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The Management of Peripheral Vascular Emergencies
The Management of Peripheral Vascular Emergencies WILFRED F. RUGGIERO, M.D., F.A.C.S. * FEY CHU, M.D.**
THE management of acute vascular emergencies, when adequately and properly instituted early, will prevent the loss of limb due to ensuing gangrene. With the advent of anticoagulants,!,2 refrigeration, 3 , 4, 5 vigorous use of sympathicolytic drugs 6 , 7 and sympathetic blocks, 8, 9 the horizon of treatment has broadened .. These adjuvants have made the treatment more effective, facilitating surgical intervention and in most instances making it the treatment of choice. Peripheral vascular emergency is caused by an interruption in the continuity of blood flow in a major peripheral artery. Arterial embolism, rapidly forming thrombosis in situ, and trauma of a major peripheral artery will produce a peripheral vascular emergency. ARTERIAL EMBOLISM
TreatInent of the General Condition
The treatment of embolism10 of a major peripheral artery such as the femoral artery resolves itself into two parts. The first of these is the treatment of the general condition, i.e., the cardiac disease which is generally the source of the embolus and the shock which is so often associated with embolization. The objective at this phase of the treatment is to restore the heart to normal function, restore the blood pressure and prevent further embolization. Ordinarily this part of the treatment is in the hands of the family physician who may look upon the arterial embolism as a secondary complication to be viewed with a pessimistic attitude. Too often the surgeon is called in many hours after the accident has occurred, when irreversible changes have taken place and gangrene * Associate Professor of Surgery; New York Medical Flower and Fifth Avenue Hospitals; Visiting Surgeon, York, N. Y. ** Assistant Professor of Surgery, New York Medical Surgeon, Flower and Fifth Avenue Hospitals; Assistant pital, New York, N. Y.
College; Attending Surgeon, Metropolitan Hospital, New College; Assistant Attending Surgeon, Metropolitan Hos-
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Wilfred F. Ruggiero, Fey Chu
of the toes and parts of the foot is inevitable. Be it as it may, surgical intervention should not be denied the patient even when gangrene is present. The ideal time for surgical intervention is within the first six hours after the arterial occlusion has occurred. Anticoagulant Therapy. The first and most important measure is to institute anticoagulant therapy, if it has not already been started. The average patient can be rapidly heparinized by administering 200 mg. of Depo-Heparin intramuscularly and 50 mg. of aqueous heparin solution intravenously, the latter being repeated every three or four hours so as to increase the coagulation time three to four times that of normal. Adequate heparinization prevents the propagation of a thrombus on the lodged embolus, and will not produce dangerous bleeding during the subsequent surgical procedure. Measures to Promote Vasodilation. The next measure of importance is to promote vasodilation of the vascular tree of the involved extremity. The continuous epidural block with Pontocaine hydrochloride produces effective vasodilation. At times subarachnoid spinal anesthesia with small doses of procaine hydrochloride (50 to 75 mg.) is used. This is sufficient to produce sympathetic paralysis without much danger of the unwanted drop in blood pressure so often seen with larger doses of spinal anesthetic agents. Papaverine hydrochloridel l intravenously in doses of 30 to 60 mg., repeated every two hours, is used. At best the effect of papaverine hydrochloride is transient and it is of little or no effect when given by mouth or intramuscularly. If the patient is not vomiting or nauseated we recommend the oral use of Priscoline hydrochloride, starting with a dose of 75 mg. and repeated every four hours. When using sympathetic blocks and vasodilators one must be on guard against a fall in blood pressure, which favors further clotting anywhere in the vascular system but more selectively on an already lodged embolus. The surgeon should discontinue all local therapy which is deleterious and ineffectual, such as heat and elevation of the ischemic extremity. No heat should be applied to an ischemic extremity. All ischemic extremities should be dependent. This is accomplished by raising the head of the bed 6 inches. The application of positive and negative pressure boots by means of machines has not been successful and in our opinion does more harm than good. EIllbolectoIllY
If, within two or three hours after the above therapy has been instituted, the pulses have not returned in the arteries of the foot and lower leg as measured by an accurate oscillometer with the readings compared with oscillations in the good leg, an arteriotomy with removal of the embolus should be performed. Anesthesia. The anesthesia of choice is local infiltration anesthesia with 2 per cent procaine hydrochloride solution. If the patient's general
The Management of Peripheral Vascular Emergencies condition is good, spinal subarachnoid anesthesia may be used, taking special precautions against a fall in blood pressure. Technique. If the embolus has lodged, as it most often does, in the iliac or femoral artery, approximately 2Yz inches of the femoral artery is exposed in the upper one-third of the thigh by making a liberal incision parallel to its course through skin, subcutaneous tissue and deep fascia. The femoral artery is carefully dissected free from its accompanying vein and two soft rubber tubes are placed around the artery, one at the upper angle and the second at the lower angle. They are to be used as tourniquet and as tractors. The arteriotomy is then performed by making a longitudinal incision about 1.5 cm. long through all the coats of the artery. If, as is quite often the case, the clot is encountered at the arteriotomy site, the distal end is first extracted, care being taken not to break any of the distal portion of the clot. This can be ascertained by examining the clot; it should have the resemblance of a whip or mouse tail. A free reflux flow of blood from the distal end of the artery is good evidence the clot has been entirely removed. The proximal end of the clot is then withdrawn. This should be followed by a sudden gush of blood which can be controlled by pulling up on the rubber tube tractor and fixing it by placing a small hemostat around the tube parallel to the artery but not encroaching upon the artery. The arteriotomy wound is closed with a continuous over-and-over arterial silk suture (atraumatic 5-0). Before completing the closure 25 mg. of aqueous heparin solution is placed in the lumen of the artery. The rubber tubes are then released, the distal one first, then the proximal one. If some bleeding occurs through the wound, a few interrupted silk sutures are placed through the bleeding points. No attempt is made to evert the intima. Following the embolectomy, the pulse of the posterior tibial artery should return. If the pulse has not returned it means that a portion of the clot is lodged either in the popliteal artery or in the posterior tibial artery, and that one has been unsuccessful in removing it by the femoral arteriotomy. The posterior tibial artery12 at the malleolus should then be exposed and opened in the same manner as the femoral. By using a No.5 ureteral catheter and flushing with saline and heparin solution, the lodged clot should be dislodged and a free flow of blood should be secured. One should be careful not to injure the intima with the ureteral catheter. If one suspects that he is dealing with a saddle-back thrombus, 13 the other femoral artery should be simultaneously exposed and so controlled during the removal of the proximal clot from the more involved femoral artery that none of the embolus is lost down the arterial tree of the lesser involved side. This is accomplished by occluding the femoral artery of the lesser involved side with the rubber tube tourniquet and before releasing it performing an arteriotomy proximal to it and allowing
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Wilfred F.Ruggiero, Fe?i,Chu
any fragments of the embolus to escape. Following the closure of the arteriotomy the wound should be loosely closed with interrupted 000 silk sutures and a soft rubber Dakin's tube drain placed down to the artery. Postoperative Care. Postoperatively, anticoagulant therapy with heparin is maintained so as to prevent secondary thrombosis. Oral Dicumarol therapy14 can now be started to supplant or aid the heparin. We recommend an initial dose of 300 mg. and a second day dose of 150 mg., so as to increase the prothrombin time three times that of normal. This is usually obtained by the third or fourth day of Dicumarol therapy and maintained on 50 to 100 mg. per day. Heparin is not discontinued until the prothrombin time has been increased as stated above. Antibiotics are routinely given to the patient postoperatively in prophylactic doses. Postoperatively all efforts should be made to maintain a normal blood pressure, which is so vital to the free flow of blood through the vascular tree of an arteriotomized extremity. The extremity should be dependent, not elevated, and should not be kept warmer than body temperature. Vasodilation with sympathicolytic drugs is continued postoperatively. Anticoagulant therapy is continued for two weeks; the dose is then gradually reduced over the following two week period. Arteriovenous Shunt
If one has failed to remove the clot from the posterior tibial or the popliteal artery because of the adherence of the clot-and this is too often the case when surgical intervention is delayed for one to several days and the inevitability of the gangrene is certain-then we recommend the fashioning of a three limb arteriovenous shunt between the femoral artery at the arteriotomy site and the femoral vein after section and ligation of the cephalad part of the femoral vein and any large venous branches at the site of anastomosis. The arteriovenous shunt is performed by using an over-and-over continuous arterial 5-0 silk suture. Bleeding points are controlled by reinforcing interrupted silk sutures. The stoma of the shunt should not be longer than 1.5 cm. In an operation by one of the authors (W.R.), the shunt was performed between the femoral artery and the long saphenous vein because of an obliterated femoral vein due to an old thrombus. With this procedure we have been able to salvage a small percentage of otherwise totally lost extremities. In only one case was there any embarrassment of the heart; this was mild and responded to medical therapy. The postoperative treatment is identical to that for simple embolectomy. Refrigeration
At times, even in early cases, operation is contraindicated because of the poor general condition of the patient, or for some other cause surgical intervention may be delayed for more than 12 hours. Anticoagulants,
The Management of Peripheral Vascular Emergencies
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antibiotics and vasodilators are administered and in addition the extremity should be immediately refrigerated. 5 • 15 Refrigeration16 is best accomplished by surrounding the extremity with a 3 inch layer of cracked ice of about the size of a walnut. The ice should reach at least 2 inches above the site of the lodged embolus. Approximately 50 pounds of ice will be required for the lower extremity. As much is placed beneath the extremity as on top of it, and the whole is held in place with a rubber sheet that is so fashioned as to allow drainage at the foot of the bed into a pail, and to promote drainage the head of the bed is raised 6 inches. Before applying ice the extremity is covered with a thin layer of petrolatum followed by a sterile stockingette so that the entire extremity is covered. Refrigeration slows the process of gangrene and will make possible successful surgical intervention several days after the arterial occlusion has occurred. A refrigerating blanket may be used in the place of ice when available. RAPIDL Y FORMING THROMBUS IN SITU
Quite often the sudden occlusion of a major peripheral artery is produced not by an embolus but by a rapidly forming thrombus in situ. The underlying cause in the majority of cases is a pre-existing disease of the artery, sometimes associated with trauma of no great force or a drop in blood pressure. Because of the similarity of the signs and symptoms, occlusion produced by a rapidly forming thrombosis in situ cannot be distinguished from an arterial occlusion produced by arterial embolus. Whereas the outlook as to life in arterial embolism is poor because of the primary heart disease and because of the possibility and greater frequency of further embolization in centrally located organs, the patient with an occlusion of a major peripheral artery due to a rapidly forming thrombus in situ has a more favorable prognosis and in the majority of cases is in better general condition. The management for this type of occlusion is about the same as for that produced by arterial embolism. TRAUMA OF MAJOR PERIPHERAL ARTERIES
A-ccompanying the present day use of high speed machines and means of transport, and modern warfare, injuries to great vessels requiring radical surgical procedures have become more frequent. In dealing with any type of trauma, the treatment of injuries to the great vessels hold top priority. Hemorrhages to the exterior, into the body cavity, and/or into the tissues will produce shock and other complications and may eventuate in death. Without adequate blood supply, however carefully other damaged structures may be reconstructed, the results will be disappointing if not catastrophic. Deficient circulation predisposes the part to loss of function, infections and local or massive gangrene, with future complications. Therefore, the fundamental objective in the treatment of
-Wilfred F. Ruggiero, Fey Chu arterial wounds is to re-establish the continuity of blood flow by any means. The contused segment of artery may produce spasm with involvement of the collateral channels, giving rise to an occlusive state. The immediate diagnosis of spasm is extremely difficult to establish. The diagnosis is suggested if, after a few hours of vigorous treatment with sympathetic blocks and antispasmodics, the vessel dilates spontaneously and peripheral pulse returns. The dilatation of the peripheral vascular bed does not exclude the presence of thrombus or embolus. If the trauma is minor, a temporary spasm may occur followed by an uneventful recovery. At times the trauma has produced such spasm of the artery that it will not respond to the removal of pressure, the evacuation of a thrombus, the local application of warm saline or the topical and intra-arterial use of papaverine hydrochloride solution. In such a situation, the constricted section of the artery should be excised and the defect bridged with a vein graft or homologous graftP· 18 Postoperatively, vasodilatation by drugs or block is included with anticoagulant and antibiotic therapy. Injuries to the arterial wall by direct or indirect force produce more extensive damage to the inner coats as compared to the outer and more elastic layers, thus making evaluation of the injury difficult on inspection of the vessel. The effect produced depends upon the extent of the injury and its complicating sequelae. Secondary thrombosis usually follows and may be massive, causing arterial occlusion and distal embolization. Injury with minimal thrombosis may produce aneurysmal dilation at a later date. When associated with injury to the accompanying vein, an arteriovenous fistula may result. Infection may also occur later with disruption of the injured wall, giving rise to secondary hemorrhage. When an artery is partially divided, retraction of the wall increases the size of the rent. The same situation occurs when retraction of the ends of a completely divided artery is prevented by local attachments, thus causing it to behave like a partially divided artery. In this situation, the artery continues to bleed intermittently. If the soft tissue damage is large, the hemorrhage will be external. The hemorrhage may occur after a few days and may be accompan}ed by infection. If the vessel is buried deep in muscle and fascia or the external opening is small, there may be intermittent bleeding or secondary hemorrhage giving rise to a pulsating hematoma, or an enlarging aneurysm which may occlude the distal circulation. Complete division of an artery is manifested by severe arterial hemorrhage and shock. When a large vessel is divided, death may ensue in a very short period. If the vessel is of major importance, signs and symptoms of arterial interruption will be present. The cut ends of the artery usually contract into the sheaths in spasm, with shortening in length and narrowing of its diameter so that spontaneous closure may occur. How-
1 The Management of Peripheral Vascular Emergencies
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ever, serious and fatal hemorrhage may follow after relaxation of the spasm. The hemorrhage should be controlled if possible by local pressure. If the lacerated vessel is visualized easily a forceps and ligature may be applied. The application of a tourniquet is usually unnecessary and is fraught with danger. The tourniquet, when applied, should be :finn enough to control arterial hemorrhage. When applied loosely, arterial blood will continue to escape into the wound and blood entering into the limb through other channels will be retained in the veins or leak into the tissue. When applied too tightly, permanent damage may be done to blood vessels, muscle and nerve. In the management of acute peripheral ischemia produced by trauma to an extremity, the primary objective of the surgeon is to restore the continuity of blood flow and to prevent secondary thrombosis. Early operative intervention, as soon as the patient's general condition allows, is in order to relieve the pressure of tissue edema, the pressure of hematoma, the obstruction produced by a thrombosis in situ and the obstruction produced by an unrelenting spasm of artery, and to restore the continuity of a lacerated artery. Antibiotic therapy and blood and electrolyte replacement should be started in the preoperative period. There should be avilable in the operating room at least 3000 cc. of whole blood and, in the case of injury to a large artery such as the iliac, a homologous graft or one of the new textile prosthesis. 19 Anticoagulant therapy as for embolization is started at the time of operation. The anesthesia of choice is spinal subarachnoid without the use of vasoconstrictor drugs for the lower extremity and general anesthesia for the upper extremity. The injured artery is exposed for a distance of at least 3 inches by means of a liberal incision. It is advisable to expose the proximal normal artery first, so as to be able to control bleeding by means of an arterial clamp or the rubber tube tourniquet described above. Ideally, a lacerated artery should be repaired by means of an end-to-end anastomosis using atraumatic arterial 5-0 silk suture. Too often, however, varying amounts of the substance of the artery have been lost, making an end-to-end anastomosis impossible or dangerous. In such a situation a section of the patient's own long saphenous vein, either from the same side or from the opposite side, will make an adequate graft for bridging defects of the femoral or smaller artery. Large arteries, as the iliac, necessitate the use of an homologous arterial graft or textile tube prosthesis. For the upper extremity either the cephalic or saphenous vein can be used. When vein grafts are used they should be further protected by covering with muscle or fascia. The graft should be of adequate length so that no tension arises on full extension of the limb, and is so placed that the distal end of the vein is anastomosed to the proximal end of the artery to avoid valvular obstruction. Heparin solution, 25 to 50 mg., is plaCed within the lumen
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of the vessel. The wound is closed loosely and a soft rubber Dakin tube is used to drain it. Postoperatively, anticoagulant therapy and antibiotic therapy should be continued for at least ten days and the extremity be kept under close observation for secondary thrombosis. Occasionally the patient's general condition is so poor as to contraindicate surgical intervention for restoration of the continuity of blood flow. At best this type of patient should receive only first aid so as to prevent any further loss of blood. While shock and the general condition are being treated, the extremity, after the wound if present is covered with sterile dressing, should be refrigerated as described above for occlusion produced by embolism. Cooling the extremity makes possible the delay of definitive surgery for several days without the developing gangrene and infection that would ordinarily occur in the absence of cooling. In conclusion, early surgical intervention with adequate use of anticoagulants and vasodilation, preoperative and postoperative, will save the majority of extremities whose vascular trees have been disrupted. The future availability of textile prosthetic tubes of various lengths and diameter in every operating room will make for a more optimistic attitude on the part of the surgeon for reconstruction of vessels of an extremity when injured or diseased. The judicious use of refrigeration as an aid to surgical intervention will increase the salvage rate of limbs with inpending gangrene. REFERENCES 1. Lindgren, S. and Wilander, 0.: Use of Heparin in Vascular Surgery. Acta med. Scandinav. 107: 148-160, 1941. 2. Murray, G. D. W. and Best, C. H.: Use of Heparin in Thrombosis. Ann. Surg. 108: 163-177, 1938. 3. Crossman, I. W., Ruggiero, W. F., Hurley, V. and Allen, F. M.: Reduced Temperatures in Surgery. A.M.A. Arch. Surg. 44: 139-156, 1942. 4. Kross, I.: Low Temperature Therapy for Preservation of Limb. J.A.M.A. 128: 19-20, 1945. 5. Bower, W. F.: Refrigeration Therapy in Vascular Trauma. Mil. Surg. 93: 289294,1943. 6. Green, H. D., Gobel, W. K., Moore, M. J. and Prince, T. C.: The Evaluation of the Ability of Priscoline, Regitone and Romiacol to Overcome Vasospasm in Normal Man; Estimation of Probable Clinical Efficacy of These Drugs in Vasospastic Peripheral Vascular Disease. Circulation 6: 520-528, 1952. 7. Elkin, D. C. and Cooper, F. W.: Effect of Vasodilation Drugs on Circulation of I Extremities. Surgery 29: 323-333, 1951. 8. Gage, M. and Ochsner, A.: The Prevention of Ischemic Gangrene Following Surgical Operations upon the Major Peripheral Arteries by Chemical Sections of the Cervicodorsal and Lumbar Sympathetics. Ann. Surg. 112: 939-959, 1940. 9. Ansbro, F. P., Black, J. J. and Latteri, F. S.: Postoperative Treatment of Peripheral Vascular Injury by Employment of Continuous Spinal Anesthesia for Eleven Days. Am. J. Surg. 84: 3-10, 1952. 10. Warren, R. and Linton, R. R.: The Treatment of Arterial Embolism. New England J. Med. 238: 421, 1948. 11. De Takats, Geza: The Use of Papaverine in Acute Arterial Occlusion, J.A.M.A. 106: 1003-1005 (Nov. 21) 1936.
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12. Olwin, J. H., Dye, W. S. and Julian, O. C.: Late Peripheral Embolectomy. Arch. Surg. 66: 480, 1953. 13. Linton, R. R.: Arterial Embolism: Simplified Technique for Removal of Saddle Embolus at Bifurcation of Aorta with Report of Successful Case. Surg., Gynec. & Obst. 80: 509-516, 1945. 14. Barker, N. W., Cromer, H. E., Hurn, M. and Waugh, J. M.: The Use of Dicumarol in the Prevention of Postoperative Thrombosis and Embolism with Special Reference to Dosage and Safe Administration. Surgery 17: 207-217, 1945. 15. McElvenny, R. T.: The Effect of Cooling Traumatized and Potentially Infected Limbs. Surg., Gynec. & Obst. 73: 263-264, 1944; Recent Evolution of Cold as an Adjunct to Surgery, Arc. Phys. Ther. 25: 599-602, 1944. 16. Crossman, L. W., Allen, F. M., Hurley, V., Ruggiero, W. F.~and Warden, C. E.: Refrigeration Anesthesia. Anesth. & Analg. 21: 241-254, 1942. 17. Edwards, S. W. and Lyons, C.: Traumatic Arterial Spasm and Thrombosis. Ann. Surg. 104:318, 1954. 18. Lord, J. W.: Restoration of Vascular Continuity by Homologous Grafts. New York J. Med. 54: 2578-2580, 1954. 19. Blakemore, A. H. and Voorhies, A. B. Jr.: The Use of Tubes Constructed from Vinyon "N" Cloth in Bridging Arterial Defects; Experimental and Clinical. Ann. Surg. 104: 324, 1954. 1249 Fifth Avenue New York 29, N. Y.
THE management of acute vascular emergencies, when adequately and properly instituted early, will prevent the loss of limb due to ensuing gangrene. With the advent of anticoagulants,!,2 refrigeration, 3 , 4, 5 vigorous use of sympathicolytic drugs 6 , 7 and sympathetic blocks, 8, 9 the horizon of treatment has broadened .. These adjuvants have made the treatment more effective, facilitating surgical intervention and in most instances making it the treatment of choice. Peripheral vascular emergency is caused by an interruption in the continuity of blood flow in a major peripheral artery. Arterial embolism, rapidly forming thrombosis in situ, and trauma of a major peripheral artery will produce a peripheral vascular emergency. ARTERIAL EMBOLISM
TreatInent of the General Condition
The treatment of embolism10 of a major peripheral artery such as the femoral artery resolves itself into two parts. The first of these is the treatment of the general condition, i.e., the cardiac disease which is generally the source of the embolus and the shock which is so often associated with embolization. The objective at this phase of the treatment is to restore the heart to normal function, restore the blood pressure and prevent further embolization. Ordinarily this part of the treatment is in the hands of the family physician who may look upon the arterial embolism as a secondary complication to be viewed with a pessimistic attitude. Too often the surgeon is called in many hours after the accident has occurred, when irreversible changes have taken place and gangrene * Associate Professor of Surgery; New York Medical Flower and Fifth Avenue Hospitals; Visiting Surgeon, York, N. Y. ** Assistant Professor of Surgery, New York Medical Surgeon, Flower and Fifth Avenue Hospitals; Assistant pital, New York, N. Y.
College; Attending Surgeon, Metropolitan Hospital, New College; Assistant Attending Surgeon, Metropolitan Hos-
1
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Wilfred F. Ruggiero, Fey Chu
of the toes and parts of the foot is inevitable. Be it as it may, surgical intervention should not be denied the patient even when gangrene is present. The ideal time for surgical intervention is within the first six hours after the arterial occlusion has occurred. Anticoagulant Therapy. The first and most important measure is to institute anticoagulant therapy, if it has not already been started. The average patient can be rapidly heparinized by administering 200 mg. of Depo-Heparin intramuscularly and 50 mg. of aqueous heparin solution intravenously, the latter being repeated every three or four hours so as to increase the coagulation time three to four times that of normal. Adequate heparinization prevents the propagation of a thrombus on the lodged embolus, and will not produce dangerous bleeding during the subsequent surgical procedure. Measures to Promote Vasodilation. The next measure of importance is to promote vasodilation of the vascular tree of the involved extremity. The continuous epidural block with Pontocaine hydrochloride produces effective vasodilation. At times subarachnoid spinal anesthesia with small doses of procaine hydrochloride (50 to 75 mg.) is used. This is sufficient to produce sympathetic paralysis without much danger of the unwanted drop in blood pressure so often seen with larger doses of spinal anesthetic agents. Papaverine hydrochloridel l intravenously in doses of 30 to 60 mg., repeated every two hours, is used. At best the effect of papaverine hydrochloride is transient and it is of little or no effect when given by mouth or intramuscularly. If the patient is not vomiting or nauseated we recommend the oral use of Priscoline hydrochloride, starting with a dose of 75 mg. and repeated every four hours. When using sympathetic blocks and vasodilators one must be on guard against a fall in blood pressure, which favors further clotting anywhere in the vascular system but more selectively on an already lodged embolus. The surgeon should discontinue all local therapy which is deleterious and ineffectual, such as heat and elevation of the ischemic extremity. No heat should be applied to an ischemic extremity. All ischemic extremities should be dependent. This is accomplished by raising the head of the bed 6 inches. The application of positive and negative pressure boots by means of machines has not been successful and in our opinion does more harm than good. EIllbolectoIllY
If, within two or three hours after the above therapy has been instituted, the pulses have not returned in the arteries of the foot and lower leg as measured by an accurate oscillometer with the readings compared with oscillations in the good leg, an arteriotomy with removal of the embolus should be performed. Anesthesia. The anesthesia of choice is local infiltration anesthesia with 2 per cent procaine hydrochloride solution. If the patient's general
The Management of Peripheral Vascular Emergencies condition is good, spinal subarachnoid anesthesia may be used, taking special precautions against a fall in blood pressure. Technique. If the embolus has lodged, as it most often does, in the iliac or femoral artery, approximately 2Yz inches of the femoral artery is exposed in the upper one-third of the thigh by making a liberal incision parallel to its course through skin, subcutaneous tissue and deep fascia. The femoral artery is carefully dissected free from its accompanying vein and two soft rubber tubes are placed around the artery, one at the upper angle and the second at the lower angle. They are to be used as tourniquet and as tractors. The arteriotomy is then performed by making a longitudinal incision about 1.5 cm. long through all the coats of the artery. If, as is quite often the case, the clot is encountered at the arteriotomy site, the distal end is first extracted, care being taken not to break any of the distal portion of the clot. This can be ascertained by examining the clot; it should have the resemblance of a whip or mouse tail. A free reflux flow of blood from the distal end of the artery is good evidence the clot has been entirely removed. The proximal end of the clot is then withdrawn. This should be followed by a sudden gush of blood which can be controlled by pulling up on the rubber tube tractor and fixing it by placing a small hemostat around the tube parallel to the artery but not encroaching upon the artery. The arteriotomy wound is closed with a continuous over-and-over arterial silk suture (atraumatic 5-0). Before completing the closure 25 mg. of aqueous heparin solution is placed in the lumen of the artery. The rubber tubes are then released, the distal one first, then the proximal one. If some bleeding occurs through the wound, a few interrupted silk sutures are placed through the bleeding points. No attempt is made to evert the intima. Following the embolectomy, the pulse of the posterior tibial artery should return. If the pulse has not returned it means that a portion of the clot is lodged either in the popliteal artery or in the posterior tibial artery, and that one has been unsuccessful in removing it by the femoral arteriotomy. The posterior tibial artery12 at the malleolus should then be exposed and opened in the same manner as the femoral. By using a No.5 ureteral catheter and flushing with saline and heparin solution, the lodged clot should be dislodged and a free flow of blood should be secured. One should be careful not to injure the intima with the ureteral catheter. If one suspects that he is dealing with a saddle-back thrombus, 13 the other femoral artery should be simultaneously exposed and so controlled during the removal of the proximal clot from the more involved femoral artery that none of the embolus is lost down the arterial tree of the lesser involved side. This is accomplished by occluding the femoral artery of the lesser involved side with the rubber tube tourniquet and before releasing it performing an arteriotomy proximal to it and allowing
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Wilfred F.Ruggiero, Fe?i,Chu
any fragments of the embolus to escape. Following the closure of the arteriotomy the wound should be loosely closed with interrupted 000 silk sutures and a soft rubber Dakin's tube drain placed down to the artery. Postoperative Care. Postoperatively, anticoagulant therapy with heparin is maintained so as to prevent secondary thrombosis. Oral Dicumarol therapy14 can now be started to supplant or aid the heparin. We recommend an initial dose of 300 mg. and a second day dose of 150 mg., so as to increase the prothrombin time three times that of normal. This is usually obtained by the third or fourth day of Dicumarol therapy and maintained on 50 to 100 mg. per day. Heparin is not discontinued until the prothrombin time has been increased as stated above. Antibiotics are routinely given to the patient postoperatively in prophylactic doses. Postoperatively all efforts should be made to maintain a normal blood pressure, which is so vital to the free flow of blood through the vascular tree of an arteriotomized extremity. The extremity should be dependent, not elevated, and should not be kept warmer than body temperature. Vasodilation with sympathicolytic drugs is continued postoperatively. Anticoagulant therapy is continued for two weeks; the dose is then gradually reduced over the following two week period. Arteriovenous Shunt
If one has failed to remove the clot from the posterior tibial or the popliteal artery because of the adherence of the clot-and this is too often the case when surgical intervention is delayed for one to several days and the inevitability of the gangrene is certain-then we recommend the fashioning of a three limb arteriovenous shunt between the femoral artery at the arteriotomy site and the femoral vein after section and ligation of the cephalad part of the femoral vein and any large venous branches at the site of anastomosis. The arteriovenous shunt is performed by using an over-and-over continuous arterial 5-0 silk suture. Bleeding points are controlled by reinforcing interrupted silk sutures. The stoma of the shunt should not be longer than 1.5 cm. In an operation by one of the authors (W.R.), the shunt was performed between the femoral artery and the long saphenous vein because of an obliterated femoral vein due to an old thrombus. With this procedure we have been able to salvage a small percentage of otherwise totally lost extremities. In only one case was there any embarrassment of the heart; this was mild and responded to medical therapy. The postoperative treatment is identical to that for simple embolectomy. Refrigeration
At times, even in early cases, operation is contraindicated because of the poor general condition of the patient, or for some other cause surgical intervention may be delayed for more than 12 hours. Anticoagulants,
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547
antibiotics and vasodilators are administered and in addition the extremity should be immediately refrigerated. 5 • 15 Refrigeration16 is best accomplished by surrounding the extremity with a 3 inch layer of cracked ice of about the size of a walnut. The ice should reach at least 2 inches above the site of the lodged embolus. Approximately 50 pounds of ice will be required for the lower extremity. As much is placed beneath the extremity as on top of it, and the whole is held in place with a rubber sheet that is so fashioned as to allow drainage at the foot of the bed into a pail, and to promote drainage the head of the bed is raised 6 inches. Before applying ice the extremity is covered with a thin layer of petrolatum followed by a sterile stockingette so that the entire extremity is covered. Refrigeration slows the process of gangrene and will make possible successful surgical intervention several days after the arterial occlusion has occurred. A refrigerating blanket may be used in the place of ice when available. RAPIDL Y FORMING THROMBUS IN SITU
Quite often the sudden occlusion of a major peripheral artery is produced not by an embolus but by a rapidly forming thrombus in situ. The underlying cause in the majority of cases is a pre-existing disease of the artery, sometimes associated with trauma of no great force or a drop in blood pressure. Because of the similarity of the signs and symptoms, occlusion produced by a rapidly forming thrombosis in situ cannot be distinguished from an arterial occlusion produced by arterial embolus. Whereas the outlook as to life in arterial embolism is poor because of the primary heart disease and because of the possibility and greater frequency of further embolization in centrally located organs, the patient with an occlusion of a major peripheral artery due to a rapidly forming thrombus in situ has a more favorable prognosis and in the majority of cases is in better general condition. The management for this type of occlusion is about the same as for that produced by arterial embolism. TRAUMA OF MAJOR PERIPHERAL ARTERIES
A-ccompanying the present day use of high speed machines and means of transport, and modern warfare, injuries to great vessels requiring radical surgical procedures have become more frequent. In dealing with any type of trauma, the treatment of injuries to the great vessels hold top priority. Hemorrhages to the exterior, into the body cavity, and/or into the tissues will produce shock and other complications and may eventuate in death. Without adequate blood supply, however carefully other damaged structures may be reconstructed, the results will be disappointing if not catastrophic. Deficient circulation predisposes the part to loss of function, infections and local or massive gangrene, with future complications. Therefore, the fundamental objective in the treatment of
-Wilfred F. Ruggiero, Fey Chu arterial wounds is to re-establish the continuity of blood flow by any means. The contused segment of artery may produce spasm with involvement of the collateral channels, giving rise to an occlusive state. The immediate diagnosis of spasm is extremely difficult to establish. The diagnosis is suggested if, after a few hours of vigorous treatment with sympathetic blocks and antispasmodics, the vessel dilates spontaneously and peripheral pulse returns. The dilatation of the peripheral vascular bed does not exclude the presence of thrombus or embolus. If the trauma is minor, a temporary spasm may occur followed by an uneventful recovery. At times the trauma has produced such spasm of the artery that it will not respond to the removal of pressure, the evacuation of a thrombus, the local application of warm saline or the topical and intra-arterial use of papaverine hydrochloride solution. In such a situation, the constricted section of the artery should be excised and the defect bridged with a vein graft or homologous graftP· 18 Postoperatively, vasodilatation by drugs or block is included with anticoagulant and antibiotic therapy. Injuries to the arterial wall by direct or indirect force produce more extensive damage to the inner coats as compared to the outer and more elastic layers, thus making evaluation of the injury difficult on inspection of the vessel. The effect produced depends upon the extent of the injury and its complicating sequelae. Secondary thrombosis usually follows and may be massive, causing arterial occlusion and distal embolization. Injury with minimal thrombosis may produce aneurysmal dilation at a later date. When associated with injury to the accompanying vein, an arteriovenous fistula may result. Infection may also occur later with disruption of the injured wall, giving rise to secondary hemorrhage. When an artery is partially divided, retraction of the wall increases the size of the rent. The same situation occurs when retraction of the ends of a completely divided artery is prevented by local attachments, thus causing it to behave like a partially divided artery. In this situation, the artery continues to bleed intermittently. If the soft tissue damage is large, the hemorrhage will be external. The hemorrhage may occur after a few days and may be accompan}ed by infection. If the vessel is buried deep in muscle and fascia or the external opening is small, there may be intermittent bleeding or secondary hemorrhage giving rise to a pulsating hematoma, or an enlarging aneurysm which may occlude the distal circulation. Complete division of an artery is manifested by severe arterial hemorrhage and shock. When a large vessel is divided, death may ensue in a very short period. If the vessel is of major importance, signs and symptoms of arterial interruption will be present. The cut ends of the artery usually contract into the sheaths in spasm, with shortening in length and narrowing of its diameter so that spontaneous closure may occur. How-
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ever, serious and fatal hemorrhage may follow after relaxation of the spasm. The hemorrhage should be controlled if possible by local pressure. If the lacerated vessel is visualized easily a forceps and ligature may be applied. The application of a tourniquet is usually unnecessary and is fraught with danger. The tourniquet, when applied, should be :finn enough to control arterial hemorrhage. When applied loosely, arterial blood will continue to escape into the wound and blood entering into the limb through other channels will be retained in the veins or leak into the tissue. When applied too tightly, permanent damage may be done to blood vessels, muscle and nerve. In the management of acute peripheral ischemia produced by trauma to an extremity, the primary objective of the surgeon is to restore the continuity of blood flow and to prevent secondary thrombosis. Early operative intervention, as soon as the patient's general condition allows, is in order to relieve the pressure of tissue edema, the pressure of hematoma, the obstruction produced by a thrombosis in situ and the obstruction produced by an unrelenting spasm of artery, and to restore the continuity of a lacerated artery. Antibiotic therapy and blood and electrolyte replacement should be started in the preoperative period. There should be avilable in the operating room at least 3000 cc. of whole blood and, in the case of injury to a large artery such as the iliac, a homologous graft or one of the new textile prosthesis. 19 Anticoagulant therapy as for embolization is started at the time of operation. The anesthesia of choice is spinal subarachnoid without the use of vasoconstrictor drugs for the lower extremity and general anesthesia for the upper extremity. The injured artery is exposed for a distance of at least 3 inches by means of a liberal incision. It is advisable to expose the proximal normal artery first, so as to be able to control bleeding by means of an arterial clamp or the rubber tube tourniquet described above. Ideally, a lacerated artery should be repaired by means of an end-to-end anastomosis using atraumatic arterial 5-0 silk suture. Too often, however, varying amounts of the substance of the artery have been lost, making an end-to-end anastomosis impossible or dangerous. In such a situation a section of the patient's own long saphenous vein, either from the same side or from the opposite side, will make an adequate graft for bridging defects of the femoral or smaller artery. Large arteries, as the iliac, necessitate the use of an homologous arterial graft or textile tube prosthesis. For the upper extremity either the cephalic or saphenous vein can be used. When vein grafts are used they should be further protected by covering with muscle or fascia. The graft should be of adequate length so that no tension arises on full extension of the limb, and is so placed that the distal end of the vein is anastomosed to the proximal end of the artery to avoid valvular obstruction. Heparin solution, 25 to 50 mg., is plaCed within the lumen
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of the vessel. The wound is closed loosely and a soft rubber Dakin tube is used to drain it. Postoperatively, anticoagulant therapy and antibiotic therapy should be continued for at least ten days and the extremity be kept under close observation for secondary thrombosis. Occasionally the patient's general condition is so poor as to contraindicate surgical intervention for restoration of the continuity of blood flow. At best this type of patient should receive only first aid so as to prevent any further loss of blood. While shock and the general condition are being treated, the extremity, after the wound if present is covered with sterile dressing, should be refrigerated as described above for occlusion produced by embolism. Cooling the extremity makes possible the delay of definitive surgery for several days without the developing gangrene and infection that would ordinarily occur in the absence of cooling. In conclusion, early surgical intervention with adequate use of anticoagulants and vasodilation, preoperative and postoperative, will save the majority of extremities whose vascular trees have been disrupted. The future availability of textile prosthetic tubes of various lengths and diameter in every operating room will make for a more optimistic attitude on the part of the surgeon for reconstruction of vessels of an extremity when injured or diseased. The judicious use of refrigeration as an aid to surgical intervention will increase the salvage rate of limbs with inpending gangrene. REFERENCES 1. Lindgren, S. and Wilander, 0.: Use of Heparin in Vascular Surgery. Acta med. Scandinav. 107: 148-160, 1941. 2. Murray, G. D. W. and Best, C. H.: Use of Heparin in Thrombosis. Ann. Surg. 108: 163-177, 1938. 3. Crossman, I. W., Ruggiero, W. F., Hurley, V. and Allen, F. M.: Reduced Temperatures in Surgery. A.M.A. Arch. Surg. 44: 139-156, 1942. 4. Kross, I.: Low Temperature Therapy for Preservation of Limb. J.A.M.A. 128: 19-20, 1945. 5. Bower, W. F.: Refrigeration Therapy in Vascular Trauma. Mil. Surg. 93: 289294,1943. 6. Green, H. D., Gobel, W. K., Moore, M. J. and Prince, T. C.: The Evaluation of the Ability of Priscoline, Regitone and Romiacol to Overcome Vasospasm in Normal Man; Estimation of Probable Clinical Efficacy of These Drugs in Vasospastic Peripheral Vascular Disease. Circulation 6: 520-528, 1952. 7. Elkin, D. C. and Cooper, F. W.: Effect of Vasodilation Drugs on Circulation of I Extremities. Surgery 29: 323-333, 1951. 8. Gage, M. and Ochsner, A.: The Prevention of Ischemic Gangrene Following Surgical Operations upon the Major Peripheral Arteries by Chemical Sections of the Cervicodorsal and Lumbar Sympathetics. Ann. Surg. 112: 939-959, 1940. 9. Ansbro, F. P., Black, J. J. and Latteri, F. S.: Postoperative Treatment of Peripheral Vascular Injury by Employment of Continuous Spinal Anesthesia for Eleven Days. Am. J. Surg. 84: 3-10, 1952. 10. Warren, R. and Linton, R. R.: The Treatment of Arterial Embolism. New England J. Med. 238: 421, 1948. 11. De Takats, Geza: The Use of Papaverine in Acute Arterial Occlusion, J.A.M.A. 106: 1003-1005 (Nov. 21) 1936.
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12. Olwin, J. H., Dye, W. S. and Julian, O. C.: Late Peripheral Embolectomy. Arch. Surg. 66: 480, 1953. 13. Linton, R. R.: Arterial Embolism: Simplified Technique for Removal of Saddle Embolus at Bifurcation of Aorta with Report of Successful Case. Surg., Gynec. & Obst. 80: 509-516, 1945. 14. Barker, N. W., Cromer, H. E., Hurn, M. and Waugh, J. M.: The Use of Dicumarol in the Prevention of Postoperative Thrombosis and Embolism with Special Reference to Dosage and Safe Administration. Surgery 17: 207-217, 1945. 15. McElvenny, R. T.: The Effect of Cooling Traumatized and Potentially Infected Limbs. Surg., Gynec. & Obst. 73: 263-264, 1944; Recent Evolution of Cold as an Adjunct to Surgery, Arc. Phys. Ther. 25: 599-602, 1944. 16. Crossman, L. W., Allen, F. M., Hurley, V., Ruggiero, W. F.~and Warden, C. E.: Refrigeration Anesthesia. Anesth. & Analg. 21: 241-254, 1942. 17. Edwards, S. W. and Lyons, C.: Traumatic Arterial Spasm and Thrombosis. Ann. Surg. 104:318, 1954. 18. Lord, J. W.: Restoration of Vascular Continuity by Homologous Grafts. New York J. Med. 54: 2578-2580, 1954. 19. Blakemore, A. H. and Voorhies, A. B. Jr.: The Use of Tubes Constructed from Vinyon "N" Cloth in Bridging Arterial Defects; Experimental and Clinical. Ann. Surg. 104: 324, 1954. 1249 Fifth Avenue New York 29, N. Y.