Routine Versus Selective Use of Intraoperative Angiography During Thromboembolectomy for Acute Lower Limb Ischemia: Analysis of Outcomes

doi:10.1016/j.avsg.2009.12.006

Annals of Vascular Surgery

Volume 24, Issue 5, July 2010, Pages 621-627

https://doi.org/10.1016/j.avsg.2009.12.006 Get rights and content

Background

The success of thromboembolectomy for acute lower limb ischemia depends on the complete removal of all thromboembolic material accessible to the Fogarty catheter. Intraoperative arteriography can be used during arterial thromboembolectomy as a guide for extension of procedure to ensure complete clearance of the arterial tree and distal patency. However, it is still matter of debate if intraoperative angiography should be routinely performed in all cases or only in selected cases, depending on intraoperative findings, when the surgeon suspects an incomplete desobstruction.

Methods

Details of 380 thromboembolectomies in 361 patients with acute lower limb ischemia due to native vessel occlusion were prospectively recorded over a 12-year period in a central hospital vascular unit setting. The relevance of intraoperative angiography was retrospectively analyzed. The procedures were divided into two groups: group A, when intraoperative angiography was performed in selected cases (selective angiography), and group B, when angiography was performed as a routine procedure in all cases (routine angiography). Thrombectomy and embolectomy cases were separately analyzed.

Results

“On-table” angiography was used in 57 (26.4%) of 216 cases in group A and in all 164 cases (100%) of group B. Included in this study were 225 embolectomies and 155 thrombectomies of native vessels. After thrombectomy, the adoption of routine intraoperative angiography (group B) resulted in a statistically significant higher intraoperative reintervention rate than did selective intraoperative angiography (group A) (53.4% vs. 29.9%; p < 0.05). Also, after embolectomy extension of procedure, the rate was higher in group B than in group A (17% vs. 9.2%), but it did not reach statistical significance (p > 0.05). Considering the overall casuistic, at 24 months after thromboembolectomy, group B resulted in a lower incidence of reocclusion in comparison with group A (p < 0.05), whereas there was no statistical difference between the two groups in terms of amputation (p > 0.05) or of mortality (p > 0.05). Considering separately patients treated by embolectomy and by thrombectomy, reocclusion rate at 24 months was lower in group B than in group A, after thrombectomy and after embolectomy, with a statistical significance (p < 0.05). Amputation rate at 24 months was similar in group A and group B after embolectomy (10.7% vs. 8.9%; p > 0.05). After thrombectomy, there was in group B a slight advantage in comparison with group A, although not reaching statistical significance (31.3% vs. 46.2%; p > 0.05). There was no difference in mortality rate according to treatment group.

Conclusion

Introduction

Since the introduction of the balloon catheter by Fogarty in 1963,¹ peripheral arterial embolectomy has been a simple vascular procedure usually adopted as golden standard treatment in cases of acute arterial occlusion with critical ischemia of the lower extremity. Independent of the site of occlusion, the success of thromboembolectomy surgery is due to the complete removal of all thromboembolic material accessible to the Fogarty catheter. Failure to recognize residual thromboembolic material after completion of the procedure is related to higher reocclusion and/or amputation rates.

Many authors advocate intraoperative angiography as the most reliable method of ensuring that complete clearance of the whole arterial tree has been achieved.2, 3, 4 Back-bleeding is considered an unreliable guide to distal patency.4, 5

When intraoperative arteriography shows inadequate clearance of the distal arterial tree, further attempts to remove the distal clot can be undertaken. Furthermore, in patients with preexisting arteriosclerotic disease, angiography provides objective information about the collateral circulation and outflow tract that is important in deciding whether an extended operation (intraoperative transluminal angioplasty, “on-table” fibrinolysis, or bypass surgery) is necessary or possible.

Although even modern textbooks advocate a completion angiogram on the table after thromboembolectomy before the patient leaves the operating theatre, it is still ill-defined whether it should be performed on a routine basis or only in clinically selected cases.6, 7, 8 The aim of this study was to elucidate this problem.

Section snippets

Methods

All patients who underwent arterial thromboembolectomy for native vessel occlusion of lower limb in the Department of Vascular and Thoracic Surgery of the Regional Hospital of Bozen between September 1991 and December 2003 were prospectively recorded and the case notes were retrospectively reviewed. We did not include patients operated on for acute infrainguinal bypass occlusion presenting with an acute ischemia, because of the different prognosis related to the occlusion of a prosthesis in

Results

Initially, 119 embolectomies and 97 thrombectomies, with selective use of intraoperative angiography on the basis of intraoperative findings (group A), and 106 embolectomies and 58 thrombectomies, with routine use of intraoperative angiography (group B), were performed.

Patients were equally distributed between the two groups of analysis in terms of gender, median age (total median age, 75.6 years; range, 18-100 years), and risk factors. Table I summarizes the demographic data of patients in the

Discussion

Intraoperative angiography is a rapid and reliable method for evaluation of the immediate results after thromboembolectomy with the Fogarty balloon catheter.10, 11 Although advocated by many authors in the past3, 4 and by modern textbooks, a completion angiogram is still not routinely used following thromboembolectomy, before the patient leaves the operating theater.

This is also due to the fact that the documented value of this technique is still ill-defined.6, 7, 8

Our study was undertaken to

Conclusion

Routine use of intraoperative angiography influences outcome after thromboembolectomy for lower limb acute arterial occlusion. Routine use of intraoperative angiography, compared with selective use, results in a higher rate of extension of the procedure for residual lesion and in a lower reocclusion rate at 24 months. To confirm the results of this retrospective nonrandomized study, in January 2004 we started a prospective randomized trial and are currently analyzing the results.

References (18)

H.W. Bosma et al.
Intra-operative arteriography in arterial embolectomy
Eur J Vasc Surg
(1990)
J. Tiek et al.
The role of thrombolysis in acute infrainguinal bypass occlusion: a prospective nonrandomized controlled study
Ann Vasc Surg
(2009)
R.E. Parsons et al.
Fluoroscopically assisted thromboembolectomy: an improved method for treating acute arterial occlusions
Ann Vasc Surg
(1996)
J.A. Gonzalez-Fajardo et al.
Intraoperative fibrinolytic therapy for salvage of limbs with acute arterial ischemia: an adjunct to thromboembolectomy
Ann Vasc Surg
(1995)
R.A. Yeager et al.
Surgical management of severe acute lower extremity ischemia
J Vasc Surg
(1992)
T.J. Fogarty et al.
A method for extraction of arterial emboli and thrombi
Surg Gynaecol Obstet
(1963)
G.E. Mavor et al.
Routine operative arteriography in arterial thromboembolectomy
Br J Surg
(1972)
F.N. Mc Kenzie et al.
Value of intraoperative arteriography in arterial embolectomy surgery
Can J Surg
(1976)
T.J. Fogarty et al.
Acute arterial occlusion

There are more references available in the full text version of this article.

Cited by (27)

Acute limb ischaemia
2022, Surgery (United Kingdom)
Citation Excerpt :
An on-table diagnostic angiogram should be performed following embolectomy to confirm a satisfactory result. Though the evidence would suggest that a completion angiogram reduces rates of re-occlusion12 it has not been shown to improve limb salvage or survival. and in cases where the limb is obviously, clinically reperfused (i.e. palpable pedal pulses) angiography can be avoided to reduce risks associated with the additional procedure.
Acute limb and/or digital ischaemia (ALI, Acute Limb Ischaemia) is a global healthcare problem that is associated with high morbidity and mortality. It is caused by occlusion of a native artery, vascular bypass graft, or angioplasty-site/stent due to embolization or thrombosis, or occlusion of digital micro-vessels due to vasospasm or thrombosis. The culprit risk factor for embolic ALI is most often cardiogenic associated with atrial fibrillation. Other risk factors for ALI include smoking, hypertension, raised cholesterol and diabetes. ALI is diagnosed clinically by identifying the classical “6 P's”: Pain, Pallor, Pulselessness, Perishing cold, Paraesthesia, and Powerlessness. Rutherford's classification is used to grade the severity of ALI, and helps the clinician ascertain whether the limb is viable (I), marginally threatened (IIa), immediately threatened (IIb), or non-salvageable (III). Immediate management of ALI involves analgesia, supplemental oxygen, intravenous fluids, intravenous heparin, and arranging for an urgent CT angiogram. Definitive revascularization options include open surgery, endovascular procedures, or a combined ‘hybrid’ surgical and radiological approach. If a limb, or digit, is non-salvageable primary amputation may be indicated. Dependent upon the severity of ischaemia and on patient fitness, the most appropriate management strategy may instead be conservative, including palliation. Whatever the management approach decided upon, the patient (and ideally their family and/or carers) should be appropriately counselled and given a realistic picture of their options, including doing nothing, with their associated risks and benefits.
Editor's Choice – European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia
2020, European Journal of Vascular and Endovascular Surgery
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Preferential use of a prosthetic graft may be considered in a patient with severe ischaemia (Rutherford grade IIB), where urgent revascularisation is necessary. There is consensus to recommend completion angiography after thrombo-embolectomy to document the outcome, as residual thrombus is common and its identification is associated with a reduced risk of re-intervention and limb loss.73,79 If residual thrombus is found after embolectomy, further embolectomy or bypass may be considered.
Hybrid revascularization procedures in acute limb ischemia
2014, Annals of Vascular Surgery
Although the clinical efficacy of hybrid procedures in patients with chronic limb ischemia has been well reported in the literature, sufficient evidence is lacking in the acute setting. Our aim was to evaluate the immediate and midterm clinical results on 28 patients with acute lower limb ischemia treated with hybrid reconstructions on emergent basis, from January 2010 to March 2013 in our tertiary referral vascular center.
A total of 28 patients (31 operated limbs) underwent emergent hybrid revascularization, with endovascular treatment performed proximally or distally to the site of open reconstruction. The median follow-up period was 6 months (range: 1–26). The immediate technical success was clinically and hemodynamically evaluated with an ankle brachial pressure index (ABPI) measurement. Six-month overall patency, limb salvage, and survival rate were also estimated. All analyses were performed with Kaplan–Meier life table method, using the STATISTICA 7.0 statistical program.
Twenty-seven patients presented with grade IIb and 1 with grade III ischemia, respectively. Technical success was achieved in all patients, whereas hemodynamic improvement rate was achieved in 98%. ABPI preoperatively was increased from 0.14 ± 0.1 to 0.69 ± 0.28 postoperatively (P < 0.05). Perioperative morbidity and mortality rates were 21% and 11% respectively. Six-month overall patency, limb salvage, and survival rate were 86%, 92%, and 79%, respectively.
Hybrid revascularization in immediately threatened limbs provides an effective and durable option with acceptable mortality and amputation rate in these high-risk patients. These findings should be further confirmed by larger scale clinical studies.
The combination of surgical embolectomy and endovascular techniques may improve outcomes of patients with acute lower limb ischemia
2014, Journal of Vascular Surgery
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It had also the potential to facilitate accurate identification, localization, and treatment of significant concomitant arterial lesions. Since then, it has been recommended to perform a routine angiography after TE,13,14 but adherence to this recommendation is still limited in clinical practice.15 Our experience confirms the central role of intraoperative angiography after TE in defining the need for as well as guiding adjunctive endovascular procedures, which are the keys for better early and midterm outcomes of ALLI patients.
Surgical arterial thromboembolectomy (TE) is an efficient treatment for acute arterial thromboemboli of lower limbs, especially if a single large artery is involved. Unfortunately, residual thrombus, propagation of thrombi, chronic atherosclerotic disease, and vessel injuries secondary to balloon catheter passage may limit the clinical success rate. Intraoperative angiography can identify any arterial imperfection after TE, which may be corrected simultaneously by endovascular techniques (so-called “hybrid procedures,” HP). The aim of this study is to compare outcomes of surgical TE vs HP in patients with acute lower limb ischemia (ALLI).
From 2006 to 2012, 322 patients with ALLI were admitted to our department. Patients received urgent surgical treatment using only a Fogarty balloon catheter (TE group = 112) or in conjunction with endovascular completion (HP group = 210). In-hospital complications, 30-day mortality, primary and secondary patency, reintervention rate, limb salvage, and overall survival rates were calculated using the Kaplan-Meier method and compared by log-rank test.
HPs (n = 210) following surgical TE consisted of angioplasty (PTA) ± stenting in 90 cases, catheter-directed intra-arterial thrombolysis + PTA ± stenting in 24, thrombus fragmentation and aspiration by large guiding catheter + PTA ± stenting in 67, vacuum-based accelerated thromboaspiration by mechanical devices in 9, and primary covered stenting in 12. Estimated primary patency was 90.4% vs 70.4% at 2-year and 87.1% vs 66.3% at 5-year follow-up, respectively, for HP and TE patients (hazard ratio, 3.1; 95% confidence interval, 1.78-5.41; P < .01). A hazard ratio of 2.1 for limb salvage was noted for the HP group (95% confidence interval, 1.01-4.34; P = .03). Estimated freedom from reintervention at 1 year was 94.4% for HP vs 82.1% for TE patients, and 89% vs 73.7% at 5 years, respectively (P = .04).
HPs for ALLI may represent the tools that, when applied to specific clinical scenarios, hold the potential to reduce the morbidity previously associated with acute arterial occlusion.
Acute Arterial Occlusion
2013, Vascular Medicine: A Companion to Braunwald's Heart Disease: Second Edition
Does routine completion angiogram during embolectomy for acute upper-limb ischemia improve outcomes?
2012, Annals of Vascular Surgery
Citation Excerpt :
The incidence of unsuccessful thromboembolectomies detected with routine use of intraoperative arteriography ranges from 11% to 44% in other series.7,12–17 In our experience with acute lower-limb ischemia, 29.9% (49 of 164) of the procedures after routine use of completion angiogram were proved to be incomplete, resulting in extension of the operation, whereas only 18.5% (40/216) were intraoperatively identified using a selective angiography (P = 0.009).5 We deduced that approximately 11% of incomplete procedures can be overlooked if selective use of angiography is used.
Since 1963, Fogarty balloon catheter thromboembolectomy is usually adopted as the gold standard treatment for acute limb ischemia. As the success of the procedure depends on complete removal of all thromboembolic material, intraoperative arteriography can be used after arterial thromboembolectomy as a guide for extension of the procedure. It is still a matter of debate whether intraoperative angiography should be routinely performed in all cases or only in selected cases, depending on intraoperative findings, when the surgeon suspects an incomplete disobstruction. Most published evidence derives from analysis of lower-limb thromboembolectomies. The aim of our retrospective study was to elucidate the value of routine completion angiogram in acute arterial embolism of the upper limb.
Clinical and demographic data of 100 patients with acute embolic upper-limb ischemia were prospectively recorded during an 18-year period in a central hospital vascular unit setting. The relevance of intraoperative angiography was retrospectively analyzed. The procedures were divided into two groups: group A, when intraoperative angiography was performed in selected cases (selective angiography); and group B, when angiography was performed as a routine procedure in all cases (routine angiography). All factors associated with reocclusion and mortality were investigated to produce meaningful information that could assist the surgeon to predict outcomes.
Cumulative reocclusion and mortality rates at 24 months were 14.0% and 70.0%, respectively. After upper-limb arterial embolectomy, the rate of extension of the procedure was significantly higher in group B than in group A (26.0% vs. 4.0%, P = 0.002). At 24 months after embolectomy, group B resulted in a lower incidence of reocclusion compared with group A (12.0% vs. 2.0%, P = 0.05), whereas there was no statistical difference between the two groups in terms of mortality (P > 0.05). On univariate analysis, the factor associated with increased 2-year reocclusion rate was only the avoidance of completion angiography, although it lost some of its predictive value on multivariate analysis. Factors associated with increased 2-year mortality rate on univariate analysis included age >80 years, diabetes mellitus [DM], and antiplatelet drug use. Only DM was significantly associated on multivariate analysis.
Routine use of intraoperative angiography influences outcome after embolectomy for upper-limb acute arterial occlusion. Routine use of intraoperative angiography, compared with selective use, results in a higher rate of extension of the procedure for residual lesion and in a lower rate of reocclusion at 24 months. In prevention of reocclusion, completion angiogram has a hazard ratio of 5.44 on multivariate analysis. Postoperative late mortality is mainly affected by old age and DM.

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Clinical ResearchRoutine Versus Selective Use of Intraoperative Angiography During Thromboembolectomy for Acute Lower Limb Ischemia: Analysis of Outcomes

Background

Methods

Results

Conclusion

Introduction

Section snippets

Methods

Results

Discussion

Conclusion

Eur J Vasc Surg

Ann Vasc Surg

Ann Vasc Surg

Ann Vasc Surg

J Vasc Surg

A method for extraction of arterial emboli and thrombi

Surg Gynaecol Obstet

Routine operative arteriography in arterial thromboembolectomy

Br J Surg

Value of intraoperative arteriography in arterial embolectomy surgery

Can J Surg

Acute arterial occlusion

Clinical Research
Routine Versus Selective Use of Intraoperative Angiography During Thromboembolectomy for Acute Lower Limb Ischemia: Analysis of Outcomes