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Matsumata T, Kanematsu T, Yoshida Y, Furuta T, Yanaga K, Sugimachi K. The indocyanine green test enables prediction of postoperative complications after hepatic resection. WorldJ Surg 1987; 11: 678-81. Takenaka K, Kanematsu T, Matsumata T, Inaba S, Sugimachi K. Plasma exchange therapy for postoperative hepatic failure in cirrhotic patients. Surg Res Comm 1988; 3: 269-74. Matsumata T, Kanematsu T, Sonoda T et al. Acute liver failure in rats inhibited by intrasplenic administration of OK-432. J Surg Res 1986; 40: 43-8. Matsumata T, Kanematsu T, Okudaira Y, Sugimachi K, Zaitsu A, Hirabayashi M. Postoperative mechanical ventilation preventing the occurrence of pleural effusion after hepatectomy. Surgery 1987; 102: 493-7. Matsumata T, Kanematsu T, Takenaka K, Yoshida Y, Nishizaki T, Sugimachi K. Patterns of intrahepatic recurrence after curative resection of hepatocellular carcinoma. Hepatology

Matsumata T, Kanematsu T, Takenaka K, Sugimachi K. Lack of intrahepatic recurrence of hepatocellular carcinoma by temporary portal venous embolization with starch microspheres. Surgery 1989; 105: 188-91. Delva E, Camus Y, Nordlinger B et al. Vascular occlusions for liver resections: operative management and tolerance to hepatic ischemia: 142 cases. Ann Surg 1989; 209: 21 1-18. Li GH, Zhu SL, Li JQ, Zhan YQ. Evaluation of partial hepatectomy for primary liver carcinoma. J Surg Oncol 1989;

Kanematsu T, Furuta T, Takenaka K er al. A 5-year experience of lipoidolization: selective regional chemotherapy for 200 patients with hepatocellular carcinoma. Hepatology 1989; 10:

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432-3.

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.. 98- 102. Paper accepted 4 January 1990

Short note

Br. J. Surg. 1990. Vol. 77, June, 680-681

Emergency arterial reconstruction for acute ischaemia

N. C . Hickey, M. C . Crowson and M. H. Simms

Department of Vascular Surgery, Selly Oak Hospital, Raddlebarn Road, Selly Oak, Birmingham B29 6JD, UK Correspondence to: Mr N. C. Hickey

Surgical treatment of the acutely ischaemic limb was revolutionized in 1963 with the introduction of the Fogarty balloon embolectomy catheter'. Since then, however, the presentation of arterial thromboembolism has changed. The decline in rheumatic heart disease has been offset by a rise in ischaemic heart disease, which is frequently associated with peripheral vascular disease. Emboli, therefore, are increasingly likely to pass into a diseased vascular tree' and acute thromboses may form in atherosclerotic arteries. This has led to a fall in the success rate of embolectomy3. This unit has employed a policy of emergency arterial reconstruction when embolectomy has not achieved successful revascularization of the acutely ischaemic limb. The results are presented below.

Patients and methods The series comprises all patients with acute lower limb ischaemia presenting to one consultant from 1985 to 1989. All limbs met criteria for defining acute limb-threatening ischaemia in that each had suffered an acute episode rendering it numb, paralysed, with no distal pulses or Doppler signals and fresh intra-arterial thrombus or embolus found at operation.

There were 62 patients (with 73 acutely ischaemic limbs) of whom

43 (69 per cent) were men and 8 (13 per cent) were diabetic. Forty-five per cent had electrocardiographic evidence of recent myocardial infarction and 41 per cent were in atrial fibrillation. The median age was 69 years (range 39-88 years). The median delay from onset of the acute episode to presentation was 5.5 h (range 2 h to 17 days).

Urgent embolectomy was always attempted for potentially recoverable limbs, even if the patient presented several days after the acute event. Preoperative angiography was not performed. Peroperative management is summarized in Figure I . A femoral approach was employed unless the presence of a popliteal pulse prompted a primary popliteal exploration. After successful embolectomy an intravenous infusion of heparin was commenced and warfarin was introduced after 3 days. If embolectomy was unsuccessful (distal pulses did not return) the degree of atheroma in the vessels was determined by their appearance and the feel of the Fogarty catheter on passage and withdrawal. If it was felt that embolectomy had been incomplete (i.e. poor backbleeding from good vessels) the popliteal artery was explored and a trifurcation embolectomy performed. If this failed to restore foot

Exp lo ra t i on o f g r o i n a n d embolectomy

t Yes 4

? Successful

t No

? U n d e r l y i n g atherosc leros is +

i c No

Exp lo re t r i f u r c a t i o n

Yes r I I a n d embolectomy

I On-table - No - ? Successful -Y angiogram

4 Bypass g r a f t

F in ibh 4

Figure 1 Treatment of acutely ischaemic limb: algorithm

680 0007-1 323/90/06068C-02 0 1990 Butterworth-Heinemann Ltd

Short note

Table 1

Procedure Patients Limbs at risk Deaths Amputations Fasciotomies Limb salvage

Arterial reconstruction ,for acute ischaemia

Inflow 9 15 2 1 3 10 Patch angioplasty 12 12 2 2 2 8 Femorodistal 15 15 3 4 3 8

Total 36 42 7 7 8 26

pulses, or if the vessels were obviously diseased at the time of groin exploration, an on-table angiogram was performed and reconstructive surgery planned. Inflow procedures for proximal stenoses were performed without angiography if the downbleed was poor. Fasciotomy was performed selectively: at the time of surgery if there was obvious muscle necrosis or a considerable delay in presentation, or subsequently if signs of compartment syndrome developed. Local or regional anaesthesia was employed preferentially in the presence of known cardiopulmonary disease.

Results Four patients with bilateral ischaemia were moribund on admission and were treated by symptom relief alone. In four patients the limb was gangrenous, requiring primary amputation (bilateral in one patient). Embolectomy was successful in 18 patients, in 13 by a femoral approach, in two by a popliteal approach and in three cases by a combined femoral and popliteal procedure. Six of these patients died. All limbs were successfully salvaged in survivors. Therefore 12 of 18 limbs were saved by embolectomy.

In 36 patients with 42 limbs at risk embolectomy failed to salvage the limb and so they proceeded to arterial reconstruction. The results of surgery are summarized in Table 1 . The inflow procedures were three aortobifemoral, three axillobifemoral and three cross-femoral grafts. Patch angioplasty was carried out for short stenoses at arterial bifurcations. One profundoplasty was performed, live femoral bifurcation patches, four popliteal trifurcation patches and two patients required both femoral and popliteal angioplasties. Patients who merely had their arteriotomy closed with a vein patch are not included in this group. All femorodistal bypasses were performed with in situ long saphenous vein, mainly to distal anterior tibia1 or peroneal arteries. Overall, 26 (62 per cent) of the 42 limbs were salvaged. The 30-day mortality rate for reconstruction was 19 per cent (seven patients).

Twenty-two patients survived reconstructive surgery with intact limbs. They have been followed up for a median period of 19 months (range 2-47 months). Two patients have died, one of breast cancer (19 months) and one from myocardial infarction (36 months). Both had functioning grafts at their last outpatient visit. The remaining 20 patients are all mobile, with functioning grafts and viable limbs. None has required further surgery. The long-term graft survival is therefore 100 per cent so far, with continued limb salvage in 91 per cent (9 per cent mortality).

Discussion Treatment of the acutely ischaemic limb remains a challenge to the vascular surgeon. The success of balloon embolectomy will be limited as the incidence of peripheral vascular disease increases4. In an attempt to improve results and lower the mortality rate of the condition, thrombolytic therapy using low dose intra-arterial streptokinase has been advocated’ but this technique is not suitable for limb-threatening acute ischaemia as defined in this series6.

Patients should not be denied limb-saving surgery on the basis of a delayed presentation or poor ‘runoff seen on a preoperative angiogram. It is possible to perform successful embolectomy several days or even weeks after the acute episode7. Our experience in treating chronic ischaemia has led us to question the use of preoperative angiography’. It will tend

to underestimate the potential ‘runoff and this is especially true in the acute situation with fresh clot in the peripheral vascular tree. On-table angiography aftcr embolectomy is better at detecting patent peripheral vessels’.

Differentiation has not been made between embolism and thrombosis because it is often impossible to distinguish between the two, even after surgical exploration10. Moreover, initial treatment would be identical, with exploration of the groin and on-table angiography.

The mortality rate in this series was 19 per cent for reconstructive surgery and 33 per cent for embolectomy. Thirteen patients died, only two of them having received a general anaesthetic. Ischaemic heart disease was the cause of death in nine cases. Most deaths, therefore, were attributable to the poor medical condition of the patient and not to complications of surgery. All survivors were successfully returned to the community.

Thrombolytic therapy will benefit a selected group of patients when the viability of an acutely ischaemic limb is not immediately threatened. Emergency arterial reconstruction is the treatment of choice when embolectomy has failed to salvage the limb and urgent reperfusion is necessary for the limb to be saved. We believe that our policy of emergency arterial reconstruction for acute ischaemia is worthwhile, with a 79 per cent limb salvage rate in survivors and excellent long-term patency rates.

In this series, reconstructive surgery was required in 36 of 54 patients undergoing embolectomy for acute limb-threatening ischaemia. Patients with an acutely ischaemic limb are likely to have underlying peripheral vascular disease, requiring a more extensive procedure than simple balloon embolectomy to achieve limb salvage. We recommend that patients presenting with acute ischaemia should be assessed and treated by experienced vascular surgeons and that embolectomy should not be delegated to the junior surgical trainee.

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Paper accepted 25 November 1989

Br. J. Surg., Vol. 77, No. 6, June1990 681