Clinical ResearchRoutine Versus Selective Use of Intraoperative Angiography During Thromboembolectomy for Acute Lower Limb Ischemia: Analysis of Outcomes
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.
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Acute arterial occlusion
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.
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 SurgeryCitation Excerpt :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 SurgeryThe combination of surgical embolectomy and endovascular techniques may improve outcomes of patients with acute lower limb ischemia
2014, Journal of Vascular SurgeryCitation Excerpt :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.
Acute Arterial Occlusion
2013, Vascular Medicine: A Companion to Braunwald's Heart Disease: Second EditionDoes routine completion angiogram during embolectomy for acute upper-limb ischemia improve outcomes?
2012, Annals of Vascular SurgeryCitation 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.