar sympathetic blocks did not improve the impaired circulation. Both patients died
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cardiac deaths aggravated by gangrene of the leg seven and ten days after the vascular accident. The third patient, a man of 76 with auricular fibrillation due to arteriosclerotic heart disease, sustained a femoral embolus of the left leg six weeks before admission. A sympathectomy had not prevented dry gangrene of leg and foot. At the time of low thigh amputation the femoral artery did not bleed at all, being filled with adherent thrombus. This experience of two deaths and one amputation in three cases of femoral emboli which were not treated by direct arterial surgery is not at all unusual. Even when the extremity and the patient survive, incapacitating claudication, skin atrophy and ulceration can be expected. The initial treatment for two of these patients was heat and elevation and no doubt contributed to the development of early gangrene. In these ischemic legs, heat, which increases cellular metabolism, should be avoided. Elevation, which drains the foot of the little blood in it, should also be avoided. The following case reports are recorded to point out certain features as a basis for discussion: CASE I. A 51 year old woman with rheumatic heart disease was hospitalized because of abdominal discomfort and distention which suggested partial intestinal obstruction. Transient auricular fibrillation was observed on 2 occasions. Three days after .admission she suddenly developed excruciating pain in the left thigh and leg. Examination showed coldness of the extremity from toes to lower thigh, cyanotic mottling of the thigh, ivory-white pallor of knee and leg (patient a blonde), a palpable femoral pulse, absent popliteal, dorsalis pedis and posterior tibial pulsations. Oscillometric determinations showed no pulsation in the leg. The pulses in the right leg were all present. A diagnosis of embolic occlusion of the left femoral artery was made and operation was begun 2 hours later. Under local anesthesia the common femoral artery and its 2 branches were generously exposed. The embolus occupied the common femoral and blocked both the superficial and profunda branches. Tapes were placed about the 3 vessels, the common femoral was incised longitudinally and the embolus was allowed to extrude from the arteriotomy wound. A large proximal secondary thrombus, long enough to reach the iliac bifurcation, was next extruded. This thrombus probably accounted for the relatively high level of vascular changes in the thigh. Further propagating thrombi were extracted from the superficial and deep femoral arteries. When free bleeding could be demonstrated both distally and proximally the artery was flushed with heparin solution, sutured, and the wound was closed. A paravertebral sympathetic block was given and parenteral heparin administration begun. The entire extremity was pink and warm. Dorsalis pedis and posterior tibial pulses could not be felt but the circulation to the foot seemed good. Postoperatively heparin was continued, Dicumarol was given and when in 48 hours the prothrombin time was 20 per cent, heparin was discontinued. Satisfactory bleeding times had been maintained. Prothrombin time levels were subsequently maintained between 20 and 30 per cent. Twelve hours after operation the skin of the foot and ankle was mottled and cool. The temperature difference between the feet, though slight, was definite.
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Gradually a line of demarcation developed just above the ankle. Three weeks after embolectomy amputation of the leg below the knee was performed. The patient made a good recovery.
The best that can be said for this experience is that embolectomy made possible the preservation of the knee joint. Quite obviously, the foot was lost because of unremoved propagating thrombi in the popliteal artery. It is likely that these clots could have been removed either by retrograde milking or by retrograde flushing, as will be illustrated in the next case. When, 12 hours after operation, mottling and cooling of the foot were evident the opportunity for successful surgical removal of the clot was still present. If such a situation were to occur now, we would go after it at once. The use of anticoagulants postoperatively was well conducted but of no value in preventing gangrene of the foot and clearly illustrates that anticoagulant treatment cannot substitute for an open unobstructed artery. It was interesting to note that the abdominal symptoms disappeared never to return again when anticoagulant therapy was instituted, suggesting that minor mesenteric embolism and/or thrombosis preceded the development of the peripheral embolus. In this regard, heparin and Dicumarol may have been valuable. CASE II, A 76 year old woman with arteriosclerotic heart disease and auricular fibrillation was admitted 2 hours after the on:>et of sudden severe pain in the right knee and calf. She was unable to move the foot. The right femoral pulse, though difficult to detect because of hypotension and fibrillation, was palpable, as was the femoral pulse on the left. No other pulsations could be detected in either lower extremity. The right foot and ankle were cool and pale. The calf showed cyanotic mottling. Oscillometric examination showed no pulsation in the right calf as compared to feeble pulsations in the left. A diagnosis of embolus of the femoral artery was made. To satisfy all concerned, intravenous papaverine was given and a left paravertebral sympathetic block was done. No change resulted. Four hours after the onset of symptoms the patient was operated upon. The embolus was found at the femoral bifurcation. The common femoral artery was opened and the embolus was allowed to extrude itself. No proximal or distal propagating thrombi were found. The profunda femoris was clear, as was the superficial femoral artery. Free bleeding from the 3 vessels ensued and the arteriotomy wound was closed. When the vessel was inspected after closure, satisfactory pulsations were seen in it to a point 4 inches distal to the suture line where they ceased. The mottling of the calf had disappeared. Pallor of the foot was difficult to evaluate because of the patient's dark skin, but the foot ,vas still cool. It was obvious that residual propagating thrombus was still lodged in either the common femoral or the popliteal artery. The common femoral was incised distal to the first incision. Bleeding from its distal end seemed brisk. No clots could be milked upward digitally. The posterior tibial artery was then exposed behind the malleolus, a large needle was inserted and with a 50 cc. syringe saline was forced upward through the vessel. A few small scraps of propagating throm-
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bus were washed out the arteriotomy wound. The arterial wounds were closed and it was then evident that the femoral artery pulsated normally. Dorsalis pedis pulsations were also present. The patient made a prompt recovery. She was walking the morning after operation and left the hospital a week later. No anticoagulants were used.
The result in this case would have been similar to that in the first if the retrograde flushing maneuver had not been used. With elimination of propagating thrombi, a good result was achieved. When the femoral artery was opened for the second time, a second incision was made in it. This maneuver results in less arterial narrowing than taking down a suture line and, after further manipulations, resuturing the artery. Three other patients, each of whom had a common femoral artery embolus, were treated successfully by embolectomy six, 12 and three hours after embolism. Two were men recovering from recent myocardial infarcts. These patients were given anticoagulants. The third patient, a woman with rheumatic heart disease and auricular fibrillation, was not given anticoagulants. CASE III. A 63 year old man who was under treatment for arteriosclerotic heart disease with decompensation and chronic auricular fibrillation suddenly developed severe pain in the right antecubital fossa. Quickly the forearm and hand became cold, painful and pale. The hand was paralyzed. Brachial pulsations were present; radial and ulnar pulsations were absent. Just above the brachial bifurcation a tender kernel could be felt. It proved to be the embolus. Four hours after embolism the embolus and propagating thrombi which extended down both the radial and ulnar arteries were extracted. The thrombi had extended down both vessels far enough to shut off collateral circulation from the ulnar and radial recurrent arteries. Following embolectomy the hand was warm and pink. Function also returned. Radial pulsations became palpable 4 hours after operation. Heparin and Dicumarol were given postoperatively with the development of a large troublesome hematoma. Full recovery and full function were obtained. CASE IV. An 82 year old man with arteriosclerotic heart disease and auricular fibrillation was seen 60 hours after he sustained an embolus of the left brachial artery. At this time the fingers and forearm were a bluish-black color, although pallor had apparently been present earlier. Pulmonary edema and cardiac failure were also present. Amputation was advised but refused by the patient and his children. Under brachial plexus block, embolectomy was attempted. An embolus was removed from the bifurcation. A proximal propagating thrombus 11 cm. long was also removed, after which the proximal artery bled freely. Further small emboli were removed from the radial and ulnar arteries by milking them with the fingers but no retrograde bleeding occurred. The ulnar and radial vessels were exposed and opened. Both were filled with adherent propagating thrombi which resisted attempts at their removal. It was evident that tissue death had taken place and the operation had been undertaken too late. Postoperatively the skin about the elbow was warm. It had been cool. The old gentleman died of pulmonary edema 30 hours after operation.
Albert G. Martin
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While this experience was disappointing, the attempt at clearing the vessels of the arm did no harm. Had permission been given, amputation, the operation of choice, would have been done. The two patients with brachial artery emboli represent exceptions to the usual run of such emboli, in that forearm circulation was shut off completely by the embolism. The patient described in Case IV benefited not at all from embolectomy but neither was he harmed by the operation. The finding of adherent propagating thrombi distal to the embolus presented a technical problem we could not overcome. When a retrograde flush via the arteries at the wrist was attempted, those vessels were also found full of adherent clots. The experience illustrates the futility of embolectomy after tissue death has taken place. It should not deter attempts at embolectomy just because a certain length of time has passed, if local tissue changes have not become irreversible. When judgment in this respect is difficult, one may be heartened by the knowledge that embolectomy will do no harm. DIAGNOSIS
Symptoms described by all were sudden severe pain, numbness, cramps and coldness of the affected extremity. Paralysis of hand or foot was usual. It should be noted that a sudden dramatic onset usually occurs. Some cases are on record where hours passed before symptoms fully developed. This slower development is said to be more frequent in patients who are on anticoagulant treatment at the time of embolism, and is unusual. Of the signs, the most important is the absence of pulsations in arteries of the affected extremity. The point of occlusion is usually found just distal to the highest palpable pulse. The actual spot where the embolus is lodged may be tender to palpation. Pulses may be hard to feel in some patients because of fibrillation, hypotension or both. Oscillometric studies, always helpful, then become especially valuable. Other signs are cyanotic mottling, pallor and cooling distal to the embolus. In femoral emboli these signs usually begin at or a little below the knee. In popliteal emboli they involve foot and ankle. Of these latter signs, cooling is the most constant. The veins are empty. Differential diagnosis includes arterial thrombosis and acute thrombophlebitis. In the former, the clinical picture develops more slowly with periods of claudication and without immediate evidence of absolute ischemia. Arteriograms may be helpful. Sudden severe acute femoral thrombophlebitis may occasionally be confused with femoral artery embolism. This confusion occurs when marked arterial spasm accompanies the phlebitis. The usual points of differentiation between femoral artery embolus and femoral thrombophlebitis are outlined in Table 2. If, after examination, a firm diagnosis
Peripheral Arterial Emboli
1061 Table 2
DIFFERE:\TIAL DIAGNOSIS OF FEMORAL ARTERY EMBOLUS AND FEMORAL THROMBOPHLEBITIS FEMORAL ARTERY EMBOLUS
Onset ........ . Color ........ . Veins ....... . Paralysis ... . Cooling ............... . Edema ...... . Pedal pulses. . . ....... .
Sudden Mottled or pale Empty Usual Local and distal None Absent
FEMORAL THROMBOPHLEBITIS
Premonitory discomfort Cyanotic Full None General Present Usually present
cannot be made, a lumbar paravertebral sympathetic block may be done. In patients with thrombophlebitis the block relieves arterial spasm with resultant decrease in pain, diminution of cyanosis, some warming of the leg and restoration of palpable pedal pulses. Oscillometric determinations can be very helpful. Paravertebral blocks must not be done in patients who are on anticoagulant treatment because of the danger of producing serious or even fatal retroperitoneal hemorrhage. EMBOLECTOMY
Operative technique combines gentleness with precision. Local 1 per cent procaine anesthesia has been entirely satisfactory for femoral emboli; brachial plexus block2 has been very satisfactory for the patients with brachial emboli. The entire extremity is prepared and included in the surgical field. Generous vertical incisions are used to expose the femoral vessels: common, superficial and profunda. A transverse incision in the antecubital fossa serves well in exposing the brachial artery and its branches. If necessary, a longitudinal extension can be made at either end of the transverse wound. Fine silk or cotton ties are used for careful control of bleeding points in the wound. When the artery and its branches have been well exposed, umbilical tapes are placed around the vessels above and below the embolus. The tapes are not tightened, nor are the vessels compressed in any way for fear of brushing off propagating thrombi. Each tape is assigned to a single person for control of bleeding after clots have been removed. A free flow of blood is to be desired and, while its appearance may be startling, it must not provoke rough or jerky handling of the vessels. The tapes are controlled by gently pinching down upon them with thumb and forefinger and without lifting or disturbing the vessels. The artery is incised at the site of the embolus, provided the vessel wall is reasonably healthy at that point. Incisions should avoid large local atheromas. An incision as long as the diameter of the artery is made.
II:
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With the artery open, intra-arterial pressure will usually extrude the embolus. The process can be helped along by gentle digital milking when needed. Often the embolus and proximal propagated thrombus will spontaneously be extruded first, followed by a gush of blood from the main artery. The proximal tape is then tightened and blood in the field is removed by suction. Heparin solution (100 mg. heparin/100 cc. saline) should then be injected into the artery proximal to the point of occlusion. Five to 10 cc. has been used. The tape can be replaced with a small arterial clamp or a hemostat can be placed upon the tape. Distal clots are allowed to extrude similarly. The success or failure of the operation depends upon the removal of all propagating thrombi. Grasping them with an instrument and pulling usually breaks off the clot. Attempts at intravascular instrumentation similar to maneuvers within the common bile duct seldom bring success and may do harm to the arterial intima. A generous exposure will allow retrograde digital milking and often no more is required. When the retrograde bleeding is free and vigorous, the artery is flushed with heparin solution and closed using 4-0 or 5-0 oiled silk on an atraumatic needle. The suture, which is a continuous over-and-over stitch, should evert the vessel edges to bring the intimal layers together. Small bites must be taken to avoid undue constriction. The distal tapes are released. Bleeding from the suture line, if it occurs, usually stops after a little pressure. The proximal tape is released last of all. When retrograde bleeding is meager or equivocal, peripheral thrombi must be removed. Crawford and DeBakey3 advocate the technique of retrograde flushing without which the second case cited would have been a failure. The posterior tibial artery is exposed by a vertical incision behind the medial malleolus. A size 14 or 16 needle is threaded into the vessel and tied in place. The vessel is temporarily occluded distally. Using a large (50 cc.) syringe, warm saline solution is forcibly injected proximally to wash the clot out through the arteriotomy. Shaw4 has amplified the technique in difficult cases of iliac femoral, and popliteal emboli by opening the vessels at several points in the leg and flushing with warm heparin saline solution (10 mg. heparin/lOO cc. saline). He used similar techniques in the upper extremity with gratifying results. Arteries should not be interrupted after this maneuver. When the patency of the arterial tree remains questionable, an arteriogram made in the operating room is recommended. Following operation the extremity is protected from the sheets and blankets by an unheated cradle. The extremity is not elevated. In cases of femoral embolism, the head of the bed is raised. Movement is encouraged and, if the patient is able, he is allowed out of bed within six to 12 hours after operation. Thereafter activity increases within the limits of his strength.
II
Peripheral Arterial Emboli
1063
POSTOPERATIVE ANTICOAGULANT TREATMENT
II'
i~ ,
II
Postoperative anticoagulant treatment was used in the earlier cases. Both heparin and Dicumarol were given immediately after operation. Heparin was continued until the prothrombin time had been depressed to between 20 per cent and 30 per cent. Heparin was then stopped and Dicumarol continued for two weeks after operation. Using the method, large troublesome hematomas developed in several cases without apparent enhancement of circulation in the extremity. The impression developed that when all thrombi are removed anticoagulants are not needed and when thrombi are left behind anticoagulants Wt'U not turn a failure into a success. We do not propose in the future to use heparin after operation in patients with emboli of the femoral, brachial or larger arteries. After removal of a popliteal embolus, heparin may be of some use in preventing suture line thrombosis in the small vessel. Postoperatively, heparin was not used in the last two successful cases. Postoperative long-term anticoagulant treatment with one of the coumadins deserves mention from another standpoint, that of prevention of further emboli. 5 This treatment, to be safe, requires the combination of an intelligent cooperative patient and an interested available physician. When the combination exists, long-term anticoagulant treatment is recommended, especially for patients with auricular fibrillation. These patients run a grave risk of further emboli. Alternative prophylactic measures consist of administration of quinidine to stop fibrillation or amputation of the auricular appendage, with or without mitral valvulotomy, to remove the likely source of emboli. The latter course is still in the experimental phase. SUMMARY AND CONCLUSIONS
II
Results in ten cases of peripheral arterial emboli are presented and methods of operative treatment are discussed from the viewpoint of a general surgeon in private practice. Three patients with common femoral artery emboli were not operated upon. Two died. One survived after low thigh amputation. Five patients with common femoral artery emboli underwent embolectomy. Four had full restoration of circulation. One required amputation below the knee. All were operated upon within 12 hours after embolism. Two patients with brachial artery emboli were operated upon. In the first patient, operation two hours after embolism was followed by full recovery. In the second, operation 60 hours after embolism was unsuccessful. An aggressive surgical approach is recommended. The period within six hours of the occurrence of the embolism remains the best for opera-
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tion, but the operation should still be considered at a later time unless actual gangrene has occurred. These patients must not be denied operation, since good results in the late cases are occasionally achieved. Embolectomy can be done under local anesthesia with minimal risk to the patient and to the remaining circulation of the extremity. The objective of operation, in addition to removal of the embolus, is removal of propagating thrombi. The completeness of their removal determines the success or failure of the operation. In this respect, the retrograde arterial flush maneuver represents an important recent addition to the surgical attack. Heparin used locally during the operation is considered a valuable adjunct in preventing intravascular clotting of occluded vessels. Used postoperatively it did not enhance the result in vessels cleared of obstruction nor did it serve as a substitute for the removal of distal thrombi. Its postoperative use in vessels as large as the brachial and femoral arteries is not recommended. Following embolectomy, long-term anticoagulant treatment in selected cases may be employed to protect these patients against the hazard of subsequent emboli. REFERENCES 1. Warren, R., Linton, R. R. and Scannell, J. G.: Arterial Embolism-Recent Progress. Ann. Surg. 140: 311, 1954.
2. Labat, Gaston: Regional Anesthesia. 2nd Ed. Philadelphia, W. B. Saunders Co., 1928, pp. 224-236. 3. Crawford, E. S. and DeBakey, M. E.: Retrograde Flush Procedure in Embolectomy and Thrombectomy. Surgery 40: 737, 1956. 4. Shaw, R. S.: A More Aggressive Approach Toward the Restoration of Blood Flow in Arterial Insufficiency. Surg., Gynec. & Obst. 103: 279, 1956. 5. Cosgriff, S. W.: Chronic Anticoagulant Therapy in Recurrent Embolism of Cardiac Origin. Ann. Int. Med. 38: 278. 1953. 324 E. Wisconsin Avenue Milwaukee 2, Wisconsin.
IN THIS day of dramatic achievements in vascular surgery, a worthwhile accompaniment has been the revived interest in surgical treatment of emboli lodged in major peripheral arteries. While part of this revival of interest may be cyclical, it is directly stimulated by the occurrence of peripheral emboli following operations upon the heart and even more by the improved results in the treatment of arterial emboli. The surgical removal of arterial emboli now carries little or no risk to life or to the circulation of the parts involved and when done early brings with it a likely prospect of restoring function to the level enjoyed before the embolus occurred. While only femoral and brachial emboli are discussed here, it is felt that these expressions apply also to axillary, iliac, popliteal and' possibly aortic emboli. Statements made regarding risk must recognize that the disease which has been complicated by an embolus carries a high mortality of itself. Embolectomy does not add to the inherent mortality of the disease which the embolus complicates, nor does a properly performed embolectomy jeopardize circulation. It may be regarded as a worthwhile emergency operation in desperate circumstances where a life as well as an arm or a leg may be saved. While the source of a small proportion of emboli cannot be determined, they most frequently complicate auricular fibrillation or myocardial infarction. Part or all of a mural thrombus breaks loose and becomes the plug. Warren, Linton and Scannelll report the incidence of peripheral embolism complicating mitral surgery as 16 per cent and 30 per cent in those patients who had previously had embolism. Emboli lodge at arterial bifurcations. Embolism is followed by spasm of the involved arteries and the propagation of thrombi proximally and distally. The proximal thrombus is usually short; the distal one long. Emboli occur at all hours of the day and night. If they are given prompt attention, regarded as emergencies of hours, gratifying results may be expected. Embolectomy within six hours after onset has for years
* Assistant Clinical Professor of Surgery, Marquette University School of Medicine; Surgeon, St. Mary's Hospital; Associate Surgeon, Columbia and Milwaukee Hospitals, Milwaukee, Wisconsin. 1055
Albert G. Martin
1056
been regarded as the optimal time. As time passes, the development of propagating thrombi makes clearing of the vessel lumen more difficult. Time was when embolectomy was not considered after 24 hours. Even this situation has been improved by an aggressive surgical approach in patients who have been seen as late as two weeks after embolism. Success in late cases seems to be greatest in the largest vessels (aorta) and in patients who are on anticoagulant treatment. In the latter instances, propagating thrombi and adherence between embolus and vessel walls are minimized. The importance of early operation should still be emphasized; for within six or even ten hours good results can be obtained in most cases. Once gangrene has occurred, salvage of the extremity by embolectomy becomes most unlikely and amputation as a life-saving measure must be considered. Whether embolectomy, if successful, will result in relatively distal demarcation in cases of early gangrene is a question worth consideration in individual cases. A group of ten cases seen in private practice is presented. The number is small but the problems presented probably have been shared by many individual surgeons. Treatment and results in eight patients with femoral emboli, five of whom were operated upon and two patients with brachial emboli, both of whom were operated upon, are summarized in Table 1. Table 1 SUMMARY OF TEN CASES NUMBER
SITE OF EMBOLUS
TREATMENT
RESULT
3
Common femoral artery
Nonsurgical
2 deaths 1 thigh amputation
5
Common femoral artery
Embolectomy
4 full recoveries 1 amputation below knee
2
Brachial artery
Embolectomy
1 full recovery 1 death
Femoral and brachial arteries are the most common sites for lodgment of emboli and in this respect these cases follow the usual patterns. The severity of the two cases of brachial artery embolus is unusual. The patients not operated upon presented clinical pictures so similar to those who received operation that it seems proper to include them. The two who died were a man of 62 and a woman of 58 years. Both had arteriosclerotic heart disease with auricular fibrillation and both developed sudden occlusion of the right femoral artery presumably due to embolus. One patient was seen 12 hours, the other 24 hours after onset of symptoms. Operation was advised but refused by the patients and their families. Anticoagulants, antispasmodics and lumbar sympathetic blocks did not improve the impaired circulation. Both patients died
Peripheral Arterial Emboli
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cardiac deaths aggravated by gangrene of the leg seven and ten days after the vascular accident. The third patient, a man of 76 with auricular fibrillation due to arteriosclerotic heart disease, sustained a femoral embolus of the left leg six weeks before admission. A sympathectomy had not prevented dry gangrene of leg and foot. At the time of low thigh amputation the femoral artery did not bleed at all, being filled with adherent thrombus. This experience of two deaths and one amputation in three cases of femoral emboli which were not treated by direct arterial surgery is not at all unusual. Even when the extremity and the patient survive, incapacitating claudication, skin atrophy and ulceration can be expected. The initial treatment for two of these patients was heat and elevation and no doubt contributed to the development of early gangrene. In these ischemic legs, heat, which increases cellular metabolism, should be avoided. Elevation, which drains the foot of the little blood in it, should also be avoided. The following case reports are recorded to point out certain features as a basis for discussion: CASE I. A 51 year old woman with rheumatic heart disease was hospitalized because of abdominal discomfort and distention which suggested partial intestinal obstruction. Transient auricular fibrillation was observed on 2 occasions. Three days after .admission she suddenly developed excruciating pain in the left thigh and leg. Examination showed coldness of the extremity from toes to lower thigh, cyanotic mottling of the thigh, ivory-white pallor of knee and leg (patient a blonde), a palpable femoral pulse, absent popliteal, dorsalis pedis and posterior tibial pulsations. Oscillometric determinations showed no pulsation in the leg. The pulses in the right leg were all present. A diagnosis of embolic occlusion of the left femoral artery was made and operation was begun 2 hours later. Under local anesthesia the common femoral artery and its 2 branches were generously exposed. The embolus occupied the common femoral and blocked both the superficial and profunda branches. Tapes were placed about the 3 vessels, the common femoral was incised longitudinally and the embolus was allowed to extrude from the arteriotomy wound. A large proximal secondary thrombus, long enough to reach the iliac bifurcation, was next extruded. This thrombus probably accounted for the relatively high level of vascular changes in the thigh. Further propagating thrombi were extracted from the superficial and deep femoral arteries. When free bleeding could be demonstrated both distally and proximally the artery was flushed with heparin solution, sutured, and the wound was closed. A paravertebral sympathetic block was given and parenteral heparin administration begun. The entire extremity was pink and warm. Dorsalis pedis and posterior tibial pulses could not be felt but the circulation to the foot seemed good. Postoperatively heparin was continued, Dicumarol was given and when in 48 hours the prothrombin time was 20 per cent, heparin was discontinued. Satisfactory bleeding times had been maintained. Prothrombin time levels were subsequently maintained between 20 and 30 per cent. Twelve hours after operation the skin of the foot and ankle was mottled and cool. The temperature difference between the feet, though slight, was definite.
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Albert G. Martin
Gradually a line of demarcation developed just above the ankle. Three weeks after embolectomy amputation of the leg below the knee was performed. The patient made a good recovery.
The best that can be said for this experience is that embolectomy made possible the preservation of the knee joint. Quite obviously, the foot was lost because of unremoved propagating thrombi in the popliteal artery. It is likely that these clots could have been removed either by retrograde milking or by retrograde flushing, as will be illustrated in the next case. When, 12 hours after operation, mottling and cooling of the foot were evident the opportunity for successful surgical removal of the clot was still present. If such a situation were to occur now, we would go after it at once. The use of anticoagulants postoperatively was well conducted but of no value in preventing gangrene of the foot and clearly illustrates that anticoagulant treatment cannot substitute for an open unobstructed artery. It was interesting to note that the abdominal symptoms disappeared never to return again when anticoagulant therapy was instituted, suggesting that minor mesenteric embolism and/or thrombosis preceded the development of the peripheral embolus. In this regard, heparin and Dicumarol may have been valuable. CASE II, A 76 year old woman with arteriosclerotic heart disease and auricular fibrillation was admitted 2 hours after the on:>et of sudden severe pain in the right knee and calf. She was unable to move the foot. The right femoral pulse, though difficult to detect because of hypotension and fibrillation, was palpable, as was the femoral pulse on the left. No other pulsations could be detected in either lower extremity. The right foot and ankle were cool and pale. The calf showed cyanotic mottling. Oscillometric examination showed no pulsation in the right calf as compared to feeble pulsations in the left. A diagnosis of embolus of the femoral artery was made. To satisfy all concerned, intravenous papaverine was given and a left paravertebral sympathetic block was done. No change resulted. Four hours after the onset of symptoms the patient was operated upon. The embolus was found at the femoral bifurcation. The common femoral artery was opened and the embolus was allowed to extrude itself. No proximal or distal propagating thrombi were found. The profunda femoris was clear, as was the superficial femoral artery. Free bleeding from the 3 vessels ensued and the arteriotomy wound was closed. When the vessel was inspected after closure, satisfactory pulsations were seen in it to a point 4 inches distal to the suture line where they ceased. The mottling of the calf had disappeared. Pallor of the foot was difficult to evaluate because of the patient's dark skin, but the foot ,vas still cool. It was obvious that residual propagating thrombus was still lodged in either the common femoral or the popliteal artery. The common femoral was incised distal to the first incision. Bleeding from its distal end seemed brisk. No clots could be milked upward digitally. The posterior tibial artery was then exposed behind the malleolus, a large needle was inserted and with a 50 cc. syringe saline was forced upward through the vessel. A few small scraps of propagating throm-
Peripheral Arterial Emboli
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bus were washed out the arteriotomy wound. The arterial wounds were closed and it was then evident that the femoral artery pulsated normally. Dorsalis pedis pulsations were also present. The patient made a prompt recovery. She was walking the morning after operation and left the hospital a week later. No anticoagulants were used.
The result in this case would have been similar to that in the first if the retrograde flushing maneuver had not been used. With elimination of propagating thrombi, a good result was achieved. When the femoral artery was opened for the second time, a second incision was made in it. This maneuver results in less arterial narrowing than taking down a suture line and, after further manipulations, resuturing the artery. Three other patients, each of whom had a common femoral artery embolus, were treated successfully by embolectomy six, 12 and three hours after embolism. Two were men recovering from recent myocardial infarcts. These patients were given anticoagulants. The third patient, a woman with rheumatic heart disease and auricular fibrillation, was not given anticoagulants. CASE III. A 63 year old man who was under treatment for arteriosclerotic heart disease with decompensation and chronic auricular fibrillation suddenly developed severe pain in the right antecubital fossa. Quickly the forearm and hand became cold, painful and pale. The hand was paralyzed. Brachial pulsations were present; radial and ulnar pulsations were absent. Just above the brachial bifurcation a tender kernel could be felt. It proved to be the embolus. Four hours after embolism the embolus and propagating thrombi which extended down both the radial and ulnar arteries were extracted. The thrombi had extended down both vessels far enough to shut off collateral circulation from the ulnar and radial recurrent arteries. Following embolectomy the hand was warm and pink. Function also returned. Radial pulsations became palpable 4 hours after operation. Heparin and Dicumarol were given postoperatively with the development of a large troublesome hematoma. Full recovery and full function were obtained. CASE IV. An 82 year old man with arteriosclerotic heart disease and auricular fibrillation was seen 60 hours after he sustained an embolus of the left brachial artery. At this time the fingers and forearm were a bluish-black color, although pallor had apparently been present earlier. Pulmonary edema and cardiac failure were also present. Amputation was advised but refused by the patient and his children. Under brachial plexus block, embolectomy was attempted. An embolus was removed from the bifurcation. A proximal propagating thrombus 11 cm. long was also removed, after which the proximal artery bled freely. Further small emboli were removed from the radial and ulnar arteries by milking them with the fingers but no retrograde bleeding occurred. The ulnar and radial vessels were exposed and opened. Both were filled with adherent propagating thrombi which resisted attempts at their removal. It was evident that tissue death had taken place and the operation had been undertaken too late. Postoperatively the skin about the elbow was warm. It had been cool. The old gentleman died of pulmonary edema 30 hours after operation.
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While this experience was disappointing, the attempt at clearing the vessels of the arm did no harm. Had permission been given, amputation, the operation of choice, would have been done. The two patients with brachial artery emboli represent exceptions to the usual run of such emboli, in that forearm circulation was shut off completely by the embolism. The patient described in Case IV benefited not at all from embolectomy but neither was he harmed by the operation. The finding of adherent propagating thrombi distal to the embolus presented a technical problem we could not overcome. When a retrograde flush via the arteries at the wrist was attempted, those vessels were also found full of adherent clots. The experience illustrates the futility of embolectomy after tissue death has taken place. It should not deter attempts at embolectomy just because a certain length of time has passed, if local tissue changes have not become irreversible. When judgment in this respect is difficult, one may be heartened by the knowledge that embolectomy will do no harm. DIAGNOSIS
Symptoms described by all were sudden severe pain, numbness, cramps and coldness of the affected extremity. Paralysis of hand or foot was usual. It should be noted that a sudden dramatic onset usually occurs. Some cases are on record where hours passed before symptoms fully developed. This slower development is said to be more frequent in patients who are on anticoagulant treatment at the time of embolism, and is unusual. Of the signs, the most important is the absence of pulsations in arteries of the affected extremity. The point of occlusion is usually found just distal to the highest palpable pulse. The actual spot where the embolus is lodged may be tender to palpation. Pulses may be hard to feel in some patients because of fibrillation, hypotension or both. Oscillometric studies, always helpful, then become especially valuable. Other signs are cyanotic mottling, pallor and cooling distal to the embolus. In femoral emboli these signs usually begin at or a little below the knee. In popliteal emboli they involve foot and ankle. Of these latter signs, cooling is the most constant. The veins are empty. Differential diagnosis includes arterial thrombosis and acute thrombophlebitis. In the former, the clinical picture develops more slowly with periods of claudication and without immediate evidence of absolute ischemia. Arteriograms may be helpful. Sudden severe acute femoral thrombophlebitis may occasionally be confused with femoral artery embolism. This confusion occurs when marked arterial spasm accompanies the phlebitis. The usual points of differentiation between femoral artery embolus and femoral thrombophlebitis are outlined in Table 2. If, after examination, a firm diagnosis
Peripheral Arterial Emboli
1061 Table 2
DIFFERE:\TIAL DIAGNOSIS OF FEMORAL ARTERY EMBOLUS AND FEMORAL THROMBOPHLEBITIS FEMORAL ARTERY EMBOLUS
Onset ........ . Color ........ . Veins ....... . Paralysis ... . Cooling ............... . Edema ...... . Pedal pulses. . . ....... .
Sudden Mottled or pale Empty Usual Local and distal None Absent
FEMORAL THROMBOPHLEBITIS
Premonitory discomfort Cyanotic Full None General Present Usually present
cannot be made, a lumbar paravertebral sympathetic block may be done. In patients with thrombophlebitis the block relieves arterial spasm with resultant decrease in pain, diminution of cyanosis, some warming of the leg and restoration of palpable pedal pulses. Oscillometric determinations can be very helpful. Paravertebral blocks must not be done in patients who are on anticoagulant treatment because of the danger of producing serious or even fatal retroperitoneal hemorrhage. EMBOLECTOMY
Operative technique combines gentleness with precision. Local 1 per cent procaine anesthesia has been entirely satisfactory for femoral emboli; brachial plexus block2 has been very satisfactory for the patients with brachial emboli. The entire extremity is prepared and included in the surgical field. Generous vertical incisions are used to expose the femoral vessels: common, superficial and profunda. A transverse incision in the antecubital fossa serves well in exposing the brachial artery and its branches. If necessary, a longitudinal extension can be made at either end of the transverse wound. Fine silk or cotton ties are used for careful control of bleeding points in the wound. When the artery and its branches have been well exposed, umbilical tapes are placed around the vessels above and below the embolus. The tapes are not tightened, nor are the vessels compressed in any way for fear of brushing off propagating thrombi. Each tape is assigned to a single person for control of bleeding after clots have been removed. A free flow of blood is to be desired and, while its appearance may be startling, it must not provoke rough or jerky handling of the vessels. The tapes are controlled by gently pinching down upon them with thumb and forefinger and without lifting or disturbing the vessels. The artery is incised at the site of the embolus, provided the vessel wall is reasonably healthy at that point. Incisions should avoid large local atheromas. An incision as long as the diameter of the artery is made.
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Albert G. Martin
With the artery open, intra-arterial pressure will usually extrude the embolus. The process can be helped along by gentle digital milking when needed. Often the embolus and proximal propagated thrombus will spontaneously be extruded first, followed by a gush of blood from the main artery. The proximal tape is then tightened and blood in the field is removed by suction. Heparin solution (100 mg. heparin/100 cc. saline) should then be injected into the artery proximal to the point of occlusion. Five to 10 cc. has been used. The tape can be replaced with a small arterial clamp or a hemostat can be placed upon the tape. Distal clots are allowed to extrude similarly. The success or failure of the operation depends upon the removal of all propagating thrombi. Grasping them with an instrument and pulling usually breaks off the clot. Attempts at intravascular instrumentation similar to maneuvers within the common bile duct seldom bring success and may do harm to the arterial intima. A generous exposure will allow retrograde digital milking and often no more is required. When the retrograde bleeding is free and vigorous, the artery is flushed with heparin solution and closed using 4-0 or 5-0 oiled silk on an atraumatic needle. The suture, which is a continuous over-and-over stitch, should evert the vessel edges to bring the intimal layers together. Small bites must be taken to avoid undue constriction. The distal tapes are released. Bleeding from the suture line, if it occurs, usually stops after a little pressure. The proximal tape is released last of all. When retrograde bleeding is meager or equivocal, peripheral thrombi must be removed. Crawford and DeBakey3 advocate the technique of retrograde flushing without which the second case cited would have been a failure. The posterior tibial artery is exposed by a vertical incision behind the medial malleolus. A size 14 or 16 needle is threaded into the vessel and tied in place. The vessel is temporarily occluded distally. Using a large (50 cc.) syringe, warm saline solution is forcibly injected proximally to wash the clot out through the arteriotomy. Shaw4 has amplified the technique in difficult cases of iliac femoral, and popliteal emboli by opening the vessels at several points in the leg and flushing with warm heparin saline solution (10 mg. heparin/lOO cc. saline). He used similar techniques in the upper extremity with gratifying results. Arteries should not be interrupted after this maneuver. When the patency of the arterial tree remains questionable, an arteriogram made in the operating room is recommended. Following operation the extremity is protected from the sheets and blankets by an unheated cradle. The extremity is not elevated. In cases of femoral embolism, the head of the bed is raised. Movement is encouraged and, if the patient is able, he is allowed out of bed within six to 12 hours after operation. Thereafter activity increases within the limits of his strength.
II
Peripheral Arterial Emboli
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POSTOPERATIVE ANTICOAGULANT TREATMENT
II'
i~ ,
II
Postoperative anticoagulant treatment was used in the earlier cases. Both heparin and Dicumarol were given immediately after operation. Heparin was continued until the prothrombin time had been depressed to between 20 per cent and 30 per cent. Heparin was then stopped and Dicumarol continued for two weeks after operation. Using the method, large troublesome hematomas developed in several cases without apparent enhancement of circulation in the extremity. The impression developed that when all thrombi are removed anticoagulants are not needed and when thrombi are left behind anticoagulants Wt'U not turn a failure into a success. We do not propose in the future to use heparin after operation in patients with emboli of the femoral, brachial or larger arteries. After removal of a popliteal embolus, heparin may be of some use in preventing suture line thrombosis in the small vessel. Postoperatively, heparin was not used in the last two successful cases. Postoperative long-term anticoagulant treatment with one of the coumadins deserves mention from another standpoint, that of prevention of further emboli. 5 This treatment, to be safe, requires the combination of an intelligent cooperative patient and an interested available physician. When the combination exists, long-term anticoagulant treatment is recommended, especially for patients with auricular fibrillation. These patients run a grave risk of further emboli. Alternative prophylactic measures consist of administration of quinidine to stop fibrillation or amputation of the auricular appendage, with or without mitral valvulotomy, to remove the likely source of emboli. The latter course is still in the experimental phase. SUMMARY AND CONCLUSIONS
II
Results in ten cases of peripheral arterial emboli are presented and methods of operative treatment are discussed from the viewpoint of a general surgeon in private practice. Three patients with common femoral artery emboli were not operated upon. Two died. One survived after low thigh amputation. Five patients with common femoral artery emboli underwent embolectomy. Four had full restoration of circulation. One required amputation below the knee. All were operated upon within 12 hours after embolism. Two patients with brachial artery emboli were operated upon. In the first patient, operation two hours after embolism was followed by full recovery. In the second, operation 60 hours after embolism was unsuccessful. An aggressive surgical approach is recommended. The period within six hours of the occurrence of the embolism remains the best for opera-
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Albert G. Martin
tion, but the operation should still be considered at a later time unless actual gangrene has occurred. These patients must not be denied operation, since good results in the late cases are occasionally achieved. Embolectomy can be done under local anesthesia with minimal risk to the patient and to the remaining circulation of the extremity. The objective of operation, in addition to removal of the embolus, is removal of propagating thrombi. The completeness of their removal determines the success or failure of the operation. In this respect, the retrograde arterial flush maneuver represents an important recent addition to the surgical attack. Heparin used locally during the operation is considered a valuable adjunct in preventing intravascular clotting of occluded vessels. Used postoperatively it did not enhance the result in vessels cleared of obstruction nor did it serve as a substitute for the removal of distal thrombi. Its postoperative use in vessels as large as the brachial and femoral arteries is not recommended. Following embolectomy, long-term anticoagulant treatment in selected cases may be employed to protect these patients against the hazard of subsequent emboli. REFERENCES 1. Warren, R., Linton, R. R. and Scannell, J. G.: Arterial Embolism-Recent Progress. Ann. Surg. 140: 311, 1954.
2. Labat, Gaston: Regional Anesthesia. 2nd Ed. Philadelphia, W. B. Saunders Co., 1928, pp. 224-236. 3. Crawford, E. S. and DeBakey, M. E.: Retrograde Flush Procedure in Embolectomy and Thrombectomy. Surgery 40: 737, 1956. 4. Shaw, R. S.: A More Aggressive Approach Toward the Restoration of Blood Flow in Arterial Insufficiency. Surg., Gynec. & Obst. 103: 279, 1956. 5. Cosgriff, S. W.: Chronic Anticoagulant Therapy in Recurrent Embolism of Cardiac Origin. Ann. Int. Med. 38: 278. 1953. 324 E. Wisconsin Avenue Milwaukee 2, Wisconsin.