Brachial Embolectomy
James Michael Forsyth in 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.
Acute limb ischaemia
S Asbury, A Mishra, KM Mokbel, M Fishman Jonathan in Principles of Operative Surgery, 2017
Embolic occlusion is a surgical emergency which requires immediate surgical intervention if the limb is salvageable. Management would be as follows. Initial resuscitation with oxygen, judicious intravenous fluids and analgesia.Establishing the source of the embolus, checking electrolytes, cardiac enzymes and an ECG, particularly for cardiac abnormalities (e.g. atrial fibrillation).Administration of continuous intravenous heparin to prevent thrombus propagation both proximally and distally to the embolus.Embolectomy under local or general anaesthesia.
Treatment algorithms for acute venous thromboembolism: Current guidelines
Peter Gloviczki, Michael C. Dalsing, Bo Eklöf, Fedor Lurie, Thomas W. Wakefield, Monika L. Gloviczki in Handbook of Venous and Lymphatic Disorders, 2017
For acute PE, treatment needs to address: (1) prevention of new thrombus; (2) clearance of obstructing thrombus from the pulmonary artery (either rapidly or over time); and (3) reduction of right ventricular (RV) dysfunction when present (see Chapter 21). Thrombolysis is recommended for patients with low bleeding risk who have massive PE. In addition, patients with sub-massive PE with new hemodynamic instability, worsening respiratory insufficiency, severe RV dysfunction, or major myocardial necrosis may be considered for thrombolysis (Figure 22.6). Catheter-based therapy or surgical embolectomy, however, may be recommended in a number of circumstances. These include a contraindication to systemic thrombolysis (recent intracranial hemorrhage or surgery, recent spinal surgery, recent head trauma, intracranial neoplasm, uncontrolled hypertension, or active or recent bleeding), a significant risk of bleeding, or insufficient time to allow infusion and the effect of systemic thrombolytics in the acute setting. Finally, some patients will fail to improve despite thrombolytic treatment and require more aggressive therapy, such as catheter-based therapy or surgical embolectomy.
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].
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
Advanced Therapies for Acute Pulmonary Embolism: A Focus on Catheter-Based Therapies and Future Directions
Published in Structural Heart, 2021
John R. Burton, Mahesh V. Madhavan, Matthew Finn, Joseph J. Ingrassia, Behnood Bikdeli, Shayan Nabavi Nouri, Yevgeniy Brailovsky, Erika B. Rosenzweig, Koji Takeda, Philip Green, Ajay J. Kirtane, Sahil A. Parikh, Sanjum S. Sethi
Risk stratification schemes can identify patients at the highest risk for clinical deterioration and those who may benefit the most from advanced therapies.8,9 However, outcomes remain poor for high-risk patients with PE, with studies suggesting that 30-day all-cause mortality rates may exceed 20%.10–12 The mainstay of treatment for acute PE remains systemic anticoagulation across the spectrum of clinical severity. While systemic fibrinolysis can lyse clot, improve hemodynamics and in some cases improve all-cause mortality, it has been reserved for the highest risk patients due to significant rates of associated intracranial bleeding (3–5%) and other major bleeding complications (20%).13–15 Surgical embolectomy can be considered in specific high-risk patients, and mechanical circulatory support may offer hemodynamic stabilization while definitive therapies are being evaluated.16,17 For patients with lower, but still substantial risk for mortality and adverse events, therapies with more favorable safety profiles are needed. In light of this, catheter-based therapies (CBT) have the potential to improve outcomes while minimizing complications. Lytic-sparing (i.e. mechanical thrombectomy) and reduced-dose, locally-directed fibrinolysis, are two categories of CBT under continued investigation.
Related Knowledge Centers
- Anticoagulant
- Necrosis
- Surgery
- Thrombectomy
- Thrombus
- Embolus
- Interventional Radiology
- Thrombolysis
- Limb-Sparing Techniques
- Acute Limb Ischaemia