_ _

hapter 196 Embolectomy 2091

[STED READING 10we Jl RJ Fillinger MF Bettmann M et al stenting of l11ultisegment iliac artery occlushyTh e durabili ty of endovasc ular treatment of sive disease) VaS( Sl-IIg 2000 32564

JR Powell RJ Walsh DB et a Early 1lultisegment iliac occlusive disease) Va ( Rwcidlo EM Powell Rj Zwolak RM et a of external iliac artery stentin g COI11- SUg 200031 1178 Early results of stent-grafting to trea t diiFuse

_ ith common fem oral artery enshy Powell RJ FiJJinger MF Walsh DB et aJ Preshy aorto-iliac occlusive disease) Va se SUIX

-~ ~ [Omy) Vase Surg 200235(6)1107 dicting outcome of angioplasty and selective 2003371175

EDITORS COMMENT

~d out by Dr Powell endov3sc ular tr~atshymptomatic aortoiliac arteri al occlusive now the fir st lin e of the rapy- Thus th e now is flot whether to ncat iliac occlusive coh CIldovc ldar techniqu es o r open slIrshy

-$ but rath er vhich pltients with iliac trea t and w hi ch iliac lesions are appro shy

- t l1dovasc ular therapy The auswCr [0 tht =-c qu esti ons is rdatively clear Patient~ to

_ ore those with hem odynamically si gn ifshy_ ~ rrcry occlusive disease and appropriate The low risk and good res ul asso ciated

J ll gioplasty and sten tin g as clearly o utshyh is chapler have lowered the threshold _1[1 0 11 and treatmellt of pa tients with --Jric iliac occlusive dise~l s c lIsing Jn g io shy tellting to include essentially all patients - th igh and l or buttock claudication and - p ro priat l fo r e lldo vasculJr treatment

Definition of iliac lesions appropriate lor cndovasshycular therapy the answer to the second qu estion is less dea r brgcly becJ usc co ntinuillg improvLment in e ndovJsc uar techniques and technology h 1Vt rc shysuIted in illlproving outcomes for treatmcnt of m o re challen ging ili ac lesiollS

As noted by Dr Powell the TASC classilicatio n helps in defining th e lesio ns appropriately or enshydovascubr (((aonem with ((eJ[llleIlt oTASC A and U lesi o ns bein g ass o ci ~Hed w ith exce llent results while treatment o f C md D le io ns is lsso ciatcd with poorer outcomes Use ofstent grafts and femor)l e11shyd3rterectolllY as descr ibed by the autho r lll ay result in improved outco llles after the treat llle Ilt o fTASC C and D lesio ns but it is important to rem c mber that the result prese nted to suppOrt that approach by ])r Powell are based on retrospectiw review of a relshy1tivciy SIllJIl number of patients and thus 11C subject to sigllificlllt selec tion bi lS This approach 11101Y be

ShOWll to improvt results suffic iently to make iliac stellt grafting for JitTuse aortoiljac occlusive di sease a fIrst- lint therapy bm that remains to be deter shymill cd Similarly dth ough Dr Powells prefe rence for primary tentill g of all iliac lesions is w idel y held by 111011) intcrvelltiollali sts data fro lll a DLJrch randOlllizeci trial of primary iliac sre ntill g verSllS

s el e ctiv~ stenting for hen10dynaluic tlly inJdeq ultt results after ang ioplast y al o ne showed no dilfer shyence in immediate and lo ng-ter m OLltcomes Il iac angiopbsty is now the first lille of therapy for aorshytoi iiar artery occlusive Ji scase and m ost pati cHts call be treatcd with lllilllm1 risks and good results

OverIL this is all cdlem chapter describing Lndovascl1lar th erapy of ililtlc arte rial occlusive dis shyease tJat h revoluti onized tr~ltlll~ 11t of this pro bshyICIll H ovever as noted above th ere is still much to be learned

J VIS

r Embolectomy196 THOMAS) FOGARTY BRADLEY B HILLAND

CHRISTOPHER K ZARINS Jshy

1 H arvey is credited with the u n of the ischemic consequences l rterial occlusion almost 3 censhysed before the first successful arshy

_~bolectomy was perfo rmed by 1911The lack of initial enthusishy

nbolec tomy can be traced to the tality and morbidity associa ted

~ extensive dissec tion required to -lv remove the e mbolus and its -ropagated thrombus as well as l ent lack of clinica l success The reatm ent of acute embolic ar teshy15ion was greatly improved and

_ in 1963 by the introduction of 1 1que of balloon catheter emshy

PHYSIOLOGY - 11 embolus has its roots in the

o rd embolos which means projecshy he embolus dislodges from the urface it is carried through th e

arterial tree until it impacts a site of lumishynal narrowing usually at an arte rial bifurshycation It is the loca tion of the embolic occlusion and the events subsequent to its impacti on that determine the eve ntual vishyability of the dependent structure

When acute embolic occlusion occurs in a major artery a soft coagulum of blood forms in the adjacent proximal and distal arterial segments secondary to stagnant flow Th e occlusive process is thus exshytended as the clot propagates along th e arshyterial tree progressively embarrassing the important collateral pathways (Fig 1) It has long been recognized that the extent of distal thrombotic propagation is the pri shymary determinant of outcome after emshybolic arterial occlusion failure to recognize and remove th e distal thrombus results in incomplete restoration of circulation and possible loss of limb In approximately one third of instan ces distal c irculatory stasis results in the development o f disco ntinushyous distal thro mbosis Backbleeding is an

unreliabl e indicator of distal patency Its presence may be secondary to remaining unobstructed collateral vessels Full-length passage of the embolectomy ca theter is th e only means of ensuring complete clot reshymoval (Fig 2)

Although most clinically significant emboli originate within th e hea rt the vessels of the lower limbs are the site of impac tion in approximately 90 of the surgically treatable emboli (Fig 3)The bishyfurcation s of th e aorta and femoral and poplitea l arteries are th e principal sites of impaction Multiple emboli are more common than is generally accepted and in approximately 10 of instances th ey invo lve more than one limb Many sm aller emboli undoubtedly lodge in well-vascushylarized silent arteri al beds and are never re cognized

The tissu es distal to the impacted emshybolus and associated thrombus are deshyprived of adequate oxygenation Because of the sensitivity of peripheral nerve tissue

2092 Part IX Vasc ula r Surgery

Thrombotic Muscle GangrenousImpaction propagation necrosis venous thrombus

Discontinuous Thrombosis

Fig 1 The pathophysi ology of acute embolic arter ial occlusion Ionic flux across the mu scle cell membrane is shown CPK creatine phosphokinase

to ischemia pain and pares th esias a re quickly noted in the affe cted limb C onshytinu ed cellular ischemia leads to anaerobic metabolism with loca l lact ic acidosis and ce ll death accompanied by n erve and muscle necrosis Although local factors determine the ra te of isc hemic damage diagnos is and therapy must be prompt beshycause tissue necrosis m ay occ ur within fi hours and is a frequent occurrence after 12 hours of profound isc hemia

J DIAGNOSIS

The sudden onset of symptoms of pro shyfound limb ischemia sho uld immediately suggest tb e diagnosis of arte rial embolus particularly in a patient with atrial fIbrillashyti o n recent myocardill infarction or abshydominal aortic aneurysm [n more tban 85 of insta nces tbe cl ini cal presentation and associated disease allow differentiation

Continuous Discontinuous thrombus 63 thrombus 37

between embolic occlusion and acut rial tbrombosis This differentiation i

ful in planning tbe su rgi ca l approl ca use addi tion al vasc ular reconstl tecbniques are often required with thrombosis but are ra rely needed I

bolizationThe characteristic cli nicai tation of acute embolic occlusion i an abrupt onset w itho ut warning it _ of th e embolic syndrome of pain pt ness pallo r paresthesias and parak~ o

The initial exami nat ion should c th e presence and amplitude of aU pulsations in the umb The colo r aI

pera ture of th e limb the presenc sence of sensation and propriocepr tbe level of moto r movement are r and related to tbe tim e of onset of addition arterial blood flow shou l eval uated and recorded by Dopp nique In most instances tbe diagJ be confirmed and the site of imparshybe lo calized by history and physic natio n alone It is an almost uniw ing that the site of embolic occlusio major arterial bifurcation il11 Ill ~ above the absent arter ial pulsation

Patie nts wi th suspected ren al ceral embolism should undergo shyative arteriography Arteriograr also be helpful in delinea ting the morphology if no ninvasive stue gest extensive atherosclerotic il1oh Time-consurning studies that mltl compro mise the isc hemic limb should be avo ided

Because virtually all patients 1

terial embolism have associated Cd

orous back bleeding could occur if the proximal clot alone were removed on the left side ease a careful evalu atio n of ca rei Fig 2 Disconti nu o us distal clot propaga tion occurs in approximately one third of instancesVigshy

Brachial 28

Aneurysm

Arteriosclerotic stenosis with secondary thrombosis

A B

Irce (A) and distribution (B) of clinically significant arterial emboli

cd simultaneously with the l5Cldar examjnation It sho uld

- ed that th e primary objecshy-1- a pati en t with an ischemic

m e his or her su rvival In few (he aphorism regarding surshy

bull dnd patien t mortality more --~ Il in arterial embolism

[ OPERATIVE GEMENT

ion of immediate anticoagshy- ~l and earl y ope rative emshy

(he most so und and most ~ed method of treatment of - arterial occlusion To preshy~ propagation of the thrombus

- n bolization anticoagulation - lI11mediately instituted with

~ of 5000 units of heparin _lo usly and maintained by a enous heparin infusion sufshy-IJIl g the partial thromboplasshy

- roximately 20 to 25 tim es - (ter initial anticoagulation

-~e care should be directed ~_ ving myocardial performshy

patien ts an intensive care middot-jch appropriate monitoring ( intervention is warra nted lte nt survival the salvage of a ( cional limb is the goal of --1I 11 t Although it can be

ea rly th at longer occlusion iJted with more profound

~ lua the absolute ischemjc

interval per se has been shown to be an unreliable determinant of the potential for limb salvage and a poor criterion for opershyability The only essential factors in limb salvage remain th e condition of the limb before the operation and the ab ility to perform a successful embol ectomy The absence of both sensation and m otor acshytivity in association with a swollen doughy muscle mass contraindicates an attempt at embolectomy in an otherwise viable pashytient Even in the presence of advanced dista l ischemia however a lowe r level of amputation may be achieved after a sucshycessful embolectomy

After th e judicious co mplet ion of the aforementioned procedures the patient is taken to the operating room Although loshycal anesthesia is frequently used an anesshythesiologist must be present to monitor closely the ofte n elderly critically ill patient and administer general anesthesia if a more extensive surgical approach is required For this eventuality a full surgical preparation of the field from th e nipple line to the toes is performed allowing exploratio n of th e other limb or the abdomen should it beshycome necessa ry

Inslmmentation

Although th e Fogarty embolectomy catheter has undergone minor modifIcashytion to improve its effectiven ess and safety since its introduction in 1961 the general concept rem ains unchanged The emshybolectomy catheter consists of a hollow pliable ca theter body with a soft distensible

Chapter 196 Embolectomy 2093

balloon placed at its tip It is available in grad uated sizes from No2 to 7 French A syringe fitting at the proximal end allows controlled inflation and def1ation of the balloo n A soft rounded extension of the balloon material covers the tip of th e stiffer ca theter body Th e smaller ca theters are constructed with a flexibl e spring tip to further reduce the chance of intimal damage or arteri al perfora tion Each size of catheter has been ca librated for an opshytimallevel of balloon distention and that reco mmended volume should not be exshyceeded Overinf1ation does not produce a considerable increase in balloon diameshyter but results in decreased fluid displaceshyment wi thin the ballo on and in creased pressure on an d possible damage to the vessel wall

SaLne solution is the routine balloon inshyElation medium however air is more approshypriately used with the No2 and 3 French ca theters Because air is considerably more compressible than saline solution the balshyloon exerts less force on and is less likely to cause damage to the smaller vessels In addishytion the operator has considerably more control over balloon size because the delay between syringe manipulation and balloon response is minimized

The general aspects of embolectomy catheter manipulation are as follows The instrument is threaded into the artery and passed either through the thrombus or beshytween the thrombus and the vessel wall It is virtually impossible to push an embolus and its associated thrombus with a deflated catheter Although th e pliability of the ca theter tip is designed to facilitate safe proximal or distal passage forceful probing at sites of nonemboLc obstruction can lead to vessel wall injury and resultant arterial occlusion Embolic material and associa ted thrombus do not in themselves offer signifshyicant resistance to catheter advancement

Even in the absence of large amounts of atherosclerotic plaque passage o f th e instrument may be hindered by angulashytion at bifurcations o r by vessel tortuosity Maneuvers often helpful in these circumshystan ces include prefornung the tip of the catheter at an angle a step that is followed by the rotation of the ca theter at the site of obstruction the simultaneous introducshytion of more than one catheter and the progressive flexion of a nearby joint to alshyter th e advancemen t an gle of th e catheter tip An additional techniqu e particularly useful in passing an eccentric plague inshyvolves gentle balJoon inflation at th e site of the difficult catheter passage followed by gentle adva ncement of the catheter during def1ation This man euver brings

Part IX Vascular Surgery 2094

Fig 4 The technique of Fogarry catheter embolectomy with catheter insertion in the distal vessel

the catheter tip away from the wall and toward the residual lumen

When the appropriately sized catheter has been gently advanced as far as possishyble the balloon is progressively inflated while the catheter is being slowly withshydrawn (Fig 4) The surgeon who withshydraws the catheter should also control balshyloon size because the feel that the surgeon gains in this manner is an imporshytant factor in ensuring complete clot reshytrieval and preventing vessel damage When traction on the catheter appears excessive it is imperative to allow suffishycient balloon deflation to permit smooth passage across segments of atherosclerotic luminal narrowing As catheter withshydrawal continues additional fluid should be added as needed to maintain gentle wall contact The catheter is so conshystructed that inflation takes place initially only in a 1-cm area in the center of the balloon jacket The increased resistance

engendered by mild atherosclerotic plaque causes displacement of tluid to the uninflated portion of the balloon allowshying the catheter to glide across areas of mild constriction without causing undue trauma to the wall (Fig 5)

) SURGICAL TECIIN1Q UE ---

ExLradion of Aortic and Iliac Emholi

In the surgical management of an aortic embolus bilateral vertical groin incisions are made and the common superficial and deep femoral (profunda femoris) arshyteries are isolated and looped with Silastic (polymeric silicone) tapes In the presshyence of atherosclerotic involvement of the femoral artery it is suggested that Fogarty-Hydragrip vascular clamps be used to allow atraumatic vessel occlusion

Fig 6 The Fogarry-H i- allows atraumatic vessel ~_ rated jaw is fluid-filled

particularly with catheter in place T il _ pressible fluid-fille d _c jaws allowing appro~ shysurfaces without ca (Fig 6)

After placemem shythe femoral artery he _shybe made in the co n~ just proximal to its bi strumentation of [he _ femoral orifices unc~~ vessel should be care1 location of plaque ~

though it IS preferabe shyverse arteriotomy a rowing during clo$u-_ location of plaque L

or even vertical inc closure ifluminal n l~shy

pnmary repaIr one s perform vein patch a _

We prefer to car [~

ration initially (Fig shysize of the vessel a shy

Fig 5 Fluid displacement in the specially des igned balloon maintains wall contact w hil e minishy catheter is gently inshymizing the potential for vessel wall injury perficial femoral ar

middot -llque of Fogarty catheter arterial - of the iliofemoral system

inflated until the arterial wall J d resistance The catheter is

-ed with the balloon in the in-on Initially only a small quanshy~ IS required Additional fluid is e catheter is extracted and the he vessel increases resistance during the introducshy

e ~ t heter gentle probing usually _ rrument to passThe catheter

Jtstally without extreme force -=1 attempts to force the catheter

omplications During the exshy-ic catheter only mild traction is

emove embolic material or a - 1 The deep femoral artery is

- 1 slllular manner but the No3 - ca theter in this vessel rarely 1 l a distance of 2S cm Care

en so that the catheter is introshy-1C deep femoral artery and not

-- he large circumflex branches cdrly origin from this vessel If -~ branch is explored it should _ har the catheter can be introshy

-x a short distanceand the No 11 catheter should be used for

ssful exploration of the distal I mL of heparinized solution

of heparin in 250 mL of inshy-0 solution) is injected into the i a the Thru-Lumen embolecshy

r (Baxter Vascular Division _ Jnd the vessels are occluded

clamps A No6 French - catheter is placed in the

common femoral artery and threaded into tne aorta The balloon is inflated with the appropriate amount of fluid and exshytracted in the inflated position During the process of extraction the balloon Can be deflated to accommodate the narrowed vessel The procedure should be repeated if a forceful pulsatile flow is not obtained on the fIrSt passage Significant bleeding even so mewhat pulsatile may occur from the proximal common femoral artery in the presence of partial continued obstrucshytion and repeated passes should be made until one is confident that all obstructing thrombi have been removed To reduce blood loss the embolectomy catheter can be passed through th e jaws of the Fogarty clamp without causing undue trauma or blood loss It is best accomplished by placshying Hydragrips 011 both blades of the clamp Immediately before the balloon portion of the catheter is removed from the ar tery the clamp is relea sed the catheter is removed from the arterial incishysion and the clamp is reapplied After adeshyquate extraction of the clot from one side a similar procedure is performed on the opposite limb Both arteriotomies are closed after ensuring bilateral simultaneous pulsatile flow

It should be mentioned again that the presence of backbleeding is no assurance that distal patency has been established beshycause collateral circulation may result in vigorous backbleeding eve n in the presshyence ofdistal arterial thrombus If the status of the distal arterial tree is uncertain opershyative angiography should be performed

I n the removal of an iliac embolus the incision is made only on the affected side Both limbs are prepared for surgical incishysion because of the small but real possibility of dislodging a high iliac embolus with subsequ ent occlusion of the previously unshyaffected contralateral vessel

E lraction of Femoral and Poplileal Emboli

In ea rly experien ce with emboli below the inguinal ligament incisions were made over what was thought to be the site of embolic occlusion It has been found however that a more satisfactory approach to removal of embo li at the level of the adductor magnus tendon and the popliteal areas is through an incision in the di stal common femoral artery This proximal approach to accessing emboli loshycated at a lower level has several advanshytages It allows exploration of the deep femoral system which can be occluded with additional thrombotic material If

Chapter 196 Embolectomy 2095

the embolus is in the common femoral artery digital pressure proximal to the emshybolus may squeeze the embolus out and reestablish forceful pulsatile flow Even in this circumstance however an embolecshytomy catheter should be passed proxishymally inflated and then withdrawn to exshytract any residual thrombotic material that may be loosely adherent to th e intima Because of the prese nce of discontinuous distal thrombosis in more than one third of the instances of acute proximal embolic occlusion catheters are threaded distally regardless of th e presence or a bsence of backbleeding from the superficial femoral ar tery

Thrombotic material can be extracted from [vo or more branches of the popliteal artery by inserting multiple catheters in the superficial femoral artery The No2 and 3 French catheters should be used for this purpose The first catheter most commonly passes into the peroneal or posterior tibial artery After initial placement of one catheter the leg is placed in a slightly fl exed position and a second catheter is inserted In this manner the second catheter is deshyflected from the obstructed orifice of the previously cannulated vessel and may find its way into an unobstructed channel Exshyamination of the thrombus can provide valuable information about the comshypleteness of clot removal The presence of a sharp cutoff usually indica tes that additional thrombotic material remains whereas a smooth taper indicates adequate clot removal

When thrombus remains in the tibial vessels and efforts to remove it from above prove unsu ccessful a direct approach to the distal popliteal artery is required through a second incision made medially at the knee The distal popliteal artery is exposed and the proximal portions of the anterior and posterior tibial arteries are looped with Silastic tapes (Fig 8) Through a small incishysion in the distal popliteal artery the No2 and 3 French embolectomy catheters should be directly introduced into the anshyterior and posterior tibial arteries respecshytively If these vessels were previously patent and uninvolved in an arterioscleshyrotic process the No2 French ca theter should be passed beyond the ankle Joint The course of the catheter can be felt by placing the fingers over the distribution of the anterior and posterior tibial arteries If the catheter is hindered at the ankle joint it can frequently be passed farther by plantar flexion of the foot

Inability to pass th e No2 French ca theter beyond the ankl e joint in the presence of angiographi c eviden ce of

i

2096 Part IX Vascular Surgery

Adherent Clot Catheter The ACC consists of a No 4 or 6 fl exible catheter body with an adJ ll pitch corkscrew-shaped distal tip ( The corkscrew balloon consists of balloo n membrane covering an Oll

ble that is loosely spiraled around a wire running the length of the cael a control handle at th e proximal lt 1

control handle allows the surgeon just the pitch and diameter corkscrew from completely strai fully spiraled Unlike the conwi Fogarty balloon catheter the AD not inflate Instead the diameter corkscrew-shaped working end catheter is varied by mechanical ref of the mner wire via a knob on th trol handle In this manner the de can be continuously adjusted from profIle No6 French size to a JargeE eter of up to 10 mm

The ACC is used like th e c( tional Fogarty balloon catheter Ari tial exploration with the standal loon catheter the ACC tip is coll al its low-profile position and passe the vessel and beyond the thromb knob on the control handle is tb tra cted until the spiral is enlarged desired diameter th ereby engagi thromboti c materi al within th e stices of th e spiral Subseque m catheter is drawn slowly back ala vessel and the material is rc through the arteriotomy As in th ventional balloon catheter tec hn i diameter of th e spiral can be adju cording to feel in response to rIO within the vessel

The ACCs mechanism of entr of the clot is thus quite differe t that of the conventional balloon c The traditional Fogarty balloon is distal to the material and essential the thrombus alo ng the vessel to arteriotomy In contrast the co r entraps thromboti c material - itmiddot spaces of the spiral providing alar of contact to grip and remove rl

_

r--

Fig 8 Technique of po pliteotibial exploration

obstru ction beyond this point necessitates direct exposure of the anterior and posteshyrior tibial arteries at the ankle By direct manipulation of the vessel combined with gentle simultaneous probing of the catheter from the proximal end one is frequently able to pass the catheter beyond the point of obstruction without the necessity of an arteriotomy If an arteriotomy at the ankle level in either of these vessels is required an incision only large enough to allow the inshytroduction of the No2 French catheter is made into the vessel The catheter is threaded distally inflated and withdrawn in the inflated condition This maneuver freshyquently brings the thrombotic material above the small arteriotomy Additional atshytempts to extract this thrombotic material should be made by introducing a No2 or 3 French catheter into either the anterior or posterior vessels at the level of the popliteal arteriotomy This maneuver avoids the neshycessity of enlarging the arteriotomy at the ankle joint and decreases the possibility of reocclusion After removal of the thromshybotic material copious irrigation of the disshytal artenal system should be ca rried out with a heparinized solution

Extraction of Upper-Limb Emboli

The technique for management of emshyboli to the upper limb is identical to that described for the lower limb Proximal subshyclavian artery emboli can be routinely reshymoved under local anesthesia by retrograde

extraction from a brachial arteriotomy It should always b e borne in mind howshyever that if the embolus appears to reside in proximity to the origin of the cranial vessels fragmentation of the embolus may occur during manipulation resultshying in central nervous system emboli and ischemia

Removal of Mature Adherent Thrombotic Material

As the patient population becomes inshycreasingly elderly and more prone to athshyerosclerosis mature adherent thrombotic lesions are becoming more prevalent The standard fluid-filled Fogarty balloon catheter is quite efficient for removing large amounts of soft fresh thrombus but it is limi ted in its ability to remove more adherent material such as olde r clot of thrombotic origin To meet this need two new tools have been designed an adhershyent clot cathete r (ACC) and a graft thrombec tomy catheter (GTC)

Fig 9 The adherent clot ca thete r in its extended position (top) during catherer introdu in contracted position (bottom) during retrieval of adherent material in native vessel

_ ~ rhe ad he rent c10r carherer rhe gra fr rhrombecromy catherer can be ldj usted so that -r in the low-profile exrended confIguration becomes larger allowi ng more aggressive l uherem clot from synrheric grafrs

u ex-covered edges of the fully corkscrew provide more of a

- edge than an inflated balloon this catheter 1110re capable of material adh ered to th e inside eI wall

-CC is designed for use in both _ ltds and synthetic grafts in situshy

( require a slightly more aggresshy-)Jch to retrieve a particularly - clot embolus or fl ap that has - mova l by a co nve ntiona l balshy ter The catheter system is apshy

- tar vessels whose diamete rs m 4 to 10 mm One particular n of this ca th ete r IS the

~~ [Ql11y of arteriovenous fistula _--J tts in which a more th orough _[ thrombotic material IS often a

bull Jlrernative to graft revision o r _cement

- 1rombectomy Catheter ruction of the GTC designed uy in syntheti c grafts is si milar to

-_ CC It consists of ei ther a N o -~ Ilch fl ex ibl e catheter body a

lg adju stable-diame ter sp iralshyOal region with a flex ible tip 101 handle (Fig 10) Unlike th e ever the double-helix-wire reshy

- GTC is shorter and sturdier -~ are not covered by latex Al so - operates over a larger range of - he exposed spiral wires collapse na tely 4 111m and can expand to ~ 16 mm - TC is a more agg res sive tool CC In use the spiral region is he low-p rofile posit ion and the

bull i t is passed along th e graft to

cction The sliding knob on the then re tracted to expand th e

[ltby engaging th e wires with

th e material to be removed The wires provide a thin circumferential line of contact with the luminal wall As with the o ther clot-retrieval ca th ete rs the pulling force can be continuously varied by adshyjustin g th e pitch of the sp iral wire dmshying middotwi thdrawal After the ca theter is reshym oved from the gra ft segments of thrombotic material are removed fro m within the sp iral regIO ns Th e device is then reinse rted and the pro cess is reshypeated until no additional residual mateshyrial can be removed As shown in Figure 11 a co nsid e rabl e volume of material call be removed by thi s method Thi s catheter is capabl C of removing all intrashyluminal m ate ri al from th e graft exposshying the bare origina l surfac e

Chapter 196 Embolecromy 2097

Improved Arce s Thru-Lumen Embolectomy Catheter

The development of th e Thru-Lumen emshybolectomy catheter has provided additional op ti ons for embolectomy and thrombecshytomy The catheter is similar to a convenshytional Foga rty embolectomy catheter ex cep t that an ad ditional lumen run s through its ce nter A V-connec to r at the proximal end has two ex tensions that alshylow access to th e tvo lumens One lumen is used for balloon inflation and the other is used for infusio n of fluids or guidewire access (Fig 12)

Whereas the stand ard Fogarty balloon ca th eter was design ed in an era in whi ch th ere was limited angiographic capability in the operating room the Thru-Lumen emb olectomy catheter has been designed to take adva ntage of the wide availab ility o f fluoroscopy in todays ope rating ro0111S The Thru-Lumen ca theter can be passed over a gLlld ewire which ca n be mon itored fluoro scopically In si tu ations of diffIcult access when a standard Fogashyrty balloon ca th e ter cannot be passed through thC obstruction a tapered Van Andel catheter can be substituted A guidewi re ca n then be placed through the Van Andel catheter Subsequently the Van An del ca th e ter ca n be removed and reshyplaced with a Thru-Lumen embolectomy ca theter Th e Thru-Lumell catheter can then be inflat ed and used for embolecshytomy in its normal manner

Fig 11 Th e grlft thrombectomy catheter is shown wirh residual clot which could not be reshymoved adequately w ith a balloon cathe ter that has been ex tracted fiom a syn th etic gra ft

2098 Part IX Vascular Surgery

Fig 12 The Tl1rLJ-LLJmen embolectomy catheter may be used to instill solutions (cop) or pass guidewires (bottom)

in electrolytes and acid-base balarlC occu r The sudden return of acidotic with a high potassium content Cd

in adverse effects on myocardial fu The necessity of using bufferin and antiarrhythmic agents shoul i ticipated at the time of clamp re and electrolyte levels should be shymeasured in the postoperative pe ~

the presence of ischemic muscle shysis restoration of limb flow may [~

the introduction of myoglobin t systemic c irculation Unless cle the kidney precipitation of myo~

the tubules may severely im pashyfunction

Myoglobinuria may be rec of1L= the absence of red blood cells in on microscopic examination ~

with a positive urinary guaiac [c ~ globinuria is suspected the patie be treated with intravenous hv middot r~_

ficient to establish a diuresis of hour as measured by indwelli r ~ catheter ou tput shy

The Thru-Lumen embolectomy catheter also can be used to deliver contrast material to monitor poundluoroscopically the clot reshymoval process without exchanging the embolectomy catheter for an angiographic catheterThe inflated balloon can also act as an occlusion device to facilitate distal localshyized injection of poundluids such as contrast media heparin or lytic agents

Management of Advanced Ischemia

Patients who have relatively far-advanced peripheral ischemia represent more diffishycult problems The recognition and treatshyment of complications that occur as a reshysult of advanced tissue ischemia lessen mortality and morbidity

The finding of acute venous thromboshysis in the presence of acute arterial occlushysion was fmt recognized in 1964 It was found that 27 of patients who had susshytained an acute arterial occlusion also had simultaneous venous occlusion and veshynous thrombectomy was required in 8 of these patients To identify venous thromshybosis a clamp is placed before arterial exshyploration to occlude venous return from the extremity After arterial embolectomy and establishment of the arterial circulashytion a second venous clamp is placed proximal to the first venous clamp and a venotomy is made between th e pair of

clamps The foot is poundlexed and extended a number of times to raise the resting veshynous pressure in the leg On release of the distal venous clamp any retained thrombus is ejected from the circulation If necessary additional venous thrombus is removed with a venous thrombectomy catheter

Swelling of a previously ischemic limb in which arterial continuity has been reestablished demands attention and is freshyquently observed in patients with obvious pregangrenous changes before the operashytion Capillary damage that results in poundluid exudation into ischemic tissue is a factor in this swelling which is often aggravated by venous outflow obstruction Fa sshyciotomy for control of massive edema has been required in 10 of the patients If manometric measurement of interstitial pressure is used any pressure exceeding 30 mm Hg is regarded as an indication for fasciotomy Failure to decompress the limb may result in compression of the arshyterial inflow and reocclusionInitial fascial decompression should be carried out through small skin incisions (a subcutashyneous fasciotomy) If immediate imshyprovement is not obtained by this limited fa sc iotomy the skin incisions should be extended and the deeper fascial compartshyments should be widely opened

Immediately after restoration of arterial continuity in limbs that present with adshyvan ced ischemia considerable alterations

POSTOPERATIVE ~ MANAGEMElT

In almost all instances anci co with intravenous heparin shou lc _ stituted 6 to 12 hours after em Although this results in wour in a few patients the likelihoo~ rent embolization is lesser ec

r ~ --

_

c

_

~_ shy

~

==

propagation of thrombus is small vessels not direcely c le ai~

embolectomy catheter Hepari ulation is continued until the fully ambulatory Oral va rfar i~ lation is also initiated 5 to I intravenous heparin adminis r co ntinued The warfarin is co definitely unless the primlr source has been defi nitive - Early ambulation is encour ce longed sitting is prohibite d~ early postoperative per iod ( effort should be expended in to un co ver a potentiall source of the embolus This 1shy

may includ e electrocardlo ~_shy

roentgenography real-time ushy

scanning cardiac radionu ci i echocardiography abdominal and angiographic evaluatio r - and thoracic and abdominal Jtshy

Secondmy Proceuure

In our series 28 of patient went balloon embolectomy to~ shy

needed additi onal surgical proshy--h ese procedures included repeat _omy balloon angioplasty or forshy la r reco nstructi on and cardiac ~ Initial imp rovement followed

- 1rati on in a postoperative limb

-

-~ ehrombos is and surgical exploshy- h repeat thrombectomy is indishy_nIb that shows marginal viability lbectomy suggests severe undershy-~ lI ive disease that must be adshye have found the combination 1 thrombec tomy and adjunctive

-Jeive balloon angioplas ty use ful 2 acute arterial occlusion caused

-_xisting atheroscl eroti c involve shylI calJy significant lesions can be -middot ieh littl e additional operative

_ middotasc ular reconstruction is warshy hould be performed early A ence of limb loss and mortality I es subsequent episodes of

SIS

orrecti on of ca rdiac sources of ~ is recommended We have pershy_ro nary artery bypass grafts aorshy- I valve replacement ventri cular

- ctomy and repair of a ventricushyJefec t resulting from infarctio n

-~ surgical balloon embo lectomy - J embolism O ur ea rly secondshydures have been performed

j signifi cant 10crease 10 major or death

eOus Thromhectomy and _lg Technologies

1~ i n g nature of vascular patholshyhe trend toward minimally inshy

~ gery have created an impetus echnologies and strategies for ieh th ro mboti c arterial occlushy

sions In recent years investi gators have p roduced a l11ultitude of pe rcutaneous thrombectomy devices and te chniques fo r clo t removal witho ut ope n surge ry An extensive review of th ese technoloshyg ies autho red by Sharafuddin and Hicks is available These new tre atm ent modali shyties include

1 Percutaneo us aspiratio n th ro mbecshyto my by whi ch suc tion is applied through a large lumen cath eter to reshymove thromboemboli c material

2 Pull-back th ro mbec tomy and clot trapping by w hich thro mbus is reshytrieved with a ball oon or basket into a trapping device for safe removal

3 Ro tati o nal and hydrauli c recirculation thrombectomy which involves the mishycrofragmentatio n of thrombus by the action of a high shea r stress hydrodyshynamic vortex

4 Fluid jets without hydrodynamic reci rshyculation to break up clo t

S T hrombectomy achi eved by the actio n of ultrasound la ser and radiofrequency energy to lyse thrombus

A new and promising approach is embodshyied in a unique device the TRELLIS that traps the fresh thromboti c occl usio n beshytween two balloons R otational mixing by this catheter system and lytic infusion intershyfaces with the fra gmented th rombus This pharmacomechanical combination enables targeted drug del ive ry and dissol ution of thrombus

N ew thrombectomy devic es and techniqu es will co ntinu e to emerge Each new technology must be carefully studi ed an d compared with standard thrombec tomy techniques to determine its clini ca l utility and to help defin e its role in the trea tment of thrombo tic arteshyrial occlusions

Chapter 196 Embolectomy 2099

SUGGESTED READING

Bar-EI Y Ada r R Sc hn eiderman Y et 11 Echocard iography in the dia gnostic assessshymen t o f periph eral arter ia l emb olization Am Hearl) 1990 119 1090

Berni GA Ba ndyk O F Zi erler RE et a Strepshytokinase treatment o f acute arterial occlushysion Ann Su rg 1983198 185

Foga rty TJ T he techniqu e o f th rombectomy and other uses of the Fogarty ca theter In Ruth erfo rd RB ed vaswlar su rgery Philade lphiaWB Sa unders 1977

Fogar ty TJ C hin A Shoor PM et a Adju nc shytive intraoperati ve arterial dilat tion simp]j shyfi ed in strumentation technique A reh Surg 1981 1 16 1391

Fogarty TJ Daily PO Shumwy NE et al Expeshyri ence with balloon catheter technique for arshyter ial embolectomy Am) Surg 1971 122231

Fogarty TJ H errmann GD N ew techniques for clo t extraction and managing acute thromshyboembolic limb ischemia lnVeith FJed Critshyical problems in vaswlar slrgery vol 3 St Louis Quali ty Medical Pub]jshers 1991

Hill B Fogarty TJThe use of the Fogarty catheter in 1998 Cardiovasc StIIg 1999 7(3)273

Sharafuddi n MJ Hicks ME C unent statu s of percutaneous mec hanical thrombectomy Part III Present and future appli ca tio ns) Vase lnlerv RadioI199 89(2) 209

Sharafuddin MJ Hicks ME C mren t status of percutane ous mechanic I thrombe ctomy Part II D evices and mec hanism of ac tion) vase lnterv RadioI19989(Pt 1) 15

Sharafuddin MJ Hicks ME C urrent status of percutaneo us mec hani ca l thrombectomy P n I General principles ) vase It1lerv Radiol 19978(6) 91l

Tawes RL Jr Beare JP Scribner R G et alV lue of postopera tive heparin therapy in per iphshye ral arterial th romboe mbolism Am) Surg 19831 46 21 3

Tawes RL Jr H arris EJ Brow n WG et alArteshyrial thromboembolism A 20-yea r perspec shytive Arch Su rg 1985 120595

SaracTp HiIleman OArko FR et al Clinical and economic evaluation of the trellis thrombecshytomy device for arterial occlusions prelimishynary analysis vase Surg 200439(3) 556

E DITORS COMMENT

__- Hill and Zarins have provided a wry trspectiv( 011 arterial embolism and

liong with an up-to-date disc ussion of -Jllagement I would first likegt to make a

between the picture of acute embolic ocshy- 1 previous normal artery and some of the Jlscussed in this chapte r As the autho rs

_ l is usually possible based on clinical presshyione to make the distincti on between

-~a l occlusion and what th ey describe as --ll1bosis In my view thjs distinction is

important If the diagn osis of ac ute eIll shy151 0n ofa previously norIllal artery can be

made based on c1 iniCJI presentation it is Ot adva ntage of the patient Under those

c ircumstances time is o f the csse-Ilee md by making the diagnosis on the clinica l picture preciolls time can be saved by getting the patient promptly to the ope(ltshying room with the expectation that the embolism and propagated thro mbus can be ~as il y removed l ith restoration of no rmal or near-normal arterial perfu shysion If however the patient is taken to the operating room w ith a dlJgnosis of Kute arterial occlusion but the underlying problem is arterial thrombosis supershyimposed on pre-existin g pcripheral vscular disease 111ltl l1 agelllenr in the operJrin g roonl can become much more complex and needlessly compromised because of inadequate information

T he questio n therefore is how does one make this distinction Lets take the Illost conlillOIl exanlshy

pie of cute occlusion of the superficial femoral ar shytery This occurs becausc an cmboli sm fi-om the hea rt has lodged at the common femoral bi fllrcashyti o n Because th e superfi cial femoral arte ry was previo llsly perfectly no rmal there is no collateral circulation and therefore the limb below the knee is iIllllleciilteiy extremely ischenlic This results in the classic picture of severe pain pallor (110 capilshylo ry filling) paresth esias and paralysis Such limbs are cadaveric in appearance and there is no ques shytio n about the no nviabil ity of the limb O ften there is a po unding waterhammer pulse palpable in the comlllon femo ral artery U nder those cirshyClIIl1stances and with th e an cillary ITlanagcll1ellt as described by the 3utho rs the patient may be taken

(co l1tin ue d)

Brachial 28

Aneurysm

Arteriosclerotic stenosis with secondary thrombosis

A B

Irce (A) and distribution (B) of clinically significant arterial emboli

cd simultaneously with the l5Cldar examjnation It sho uld

- ed that th e primary objecshy-1- a pati en t with an ischemic

m e his or her su rvival In few (he aphorism regarding surshy

bull dnd patien t mortality more --~ Il in arterial embolism

[ OPERATIVE GEMENT

ion of immediate anticoagshy- ~l and earl y ope rative emshy

(he most so und and most ~ed method of treatment of - arterial occlusion To preshy~ propagation of the thrombus

- n bolization anticoagulation - lI11mediately instituted with

~ of 5000 units of heparin _lo usly and maintained by a enous heparin infusion sufshy-IJIl g the partial thromboplasshy

- roximately 20 to 25 tim es - (ter initial anticoagulation

-~e care should be directed ~_ ving myocardial performshy

patien ts an intensive care middot-jch appropriate monitoring ( intervention is warra nted lte nt survival the salvage of a ( cional limb is the goal of --1I 11 t Although it can be

ea rly th at longer occlusion iJted with more profound

~ lua the absolute ischemjc

interval per se has been shown to be an unreliable determinant of the potential for limb salvage and a poor criterion for opershyability The only essential factors in limb salvage remain th e condition of the limb before the operation and the ab ility to perform a successful embol ectomy The absence of both sensation and m otor acshytivity in association with a swollen doughy muscle mass contraindicates an attempt at embolectomy in an otherwise viable pashytient Even in the presence of advanced dista l ischemia however a lowe r level of amputation may be achieved after a sucshycessful embolectomy

After th e judicious co mplet ion of the aforementioned procedures the patient is taken to the operating room Although loshycal anesthesia is frequently used an anesshythesiologist must be present to monitor closely the ofte n elderly critically ill patient and administer general anesthesia if a more extensive surgical approach is required For this eventuality a full surgical preparation of the field from th e nipple line to the toes is performed allowing exploratio n of th e other limb or the abdomen should it beshycome necessa ry

Inslmmentation

Although th e Fogarty embolectomy catheter has undergone minor modifIcashytion to improve its effectiven ess and safety since its introduction in 1961 the general concept rem ains unchanged The emshybolectomy catheter consists of a hollow pliable ca theter body with a soft distensible

Chapter 196 Embolectomy 2093

balloon placed at its tip It is available in grad uated sizes from No2 to 7 French A syringe fitting at the proximal end allows controlled inflation and def1ation of the balloo n A soft rounded extension of the balloon material covers the tip of th e stiffer ca theter body Th e smaller ca theters are constructed with a flexibl e spring tip to further reduce the chance of intimal damage or arteri al perfora tion Each size of catheter has been ca librated for an opshytimallevel of balloon distention and that reco mmended volume should not be exshyceeded Overinf1ation does not produce a considerable increase in balloon diameshyter but results in decreased fluid displaceshyment wi thin the ballo on and in creased pressure on an d possible damage to the vessel wall

SaLne solution is the routine balloon inshyElation medium however air is more approshypriately used with the No2 and 3 French ca theters Because air is considerably more compressible than saline solution the balshyloon exerts less force on and is less likely to cause damage to the smaller vessels In addishytion the operator has considerably more control over balloon size because the delay between syringe manipulation and balloon response is minimized

The general aspects of embolectomy catheter manipulation are as follows The instrument is threaded into the artery and passed either through the thrombus or beshytween the thrombus and the vessel wall It is virtually impossible to push an embolus and its associated thrombus with a deflated catheter Although th e pliability of the ca theter tip is designed to facilitate safe proximal or distal passage forceful probing at sites of nonemboLc obstruction can lead to vessel wall injury and resultant arterial occlusion Embolic material and associa ted thrombus do not in themselves offer signifshyicant resistance to catheter advancement

Even in the absence of large amounts of atherosclerotic plaque passage o f th e instrument may be hindered by angulashytion at bifurcations o r by vessel tortuosity Maneuvers often helpful in these circumshystan ces include prefornung the tip of the catheter at an angle a step that is followed by the rotation of the ca theter at the site of obstruction the simultaneous introducshytion of more than one catheter and the progressive flexion of a nearby joint to alshyter th e advancemen t an gle of th e catheter tip An additional techniqu e particularly useful in passing an eccentric plague inshyvolves gentle balJoon inflation at th e site of the difficult catheter passage followed by gentle adva ncement of the catheter during def1ation This man euver brings

Part IX Vascular Surgery 2094

Fig 4 The technique of Fogarry catheter embolectomy with catheter insertion in the distal vessel

the catheter tip away from the wall and toward the residual lumen

When the appropriately sized catheter has been gently advanced as far as possishyble the balloon is progressively inflated while the catheter is being slowly withshydrawn (Fig 4) The surgeon who withshydraws the catheter should also control balshyloon size because the feel that the surgeon gains in this manner is an imporshytant factor in ensuring complete clot reshytrieval and preventing vessel damage When traction on the catheter appears excessive it is imperative to allow suffishycient balloon deflation to permit smooth passage across segments of atherosclerotic luminal narrowing As catheter withshydrawal continues additional fluid should be added as needed to maintain gentle wall contact The catheter is so conshystructed that inflation takes place initially only in a 1-cm area in the center of the balloon jacket The increased resistance

engendered by mild atherosclerotic plaque causes displacement of tluid to the uninflated portion of the balloon allowshying the catheter to glide across areas of mild constriction without causing undue trauma to the wall (Fig 5)

) SURGICAL TECIIN1Q UE ---

ExLradion of Aortic and Iliac Emholi

In the surgical management of an aortic embolus bilateral vertical groin incisions are made and the common superficial and deep femoral (profunda femoris) arshyteries are isolated and looped with Silastic (polymeric silicone) tapes In the presshyence of atherosclerotic involvement of the femoral artery it is suggested that Fogarty-Hydragrip vascular clamps be used to allow atraumatic vessel occlusion

Fig 6 The Fogarry-H i- allows atraumatic vessel ~_ rated jaw is fluid-filled

particularly with catheter in place T il _ pressible fluid-fille d _c jaws allowing appro~ shysurfaces without ca (Fig 6)

After placemem shythe femoral artery he _shybe made in the co n~ just proximal to its bi strumentation of [he _ femoral orifices unc~~ vessel should be care1 location of plaque ~

though it IS preferabe shyverse arteriotomy a rowing during clo$u-_ location of plaque L

or even vertical inc closure ifluminal n l~shy

pnmary repaIr one s perform vein patch a _

We prefer to car [~

ration initially (Fig shysize of the vessel a shy

Fig 5 Fluid displacement in the specially des igned balloon maintains wall contact w hil e minishy catheter is gently inshymizing the potential for vessel wall injury perficial femoral ar

middot -llque of Fogarty catheter arterial - of the iliofemoral system

inflated until the arterial wall J d resistance The catheter is

-ed with the balloon in the in-on Initially only a small quanshy~ IS required Additional fluid is e catheter is extracted and the he vessel increases resistance during the introducshy

e ~ t heter gentle probing usually _ rrument to passThe catheter

Jtstally without extreme force -=1 attempts to force the catheter

omplications During the exshy-ic catheter only mild traction is

emove embolic material or a - 1 The deep femoral artery is

- 1 slllular manner but the No3 - ca theter in this vessel rarely 1 l a distance of 2S cm Care

en so that the catheter is introshy-1C deep femoral artery and not

-- he large circumflex branches cdrly origin from this vessel If -~ branch is explored it should _ har the catheter can be introshy

-x a short distanceand the No 11 catheter should be used for

ssful exploration of the distal I mL of heparinized solution

of heparin in 250 mL of inshy-0 solution) is injected into the i a the Thru-Lumen embolecshy

r (Baxter Vascular Division _ Jnd the vessels are occluded

clamps A No6 French - catheter is placed in the

common femoral artery and threaded into tne aorta The balloon is inflated with the appropriate amount of fluid and exshytracted in the inflated position During the process of extraction the balloon Can be deflated to accommodate the narrowed vessel The procedure should be repeated if a forceful pulsatile flow is not obtained on the fIrSt passage Significant bleeding even so mewhat pulsatile may occur from the proximal common femoral artery in the presence of partial continued obstrucshytion and repeated passes should be made until one is confident that all obstructing thrombi have been removed To reduce blood loss the embolectomy catheter can be passed through th e jaws of the Fogarty clamp without causing undue trauma or blood loss It is best accomplished by placshying Hydragrips 011 both blades of the clamp Immediately before the balloon portion of the catheter is removed from the ar tery the clamp is relea sed the catheter is removed from the arterial incishysion and the clamp is reapplied After adeshyquate extraction of the clot from one side a similar procedure is performed on the opposite limb Both arteriotomies are closed after ensuring bilateral simultaneous pulsatile flow

It should be mentioned again that the presence of backbleeding is no assurance that distal patency has been established beshycause collateral circulation may result in vigorous backbleeding eve n in the presshyence ofdistal arterial thrombus If the status of the distal arterial tree is uncertain opershyative angiography should be performed

I n the removal of an iliac embolus the incision is made only on the affected side Both limbs are prepared for surgical incishysion because of the small but real possibility of dislodging a high iliac embolus with subsequ ent occlusion of the previously unshyaffected contralateral vessel

E lraction of Femoral and Poplileal Emboli

In ea rly experien ce with emboli below the inguinal ligament incisions were made over what was thought to be the site of embolic occlusion It has been found however that a more satisfactory approach to removal of embo li at the level of the adductor magnus tendon and the popliteal areas is through an incision in the di stal common femoral artery This proximal approach to accessing emboli loshycated at a lower level has several advanshytages It allows exploration of the deep femoral system which can be occluded with additional thrombotic material If

Chapter 196 Embolectomy 2095

the embolus is in the common femoral artery digital pressure proximal to the emshybolus may squeeze the embolus out and reestablish forceful pulsatile flow Even in this circumstance however an embolecshytomy catheter should be passed proxishymally inflated and then withdrawn to exshytract any residual thrombotic material that may be loosely adherent to th e intima Because of the prese nce of discontinuous distal thrombosis in more than one third of the instances of acute proximal embolic occlusion catheters are threaded distally regardless of th e presence or a bsence of backbleeding from the superficial femoral ar tery

Thrombotic material can be extracted from [vo or more branches of the popliteal artery by inserting multiple catheters in the superficial femoral artery The No2 and 3 French catheters should be used for this purpose The first catheter most commonly passes into the peroneal or posterior tibial artery After initial placement of one catheter the leg is placed in a slightly fl exed position and a second catheter is inserted In this manner the second catheter is deshyflected from the obstructed orifice of the previously cannulated vessel and may find its way into an unobstructed channel Exshyamination of the thrombus can provide valuable information about the comshypleteness of clot removal The presence of a sharp cutoff usually indica tes that additional thrombotic material remains whereas a smooth taper indicates adequate clot removal

When thrombus remains in the tibial vessels and efforts to remove it from above prove unsu ccessful a direct approach to the distal popliteal artery is required through a second incision made medially at the knee The distal popliteal artery is exposed and the proximal portions of the anterior and posterior tibial arteries are looped with Silastic tapes (Fig 8) Through a small incishysion in the distal popliteal artery the No2 and 3 French embolectomy catheters should be directly introduced into the anshyterior and posterior tibial arteries respecshytively If these vessels were previously patent and uninvolved in an arterioscleshyrotic process the No2 French ca theter should be passed beyond the ankle Joint The course of the catheter can be felt by placing the fingers over the distribution of the anterior and posterior tibial arteries If the catheter is hindered at the ankle joint it can frequently be passed farther by plantar flexion of the foot

Inability to pass th e No2 French ca theter beyond the ankl e joint in the presence of angiographi c eviden ce of

i

2096 Part IX Vascular Surgery

Adherent Clot Catheter The ACC consists of a No 4 or 6 fl exible catheter body with an adJ ll pitch corkscrew-shaped distal tip ( The corkscrew balloon consists of balloo n membrane covering an Oll

ble that is loosely spiraled around a wire running the length of the cael a control handle at th e proximal lt 1

control handle allows the surgeon just the pitch and diameter corkscrew from completely strai fully spiraled Unlike the conwi Fogarty balloon catheter the AD not inflate Instead the diameter corkscrew-shaped working end catheter is varied by mechanical ref of the mner wire via a knob on th trol handle In this manner the de can be continuously adjusted from profIle No6 French size to a JargeE eter of up to 10 mm

The ACC is used like th e c( tional Fogarty balloon catheter Ari tial exploration with the standal loon catheter the ACC tip is coll al its low-profile position and passe the vessel and beyond the thromb knob on the control handle is tb tra cted until the spiral is enlarged desired diameter th ereby engagi thromboti c materi al within th e stices of th e spiral Subseque m catheter is drawn slowly back ala vessel and the material is rc through the arteriotomy As in th ventional balloon catheter tec hn i diameter of th e spiral can be adju cording to feel in response to rIO within the vessel

The ACCs mechanism of entr of the clot is thus quite differe t that of the conventional balloon c The traditional Fogarty balloon is distal to the material and essential the thrombus alo ng the vessel to arteriotomy In contrast the co r entraps thromboti c material - itmiddot spaces of the spiral providing alar of contact to grip and remove rl

_

r--

Fig 8 Technique of po pliteotibial exploration

obstru ction beyond this point necessitates direct exposure of the anterior and posteshyrior tibial arteries at the ankle By direct manipulation of the vessel combined with gentle simultaneous probing of the catheter from the proximal end one is frequently able to pass the catheter beyond the point of obstruction without the necessity of an arteriotomy If an arteriotomy at the ankle level in either of these vessels is required an incision only large enough to allow the inshytroduction of the No2 French catheter is made into the vessel The catheter is threaded distally inflated and withdrawn in the inflated condition This maneuver freshyquently brings the thrombotic material above the small arteriotomy Additional atshytempts to extract this thrombotic material should be made by introducing a No2 or 3 French catheter into either the anterior or posterior vessels at the level of the popliteal arteriotomy This maneuver avoids the neshycessity of enlarging the arteriotomy at the ankle joint and decreases the possibility of reocclusion After removal of the thromshybotic material copious irrigation of the disshytal artenal system should be ca rried out with a heparinized solution

Extraction of Upper-Limb Emboli

The technique for management of emshyboli to the upper limb is identical to that described for the lower limb Proximal subshyclavian artery emboli can be routinely reshymoved under local anesthesia by retrograde

extraction from a brachial arteriotomy It should always b e borne in mind howshyever that if the embolus appears to reside in proximity to the origin of the cranial vessels fragmentation of the embolus may occur during manipulation resultshying in central nervous system emboli and ischemia

Removal of Mature Adherent Thrombotic Material

As the patient population becomes inshycreasingly elderly and more prone to athshyerosclerosis mature adherent thrombotic lesions are becoming more prevalent The standard fluid-filled Fogarty balloon catheter is quite efficient for removing large amounts of soft fresh thrombus but it is limi ted in its ability to remove more adherent material such as olde r clot of thrombotic origin To meet this need two new tools have been designed an adhershyent clot cathete r (ACC) and a graft thrombec tomy catheter (GTC)

Fig 9 The adherent clot ca thete r in its extended position (top) during catherer introdu in contracted position (bottom) during retrieval of adherent material in native vessel

_ ~ rhe ad he rent c10r carherer rhe gra fr rhrombecromy catherer can be ldj usted so that -r in the low-profile exrended confIguration becomes larger allowi ng more aggressive l uherem clot from synrheric grafrs

u ex-covered edges of the fully corkscrew provide more of a

- edge than an inflated balloon this catheter 1110re capable of material adh ered to th e inside eI wall

-CC is designed for use in both _ ltds and synthetic grafts in situshy

( require a slightly more aggresshy-)Jch to retrieve a particularly - clot embolus or fl ap that has - mova l by a co nve ntiona l balshy ter The catheter system is apshy

- tar vessels whose diamete rs m 4 to 10 mm One particular n of this ca th ete r IS the

~~ [Ql11y of arteriovenous fistula _--J tts in which a more th orough _[ thrombotic material IS often a

bull Jlrernative to graft revision o r _cement

- 1rombectomy Catheter ruction of the GTC designed uy in syntheti c grafts is si milar to

-_ CC It consists of ei ther a N o -~ Ilch fl ex ibl e catheter body a

lg adju stable-diame ter sp iralshyOal region with a flex ible tip 101 handle (Fig 10) Unlike th e ever the double-helix-wire reshy

- GTC is shorter and sturdier -~ are not covered by latex Al so - operates over a larger range of - he exposed spiral wires collapse na tely 4 111m and can expand to ~ 16 mm - TC is a more agg res sive tool CC In use the spiral region is he low-p rofile posit ion and the

bull i t is passed along th e graft to

cction The sliding knob on the then re tracted to expand th e

[ltby engaging th e wires with

th e material to be removed The wires provide a thin circumferential line of contact with the luminal wall As with the o ther clot-retrieval ca th ete rs the pulling force can be continuously varied by adshyjustin g th e pitch of the sp iral wire dmshying middotwi thdrawal After the ca theter is reshym oved from the gra ft segments of thrombotic material are removed fro m within the sp iral regIO ns Th e device is then reinse rted and the pro cess is reshypeated until no additional residual mateshyrial can be removed As shown in Figure 11 a co nsid e rabl e volume of material call be removed by thi s method Thi s catheter is capabl C of removing all intrashyluminal m ate ri al from th e graft exposshying the bare origina l surfac e

Chapter 196 Embolecromy 2097

Improved Arce s Thru-Lumen Embolectomy Catheter

The development of th e Thru-Lumen emshybolectomy catheter has provided additional op ti ons for embolectomy and thrombecshytomy The catheter is similar to a convenshytional Foga rty embolectomy catheter ex cep t that an ad ditional lumen run s through its ce nter A V-connec to r at the proximal end has two ex tensions that alshylow access to th e tvo lumens One lumen is used for balloon inflation and the other is used for infusio n of fluids or guidewire access (Fig 12)

Whereas the stand ard Fogarty balloon ca th eter was design ed in an era in whi ch th ere was limited angiographic capability in the operating room the Thru-Lumen emb olectomy catheter has been designed to take adva ntage of the wide availab ility o f fluoroscopy in todays ope rating ro0111S The Thru-Lumen ca theter can be passed over a gLlld ewire which ca n be mon itored fluoro scopically In si tu ations of diffIcult access when a standard Fogashyrty balloon ca th e ter cannot be passed through thC obstruction a tapered Van Andel catheter can be substituted A guidewi re ca n then be placed through the Van Andel catheter Subsequently the Van An del ca th e ter ca n be removed and reshyplaced with a Thru-Lumen embolectomy ca theter Th e Thru-Lumell catheter can then be inflat ed and used for embolecshytomy in its normal manner

Fig 11 Th e grlft thrombectomy catheter is shown wirh residual clot which could not be reshymoved adequately w ith a balloon cathe ter that has been ex tracted fiom a syn th etic gra ft

2098 Part IX Vascular Surgery

Fig 12 The Tl1rLJ-LLJmen embolectomy catheter may be used to instill solutions (cop) or pass guidewires (bottom)

in electrolytes and acid-base balarlC occu r The sudden return of acidotic with a high potassium content Cd

in adverse effects on myocardial fu The necessity of using bufferin and antiarrhythmic agents shoul i ticipated at the time of clamp re and electrolyte levels should be shymeasured in the postoperative pe ~

the presence of ischemic muscle shysis restoration of limb flow may [~

the introduction of myoglobin t systemic c irculation Unless cle the kidney precipitation of myo~

the tubules may severely im pashyfunction

Myoglobinuria may be rec of1L= the absence of red blood cells in on microscopic examination ~

with a positive urinary guaiac [c ~ globinuria is suspected the patie be treated with intravenous hv middot r~_

ficient to establish a diuresis of hour as measured by indwelli r ~ catheter ou tput shy

The Thru-Lumen embolectomy catheter also can be used to deliver contrast material to monitor poundluoroscopically the clot reshymoval process without exchanging the embolectomy catheter for an angiographic catheterThe inflated balloon can also act as an occlusion device to facilitate distal localshyized injection of poundluids such as contrast media heparin or lytic agents

Management of Advanced Ischemia

Patients who have relatively far-advanced peripheral ischemia represent more diffishycult problems The recognition and treatshyment of complications that occur as a reshysult of advanced tissue ischemia lessen mortality and morbidity

The finding of acute venous thromboshysis in the presence of acute arterial occlushysion was fmt recognized in 1964 It was found that 27 of patients who had susshytained an acute arterial occlusion also had simultaneous venous occlusion and veshynous thrombectomy was required in 8 of these patients To identify venous thromshybosis a clamp is placed before arterial exshyploration to occlude venous return from the extremity After arterial embolectomy and establishment of the arterial circulashytion a second venous clamp is placed proximal to the first venous clamp and a venotomy is made between th e pair of

clamps The foot is poundlexed and extended a number of times to raise the resting veshynous pressure in the leg On release of the distal venous clamp any retained thrombus is ejected from the circulation If necessary additional venous thrombus is removed with a venous thrombectomy catheter

Swelling of a previously ischemic limb in which arterial continuity has been reestablished demands attention and is freshyquently observed in patients with obvious pregangrenous changes before the operashytion Capillary damage that results in poundluid exudation into ischemic tissue is a factor in this swelling which is often aggravated by venous outflow obstruction Fa sshyciotomy for control of massive edema has been required in 10 of the patients If manometric measurement of interstitial pressure is used any pressure exceeding 30 mm Hg is regarded as an indication for fasciotomy Failure to decompress the limb may result in compression of the arshyterial inflow and reocclusionInitial fascial decompression should be carried out through small skin incisions (a subcutashyneous fasciotomy) If immediate imshyprovement is not obtained by this limited fa sc iotomy the skin incisions should be extended and the deeper fascial compartshyments should be widely opened

Immediately after restoration of arterial continuity in limbs that present with adshyvan ced ischemia considerable alterations

POSTOPERATIVE ~ MANAGEMElT

In almost all instances anci co with intravenous heparin shou lc _ stituted 6 to 12 hours after em Although this results in wour in a few patients the likelihoo~ rent embolization is lesser ec

r ~ --

_

c

_

~_ shy

~

==

propagation of thrombus is small vessels not direcely c le ai~

embolectomy catheter Hepari ulation is continued until the fully ambulatory Oral va rfar i~ lation is also initiated 5 to I intravenous heparin adminis r co ntinued The warfarin is co definitely unless the primlr source has been defi nitive - Early ambulation is encour ce longed sitting is prohibite d~ early postoperative per iod ( effort should be expended in to un co ver a potentiall source of the embolus This 1shy

may includ e electrocardlo ~_shy

roentgenography real-time ushy

scanning cardiac radionu ci i echocardiography abdominal and angiographic evaluatio r - and thoracic and abdominal Jtshy

Secondmy Proceuure

In our series 28 of patient went balloon embolectomy to~ shy

needed additi onal surgical proshy--h ese procedures included repeat _omy balloon angioplasty or forshy la r reco nstructi on and cardiac ~ Initial imp rovement followed

- 1rati on in a postoperative limb

-

-~ ehrombos is and surgical exploshy- h repeat thrombectomy is indishy_nIb that shows marginal viability lbectomy suggests severe undershy-~ lI ive disease that must be adshye have found the combination 1 thrombec tomy and adjunctive

-Jeive balloon angioplas ty use ful 2 acute arterial occlusion caused

-_xisting atheroscl eroti c involve shylI calJy significant lesions can be -middot ieh littl e additional operative

_ middotasc ular reconstruction is warshy hould be performed early A ence of limb loss and mortality I es subsequent episodes of

SIS

orrecti on of ca rdiac sources of ~ is recommended We have pershy_ro nary artery bypass grafts aorshy- I valve replacement ventri cular

- ctomy and repair of a ventricushyJefec t resulting from infarctio n

-~ surgical balloon embo lectomy - J embolism O ur ea rly secondshydures have been performed

j signifi cant 10crease 10 major or death

eOus Thromhectomy and _lg Technologies

1~ i n g nature of vascular patholshyhe trend toward minimally inshy

~ gery have created an impetus echnologies and strategies for ieh th ro mboti c arterial occlushy

sions In recent years investi gators have p roduced a l11ultitude of pe rcutaneous thrombectomy devices and te chniques fo r clo t removal witho ut ope n surge ry An extensive review of th ese technoloshyg ies autho red by Sharafuddin and Hicks is available These new tre atm ent modali shyties include

1 Percutaneo us aspiratio n th ro mbecshyto my by whi ch suc tion is applied through a large lumen cath eter to reshymove thromboemboli c material

2 Pull-back th ro mbec tomy and clot trapping by w hich thro mbus is reshytrieved with a ball oon or basket into a trapping device for safe removal

3 Ro tati o nal and hydrauli c recirculation thrombectomy which involves the mishycrofragmentatio n of thrombus by the action of a high shea r stress hydrodyshynamic vortex

4 Fluid jets without hydrodynamic reci rshyculation to break up clo t

S T hrombectomy achi eved by the actio n of ultrasound la ser and radiofrequency energy to lyse thrombus

A new and promising approach is embodshyied in a unique device the TRELLIS that traps the fresh thromboti c occl usio n beshytween two balloons R otational mixing by this catheter system and lytic infusion intershyfaces with the fra gmented th rombus This pharmacomechanical combination enables targeted drug del ive ry and dissol ution of thrombus

N ew thrombectomy devic es and techniqu es will co ntinu e to emerge Each new technology must be carefully studi ed an d compared with standard thrombec tomy techniques to determine its clini ca l utility and to help defin e its role in the trea tment of thrombo tic arteshyrial occlusions

Chapter 196 Embolectomy 2099

SUGGESTED READING

Bar-EI Y Ada r R Sc hn eiderman Y et 11 Echocard iography in the dia gnostic assessshymen t o f periph eral arter ia l emb olization Am Hearl) 1990 119 1090

Berni GA Ba ndyk O F Zi erler RE et a Strepshytokinase treatment o f acute arterial occlushysion Ann Su rg 1983198 185

Foga rty TJ T he techniqu e o f th rombectomy and other uses of the Fogarty ca theter In Ruth erfo rd RB ed vaswlar su rgery Philade lphiaWB Sa unders 1977

Fogar ty TJ C hin A Shoor PM et a Adju nc shytive intraoperati ve arterial dilat tion simp]j shyfi ed in strumentation technique A reh Surg 1981 1 16 1391

Fogarty TJ Daily PO Shumwy NE et al Expeshyri ence with balloon catheter technique for arshyter ial embolectomy Am) Surg 1971 122231

Fogarty TJ H errmann GD N ew techniques for clo t extraction and managing acute thromshyboembolic limb ischemia lnVeith FJed Critshyical problems in vaswlar slrgery vol 3 St Louis Quali ty Medical Pub]jshers 1991

Hill B Fogarty TJThe use of the Fogarty catheter in 1998 Cardiovasc StIIg 1999 7(3)273

Sharafuddi n MJ Hicks ME C unent statu s of percutaneous mec hanical thrombectomy Part III Present and future appli ca tio ns) Vase lnlerv RadioI199 89(2) 209

Sharafuddin MJ Hicks ME C mren t status of percutane ous mechanic I thrombe ctomy Part II D evices and mec hanism of ac tion) vase lnterv RadioI19989(Pt 1) 15

Sharafuddin MJ Hicks ME C urrent status of percutaneo us mec hani ca l thrombectomy P n I General principles ) vase It1lerv Radiol 19978(6) 91l

Tawes RL Jr Beare JP Scribner R G et alV lue of postopera tive heparin therapy in per iphshye ral arterial th romboe mbolism Am) Surg 19831 46 21 3

Tawes RL Jr H arris EJ Brow n WG et alArteshyrial thromboembolism A 20-yea r perspec shytive Arch Su rg 1985 120595

SaracTp HiIleman OArko FR et al Clinical and economic evaluation of the trellis thrombecshytomy device for arterial occlusions prelimishynary analysis vase Surg 200439(3) 556

E DITORS COMMENT

__- Hill and Zarins have provided a wry trspectiv( 011 arterial embolism and

liong with an up-to-date disc ussion of -Jllagement I would first likegt to make a

between the picture of acute embolic ocshy- 1 previous normal artery and some of the Jlscussed in this chapte r As the autho rs

_ l is usually possible based on clinical presshyione to make the distincti on between

-~a l occlusion and what th ey describe as --ll1bosis In my view thjs distinction is

important If the diagn osis of ac ute eIll shy151 0n ofa previously norIllal artery can be

made based on c1 iniCJI presentation it is Ot adva ntage of the patient Under those

c ircumstances time is o f the csse-Ilee md by making the diagnosis on the clinica l picture preciolls time can be saved by getting the patient promptly to the ope(ltshying room with the expectation that the embolism and propagated thro mbus can be ~as il y removed l ith restoration of no rmal or near-normal arterial perfu shysion If however the patient is taken to the operating room w ith a dlJgnosis of Kute arterial occlusion but the underlying problem is arterial thrombosis supershyimposed on pre-existin g pcripheral vscular disease 111ltl l1 agelllenr in the operJrin g roonl can become much more complex and needlessly compromised because of inadequate information

T he questio n therefore is how does one make this distinction Lets take the Illost conlillOIl exanlshy

pie of cute occlusion of the superficial femoral ar shytery This occurs becausc an cmboli sm fi-om the hea rt has lodged at the common femoral bi fllrcashyti o n Because th e superfi cial femoral arte ry was previo llsly perfectly no rmal there is no collateral circulation and therefore the limb below the knee is iIllllleciilteiy extremely ischenlic This results in the classic picture of severe pain pallor (110 capilshylo ry filling) paresth esias and paralysis Such limbs are cadaveric in appearance and there is no ques shytio n about the no nviabil ity of the limb O ften there is a po unding waterhammer pulse palpable in the comlllon femo ral artery U nder those cirshyClIIl1stances and with th e an cillary ITlanagcll1ellt as described by the 3utho rs the patient may be taken

(co l1tin ue d)

Part IX Vascular Surgery 2094

Fig 4 The technique of Fogarry catheter embolectomy with catheter insertion in the distal vessel

the catheter tip away from the wall and toward the residual lumen

When the appropriately sized catheter has been gently advanced as far as possishyble the balloon is progressively inflated while the catheter is being slowly withshydrawn (Fig 4) The surgeon who withshydraws the catheter should also control balshyloon size because the feel that the surgeon gains in this manner is an imporshytant factor in ensuring complete clot reshytrieval and preventing vessel damage When traction on the catheter appears excessive it is imperative to allow suffishycient balloon deflation to permit smooth passage across segments of atherosclerotic luminal narrowing As catheter withshydrawal continues additional fluid should be added as needed to maintain gentle wall contact The catheter is so conshystructed that inflation takes place initially only in a 1-cm area in the center of the balloon jacket The increased resistance

engendered by mild atherosclerotic plaque causes displacement of tluid to the uninflated portion of the balloon allowshying the catheter to glide across areas of mild constriction without causing undue trauma to the wall (Fig 5)

) SURGICAL TECIIN1Q UE ---

ExLradion of Aortic and Iliac Emholi

In the surgical management of an aortic embolus bilateral vertical groin incisions are made and the common superficial and deep femoral (profunda femoris) arshyteries are isolated and looped with Silastic (polymeric silicone) tapes In the presshyence of atherosclerotic involvement of the femoral artery it is suggested that Fogarty-Hydragrip vascular clamps be used to allow atraumatic vessel occlusion

Fig 6 The Fogarry-H i- allows atraumatic vessel ~_ rated jaw is fluid-filled

particularly with catheter in place T il _ pressible fluid-fille d _c jaws allowing appro~ shysurfaces without ca (Fig 6)

After placemem shythe femoral artery he _shybe made in the co n~ just proximal to its bi strumentation of [he _ femoral orifices unc~~ vessel should be care1 location of plaque ~

though it IS preferabe shyverse arteriotomy a rowing during clo$u-_ location of plaque L

or even vertical inc closure ifluminal n l~shy

pnmary repaIr one s perform vein patch a _

We prefer to car [~

ration initially (Fig shysize of the vessel a shy

Fig 5 Fluid displacement in the specially des igned balloon maintains wall contact w hil e minishy catheter is gently inshymizing the potential for vessel wall injury perficial femoral ar

middot -llque of Fogarty catheter arterial - of the iliofemoral system

inflated until the arterial wall J d resistance The catheter is

-ed with the balloon in the in-on Initially only a small quanshy~ IS required Additional fluid is e catheter is extracted and the he vessel increases resistance during the introducshy

e ~ t heter gentle probing usually _ rrument to passThe catheter

Jtstally without extreme force -=1 attempts to force the catheter

omplications During the exshy-ic catheter only mild traction is

emove embolic material or a - 1 The deep femoral artery is

- 1 slllular manner but the No3 - ca theter in this vessel rarely 1 l a distance of 2S cm Care

en so that the catheter is introshy-1C deep femoral artery and not

-- he large circumflex branches cdrly origin from this vessel If -~ branch is explored it should _ har the catheter can be introshy

-x a short distanceand the No 11 catheter should be used for

ssful exploration of the distal I mL of heparinized solution

of heparin in 250 mL of inshy-0 solution) is injected into the i a the Thru-Lumen embolecshy

r (Baxter Vascular Division _ Jnd the vessels are occluded

clamps A No6 French - catheter is placed in the

common femoral artery and threaded into tne aorta The balloon is inflated with the appropriate amount of fluid and exshytracted in the inflated position During the process of extraction the balloon Can be deflated to accommodate the narrowed vessel The procedure should be repeated if a forceful pulsatile flow is not obtained on the fIrSt passage Significant bleeding even so mewhat pulsatile may occur from the proximal common femoral artery in the presence of partial continued obstrucshytion and repeated passes should be made until one is confident that all obstructing thrombi have been removed To reduce blood loss the embolectomy catheter can be passed through th e jaws of the Fogarty clamp without causing undue trauma or blood loss It is best accomplished by placshying Hydragrips 011 both blades of the clamp Immediately before the balloon portion of the catheter is removed from the ar tery the clamp is relea sed the catheter is removed from the arterial incishysion and the clamp is reapplied After adeshyquate extraction of the clot from one side a similar procedure is performed on the opposite limb Both arteriotomies are closed after ensuring bilateral simultaneous pulsatile flow

It should be mentioned again that the presence of backbleeding is no assurance that distal patency has been established beshycause collateral circulation may result in vigorous backbleeding eve n in the presshyence ofdistal arterial thrombus If the status of the distal arterial tree is uncertain opershyative angiography should be performed

I n the removal of an iliac embolus the incision is made only on the affected side Both limbs are prepared for surgical incishysion because of the small but real possibility of dislodging a high iliac embolus with subsequ ent occlusion of the previously unshyaffected contralateral vessel

E lraction of Femoral and Poplileal Emboli

In ea rly experien ce with emboli below the inguinal ligament incisions were made over what was thought to be the site of embolic occlusion It has been found however that a more satisfactory approach to removal of embo li at the level of the adductor magnus tendon and the popliteal areas is through an incision in the di stal common femoral artery This proximal approach to accessing emboli loshycated at a lower level has several advanshytages It allows exploration of the deep femoral system which can be occluded with additional thrombotic material If

Chapter 196 Embolectomy 2095

the embolus is in the common femoral artery digital pressure proximal to the emshybolus may squeeze the embolus out and reestablish forceful pulsatile flow Even in this circumstance however an embolecshytomy catheter should be passed proxishymally inflated and then withdrawn to exshytract any residual thrombotic material that may be loosely adherent to th e intima Because of the prese nce of discontinuous distal thrombosis in more than one third of the instances of acute proximal embolic occlusion catheters are threaded distally regardless of th e presence or a bsence of backbleeding from the superficial femoral ar tery

Thrombotic material can be extracted from [vo or more branches of the popliteal artery by inserting multiple catheters in the superficial femoral artery The No2 and 3 French catheters should be used for this purpose The first catheter most commonly passes into the peroneal or posterior tibial artery After initial placement of one catheter the leg is placed in a slightly fl exed position and a second catheter is inserted In this manner the second catheter is deshyflected from the obstructed orifice of the previously cannulated vessel and may find its way into an unobstructed channel Exshyamination of the thrombus can provide valuable information about the comshypleteness of clot removal The presence of a sharp cutoff usually indica tes that additional thrombotic material remains whereas a smooth taper indicates adequate clot removal

When thrombus remains in the tibial vessels and efforts to remove it from above prove unsu ccessful a direct approach to the distal popliteal artery is required through a second incision made medially at the knee The distal popliteal artery is exposed and the proximal portions of the anterior and posterior tibial arteries are looped with Silastic tapes (Fig 8) Through a small incishysion in the distal popliteal artery the No2 and 3 French embolectomy catheters should be directly introduced into the anshyterior and posterior tibial arteries respecshytively If these vessels were previously patent and uninvolved in an arterioscleshyrotic process the No2 French ca theter should be passed beyond the ankle Joint The course of the catheter can be felt by placing the fingers over the distribution of the anterior and posterior tibial arteries If the catheter is hindered at the ankle joint it can frequently be passed farther by plantar flexion of the foot

Inability to pass th e No2 French ca theter beyond the ankl e joint in the presence of angiographi c eviden ce of

i

2096 Part IX Vascular Surgery

Adherent Clot Catheter The ACC consists of a No 4 or 6 fl exible catheter body with an adJ ll pitch corkscrew-shaped distal tip ( The corkscrew balloon consists of balloo n membrane covering an Oll

ble that is loosely spiraled around a wire running the length of the cael a control handle at th e proximal lt 1

control handle allows the surgeon just the pitch and diameter corkscrew from completely strai fully spiraled Unlike the conwi Fogarty balloon catheter the AD not inflate Instead the diameter corkscrew-shaped working end catheter is varied by mechanical ref of the mner wire via a knob on th trol handle In this manner the de can be continuously adjusted from profIle No6 French size to a JargeE eter of up to 10 mm

The ACC is used like th e c( tional Fogarty balloon catheter Ari tial exploration with the standal loon catheter the ACC tip is coll al its low-profile position and passe the vessel and beyond the thromb knob on the control handle is tb tra cted until the spiral is enlarged desired diameter th ereby engagi thromboti c materi al within th e stices of th e spiral Subseque m catheter is drawn slowly back ala vessel and the material is rc through the arteriotomy As in th ventional balloon catheter tec hn i diameter of th e spiral can be adju cording to feel in response to rIO within the vessel

The ACCs mechanism of entr of the clot is thus quite differe t that of the conventional balloon c The traditional Fogarty balloon is distal to the material and essential the thrombus alo ng the vessel to arteriotomy In contrast the co r entraps thromboti c material - itmiddot spaces of the spiral providing alar of contact to grip and remove rl

_

r--

Fig 8 Technique of po pliteotibial exploration

obstru ction beyond this point necessitates direct exposure of the anterior and posteshyrior tibial arteries at the ankle By direct manipulation of the vessel combined with gentle simultaneous probing of the catheter from the proximal end one is frequently able to pass the catheter beyond the point of obstruction without the necessity of an arteriotomy If an arteriotomy at the ankle level in either of these vessels is required an incision only large enough to allow the inshytroduction of the No2 French catheter is made into the vessel The catheter is threaded distally inflated and withdrawn in the inflated condition This maneuver freshyquently brings the thrombotic material above the small arteriotomy Additional atshytempts to extract this thrombotic material should be made by introducing a No2 or 3 French catheter into either the anterior or posterior vessels at the level of the popliteal arteriotomy This maneuver avoids the neshycessity of enlarging the arteriotomy at the ankle joint and decreases the possibility of reocclusion After removal of the thromshybotic material copious irrigation of the disshytal artenal system should be ca rried out with a heparinized solution

Extraction of Upper-Limb Emboli

The technique for management of emshyboli to the upper limb is identical to that described for the lower limb Proximal subshyclavian artery emboli can be routinely reshymoved under local anesthesia by retrograde

extraction from a brachial arteriotomy It should always b e borne in mind howshyever that if the embolus appears to reside in proximity to the origin of the cranial vessels fragmentation of the embolus may occur during manipulation resultshying in central nervous system emboli and ischemia

Removal of Mature Adherent Thrombotic Material

As the patient population becomes inshycreasingly elderly and more prone to athshyerosclerosis mature adherent thrombotic lesions are becoming more prevalent The standard fluid-filled Fogarty balloon catheter is quite efficient for removing large amounts of soft fresh thrombus but it is limi ted in its ability to remove more adherent material such as olde r clot of thrombotic origin To meet this need two new tools have been designed an adhershyent clot cathete r (ACC) and a graft thrombec tomy catheter (GTC)

Fig 9 The adherent clot ca thete r in its extended position (top) during catherer introdu in contracted position (bottom) during retrieval of adherent material in native vessel

_ ~ rhe ad he rent c10r carherer rhe gra fr rhrombecromy catherer can be ldj usted so that -r in the low-profile exrended confIguration becomes larger allowi ng more aggressive l uherem clot from synrheric grafrs

u ex-covered edges of the fully corkscrew provide more of a

- edge than an inflated balloon this catheter 1110re capable of material adh ered to th e inside eI wall

-CC is designed for use in both _ ltds and synthetic grafts in situshy

( require a slightly more aggresshy-)Jch to retrieve a particularly - clot embolus or fl ap that has - mova l by a co nve ntiona l balshy ter The catheter system is apshy

- tar vessels whose diamete rs m 4 to 10 mm One particular n of this ca th ete r IS the

~~ [Ql11y of arteriovenous fistula _--J tts in which a more th orough _[ thrombotic material IS often a

bull Jlrernative to graft revision o r _cement

- 1rombectomy Catheter ruction of the GTC designed uy in syntheti c grafts is si milar to

-_ CC It consists of ei ther a N o -~ Ilch fl ex ibl e catheter body a

lg adju stable-diame ter sp iralshyOal region with a flex ible tip 101 handle (Fig 10) Unlike th e ever the double-helix-wire reshy

- GTC is shorter and sturdier -~ are not covered by latex Al so - operates over a larger range of - he exposed spiral wires collapse na tely 4 111m and can expand to ~ 16 mm - TC is a more agg res sive tool CC In use the spiral region is he low-p rofile posit ion and the

bull i t is passed along th e graft to

cction The sliding knob on the then re tracted to expand th e

[ltby engaging th e wires with

th e material to be removed The wires provide a thin circumferential line of contact with the luminal wall As with the o ther clot-retrieval ca th ete rs the pulling force can be continuously varied by adshyjustin g th e pitch of the sp iral wire dmshying middotwi thdrawal After the ca theter is reshym oved from the gra ft segments of thrombotic material are removed fro m within the sp iral regIO ns Th e device is then reinse rted and the pro cess is reshypeated until no additional residual mateshyrial can be removed As shown in Figure 11 a co nsid e rabl e volume of material call be removed by thi s method Thi s catheter is capabl C of removing all intrashyluminal m ate ri al from th e graft exposshying the bare origina l surfac e

Chapter 196 Embolecromy 2097

Improved Arce s Thru-Lumen Embolectomy Catheter

The development of th e Thru-Lumen emshybolectomy catheter has provided additional op ti ons for embolectomy and thrombecshytomy The catheter is similar to a convenshytional Foga rty embolectomy catheter ex cep t that an ad ditional lumen run s through its ce nter A V-connec to r at the proximal end has two ex tensions that alshylow access to th e tvo lumens One lumen is used for balloon inflation and the other is used for infusio n of fluids or guidewire access (Fig 12)

Whereas the stand ard Fogarty balloon ca th eter was design ed in an era in whi ch th ere was limited angiographic capability in the operating room the Thru-Lumen emb olectomy catheter has been designed to take adva ntage of the wide availab ility o f fluoroscopy in todays ope rating ro0111S The Thru-Lumen ca theter can be passed over a gLlld ewire which ca n be mon itored fluoro scopically In si tu ations of diffIcult access when a standard Fogashyrty balloon ca th e ter cannot be passed through thC obstruction a tapered Van Andel catheter can be substituted A guidewi re ca n then be placed through the Van Andel catheter Subsequently the Van An del ca th e ter ca n be removed and reshyplaced with a Thru-Lumen embolectomy ca theter Th e Thru-Lumell catheter can then be inflat ed and used for embolecshytomy in its normal manner

Fig 11 Th e grlft thrombectomy catheter is shown wirh residual clot which could not be reshymoved adequately w ith a balloon cathe ter that has been ex tracted fiom a syn th etic gra ft

2098 Part IX Vascular Surgery

Fig 12 The Tl1rLJ-LLJmen embolectomy catheter may be used to instill solutions (cop) or pass guidewires (bottom)

in electrolytes and acid-base balarlC occu r The sudden return of acidotic with a high potassium content Cd

in adverse effects on myocardial fu The necessity of using bufferin and antiarrhythmic agents shoul i ticipated at the time of clamp re and electrolyte levels should be shymeasured in the postoperative pe ~

the presence of ischemic muscle shysis restoration of limb flow may [~

the introduction of myoglobin t systemic c irculation Unless cle the kidney precipitation of myo~

the tubules may severely im pashyfunction

Myoglobinuria may be rec of1L= the absence of red blood cells in on microscopic examination ~

with a positive urinary guaiac [c ~ globinuria is suspected the patie be treated with intravenous hv middot r~_

ficient to establish a diuresis of hour as measured by indwelli r ~ catheter ou tput shy

The Thru-Lumen embolectomy catheter also can be used to deliver contrast material to monitor poundluoroscopically the clot reshymoval process without exchanging the embolectomy catheter for an angiographic catheterThe inflated balloon can also act as an occlusion device to facilitate distal localshyized injection of poundluids such as contrast media heparin or lytic agents

Management of Advanced Ischemia

Patients who have relatively far-advanced peripheral ischemia represent more diffishycult problems The recognition and treatshyment of complications that occur as a reshysult of advanced tissue ischemia lessen mortality and morbidity

The finding of acute venous thromboshysis in the presence of acute arterial occlushysion was fmt recognized in 1964 It was found that 27 of patients who had susshytained an acute arterial occlusion also had simultaneous venous occlusion and veshynous thrombectomy was required in 8 of these patients To identify venous thromshybosis a clamp is placed before arterial exshyploration to occlude venous return from the extremity After arterial embolectomy and establishment of the arterial circulashytion a second venous clamp is placed proximal to the first venous clamp and a venotomy is made between th e pair of

clamps The foot is poundlexed and extended a number of times to raise the resting veshynous pressure in the leg On release of the distal venous clamp any retained thrombus is ejected from the circulation If necessary additional venous thrombus is removed with a venous thrombectomy catheter

Swelling of a previously ischemic limb in which arterial continuity has been reestablished demands attention and is freshyquently observed in patients with obvious pregangrenous changes before the operashytion Capillary damage that results in poundluid exudation into ischemic tissue is a factor in this swelling which is often aggravated by venous outflow obstruction Fa sshyciotomy for control of massive edema has been required in 10 of the patients If manometric measurement of interstitial pressure is used any pressure exceeding 30 mm Hg is regarded as an indication for fasciotomy Failure to decompress the limb may result in compression of the arshyterial inflow and reocclusionInitial fascial decompression should be carried out through small skin incisions (a subcutashyneous fasciotomy) If immediate imshyprovement is not obtained by this limited fa sc iotomy the skin incisions should be extended and the deeper fascial compartshyments should be widely opened

Immediately after restoration of arterial continuity in limbs that present with adshyvan ced ischemia considerable alterations

POSTOPERATIVE ~ MANAGEMElT

In almost all instances anci co with intravenous heparin shou lc _ stituted 6 to 12 hours after em Although this results in wour in a few patients the likelihoo~ rent embolization is lesser ec

r ~ --

_

c

_

~_ shy

~

==

propagation of thrombus is small vessels not direcely c le ai~

embolectomy catheter Hepari ulation is continued until the fully ambulatory Oral va rfar i~ lation is also initiated 5 to I intravenous heparin adminis r co ntinued The warfarin is co definitely unless the primlr source has been defi nitive - Early ambulation is encour ce longed sitting is prohibite d~ early postoperative per iod ( effort should be expended in to un co ver a potentiall source of the embolus This 1shy

may includ e electrocardlo ~_shy

roentgenography real-time ushy

scanning cardiac radionu ci i echocardiography abdominal and angiographic evaluatio r - and thoracic and abdominal Jtshy

Secondmy Proceuure

In our series 28 of patient went balloon embolectomy to~ shy

needed additi onal surgical proshy--h ese procedures included repeat _omy balloon angioplasty or forshy la r reco nstructi on and cardiac ~ Initial imp rovement followed

- 1rati on in a postoperative limb

-

-~ ehrombos is and surgical exploshy- h repeat thrombectomy is indishy_nIb that shows marginal viability lbectomy suggests severe undershy-~ lI ive disease that must be adshye have found the combination 1 thrombec tomy and adjunctive

-Jeive balloon angioplas ty use ful 2 acute arterial occlusion caused

-_xisting atheroscl eroti c involve shylI calJy significant lesions can be -middot ieh littl e additional operative

_ middotasc ular reconstruction is warshy hould be performed early A ence of limb loss and mortality I es subsequent episodes of

SIS

orrecti on of ca rdiac sources of ~ is recommended We have pershy_ro nary artery bypass grafts aorshy- I valve replacement ventri cular

- ctomy and repair of a ventricushyJefec t resulting from infarctio n

-~ surgical balloon embo lectomy - J embolism O ur ea rly secondshydures have been performed

j signifi cant 10crease 10 major or death

eOus Thromhectomy and _lg Technologies

1~ i n g nature of vascular patholshyhe trend toward minimally inshy

~ gery have created an impetus echnologies and strategies for ieh th ro mboti c arterial occlushy

sions In recent years investi gators have p roduced a l11ultitude of pe rcutaneous thrombectomy devices and te chniques fo r clo t removal witho ut ope n surge ry An extensive review of th ese technoloshyg ies autho red by Sharafuddin and Hicks is available These new tre atm ent modali shyties include

1 Percutaneo us aspiratio n th ro mbecshyto my by whi ch suc tion is applied through a large lumen cath eter to reshymove thromboemboli c material

2 Pull-back th ro mbec tomy and clot trapping by w hich thro mbus is reshytrieved with a ball oon or basket into a trapping device for safe removal

3 Ro tati o nal and hydrauli c recirculation thrombectomy which involves the mishycrofragmentatio n of thrombus by the action of a high shea r stress hydrodyshynamic vortex

4 Fluid jets without hydrodynamic reci rshyculation to break up clo t

S T hrombectomy achi eved by the actio n of ultrasound la ser and radiofrequency energy to lyse thrombus

A new and promising approach is embodshyied in a unique device the TRELLIS that traps the fresh thromboti c occl usio n beshytween two balloons R otational mixing by this catheter system and lytic infusion intershyfaces with the fra gmented th rombus This pharmacomechanical combination enables targeted drug del ive ry and dissol ution of thrombus

N ew thrombectomy devic es and techniqu es will co ntinu e to emerge Each new technology must be carefully studi ed an d compared with standard thrombec tomy techniques to determine its clini ca l utility and to help defin e its role in the trea tment of thrombo tic arteshyrial occlusions

Chapter 196 Embolectomy 2099

SUGGESTED READING

Bar-EI Y Ada r R Sc hn eiderman Y et 11 Echocard iography in the dia gnostic assessshymen t o f periph eral arter ia l emb olization Am Hearl) 1990 119 1090

Berni GA Ba ndyk O F Zi erler RE et a Strepshytokinase treatment o f acute arterial occlushysion Ann Su rg 1983198 185

Foga rty TJ T he techniqu e o f th rombectomy and other uses of the Fogarty ca theter In Ruth erfo rd RB ed vaswlar su rgery Philade lphiaWB Sa unders 1977

Fogar ty TJ C hin A Shoor PM et a Adju nc shytive intraoperati ve arterial dilat tion simp]j shyfi ed in strumentation technique A reh Surg 1981 1 16 1391

Fogarty TJ Daily PO Shumwy NE et al Expeshyri ence with balloon catheter technique for arshyter ial embolectomy Am) Surg 1971 122231

Fogarty TJ H errmann GD N ew techniques for clo t extraction and managing acute thromshyboembolic limb ischemia lnVeith FJed Critshyical problems in vaswlar slrgery vol 3 St Louis Quali ty Medical Pub]jshers 1991

Hill B Fogarty TJThe use of the Fogarty catheter in 1998 Cardiovasc StIIg 1999 7(3)273

Sharafuddi n MJ Hicks ME C unent statu s of percutaneous mec hanical thrombectomy Part III Present and future appli ca tio ns) Vase lnlerv RadioI199 89(2) 209

Sharafuddin MJ Hicks ME C mren t status of percutane ous mechanic I thrombe ctomy Part II D evices and mec hanism of ac tion) vase lnterv RadioI19989(Pt 1) 15

Sharafuddin MJ Hicks ME C urrent status of percutaneo us mec hani ca l thrombectomy P n I General principles ) vase It1lerv Radiol 19978(6) 91l

Tawes RL Jr Beare JP Scribner R G et alV lue of postopera tive heparin therapy in per iphshye ral arterial th romboe mbolism Am) Surg 19831 46 21 3

Tawes RL Jr H arris EJ Brow n WG et alArteshyrial thromboembolism A 20-yea r perspec shytive Arch Su rg 1985 120595

SaracTp HiIleman OArko FR et al Clinical and economic evaluation of the trellis thrombecshytomy device for arterial occlusions prelimishynary analysis vase Surg 200439(3) 556

E DITORS COMMENT

__- Hill and Zarins have provided a wry trspectiv( 011 arterial embolism and

liong with an up-to-date disc ussion of -Jllagement I would first likegt to make a

between the picture of acute embolic ocshy- 1 previous normal artery and some of the Jlscussed in this chapte r As the autho rs

_ l is usually possible based on clinical presshyione to make the distincti on between

-~a l occlusion and what th ey describe as --ll1bosis In my view thjs distinction is

important If the diagn osis of ac ute eIll shy151 0n ofa previously norIllal artery can be

made based on c1 iniCJI presentation it is Ot adva ntage of the patient Under those

c ircumstances time is o f the csse-Ilee md by making the diagnosis on the clinica l picture preciolls time can be saved by getting the patient promptly to the ope(ltshying room with the expectation that the embolism and propagated thro mbus can be ~as il y removed l ith restoration of no rmal or near-normal arterial perfu shysion If however the patient is taken to the operating room w ith a dlJgnosis of Kute arterial occlusion but the underlying problem is arterial thrombosis supershyimposed on pre-existin g pcripheral vscular disease 111ltl l1 agelllenr in the operJrin g roonl can become much more complex and needlessly compromised because of inadequate information

T he questio n therefore is how does one make this distinction Lets take the Illost conlillOIl exanlshy

pie of cute occlusion of the superficial femoral ar shytery This occurs becausc an cmboli sm fi-om the hea rt has lodged at the common femoral bi fllrcashyti o n Because th e superfi cial femoral arte ry was previo llsly perfectly no rmal there is no collateral circulation and therefore the limb below the knee is iIllllleciilteiy extremely ischenlic This results in the classic picture of severe pain pallor (110 capilshylo ry filling) paresth esias and paralysis Such limbs are cadaveric in appearance and there is no ques shytio n about the no nviabil ity of the limb O ften there is a po unding waterhammer pulse palpable in the comlllon femo ral artery U nder those cirshyClIIl1stances and with th e an cillary ITlanagcll1ellt as described by the 3utho rs the patient may be taken

(co l1tin ue d)

middot -llque of Fogarty catheter arterial - of the iliofemoral system

inflated until the arterial wall J d resistance The catheter is

-ed with the balloon in the in-on Initially only a small quanshy~ IS required Additional fluid is e catheter is extracted and the he vessel increases resistance during the introducshy

e ~ t heter gentle probing usually _ rrument to passThe catheter

Jtstally without extreme force -=1 attempts to force the catheter

omplications During the exshy-ic catheter only mild traction is

emove embolic material or a - 1 The deep femoral artery is

- 1 slllular manner but the No3 - ca theter in this vessel rarely 1 l a distance of 2S cm Care

en so that the catheter is introshy-1C deep femoral artery and not

-- he large circumflex branches cdrly origin from this vessel If -~ branch is explored it should _ har the catheter can be introshy

-x a short distanceand the No 11 catheter should be used for

ssful exploration of the distal I mL of heparinized solution

of heparin in 250 mL of inshy-0 solution) is injected into the i a the Thru-Lumen embolecshy

r (Baxter Vascular Division _ Jnd the vessels are occluded

clamps A No6 French - catheter is placed in the

common femoral artery and threaded into tne aorta The balloon is inflated with the appropriate amount of fluid and exshytracted in the inflated position During the process of extraction the balloon Can be deflated to accommodate the narrowed vessel The procedure should be repeated if a forceful pulsatile flow is not obtained on the fIrSt passage Significant bleeding even so mewhat pulsatile may occur from the proximal common femoral artery in the presence of partial continued obstrucshytion and repeated passes should be made until one is confident that all obstructing thrombi have been removed To reduce blood loss the embolectomy catheter can be passed through th e jaws of the Fogarty clamp without causing undue trauma or blood loss It is best accomplished by placshying Hydragrips 011 both blades of the clamp Immediately before the balloon portion of the catheter is removed from the ar tery the clamp is relea sed the catheter is removed from the arterial incishysion and the clamp is reapplied After adeshyquate extraction of the clot from one side a similar procedure is performed on the opposite limb Both arteriotomies are closed after ensuring bilateral simultaneous pulsatile flow

It should be mentioned again that the presence of backbleeding is no assurance that distal patency has been established beshycause collateral circulation may result in vigorous backbleeding eve n in the presshyence ofdistal arterial thrombus If the status of the distal arterial tree is uncertain opershyative angiography should be performed

I n the removal of an iliac embolus the incision is made only on the affected side Both limbs are prepared for surgical incishysion because of the small but real possibility of dislodging a high iliac embolus with subsequ ent occlusion of the previously unshyaffected contralateral vessel

E lraction of Femoral and Poplileal Emboli

In ea rly experien ce with emboli below the inguinal ligament incisions were made over what was thought to be the site of embolic occlusion It has been found however that a more satisfactory approach to removal of embo li at the level of the adductor magnus tendon and the popliteal areas is through an incision in the di stal common femoral artery This proximal approach to accessing emboli loshycated at a lower level has several advanshytages It allows exploration of the deep femoral system which can be occluded with additional thrombotic material If

Chapter 196 Embolectomy 2095

the embolus is in the common femoral artery digital pressure proximal to the emshybolus may squeeze the embolus out and reestablish forceful pulsatile flow Even in this circumstance however an embolecshytomy catheter should be passed proxishymally inflated and then withdrawn to exshytract any residual thrombotic material that may be loosely adherent to th e intima Because of the prese nce of discontinuous distal thrombosis in more than one third of the instances of acute proximal embolic occlusion catheters are threaded distally regardless of th e presence or a bsence of backbleeding from the superficial femoral ar tery

Thrombotic material can be extracted from [vo or more branches of the popliteal artery by inserting multiple catheters in the superficial femoral artery The No2 and 3 French catheters should be used for this purpose The first catheter most commonly passes into the peroneal or posterior tibial artery After initial placement of one catheter the leg is placed in a slightly fl exed position and a second catheter is inserted In this manner the second catheter is deshyflected from the obstructed orifice of the previously cannulated vessel and may find its way into an unobstructed channel Exshyamination of the thrombus can provide valuable information about the comshypleteness of clot removal The presence of a sharp cutoff usually indica tes that additional thrombotic material remains whereas a smooth taper indicates adequate clot removal

When thrombus remains in the tibial vessels and efforts to remove it from above prove unsu ccessful a direct approach to the distal popliteal artery is required through a second incision made medially at the knee The distal popliteal artery is exposed and the proximal portions of the anterior and posterior tibial arteries are looped with Silastic tapes (Fig 8) Through a small incishysion in the distal popliteal artery the No2 and 3 French embolectomy catheters should be directly introduced into the anshyterior and posterior tibial arteries respecshytively If these vessels were previously patent and uninvolved in an arterioscleshyrotic process the No2 French ca theter should be passed beyond the ankle Joint The course of the catheter can be felt by placing the fingers over the distribution of the anterior and posterior tibial arteries If the catheter is hindered at the ankle joint it can frequently be passed farther by plantar flexion of the foot

Inability to pass th e No2 French ca theter beyond the ankl e joint in the presence of angiographi c eviden ce of

i

2096 Part IX Vascular Surgery

Adherent Clot Catheter The ACC consists of a No 4 or 6 fl exible catheter body with an adJ ll pitch corkscrew-shaped distal tip ( The corkscrew balloon consists of balloo n membrane covering an Oll

ble that is loosely spiraled around a wire running the length of the cael a control handle at th e proximal lt 1

control handle allows the surgeon just the pitch and diameter corkscrew from completely strai fully spiraled Unlike the conwi Fogarty balloon catheter the AD not inflate Instead the diameter corkscrew-shaped working end catheter is varied by mechanical ref of the mner wire via a knob on th trol handle In this manner the de can be continuously adjusted from profIle No6 French size to a JargeE eter of up to 10 mm

The ACC is used like th e c( tional Fogarty balloon catheter Ari tial exploration with the standal loon catheter the ACC tip is coll al its low-profile position and passe the vessel and beyond the thromb knob on the control handle is tb tra cted until the spiral is enlarged desired diameter th ereby engagi thromboti c materi al within th e stices of th e spiral Subseque m catheter is drawn slowly back ala vessel and the material is rc through the arteriotomy As in th ventional balloon catheter tec hn i diameter of th e spiral can be adju cording to feel in response to rIO within the vessel

The ACCs mechanism of entr of the clot is thus quite differe t that of the conventional balloon c The traditional Fogarty balloon is distal to the material and essential the thrombus alo ng the vessel to arteriotomy In contrast the co r entraps thromboti c material - itmiddot spaces of the spiral providing alar of contact to grip and remove rl

_

r--

Fig 8 Technique of po pliteotibial exploration

obstru ction beyond this point necessitates direct exposure of the anterior and posteshyrior tibial arteries at the ankle By direct manipulation of the vessel combined with gentle simultaneous probing of the catheter from the proximal end one is frequently able to pass the catheter beyond the point of obstruction without the necessity of an arteriotomy If an arteriotomy at the ankle level in either of these vessels is required an incision only large enough to allow the inshytroduction of the No2 French catheter is made into the vessel The catheter is threaded distally inflated and withdrawn in the inflated condition This maneuver freshyquently brings the thrombotic material above the small arteriotomy Additional atshytempts to extract this thrombotic material should be made by introducing a No2 or 3 French catheter into either the anterior or posterior vessels at the level of the popliteal arteriotomy This maneuver avoids the neshycessity of enlarging the arteriotomy at the ankle joint and decreases the possibility of reocclusion After removal of the thromshybotic material copious irrigation of the disshytal artenal system should be ca rried out with a heparinized solution

Extraction of Upper-Limb Emboli

The technique for management of emshyboli to the upper limb is identical to that described for the lower limb Proximal subshyclavian artery emboli can be routinely reshymoved under local anesthesia by retrograde

extraction from a brachial arteriotomy It should always b e borne in mind howshyever that if the embolus appears to reside in proximity to the origin of the cranial vessels fragmentation of the embolus may occur during manipulation resultshying in central nervous system emboli and ischemia

Removal of Mature Adherent Thrombotic Material

As the patient population becomes inshycreasingly elderly and more prone to athshyerosclerosis mature adherent thrombotic lesions are becoming more prevalent The standard fluid-filled Fogarty balloon catheter is quite efficient for removing large amounts of soft fresh thrombus but it is limi ted in its ability to remove more adherent material such as olde r clot of thrombotic origin To meet this need two new tools have been designed an adhershyent clot cathete r (ACC) and a graft thrombec tomy catheter (GTC)

Fig 9 The adherent clot ca thete r in its extended position (top) during catherer introdu in contracted position (bottom) during retrieval of adherent material in native vessel

_ ~ rhe ad he rent c10r carherer rhe gra fr rhrombecromy catherer can be ldj usted so that -r in the low-profile exrended confIguration becomes larger allowi ng more aggressive l uherem clot from synrheric grafrs

u ex-covered edges of the fully corkscrew provide more of a

- edge than an inflated balloon this catheter 1110re capable of material adh ered to th e inside eI wall

-CC is designed for use in both _ ltds and synthetic grafts in situshy

( require a slightly more aggresshy-)Jch to retrieve a particularly - clot embolus or fl ap that has - mova l by a co nve ntiona l balshy ter The catheter system is apshy

- tar vessels whose diamete rs m 4 to 10 mm One particular n of this ca th ete r IS the

~~ [Ql11y of arteriovenous fistula _--J tts in which a more th orough _[ thrombotic material IS often a

bull Jlrernative to graft revision o r _cement

- 1rombectomy Catheter ruction of the GTC designed uy in syntheti c grafts is si milar to

-_ CC It consists of ei ther a N o -~ Ilch fl ex ibl e catheter body a

lg adju stable-diame ter sp iralshyOal region with a flex ible tip 101 handle (Fig 10) Unlike th e ever the double-helix-wire reshy

- GTC is shorter and sturdier -~ are not covered by latex Al so - operates over a larger range of - he exposed spiral wires collapse na tely 4 111m and can expand to ~ 16 mm - TC is a more agg res sive tool CC In use the spiral region is he low-p rofile posit ion and the

bull i t is passed along th e graft to

cction The sliding knob on the then re tracted to expand th e

[ltby engaging th e wires with

th e material to be removed The wires provide a thin circumferential line of contact with the luminal wall As with the o ther clot-retrieval ca th ete rs the pulling force can be continuously varied by adshyjustin g th e pitch of the sp iral wire dmshying middotwi thdrawal After the ca theter is reshym oved from the gra ft segments of thrombotic material are removed fro m within the sp iral regIO ns Th e device is then reinse rted and the pro cess is reshypeated until no additional residual mateshyrial can be removed As shown in Figure 11 a co nsid e rabl e volume of material call be removed by thi s method Thi s catheter is capabl C of removing all intrashyluminal m ate ri al from th e graft exposshying the bare origina l surfac e

Chapter 196 Embolecromy 2097

Improved Arce s Thru-Lumen Embolectomy Catheter

The development of th e Thru-Lumen emshybolectomy catheter has provided additional op ti ons for embolectomy and thrombecshytomy The catheter is similar to a convenshytional Foga rty embolectomy catheter ex cep t that an ad ditional lumen run s through its ce nter A V-connec to r at the proximal end has two ex tensions that alshylow access to th e tvo lumens One lumen is used for balloon inflation and the other is used for infusio n of fluids or guidewire access (Fig 12)

Whereas the stand ard Fogarty balloon ca th eter was design ed in an era in whi ch th ere was limited angiographic capability in the operating room the Thru-Lumen emb olectomy catheter has been designed to take adva ntage of the wide availab ility o f fluoroscopy in todays ope rating ro0111S The Thru-Lumen ca theter can be passed over a gLlld ewire which ca n be mon itored fluoro scopically In si tu ations of diffIcult access when a standard Fogashyrty balloon ca th e ter cannot be passed through thC obstruction a tapered Van Andel catheter can be substituted A guidewi re ca n then be placed through the Van Andel catheter Subsequently the Van An del ca th e ter ca n be removed and reshyplaced with a Thru-Lumen embolectomy ca theter Th e Thru-Lumell catheter can then be inflat ed and used for embolecshytomy in its normal manner

Fig 11 Th e grlft thrombectomy catheter is shown wirh residual clot which could not be reshymoved adequately w ith a balloon cathe ter that has been ex tracted fiom a syn th etic gra ft

2098 Part IX Vascular Surgery

Fig 12 The Tl1rLJ-LLJmen embolectomy catheter may be used to instill solutions (cop) or pass guidewires (bottom)

in electrolytes and acid-base balarlC occu r The sudden return of acidotic with a high potassium content Cd

in adverse effects on myocardial fu The necessity of using bufferin and antiarrhythmic agents shoul i ticipated at the time of clamp re and electrolyte levels should be shymeasured in the postoperative pe ~

the presence of ischemic muscle shysis restoration of limb flow may [~

the introduction of myoglobin t systemic c irculation Unless cle the kidney precipitation of myo~

the tubules may severely im pashyfunction

Myoglobinuria may be rec of1L= the absence of red blood cells in on microscopic examination ~

with a positive urinary guaiac [c ~ globinuria is suspected the patie be treated with intravenous hv middot r~_

ficient to establish a diuresis of hour as measured by indwelli r ~ catheter ou tput shy

The Thru-Lumen embolectomy catheter also can be used to deliver contrast material to monitor poundluoroscopically the clot reshymoval process without exchanging the embolectomy catheter for an angiographic catheterThe inflated balloon can also act as an occlusion device to facilitate distal localshyized injection of poundluids such as contrast media heparin or lytic agents

Management of Advanced Ischemia

Patients who have relatively far-advanced peripheral ischemia represent more diffishycult problems The recognition and treatshyment of complications that occur as a reshysult of advanced tissue ischemia lessen mortality and morbidity

The finding of acute venous thromboshysis in the presence of acute arterial occlushysion was fmt recognized in 1964 It was found that 27 of patients who had susshytained an acute arterial occlusion also had simultaneous venous occlusion and veshynous thrombectomy was required in 8 of these patients To identify venous thromshybosis a clamp is placed before arterial exshyploration to occlude venous return from the extremity After arterial embolectomy and establishment of the arterial circulashytion a second venous clamp is placed proximal to the first venous clamp and a venotomy is made between th e pair of

clamps The foot is poundlexed and extended a number of times to raise the resting veshynous pressure in the leg On release of the distal venous clamp any retained thrombus is ejected from the circulation If necessary additional venous thrombus is removed with a venous thrombectomy catheter

Swelling of a previously ischemic limb in which arterial continuity has been reestablished demands attention and is freshyquently observed in patients with obvious pregangrenous changes before the operashytion Capillary damage that results in poundluid exudation into ischemic tissue is a factor in this swelling which is often aggravated by venous outflow obstruction Fa sshyciotomy for control of massive edema has been required in 10 of the patients If manometric measurement of interstitial pressure is used any pressure exceeding 30 mm Hg is regarded as an indication for fasciotomy Failure to decompress the limb may result in compression of the arshyterial inflow and reocclusionInitial fascial decompression should be carried out through small skin incisions (a subcutashyneous fasciotomy) If immediate imshyprovement is not obtained by this limited fa sc iotomy the skin incisions should be extended and the deeper fascial compartshyments should be widely opened

Immediately after restoration of arterial continuity in limbs that present with adshyvan ced ischemia considerable alterations

POSTOPERATIVE ~ MANAGEMElT

In almost all instances anci co with intravenous heparin shou lc _ stituted 6 to 12 hours after em Although this results in wour in a few patients the likelihoo~ rent embolization is lesser ec

r ~ --

_

c

_

~_ shy

~

==

propagation of thrombus is small vessels not direcely c le ai~

embolectomy catheter Hepari ulation is continued until the fully ambulatory Oral va rfar i~ lation is also initiated 5 to I intravenous heparin adminis r co ntinued The warfarin is co definitely unless the primlr source has been defi nitive - Early ambulation is encour ce longed sitting is prohibite d~ early postoperative per iod ( effort should be expended in to un co ver a potentiall source of the embolus This 1shy

may includ e electrocardlo ~_shy

roentgenography real-time ushy

scanning cardiac radionu ci i echocardiography abdominal and angiographic evaluatio r - and thoracic and abdominal Jtshy

Secondmy Proceuure

In our series 28 of patient went balloon embolectomy to~ shy

needed additi onal surgical proshy--h ese procedures included repeat _omy balloon angioplasty or forshy la r reco nstructi on and cardiac ~ Initial imp rovement followed

- 1rati on in a postoperative limb

-

-~ ehrombos is and surgical exploshy- h repeat thrombectomy is indishy_nIb that shows marginal viability lbectomy suggests severe undershy-~ lI ive disease that must be adshye have found the combination 1 thrombec tomy and adjunctive

-Jeive balloon angioplas ty use ful 2 acute arterial occlusion caused

-_xisting atheroscl eroti c involve shylI calJy significant lesions can be -middot ieh littl e additional operative

_ middotasc ular reconstruction is warshy hould be performed early A ence of limb loss and mortality I es subsequent episodes of

SIS

orrecti on of ca rdiac sources of ~ is recommended We have pershy_ro nary artery bypass grafts aorshy- I valve replacement ventri cular

- ctomy and repair of a ventricushyJefec t resulting from infarctio n

-~ surgical balloon embo lectomy - J embolism O ur ea rly secondshydures have been performed

j signifi cant 10crease 10 major or death

eOus Thromhectomy and _lg Technologies

1~ i n g nature of vascular patholshyhe trend toward minimally inshy

~ gery have created an impetus echnologies and strategies for ieh th ro mboti c arterial occlushy

sions In recent years investi gators have p roduced a l11ultitude of pe rcutaneous thrombectomy devices and te chniques fo r clo t removal witho ut ope n surge ry An extensive review of th ese technoloshyg ies autho red by Sharafuddin and Hicks is available These new tre atm ent modali shyties include

1 Percutaneo us aspiratio n th ro mbecshyto my by whi ch suc tion is applied through a large lumen cath eter to reshymove thromboemboli c material

2 Pull-back th ro mbec tomy and clot trapping by w hich thro mbus is reshytrieved with a ball oon or basket into a trapping device for safe removal

3 Ro tati o nal and hydrauli c recirculation thrombectomy which involves the mishycrofragmentatio n of thrombus by the action of a high shea r stress hydrodyshynamic vortex

4 Fluid jets without hydrodynamic reci rshyculation to break up clo t

S T hrombectomy achi eved by the actio n of ultrasound la ser and radiofrequency energy to lyse thrombus

A new and promising approach is embodshyied in a unique device the TRELLIS that traps the fresh thromboti c occl usio n beshytween two balloons R otational mixing by this catheter system and lytic infusion intershyfaces with the fra gmented th rombus This pharmacomechanical combination enables targeted drug del ive ry and dissol ution of thrombus

N ew thrombectomy devic es and techniqu es will co ntinu e to emerge Each new technology must be carefully studi ed an d compared with standard thrombec tomy techniques to determine its clini ca l utility and to help defin e its role in the trea tment of thrombo tic arteshyrial occlusions

Chapter 196 Embolectomy 2099

SUGGESTED READING

Bar-EI Y Ada r R Sc hn eiderman Y et 11 Echocard iography in the dia gnostic assessshymen t o f periph eral arter ia l emb olization Am Hearl) 1990 119 1090

Berni GA Ba ndyk O F Zi erler RE et a Strepshytokinase treatment o f acute arterial occlushysion Ann Su rg 1983198 185

Foga rty TJ T he techniqu e o f th rombectomy and other uses of the Fogarty ca theter In Ruth erfo rd RB ed vaswlar su rgery Philade lphiaWB Sa unders 1977

Fogar ty TJ C hin A Shoor PM et a Adju nc shytive intraoperati ve arterial dilat tion simp]j shyfi ed in strumentation technique A reh Surg 1981 1 16 1391

Fogarty TJ Daily PO Shumwy NE et al Expeshyri ence with balloon catheter technique for arshyter ial embolectomy Am) Surg 1971 122231

Fogarty TJ H errmann GD N ew techniques for clo t extraction and managing acute thromshyboembolic limb ischemia lnVeith FJed Critshyical problems in vaswlar slrgery vol 3 St Louis Quali ty Medical Pub]jshers 1991

Hill B Fogarty TJThe use of the Fogarty catheter in 1998 Cardiovasc StIIg 1999 7(3)273

Sharafuddi n MJ Hicks ME C unent statu s of percutaneous mec hanical thrombectomy Part III Present and future appli ca tio ns) Vase lnlerv RadioI199 89(2) 209

Sharafuddin MJ Hicks ME C mren t status of percutane ous mechanic I thrombe ctomy Part II D evices and mec hanism of ac tion) vase lnterv RadioI19989(Pt 1) 15

Sharafuddin MJ Hicks ME C urrent status of percutaneo us mec hani ca l thrombectomy P n I General principles ) vase It1lerv Radiol 19978(6) 91l

Tawes RL Jr Beare JP Scribner R G et alV lue of postopera tive heparin therapy in per iphshye ral arterial th romboe mbolism Am) Surg 19831 46 21 3

Tawes RL Jr H arris EJ Brow n WG et alArteshyrial thromboembolism A 20-yea r perspec shytive Arch Su rg 1985 120595

SaracTp HiIleman OArko FR et al Clinical and economic evaluation of the trellis thrombecshytomy device for arterial occlusions prelimishynary analysis vase Surg 200439(3) 556

E DITORS COMMENT

__- Hill and Zarins have provided a wry trspectiv( 011 arterial embolism and

liong with an up-to-date disc ussion of -Jllagement I would first likegt to make a

between the picture of acute embolic ocshy- 1 previous normal artery and some of the Jlscussed in this chapte r As the autho rs

_ l is usually possible based on clinical presshyione to make the distincti on between

-~a l occlusion and what th ey describe as --ll1bosis In my view thjs distinction is

important If the diagn osis of ac ute eIll shy151 0n ofa previously norIllal artery can be

made based on c1 iniCJI presentation it is Ot adva ntage of the patient Under those

c ircumstances time is o f the csse-Ilee md by making the diagnosis on the clinica l picture preciolls time can be saved by getting the patient promptly to the ope(ltshying room with the expectation that the embolism and propagated thro mbus can be ~as il y removed l ith restoration of no rmal or near-normal arterial perfu shysion If however the patient is taken to the operating room w ith a dlJgnosis of Kute arterial occlusion but the underlying problem is arterial thrombosis supershyimposed on pre-existin g pcripheral vscular disease 111ltl l1 agelllenr in the operJrin g roonl can become much more complex and needlessly compromised because of inadequate information

T he questio n therefore is how does one make this distinction Lets take the Illost conlillOIl exanlshy

pie of cute occlusion of the superficial femoral ar shytery This occurs becausc an cmboli sm fi-om the hea rt has lodged at the common femoral bi fllrcashyti o n Because th e superfi cial femoral arte ry was previo llsly perfectly no rmal there is no collateral circulation and therefore the limb below the knee is iIllllleciilteiy extremely ischenlic This results in the classic picture of severe pain pallor (110 capilshylo ry filling) paresth esias and paralysis Such limbs are cadaveric in appearance and there is no ques shytio n about the no nviabil ity of the limb O ften there is a po unding waterhammer pulse palpable in the comlllon femo ral artery U nder those cirshyClIIl1stances and with th e an cillary ITlanagcll1ellt as described by the 3utho rs the patient may be taken

(co l1tin ue d)

i

2096 Part IX Vascular Surgery

Adherent Clot Catheter The ACC consists of a No 4 or 6 fl exible catheter body with an adJ ll pitch corkscrew-shaped distal tip ( The corkscrew balloon consists of balloo n membrane covering an Oll

ble that is loosely spiraled around a wire running the length of the cael a control handle at th e proximal lt 1

control handle allows the surgeon just the pitch and diameter corkscrew from completely strai fully spiraled Unlike the conwi Fogarty balloon catheter the AD not inflate Instead the diameter corkscrew-shaped working end catheter is varied by mechanical ref of the mner wire via a knob on th trol handle In this manner the de can be continuously adjusted from profIle No6 French size to a JargeE eter of up to 10 mm

The ACC is used like th e c( tional Fogarty balloon catheter Ari tial exploration with the standal loon catheter the ACC tip is coll al its low-profile position and passe the vessel and beyond the thromb knob on the control handle is tb tra cted until the spiral is enlarged desired diameter th ereby engagi thromboti c materi al within th e stices of th e spiral Subseque m catheter is drawn slowly back ala vessel and the material is rc through the arteriotomy As in th ventional balloon catheter tec hn i diameter of th e spiral can be adju cording to feel in response to rIO within the vessel

The ACCs mechanism of entr of the clot is thus quite differe t that of the conventional balloon c The traditional Fogarty balloon is distal to the material and essential the thrombus alo ng the vessel to arteriotomy In contrast the co r entraps thromboti c material - itmiddot spaces of the spiral providing alar of contact to grip and remove rl

_

r--

Fig 8 Technique of po pliteotibial exploration

obstru ction beyond this point necessitates direct exposure of the anterior and posteshyrior tibial arteries at the ankle By direct manipulation of the vessel combined with gentle simultaneous probing of the catheter from the proximal end one is frequently able to pass the catheter beyond the point of obstruction without the necessity of an arteriotomy If an arteriotomy at the ankle level in either of these vessels is required an incision only large enough to allow the inshytroduction of the No2 French catheter is made into the vessel The catheter is threaded distally inflated and withdrawn in the inflated condition This maneuver freshyquently brings the thrombotic material above the small arteriotomy Additional atshytempts to extract this thrombotic material should be made by introducing a No2 or 3 French catheter into either the anterior or posterior vessels at the level of the popliteal arteriotomy This maneuver avoids the neshycessity of enlarging the arteriotomy at the ankle joint and decreases the possibility of reocclusion After removal of the thromshybotic material copious irrigation of the disshytal artenal system should be ca rried out with a heparinized solution

Extraction of Upper-Limb Emboli

The technique for management of emshyboli to the upper limb is identical to that described for the lower limb Proximal subshyclavian artery emboli can be routinely reshymoved under local anesthesia by retrograde

extraction from a brachial arteriotomy It should always b e borne in mind howshyever that if the embolus appears to reside in proximity to the origin of the cranial vessels fragmentation of the embolus may occur during manipulation resultshying in central nervous system emboli and ischemia

Removal of Mature Adherent Thrombotic Material

As the patient population becomes inshycreasingly elderly and more prone to athshyerosclerosis mature adherent thrombotic lesions are becoming more prevalent The standard fluid-filled Fogarty balloon catheter is quite efficient for removing large amounts of soft fresh thrombus but it is limi ted in its ability to remove more adherent material such as olde r clot of thrombotic origin To meet this need two new tools have been designed an adhershyent clot cathete r (ACC) and a graft thrombec tomy catheter (GTC)

Fig 9 The adherent clot ca thete r in its extended position (top) during catherer introdu in contracted position (bottom) during retrieval of adherent material in native vessel

_ ~ rhe ad he rent c10r carherer rhe gra fr rhrombecromy catherer can be ldj usted so that -r in the low-profile exrended confIguration becomes larger allowi ng more aggressive l uherem clot from synrheric grafrs

u ex-covered edges of the fully corkscrew provide more of a

- edge than an inflated balloon this catheter 1110re capable of material adh ered to th e inside eI wall

-CC is designed for use in both _ ltds and synthetic grafts in situshy

( require a slightly more aggresshy-)Jch to retrieve a particularly - clot embolus or fl ap that has - mova l by a co nve ntiona l balshy ter The catheter system is apshy

- tar vessels whose diamete rs m 4 to 10 mm One particular n of this ca th ete r IS the

~~ [Ql11y of arteriovenous fistula _--J tts in which a more th orough _[ thrombotic material IS often a

bull Jlrernative to graft revision o r _cement

- 1rombectomy Catheter ruction of the GTC designed uy in syntheti c grafts is si milar to

-_ CC It consists of ei ther a N o -~ Ilch fl ex ibl e catheter body a

lg adju stable-diame ter sp iralshyOal region with a flex ible tip 101 handle (Fig 10) Unlike th e ever the double-helix-wire reshy

- GTC is shorter and sturdier -~ are not covered by latex Al so - operates over a larger range of - he exposed spiral wires collapse na tely 4 111m and can expand to ~ 16 mm - TC is a more agg res sive tool CC In use the spiral region is he low-p rofile posit ion and the

bull i t is passed along th e graft to

cction The sliding knob on the then re tracted to expand th e

[ltby engaging th e wires with

th e material to be removed The wires provide a thin circumferential line of contact with the luminal wall As with the o ther clot-retrieval ca th ete rs the pulling force can be continuously varied by adshyjustin g th e pitch of the sp iral wire dmshying middotwi thdrawal After the ca theter is reshym oved from the gra ft segments of thrombotic material are removed fro m within the sp iral regIO ns Th e device is then reinse rted and the pro cess is reshypeated until no additional residual mateshyrial can be removed As shown in Figure 11 a co nsid e rabl e volume of material call be removed by thi s method Thi s catheter is capabl C of removing all intrashyluminal m ate ri al from th e graft exposshying the bare origina l surfac e

Chapter 196 Embolecromy 2097

Improved Arce s Thru-Lumen Embolectomy Catheter

The development of th e Thru-Lumen emshybolectomy catheter has provided additional op ti ons for embolectomy and thrombecshytomy The catheter is similar to a convenshytional Foga rty embolectomy catheter ex cep t that an ad ditional lumen run s through its ce nter A V-connec to r at the proximal end has two ex tensions that alshylow access to th e tvo lumens One lumen is used for balloon inflation and the other is used for infusio n of fluids or guidewire access (Fig 12)

Whereas the stand ard Fogarty balloon ca th eter was design ed in an era in whi ch th ere was limited angiographic capability in the operating room the Thru-Lumen emb olectomy catheter has been designed to take adva ntage of the wide availab ility o f fluoroscopy in todays ope rating ro0111S The Thru-Lumen ca theter can be passed over a gLlld ewire which ca n be mon itored fluoro scopically In si tu ations of diffIcult access when a standard Fogashyrty balloon ca th e ter cannot be passed through thC obstruction a tapered Van Andel catheter can be substituted A guidewi re ca n then be placed through the Van Andel catheter Subsequently the Van An del ca th e ter ca n be removed and reshyplaced with a Thru-Lumen embolectomy ca theter Th e Thru-Lumell catheter can then be inflat ed and used for embolecshytomy in its normal manner

Fig 11 Th e grlft thrombectomy catheter is shown wirh residual clot which could not be reshymoved adequately w ith a balloon cathe ter that has been ex tracted fiom a syn th etic gra ft

2098 Part IX Vascular Surgery

Fig 12 The Tl1rLJ-LLJmen embolectomy catheter may be used to instill solutions (cop) or pass guidewires (bottom)

in electrolytes and acid-base balarlC occu r The sudden return of acidotic with a high potassium content Cd

in adverse effects on myocardial fu The necessity of using bufferin and antiarrhythmic agents shoul i ticipated at the time of clamp re and electrolyte levels should be shymeasured in the postoperative pe ~

the presence of ischemic muscle shysis restoration of limb flow may [~

the introduction of myoglobin t systemic c irculation Unless cle the kidney precipitation of myo~

the tubules may severely im pashyfunction

Myoglobinuria may be rec of1L= the absence of red blood cells in on microscopic examination ~

with a positive urinary guaiac [c ~ globinuria is suspected the patie be treated with intravenous hv middot r~_

ficient to establish a diuresis of hour as measured by indwelli r ~ catheter ou tput shy

The Thru-Lumen embolectomy catheter also can be used to deliver contrast material to monitor poundluoroscopically the clot reshymoval process without exchanging the embolectomy catheter for an angiographic catheterThe inflated balloon can also act as an occlusion device to facilitate distal localshyized injection of poundluids such as contrast media heparin or lytic agents

Management of Advanced Ischemia

Patients who have relatively far-advanced peripheral ischemia represent more diffishycult problems The recognition and treatshyment of complications that occur as a reshysult of advanced tissue ischemia lessen mortality and morbidity

The finding of acute venous thromboshysis in the presence of acute arterial occlushysion was fmt recognized in 1964 It was found that 27 of patients who had susshytained an acute arterial occlusion also had simultaneous venous occlusion and veshynous thrombectomy was required in 8 of these patients To identify venous thromshybosis a clamp is placed before arterial exshyploration to occlude venous return from the extremity After arterial embolectomy and establishment of the arterial circulashytion a second venous clamp is placed proximal to the first venous clamp and a venotomy is made between th e pair of

clamps The foot is poundlexed and extended a number of times to raise the resting veshynous pressure in the leg On release of the distal venous clamp any retained thrombus is ejected from the circulation If necessary additional venous thrombus is removed with a venous thrombectomy catheter

Swelling of a previously ischemic limb in which arterial continuity has been reestablished demands attention and is freshyquently observed in patients with obvious pregangrenous changes before the operashytion Capillary damage that results in poundluid exudation into ischemic tissue is a factor in this swelling which is often aggravated by venous outflow obstruction Fa sshyciotomy for control of massive edema has been required in 10 of the patients If manometric measurement of interstitial pressure is used any pressure exceeding 30 mm Hg is regarded as an indication for fasciotomy Failure to decompress the limb may result in compression of the arshyterial inflow and reocclusionInitial fascial decompression should be carried out through small skin incisions (a subcutashyneous fasciotomy) If immediate imshyprovement is not obtained by this limited fa sc iotomy the skin incisions should be extended and the deeper fascial compartshyments should be widely opened

Immediately after restoration of arterial continuity in limbs that present with adshyvan ced ischemia considerable alterations

POSTOPERATIVE ~ MANAGEMElT

In almost all instances anci co with intravenous heparin shou lc _ stituted 6 to 12 hours after em Although this results in wour in a few patients the likelihoo~ rent embolization is lesser ec

r ~ --

_

c

_

~_ shy

~

==

propagation of thrombus is small vessels not direcely c le ai~

embolectomy catheter Hepari ulation is continued until the fully ambulatory Oral va rfar i~ lation is also initiated 5 to I intravenous heparin adminis r co ntinued The warfarin is co definitely unless the primlr source has been defi nitive - Early ambulation is encour ce longed sitting is prohibite d~ early postoperative per iod ( effort should be expended in to un co ver a potentiall source of the embolus This 1shy

may includ e electrocardlo ~_shy

roentgenography real-time ushy

scanning cardiac radionu ci i echocardiography abdominal and angiographic evaluatio r - and thoracic and abdominal Jtshy

Secondmy Proceuure

In our series 28 of patient went balloon embolectomy to~ shy

needed additi onal surgical proshy--h ese procedures included repeat _omy balloon angioplasty or forshy la r reco nstructi on and cardiac ~ Initial imp rovement followed

- 1rati on in a postoperative limb

-

-~ ehrombos is and surgical exploshy- h repeat thrombectomy is indishy_nIb that shows marginal viability lbectomy suggests severe undershy-~ lI ive disease that must be adshye have found the combination 1 thrombec tomy and adjunctive

-Jeive balloon angioplas ty use ful 2 acute arterial occlusion caused

-_xisting atheroscl eroti c involve shylI calJy significant lesions can be -middot ieh littl e additional operative

_ middotasc ular reconstruction is warshy hould be performed early A ence of limb loss and mortality I es subsequent episodes of

SIS

orrecti on of ca rdiac sources of ~ is recommended We have pershy_ro nary artery bypass grafts aorshy- I valve replacement ventri cular

- ctomy and repair of a ventricushyJefec t resulting from infarctio n

-~ surgical balloon embo lectomy - J embolism O ur ea rly secondshydures have been performed

j signifi cant 10crease 10 major or death

eOus Thromhectomy and _lg Technologies

1~ i n g nature of vascular patholshyhe trend toward minimally inshy

~ gery have created an impetus echnologies and strategies for ieh th ro mboti c arterial occlushy

sions In recent years investi gators have p roduced a l11ultitude of pe rcutaneous thrombectomy devices and te chniques fo r clo t removal witho ut ope n surge ry An extensive review of th ese technoloshyg ies autho red by Sharafuddin and Hicks is available These new tre atm ent modali shyties include

1 Percutaneo us aspiratio n th ro mbecshyto my by whi ch suc tion is applied through a large lumen cath eter to reshymove thromboemboli c material

2 Pull-back th ro mbec tomy and clot trapping by w hich thro mbus is reshytrieved with a ball oon or basket into a trapping device for safe removal

3 Ro tati o nal and hydrauli c recirculation thrombectomy which involves the mishycrofragmentatio n of thrombus by the action of a high shea r stress hydrodyshynamic vortex

4 Fluid jets without hydrodynamic reci rshyculation to break up clo t

S T hrombectomy achi eved by the actio n of ultrasound la ser and radiofrequency energy to lyse thrombus

A new and promising approach is embodshyied in a unique device the TRELLIS that traps the fresh thromboti c occl usio n beshytween two balloons R otational mixing by this catheter system and lytic infusion intershyfaces with the fra gmented th rombus This pharmacomechanical combination enables targeted drug del ive ry and dissol ution of thrombus

N ew thrombectomy devic es and techniqu es will co ntinu e to emerge Each new technology must be carefully studi ed an d compared with standard thrombec tomy techniques to determine its clini ca l utility and to help defin e its role in the trea tment of thrombo tic arteshyrial occlusions

Chapter 196 Embolectomy 2099

SUGGESTED READING

Bar-EI Y Ada r R Sc hn eiderman Y et 11 Echocard iography in the dia gnostic assessshymen t o f periph eral arter ia l emb olization Am Hearl) 1990 119 1090

Berni GA Ba ndyk O F Zi erler RE et a Strepshytokinase treatment o f acute arterial occlushysion Ann Su rg 1983198 185

Foga rty TJ T he techniqu e o f th rombectomy and other uses of the Fogarty ca theter In Ruth erfo rd RB ed vaswlar su rgery Philade lphiaWB Sa unders 1977

Fogar ty TJ C hin A Shoor PM et a Adju nc shytive intraoperati ve arterial dilat tion simp]j shyfi ed in strumentation technique A reh Surg 1981 1 16 1391

Fogarty TJ Daily PO Shumwy NE et al Expeshyri ence with balloon catheter technique for arshyter ial embolectomy Am) Surg 1971 122231

Fogarty TJ H errmann GD N ew techniques for clo t extraction and managing acute thromshyboembolic limb ischemia lnVeith FJed Critshyical problems in vaswlar slrgery vol 3 St Louis Quali ty Medical Pub]jshers 1991

Hill B Fogarty TJThe use of the Fogarty catheter in 1998 Cardiovasc StIIg 1999 7(3)273

Sharafuddi n MJ Hicks ME C unent statu s of percutaneous mec hanical thrombectomy Part III Present and future appli ca tio ns) Vase lnlerv RadioI199 89(2) 209

Sharafuddin MJ Hicks ME C mren t status of percutane ous mechanic I thrombe ctomy Part II D evices and mec hanism of ac tion) vase lnterv RadioI19989(Pt 1) 15

Sharafuddin MJ Hicks ME C urrent status of percutaneo us mec hani ca l thrombectomy P n I General principles ) vase It1lerv Radiol 19978(6) 91l

Tawes RL Jr Beare JP Scribner R G et alV lue of postopera tive heparin therapy in per iphshye ral arterial th romboe mbolism Am) Surg 19831 46 21 3

Tawes RL Jr H arris EJ Brow n WG et alArteshyrial thromboembolism A 20-yea r perspec shytive Arch Su rg 1985 120595

SaracTp HiIleman OArko FR et al Clinical and economic evaluation of the trellis thrombecshytomy device for arterial occlusions prelimishynary analysis vase Surg 200439(3) 556

E DITORS COMMENT

__- Hill and Zarins have provided a wry trspectiv( 011 arterial embolism and

liong with an up-to-date disc ussion of -Jllagement I would first likegt to make a

between the picture of acute embolic ocshy- 1 previous normal artery and some of the Jlscussed in this chapte r As the autho rs

_ l is usually possible based on clinical presshyione to make the distincti on between

-~a l occlusion and what th ey describe as --ll1bosis In my view thjs distinction is

important If the diagn osis of ac ute eIll shy151 0n ofa previously norIllal artery can be

made based on c1 iniCJI presentation it is Ot adva ntage of the patient Under those

c ircumstances time is o f the csse-Ilee md by making the diagnosis on the clinica l picture preciolls time can be saved by getting the patient promptly to the ope(ltshying room with the expectation that the embolism and propagated thro mbus can be ~as il y removed l ith restoration of no rmal or near-normal arterial perfu shysion If however the patient is taken to the operating room w ith a dlJgnosis of Kute arterial occlusion but the underlying problem is arterial thrombosis supershyimposed on pre-existin g pcripheral vscular disease 111ltl l1 agelllenr in the operJrin g roonl can become much more complex and needlessly compromised because of inadequate information

T he questio n therefore is how does one make this distinction Lets take the Illost conlillOIl exanlshy

pie of cute occlusion of the superficial femoral ar shytery This occurs becausc an cmboli sm fi-om the hea rt has lodged at the common femoral bi fllrcashyti o n Because th e superfi cial femoral arte ry was previo llsly perfectly no rmal there is no collateral circulation and therefore the limb below the knee is iIllllleciilteiy extremely ischenlic This results in the classic picture of severe pain pallor (110 capilshylo ry filling) paresth esias and paralysis Such limbs are cadaveric in appearance and there is no ques shytio n about the no nviabil ity of the limb O ften there is a po unding waterhammer pulse palpable in the comlllon femo ral artery U nder those cirshyClIIl1stances and with th e an cillary ITlanagcll1ellt as described by the 3utho rs the patient may be taken

(co l1tin ue d)

_ ~ rhe ad he rent c10r carherer rhe gra fr rhrombecromy catherer can be ldj usted so that -r in the low-profile exrended confIguration becomes larger allowi ng more aggressive l uherem clot from synrheric grafrs

u ex-covered edges of the fully corkscrew provide more of a

- edge than an inflated balloon this catheter 1110re capable of material adh ered to th e inside eI wall

-CC is designed for use in both _ ltds and synthetic grafts in situshy

( require a slightly more aggresshy-)Jch to retrieve a particularly - clot embolus or fl ap that has - mova l by a co nve ntiona l balshy ter The catheter system is apshy

- tar vessels whose diamete rs m 4 to 10 mm One particular n of this ca th ete r IS the

~~ [Ql11y of arteriovenous fistula _--J tts in which a more th orough _[ thrombotic material IS often a

bull Jlrernative to graft revision o r _cement

- 1rombectomy Catheter ruction of the GTC designed uy in syntheti c grafts is si milar to

-_ CC It consists of ei ther a N o -~ Ilch fl ex ibl e catheter body a

lg adju stable-diame ter sp iralshyOal region with a flex ible tip 101 handle (Fig 10) Unlike th e ever the double-helix-wire reshy

- GTC is shorter and sturdier -~ are not covered by latex Al so - operates over a larger range of - he exposed spiral wires collapse na tely 4 111m and can expand to ~ 16 mm - TC is a more agg res sive tool CC In use the spiral region is he low-p rofile posit ion and the

bull i t is passed along th e graft to

cction The sliding knob on the then re tracted to expand th e

[ltby engaging th e wires with

th e material to be removed The wires provide a thin circumferential line of contact with the luminal wall As with the o ther clot-retrieval ca th ete rs the pulling force can be continuously varied by adshyjustin g th e pitch of the sp iral wire dmshying middotwi thdrawal After the ca theter is reshym oved from the gra ft segments of thrombotic material are removed fro m within the sp iral regIO ns Th e device is then reinse rted and the pro cess is reshypeated until no additional residual mateshyrial can be removed As shown in Figure 11 a co nsid e rabl e volume of material call be removed by thi s method Thi s catheter is capabl C of removing all intrashyluminal m ate ri al from th e graft exposshying the bare origina l surfac e

Chapter 196 Embolecromy 2097

Improved Arce s Thru-Lumen Embolectomy Catheter

The development of th e Thru-Lumen emshybolectomy catheter has provided additional op ti ons for embolectomy and thrombecshytomy The catheter is similar to a convenshytional Foga rty embolectomy catheter ex cep t that an ad ditional lumen run s through its ce nter A V-connec to r at the proximal end has two ex tensions that alshylow access to th e tvo lumens One lumen is used for balloon inflation and the other is used for infusio n of fluids or guidewire access (Fig 12)

Whereas the stand ard Fogarty balloon ca th eter was design ed in an era in whi ch th ere was limited angiographic capability in the operating room the Thru-Lumen emb olectomy catheter has been designed to take adva ntage of the wide availab ility o f fluoroscopy in todays ope rating ro0111S The Thru-Lumen ca theter can be passed over a gLlld ewire which ca n be mon itored fluoro scopically In si tu ations of diffIcult access when a standard Fogashyrty balloon ca th e ter cannot be passed through thC obstruction a tapered Van Andel catheter can be substituted A guidewi re ca n then be placed through the Van Andel catheter Subsequently the Van An del ca th e ter ca n be removed and reshyplaced with a Thru-Lumen embolectomy ca theter Th e Thru-Lumell catheter can then be inflat ed and used for embolecshytomy in its normal manner

Fig 11 Th e grlft thrombectomy catheter is shown wirh residual clot which could not be reshymoved adequately w ith a balloon cathe ter that has been ex tracted fiom a syn th etic gra ft

2098 Part IX Vascular Surgery

Fig 12 The Tl1rLJ-LLJmen embolectomy catheter may be used to instill solutions (cop) or pass guidewires (bottom)

in electrolytes and acid-base balarlC occu r The sudden return of acidotic with a high potassium content Cd

in adverse effects on myocardial fu The necessity of using bufferin and antiarrhythmic agents shoul i ticipated at the time of clamp re and electrolyte levels should be shymeasured in the postoperative pe ~

the presence of ischemic muscle shysis restoration of limb flow may [~

the introduction of myoglobin t systemic c irculation Unless cle the kidney precipitation of myo~

the tubules may severely im pashyfunction

Myoglobinuria may be rec of1L= the absence of red blood cells in on microscopic examination ~

with a positive urinary guaiac [c ~ globinuria is suspected the patie be treated with intravenous hv middot r~_

ficient to establish a diuresis of hour as measured by indwelli r ~ catheter ou tput shy

The Thru-Lumen embolectomy catheter also can be used to deliver contrast material to monitor poundluoroscopically the clot reshymoval process without exchanging the embolectomy catheter for an angiographic catheterThe inflated balloon can also act as an occlusion device to facilitate distal localshyized injection of poundluids such as contrast media heparin or lytic agents

Management of Advanced Ischemia

Patients who have relatively far-advanced peripheral ischemia represent more diffishycult problems The recognition and treatshyment of complications that occur as a reshysult of advanced tissue ischemia lessen mortality and morbidity

The finding of acute venous thromboshysis in the presence of acute arterial occlushysion was fmt recognized in 1964 It was found that 27 of patients who had susshytained an acute arterial occlusion also had simultaneous venous occlusion and veshynous thrombectomy was required in 8 of these patients To identify venous thromshybosis a clamp is placed before arterial exshyploration to occlude venous return from the extremity After arterial embolectomy and establishment of the arterial circulashytion a second venous clamp is placed proximal to the first venous clamp and a venotomy is made between th e pair of

clamps The foot is poundlexed and extended a number of times to raise the resting veshynous pressure in the leg On release of the distal venous clamp any retained thrombus is ejected from the circulation If necessary additional venous thrombus is removed with a venous thrombectomy catheter

Swelling of a previously ischemic limb in which arterial continuity has been reestablished demands attention and is freshyquently observed in patients with obvious pregangrenous changes before the operashytion Capillary damage that results in poundluid exudation into ischemic tissue is a factor in this swelling which is often aggravated by venous outflow obstruction Fa sshyciotomy for control of massive edema has been required in 10 of the patients If manometric measurement of interstitial pressure is used any pressure exceeding 30 mm Hg is regarded as an indication for fasciotomy Failure to decompress the limb may result in compression of the arshyterial inflow and reocclusionInitial fascial decompression should be carried out through small skin incisions (a subcutashyneous fasciotomy) If immediate imshyprovement is not obtained by this limited fa sc iotomy the skin incisions should be extended and the deeper fascial compartshyments should be widely opened

Immediately after restoration of arterial continuity in limbs that present with adshyvan ced ischemia considerable alterations

POSTOPERATIVE ~ MANAGEMElT

In almost all instances anci co with intravenous heparin shou lc _ stituted 6 to 12 hours after em Although this results in wour in a few patients the likelihoo~ rent embolization is lesser ec

r ~ --

_

c

_

~_ shy

~

==

propagation of thrombus is small vessels not direcely c le ai~

embolectomy catheter Hepari ulation is continued until the fully ambulatory Oral va rfar i~ lation is also initiated 5 to I intravenous heparin adminis r co ntinued The warfarin is co definitely unless the primlr source has been defi nitive - Early ambulation is encour ce longed sitting is prohibite d~ early postoperative per iod ( effort should be expended in to un co ver a potentiall source of the embolus This 1shy

may includ e electrocardlo ~_shy

roentgenography real-time ushy

scanning cardiac radionu ci i echocardiography abdominal and angiographic evaluatio r - and thoracic and abdominal Jtshy

Secondmy Proceuure

In our series 28 of patient went balloon embolectomy to~ shy

needed additi onal surgical proshy--h ese procedures included repeat _omy balloon angioplasty or forshy la r reco nstructi on and cardiac ~ Initial imp rovement followed

- 1rati on in a postoperative limb

-

-~ ehrombos is and surgical exploshy- h repeat thrombectomy is indishy_nIb that shows marginal viability lbectomy suggests severe undershy-~ lI ive disease that must be adshye have found the combination 1 thrombec tomy and adjunctive

-Jeive balloon angioplas ty use ful 2 acute arterial occlusion caused

-_xisting atheroscl eroti c involve shylI calJy significant lesions can be -middot ieh littl e additional operative

_ middotasc ular reconstruction is warshy hould be performed early A ence of limb loss and mortality I es subsequent episodes of

SIS

orrecti on of ca rdiac sources of ~ is recommended We have pershy_ro nary artery bypass grafts aorshy- I valve replacement ventri cular

- ctomy and repair of a ventricushyJefec t resulting from infarctio n

-~ surgical balloon embo lectomy - J embolism O ur ea rly secondshydures have been performed

j signifi cant 10crease 10 major or death

eOus Thromhectomy and _lg Technologies

1~ i n g nature of vascular patholshyhe trend toward minimally inshy

~ gery have created an impetus echnologies and strategies for ieh th ro mboti c arterial occlushy

sions In recent years investi gators have p roduced a l11ultitude of pe rcutaneous thrombectomy devices and te chniques fo r clo t removal witho ut ope n surge ry An extensive review of th ese technoloshyg ies autho red by Sharafuddin and Hicks is available These new tre atm ent modali shyties include

1 Percutaneo us aspiratio n th ro mbecshyto my by whi ch suc tion is applied through a large lumen cath eter to reshymove thromboemboli c material

2 Pull-back th ro mbec tomy and clot trapping by w hich thro mbus is reshytrieved with a ball oon or basket into a trapping device for safe removal

3 Ro tati o nal and hydrauli c recirculation thrombectomy which involves the mishycrofragmentatio n of thrombus by the action of a high shea r stress hydrodyshynamic vortex

4 Fluid jets without hydrodynamic reci rshyculation to break up clo t

S T hrombectomy achi eved by the actio n of ultrasound la ser and radiofrequency energy to lyse thrombus

A new and promising approach is embodshyied in a unique device the TRELLIS that traps the fresh thromboti c occl usio n beshytween two balloons R otational mixing by this catheter system and lytic infusion intershyfaces with the fra gmented th rombus This pharmacomechanical combination enables targeted drug del ive ry and dissol ution of thrombus

N ew thrombectomy devic es and techniqu es will co ntinu e to emerge Each new technology must be carefully studi ed an d compared with standard thrombec tomy techniques to determine its clini ca l utility and to help defin e its role in the trea tment of thrombo tic arteshyrial occlusions

Chapter 196 Embolectomy 2099

SUGGESTED READING

Bar-EI Y Ada r R Sc hn eiderman Y et 11 Echocard iography in the dia gnostic assessshymen t o f periph eral arter ia l emb olization Am Hearl) 1990 119 1090

Berni GA Ba ndyk O F Zi erler RE et a Strepshytokinase treatment o f acute arterial occlushysion Ann Su rg 1983198 185

Foga rty TJ T he techniqu e o f th rombectomy and other uses of the Fogarty ca theter In Ruth erfo rd RB ed vaswlar su rgery Philade lphiaWB Sa unders 1977

Fogar ty TJ C hin A Shoor PM et a Adju nc shytive intraoperati ve arterial dilat tion simp]j shyfi ed in strumentation technique A reh Surg 1981 1 16 1391

Fogarty TJ Daily PO Shumwy NE et al Expeshyri ence with balloon catheter technique for arshyter ial embolectomy Am) Surg 1971 122231

Fogarty TJ H errmann GD N ew techniques for clo t extraction and managing acute thromshyboembolic limb ischemia lnVeith FJed Critshyical problems in vaswlar slrgery vol 3 St Louis Quali ty Medical Pub]jshers 1991

Hill B Fogarty TJThe use of the Fogarty catheter in 1998 Cardiovasc StIIg 1999 7(3)273

Sharafuddi n MJ Hicks ME C unent statu s of percutaneous mec hanical thrombectomy Part III Present and future appli ca tio ns) Vase lnlerv RadioI199 89(2) 209

Sharafuddin MJ Hicks ME C mren t status of percutane ous mechanic I thrombe ctomy Part II D evices and mec hanism of ac tion) vase lnterv RadioI19989(Pt 1) 15

Sharafuddin MJ Hicks ME C urrent status of percutaneo us mec hani ca l thrombectomy P n I General principles ) vase It1lerv Radiol 19978(6) 91l

Tawes RL Jr Beare JP Scribner R G et alV lue of postopera tive heparin therapy in per iphshye ral arterial th romboe mbolism Am) Surg 19831 46 21 3

Tawes RL Jr H arris EJ Brow n WG et alArteshyrial thromboembolism A 20-yea r perspec shytive Arch Su rg 1985 120595

SaracTp HiIleman OArko FR et al Clinical and economic evaluation of the trellis thrombecshytomy device for arterial occlusions prelimishynary analysis vase Surg 200439(3) 556

E DITORS COMMENT

__- Hill and Zarins have provided a wry trspectiv( 011 arterial embolism and

liong with an up-to-date disc ussion of -Jllagement I would first likegt to make a

between the picture of acute embolic ocshy- 1 previous normal artery and some of the Jlscussed in this chapte r As the autho rs

_ l is usually possible based on clinical presshyione to make the distincti on between

-~a l occlusion and what th ey describe as --ll1bosis In my view thjs distinction is

important If the diagn osis of ac ute eIll shy151 0n ofa previously norIllal artery can be

made based on c1 iniCJI presentation it is Ot adva ntage of the patient Under those

c ircumstances time is o f the csse-Ilee md by making the diagnosis on the clinica l picture preciolls time can be saved by getting the patient promptly to the ope(ltshying room with the expectation that the embolism and propagated thro mbus can be ~as il y removed l ith restoration of no rmal or near-normal arterial perfu shysion If however the patient is taken to the operating room w ith a dlJgnosis of Kute arterial occlusion but the underlying problem is arterial thrombosis supershyimposed on pre-existin g pcripheral vscular disease 111ltl l1 agelllenr in the operJrin g roonl can become much more complex and needlessly compromised because of inadequate information

T he questio n therefore is how does one make this distinction Lets take the Illost conlillOIl exanlshy

pie of cute occlusion of the superficial femoral ar shytery This occurs becausc an cmboli sm fi-om the hea rt has lodged at the common femoral bi fllrcashyti o n Because th e superfi cial femoral arte ry was previo llsly perfectly no rmal there is no collateral circulation and therefore the limb below the knee is iIllllleciilteiy extremely ischenlic This results in the classic picture of severe pain pallor (110 capilshylo ry filling) paresth esias and paralysis Such limbs are cadaveric in appearance and there is no ques shytio n about the no nviabil ity of the limb O ften there is a po unding waterhammer pulse palpable in the comlllon femo ral artery U nder those cirshyClIIl1stances and with th e an cillary ITlanagcll1ellt as described by the 3utho rs the patient may be taken

(co l1tin ue d)

2098 Part IX Vascular Surgery

Fig 12 The Tl1rLJ-LLJmen embolectomy catheter may be used to instill solutions (cop) or pass guidewires (bottom)

in electrolytes and acid-base balarlC occu r The sudden return of acidotic with a high potassium content Cd

in adverse effects on myocardial fu The necessity of using bufferin and antiarrhythmic agents shoul i ticipated at the time of clamp re and electrolyte levels should be shymeasured in the postoperative pe ~

the presence of ischemic muscle shysis restoration of limb flow may [~

the introduction of myoglobin t systemic c irculation Unless cle the kidney precipitation of myo~

the tubules may severely im pashyfunction

Myoglobinuria may be rec of1L= the absence of red blood cells in on microscopic examination ~

with a positive urinary guaiac [c ~ globinuria is suspected the patie be treated with intravenous hv middot r~_

ficient to establish a diuresis of hour as measured by indwelli r ~ catheter ou tput shy

The Thru-Lumen embolectomy catheter also can be used to deliver contrast material to monitor poundluoroscopically the clot reshymoval process without exchanging the embolectomy catheter for an angiographic catheterThe inflated balloon can also act as an occlusion device to facilitate distal localshyized injection of poundluids such as contrast media heparin or lytic agents

Management of Advanced Ischemia

Patients who have relatively far-advanced peripheral ischemia represent more diffishycult problems The recognition and treatshyment of complications that occur as a reshysult of advanced tissue ischemia lessen mortality and morbidity

The finding of acute venous thromboshysis in the presence of acute arterial occlushysion was fmt recognized in 1964 It was found that 27 of patients who had susshytained an acute arterial occlusion also had simultaneous venous occlusion and veshynous thrombectomy was required in 8 of these patients To identify venous thromshybosis a clamp is placed before arterial exshyploration to occlude venous return from the extremity After arterial embolectomy and establishment of the arterial circulashytion a second venous clamp is placed proximal to the first venous clamp and a venotomy is made between th e pair of

clamps The foot is poundlexed and extended a number of times to raise the resting veshynous pressure in the leg On release of the distal venous clamp any retained thrombus is ejected from the circulation If necessary additional venous thrombus is removed with a venous thrombectomy catheter

Swelling of a previously ischemic limb in which arterial continuity has been reestablished demands attention and is freshyquently observed in patients with obvious pregangrenous changes before the operashytion Capillary damage that results in poundluid exudation into ischemic tissue is a factor in this swelling which is often aggravated by venous outflow obstruction Fa sshyciotomy for control of massive edema has been required in 10 of the patients If manometric measurement of interstitial pressure is used any pressure exceeding 30 mm Hg is regarded as an indication for fasciotomy Failure to decompress the limb may result in compression of the arshyterial inflow and reocclusionInitial fascial decompression should be carried out through small skin incisions (a subcutashyneous fasciotomy) If immediate imshyprovement is not obtained by this limited fa sc iotomy the skin incisions should be extended and the deeper fascial compartshyments should be widely opened

Immediately after restoration of arterial continuity in limbs that present with adshyvan ced ischemia considerable alterations

POSTOPERATIVE ~ MANAGEMElT

In almost all instances anci co with intravenous heparin shou lc _ stituted 6 to 12 hours after em Although this results in wour in a few patients the likelihoo~ rent embolization is lesser ec

r ~ --

_

c

_

~_ shy

~

==

propagation of thrombus is small vessels not direcely c le ai~

embolectomy catheter Hepari ulation is continued until the fully ambulatory Oral va rfar i~ lation is also initiated 5 to I intravenous heparin adminis r co ntinued The warfarin is co definitely unless the primlr source has been defi nitive - Early ambulation is encour ce longed sitting is prohibite d~ early postoperative per iod ( effort should be expended in to un co ver a potentiall source of the embolus This 1shy

may includ e electrocardlo ~_shy

roentgenography real-time ushy

scanning cardiac radionu ci i echocardiography abdominal and angiographic evaluatio r - and thoracic and abdominal Jtshy

Secondmy Proceuure

In our series 28 of patient went balloon embolectomy to~ shy

needed additi onal surgical proshy--h ese procedures included repeat _omy balloon angioplasty or forshy la r reco nstructi on and cardiac ~ Initial imp rovement followed

- 1rati on in a postoperative limb

-

-~ ehrombos is and surgical exploshy- h repeat thrombectomy is indishy_nIb that shows marginal viability lbectomy suggests severe undershy-~ lI ive disease that must be adshye have found the combination 1 thrombec tomy and adjunctive

-Jeive balloon angioplas ty use ful 2 acute arterial occlusion caused

-_xisting atheroscl eroti c involve shylI calJy significant lesions can be -middot ieh littl e additional operative

_ middotasc ular reconstruction is warshy hould be performed early A ence of limb loss and mortality I es subsequent episodes of

SIS

orrecti on of ca rdiac sources of ~ is recommended We have pershy_ro nary artery bypass grafts aorshy- I valve replacement ventri cular

- ctomy and repair of a ventricushyJefec t resulting from infarctio n

-~ surgical balloon embo lectomy - J embolism O ur ea rly secondshydures have been performed

j signifi cant 10crease 10 major or death

eOus Thromhectomy and _lg Technologies

1~ i n g nature of vascular patholshyhe trend toward minimally inshy

~ gery have created an impetus echnologies and strategies for ieh th ro mboti c arterial occlushy

sions In recent years investi gators have p roduced a l11ultitude of pe rcutaneous thrombectomy devices and te chniques fo r clo t removal witho ut ope n surge ry An extensive review of th ese technoloshyg ies autho red by Sharafuddin and Hicks is available These new tre atm ent modali shyties include

1 Percutaneo us aspiratio n th ro mbecshyto my by whi ch suc tion is applied through a large lumen cath eter to reshymove thromboemboli c material

2 Pull-back th ro mbec tomy and clot trapping by w hich thro mbus is reshytrieved with a ball oon or basket into a trapping device for safe removal

3 Ro tati o nal and hydrauli c recirculation thrombectomy which involves the mishycrofragmentatio n of thrombus by the action of a high shea r stress hydrodyshynamic vortex

4 Fluid jets without hydrodynamic reci rshyculation to break up clo t

S T hrombectomy achi eved by the actio n of ultrasound la ser and radiofrequency energy to lyse thrombus

A new and promising approach is embodshyied in a unique device the TRELLIS that traps the fresh thromboti c occl usio n beshytween two balloons R otational mixing by this catheter system and lytic infusion intershyfaces with the fra gmented th rombus This pharmacomechanical combination enables targeted drug del ive ry and dissol ution of thrombus

N ew thrombectomy devic es and techniqu es will co ntinu e to emerge Each new technology must be carefully studi ed an d compared with standard thrombec tomy techniques to determine its clini ca l utility and to help defin e its role in the trea tment of thrombo tic arteshyrial occlusions

Chapter 196 Embolectomy 2099

SUGGESTED READING

Bar-EI Y Ada r R Sc hn eiderman Y et 11 Echocard iography in the dia gnostic assessshymen t o f periph eral arter ia l emb olization Am Hearl) 1990 119 1090

Berni GA Ba ndyk O F Zi erler RE et a Strepshytokinase treatment o f acute arterial occlushysion Ann Su rg 1983198 185

Foga rty TJ T he techniqu e o f th rombectomy and other uses of the Fogarty ca theter In Ruth erfo rd RB ed vaswlar su rgery Philade lphiaWB Sa unders 1977

Fogar ty TJ C hin A Shoor PM et a Adju nc shytive intraoperati ve arterial dilat tion simp]j shyfi ed in strumentation technique A reh Surg 1981 1 16 1391

Fogarty TJ Daily PO Shumwy NE et al Expeshyri ence with balloon catheter technique for arshyter ial embolectomy Am) Surg 1971 122231

Fogarty TJ H errmann GD N ew techniques for clo t extraction and managing acute thromshyboembolic limb ischemia lnVeith FJed Critshyical problems in vaswlar slrgery vol 3 St Louis Quali ty Medical Pub]jshers 1991

Hill B Fogarty TJThe use of the Fogarty catheter in 1998 Cardiovasc StIIg 1999 7(3)273

Sharafuddi n MJ Hicks ME C unent statu s of percutaneous mec hanical thrombectomy Part III Present and future appli ca tio ns) Vase lnlerv RadioI199 89(2) 209

Sharafuddin MJ Hicks ME C mren t status of percutane ous mechanic I thrombe ctomy Part II D evices and mec hanism of ac tion) vase lnterv RadioI19989(Pt 1) 15

Sharafuddin MJ Hicks ME C urrent status of percutaneo us mec hani ca l thrombectomy P n I General principles ) vase It1lerv Radiol 19978(6) 91l

Tawes RL Jr Beare JP Scribner R G et alV lue of postopera tive heparin therapy in per iphshye ral arterial th romboe mbolism Am) Surg 19831 46 21 3

Tawes RL Jr H arris EJ Brow n WG et alArteshyrial thromboembolism A 20-yea r perspec shytive Arch Su rg 1985 120595

SaracTp HiIleman OArko FR et al Clinical and economic evaluation of the trellis thrombecshytomy device for arterial occlusions prelimishynary analysis vase Surg 200439(3) 556

E DITORS COMMENT

__- Hill and Zarins have provided a wry trspectiv( 011 arterial embolism and

liong with an up-to-date disc ussion of -Jllagement I would first likegt to make a

between the picture of acute embolic ocshy- 1 previous normal artery and some of the Jlscussed in this chapte r As the autho rs

_ l is usually possible based on clinical presshyione to make the distincti on between

-~a l occlusion and what th ey describe as --ll1bosis In my view thjs distinction is

important If the diagn osis of ac ute eIll shy151 0n ofa previously norIllal artery can be

made based on c1 iniCJI presentation it is Ot adva ntage of the patient Under those

c ircumstances time is o f the csse-Ilee md by making the diagnosis on the clinica l picture preciolls time can be saved by getting the patient promptly to the ope(ltshying room with the expectation that the embolism and propagated thro mbus can be ~as il y removed l ith restoration of no rmal or near-normal arterial perfu shysion If however the patient is taken to the operating room w ith a dlJgnosis of Kute arterial occlusion but the underlying problem is arterial thrombosis supershyimposed on pre-existin g pcripheral vscular disease 111ltl l1 agelllenr in the operJrin g roonl can become much more complex and needlessly compromised because of inadequate information

T he questio n therefore is how does one make this distinction Lets take the Illost conlillOIl exanlshy

pie of cute occlusion of the superficial femoral ar shytery This occurs becausc an cmboli sm fi-om the hea rt has lodged at the common femoral bi fllrcashyti o n Because th e superfi cial femoral arte ry was previo llsly perfectly no rmal there is no collateral circulation and therefore the limb below the knee is iIllllleciilteiy extremely ischenlic This results in the classic picture of severe pain pallor (110 capilshylo ry filling) paresth esias and paralysis Such limbs are cadaveric in appearance and there is no ques shytio n about the no nviabil ity of the limb O ften there is a po unding waterhammer pulse palpable in the comlllon femo ral artery U nder those cirshyClIIl1stances and with th e an cillary ITlanagcll1ellt as described by the 3utho rs the patient may be taken

(co l1tin ue d)

needed additi onal surgical proshy--h ese procedures included repeat _omy balloon angioplasty or forshy la r reco nstructi on and cardiac ~ Initial imp rovement followed

- 1rati on in a postoperative limb

-

-~ ehrombos is and surgical exploshy- h repeat thrombectomy is indishy_nIb that shows marginal viability lbectomy suggests severe undershy-~ lI ive disease that must be adshye have found the combination 1 thrombec tomy and adjunctive

-Jeive balloon angioplas ty use ful 2 acute arterial occlusion caused

-_xisting atheroscl eroti c involve shylI calJy significant lesions can be -middot ieh littl e additional operative

_ middotasc ular reconstruction is warshy hould be performed early A ence of limb loss and mortality I es subsequent episodes of

SIS

orrecti on of ca rdiac sources of ~ is recommended We have pershy_ro nary artery bypass grafts aorshy- I valve replacement ventri cular

- ctomy and repair of a ventricushyJefec t resulting from infarctio n

-~ surgical balloon embo lectomy - J embolism O ur ea rly secondshydures have been performed

j signifi cant 10crease 10 major or death

eOus Thromhectomy and _lg Technologies

1~ i n g nature of vascular patholshyhe trend toward minimally inshy

~ gery have created an impetus echnologies and strategies for ieh th ro mboti c arterial occlushy

sions In recent years investi gators have p roduced a l11ultitude of pe rcutaneous thrombectomy devices and te chniques fo r clo t removal witho ut ope n surge ry An extensive review of th ese technoloshyg ies autho red by Sharafuddin and Hicks is available These new tre atm ent modali shyties include

1 Percutaneo us aspiratio n th ro mbecshyto my by whi ch suc tion is applied through a large lumen cath eter to reshymove thromboemboli c material

2 Pull-back th ro mbec tomy and clot trapping by w hich thro mbus is reshytrieved with a ball oon or basket into a trapping device for safe removal

3 Ro tati o nal and hydrauli c recirculation thrombectomy which involves the mishycrofragmentatio n of thrombus by the action of a high shea r stress hydrodyshynamic vortex

4 Fluid jets without hydrodynamic reci rshyculation to break up clo t

S T hrombectomy achi eved by the actio n of ultrasound la ser and radiofrequency energy to lyse thrombus

A new and promising approach is embodshyied in a unique device the TRELLIS that traps the fresh thromboti c occl usio n beshytween two balloons R otational mixing by this catheter system and lytic infusion intershyfaces with the fra gmented th rombus This pharmacomechanical combination enables targeted drug del ive ry and dissol ution of thrombus

N ew thrombectomy devic es and techniqu es will co ntinu e to emerge Each new technology must be carefully studi ed an d compared with standard thrombec tomy techniques to determine its clini ca l utility and to help defin e its role in the trea tment of thrombo tic arteshyrial occlusions

Chapter 196 Embolectomy 2099

SUGGESTED READING

Bar-EI Y Ada r R Sc hn eiderman Y et 11 Echocard iography in the dia gnostic assessshymen t o f periph eral arter ia l emb olization Am Hearl) 1990 119 1090

Berni GA Ba ndyk O F Zi erler RE et a Strepshytokinase treatment o f acute arterial occlushysion Ann Su rg 1983198 185

Foga rty TJ T he techniqu e o f th rombectomy and other uses of the Fogarty ca theter In Ruth erfo rd RB ed vaswlar su rgery Philade lphiaWB Sa unders 1977

Fogar ty TJ C hin A Shoor PM et a Adju nc shytive intraoperati ve arterial dilat tion simp]j shyfi ed in strumentation technique A reh Surg 1981 1 16 1391

Fogarty TJ Daily PO Shumwy NE et al Expeshyri ence with balloon catheter technique for arshyter ial embolectomy Am) Surg 1971 122231

Fogarty TJ H errmann GD N ew techniques for clo t extraction and managing acute thromshyboembolic limb ischemia lnVeith FJed Critshyical problems in vaswlar slrgery vol 3 St Louis Quali ty Medical Pub]jshers 1991

Hill B Fogarty TJThe use of the Fogarty catheter in 1998 Cardiovasc StIIg 1999 7(3)273

Sharafuddi n MJ Hicks ME C unent statu s of percutaneous mec hanical thrombectomy Part III Present and future appli ca tio ns) Vase lnlerv RadioI199 89(2) 209

Sharafuddin MJ Hicks ME C mren t status of percutane ous mechanic I thrombe ctomy Part II D evices and mec hanism of ac tion) vase lnterv RadioI19989(Pt 1) 15

Sharafuddin MJ Hicks ME C urrent status of percutaneo us mec hani ca l thrombectomy P n I General principles ) vase It1lerv Radiol 19978(6) 91l

Tawes RL Jr Beare JP Scribner R G et alV lue of postopera tive heparin therapy in per iphshye ral arterial th romboe mbolism Am) Surg 19831 46 21 3

Tawes RL Jr H arris EJ Brow n WG et alArteshyrial thromboembolism A 20-yea r perspec shytive Arch Su rg 1985 120595

SaracTp HiIleman OArko FR et al Clinical and economic evaluation of the trellis thrombecshytomy device for arterial occlusions prelimishynary analysis vase Surg 200439(3) 556

E DITORS COMMENT

__- Hill and Zarins have provided a wry trspectiv( 011 arterial embolism and

liong with an up-to-date disc ussion of -Jllagement I would first likegt to make a

between the picture of acute embolic ocshy- 1 previous normal artery and some of the Jlscussed in this chapte r As the autho rs

_ l is usually possible based on clinical presshyione to make the distincti on between

-~a l occlusion and what th ey describe as --ll1bosis In my view thjs distinction is

important If the diagn osis of ac ute eIll shy151 0n ofa previously norIllal artery can be

made based on c1 iniCJI presentation it is Ot adva ntage of the patient Under those

c ircumstances time is o f the csse-Ilee md by making the diagnosis on the clinica l picture preciolls time can be saved by getting the patient promptly to the ope(ltshying room with the expectation that the embolism and propagated thro mbus can be ~as il y removed l ith restoration of no rmal or near-normal arterial perfu shysion If however the patient is taken to the operating room w ith a dlJgnosis of Kute arterial occlusion but the underlying problem is arterial thrombosis supershyimposed on pre-existin g pcripheral vscular disease 111ltl l1 agelllenr in the operJrin g roonl can become much more complex and needlessly compromised because of inadequate information

T he questio n therefore is how does one make this distinction Lets take the Illost conlillOIl exanlshy

pie of cute occlusion of the superficial femoral ar shytery This occurs becausc an cmboli sm fi-om the hea rt has lodged at the common femoral bi fllrcashyti o n Because th e superfi cial femoral arte ry was previo llsly perfectly no rmal there is no collateral circulation and therefore the limb below the knee is iIllllleciilteiy extremely ischenlic This results in the classic picture of severe pain pallor (110 capilshylo ry filling) paresth esias and paralysis Such limbs are cadaveric in appearance and there is no ques shytio n about the no nviabil ity of the limb O ften there is a po unding waterhammer pulse palpable in the comlllon femo ral artery U nder those cirshyClIIl1stances and with th e an cillary ITlanagcll1ellt as described by the 3utho rs the patient may be taken

(co l1tin ue d)