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Brachial Embolectomy
Published in James Michael Forsyth, How to Be a Safe Consultant Vascular Surgeon from Day One, 2023
Also be wary of “proximal disease” in the context of embolic upper limb ischaemia. I have had two recent cases of exactly this. One was a young gentleman with a Rutherford 2B upper limb ischaemia. He had embolus in his distal axillary artery, and also embolus around the very proximal subclavian artery. This was removed with the help of interventional radiology i.e. we did an over-the-wire embolectomy. A neurointerventional radiologist was also given the heads up in case any clot was dislodged and went into the carotid / vertebral system (which never took place but we were ready for this). The other case was a young woman with occlusion of the proximal brachiocephalic artery and further clot in the proximal axillary artery. Her hand was viable. The decision in this case was to manage conservatively with anticoagulation alone, with a plan to reassess in 6 weeks and then decide on further endovascular intervention. Just remember in these cases not to blindly rush into doing an embolectomy because of the genuine risk of causing a stroke.
Mesenteric Ischemia
Published in Stephen M. Cohn, Alan Lisbon, Stephen Heard, 50 Landmark Papers, 2021
The goal of intervention is focused on expeditious restoration of visceral perfusion (Ryer et al., 2012; Corcos et al., 2013). In patients with embolism, a midline laparotomy is performed and a Fogarty embolectomy catheter is passed proximally and distally and flow is restored. This approach also allows for assessment of bowel viability. In patients with mesenteric thrombosis, thrombectomy alone is unlikely to be effective or durable. Mesenteric bypass, classically considered the “gold-standard,” constructs a graft from the aorta or iliac artery to a site distal to the occlusion. It offers excellent relief and is remarkably durable, however, it can be prohibitive in patients in shock or those with extensive cardiovascular comorbidities (Johnston et al., 1995; Klempnauer et al., 1997; Björck et al., 2002; Cho et al., 2002; Roussel et al., 2015). Endovascular and hybrid approaches, typically by means of mechanical thrombectomy or angioplasty and stenting, may be as effective as traditional surgical approaches while eliminating the need for aortic cross clamping, minimizing physiologic insult (Milner et al., 2004; Wyers et al., 2007). If endovascular-only therapy is pursued, any evidence of clinical deterioration or peritonitis necessitates operative exploration (Clair and Beach, 2016). Poor-risk surgical candidates with extensive small bowel infarction may be best served by a palliative approach.
Introduction to the clinical stations
Published in Sukhpreet Singh Dubb, Core Surgical Training Interviews, 2020
Patients with evidence of infarction, perforation or peritonitis require exploratory laparotomy with potential bowel resection. In superior mesenteric artery embolus, or thrombosis, papaverine infusion with embolectomy is advocated. If embolectomy is not possible, an arterial bypass or even resection may be necessary. Papaverine infusion continues preoperatively through to the postoperative period, unless there is radiological evidence showing cessation of vasoconstriction. In thrombus situations, postoperative heparinisation is also recommended.
Extracorporeal membrane oxygenation for large pulmonary emboli
Published in Baylor University Medical Center Proceedings, 2023
Timothy J. George, Jenelle Sheasby, Rahul Sawhney, J. Michael DiMaio, Aasim Afzal, Dennis Gable, Sameh Sayfo
Acute pulmonary embolism (PE) is a common and growing problem.1 Large submassive and massive PE large enough to cause significant obstruction of the pulmonary arteries can cause hypoxia, hypercapnia, right ventricular failure, and hemodynamic instability.1,2 In some cases, patients will suffer cardiovascular collapse requiring cardiopulmonary resuscitation (CPR). In patients requiring CPR, in-hospital mortality is high, ranging from 25% to 80%.2–5 Although the first line of therapy consists of anticoagulation, treatment options include systemic thrombolysis, directed thrombolysis, percutaneous thrombectomy, and open surgical embolectomy. These therapies have been employed with varying degrees of success in different clinical situations.
Osteosarcoma emboli presenting as chronic thromboembolic pulmonary hypertension in a child
Published in Pediatric Hematology and Oncology, 2023
Laura L. Donahoe, Serina Patel, Soumitra Tole, Alexandra P. Zorzi, Lennox Huang, Osami Honjo, Marc de Perrot
Typically, the management of PE includes anticoagulation for minimum 3 months and reassessment with imaging (CT-PA and ventilation-perfusion scan). In adults with ongoing dyspnea, physiologic testing (echocardiogram, right heart catheterization, 6-minute walk test) is used. Although CTEPH is commonly diagnosed when adults have non-resolving dyspnea and imaging findings of chronic PE, in adults with active malignancy there should be a low threshold for PET-scan or transluminal biopsy given the not insignificant risk of pulmonary tumor emboli. Although tumor emboli are extremely rare in the pediatric population, these same investigations should be considered for children with a malignancy and non-resolving PE. The treatment for CTEPH is surgery in the form of elective PTE in the absence of heart failure. Surgical embolectomy is an option in the acute setting for patients with massive PE when thrombolysis is not feasible or has failed.8
FlowTriever Retrieval System for the treatment of pulmonary embolism: overview of its safety and efficacy
Published in Expert Review of Medical Devices, 2021
Vivian L. Bishay, Omosalewa Adenikinju, Rachel Todd
Angiovac (Angiodynamics, Inc, Latham, NY) veno–veno bypass circuit uses a balloon expandable funnel-shaped inflow cannula to facilitate suction embolectomy. Thrombus is extracted from the inflow cannula and disposed of in a filter, with return of blood via a reperfusion/outflow cannula [2,8]. Given its size, large bore embolectomy has been performed successfully for thrombus/tumor/foreign body removal, and thrombus-in-transit cases in large caliber veins. Earlier generations were limited in the treatment of submassive and massive PEs due to poor torqueability of the device through the right ventricular outflow tract [2]. Even with improved steerability, the use of newer generations of AngioVac in PEs is typically reserved for select cases given its limited reproducible success and safety and the need for a perfusionist and veno-veno bypass circuit [37,38].