SCIENTIFIC PAPERS

Management of Acute Aortic Occlusion Sharon 6. Drager, MD, New York, New York Thomas S. Riles, MD, New York, New York Anthony M. Imparato, MD, New York, New York

Acute aortic occlusion is a catastrophe that may occur either in patients with established severe heart disease or in elderly patients. The sudden interruption of blood flow to the lower extremities, added to the stress of cardiac disease or advanced years, almost always results in death without immediate surgical intervention. Sudden aortic occlusion may result from saddle embolus, thrombosis of an atherosclerotic plaque, thrombosis of an abdominal aortic aneurysm, or a dissecting aneurysm. Surgical mortality from disobliteration of the aortic bifurcation was prohibitively high until the introduction of technics and equipment such as the Fogarty catheter that permitted surgical intervention by way of the transfemoral rather than the transabdominal route. This dramatic turnabout occurred approximately two decades ago. However, the death rate from acute thrombotic aortic occlusion, which continued to require the transabdominal approach, remained high, with reported mortality rates of up to 100 per cent [l-3]. The current availability of extraanatomic bypass procedures offers the promise of an alternative, equally effective, and less hazardous method of surgical intervention. Results

Over the past 3 years, six patients aged 55 to 87 years were treated at New York University Medical Center for acute aortic occlusion. All presented with sudden, profound ischemia of the lower extremities. Three of the patients were recuperating from major operative procedures at the time of occlusion, and all had significant cardiac disease. Five of the six patients had successful surgical management of aortic occlusion. One of these five patients was treated with a transFrom The Department of Surgery, New York University School of Medicine, New York, New York. Reprint requests should be addressed to Anthony M. Imparato, MO, New York University Medical School, 560 First Avenue, New York, New York 10016.

Volume 138, August 1979

femoral embolectomy, and axillobifemoral bypass was necessary in the other four patients. The sixth patient, unstable from a recent myocardial infarction, died in the operating room during an attempted embolectomy. Transaxillary aortography was used preoperatively in three patients, two of whom had transient postoperative renal failure. One patient developed an axillary hematoma after angiographic catheterization that required surgical exploration. Other postoperative complications were primarily related to the underlying’cardiac disease (Table I). Comments

The diagnosis of acute aortic occlusion can be made clinically by the sudden appearance of coolness, mottling, paralysis, and paresthesias of the lower extremities and the absence of femoral pulsations. The differential diagnosis of this condition includes saddle embolus, thrombosis of an atherosclerotic aorta, thrombosis of an abdominal aortic aneurysm, and dissecting aortic aneurysm. Dissection is usually distinguished by the presence of severe back pain, an abnormal chest X-ray, and signs of occlusion of major visceral vessels. If dissection is clinically suspected, aortography is useful in establishing the diagnosis. Thrombosis of an abdominal aortic aneurysm is a rare entity and may be missed unless the aneurysm is palpated on physical examination or visualized with abdominal X-rays. Janetta and Roberts [4] first described the successful treatment of this condition using a transabdominal approach. In our series, one patient was noted to have a palpable 7 cm abdominal aortic aneurysm at the time he was evaluated for acute ischemia of both lower extremities. Aortography revealed the aorta to be totally occluded below the renal arteries. Resection of the aneurysm was not attempted because of severe congestive heart failure, and axillobifemoral bypass was successfully performed.

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Although cardioarterial embolus is frequently the cause of acute aortic occlusion in patients with atria1 fibrillation, mitral valve disease, or recent myocardial infarction, differentiation from thrombosis of chronic aortoiliac occlusion disease is often difficult; we found little value in distinguishing between these two conditions during the initial management. Except for the patient with the thrombosed abdominal aortic aneurysm, retrograde femoral embolectomy was attempted first in all patients. This procedure successfully restored flow only in case 2, a patient with known atria1 fibrillation. In the three patients in whom embolectomy was unsuccessful, axillobifemoral bypass was used. As previously noted, preoperative aortography was performed in three patients. The information obtained from this procedure was of little value in differentiating saddle embolus from acute thrombosis. The determination of the patency of the renal arteries in these patients is probably unnecessary in the presence of adequate urinary output. The femoral vessels were not adequately visualized by suprarenal aortography in any patient. Furthermore, in two of the three patients who underwent preoperative suprarenal aortography, transient renal failure developed postoperatively. One patient required repair of the axillary artery after a massive hematoma developed at the site of catheterization. Axillobifemoral bypass has been used extensively in older patients with chronic aortoiliac occlusive disease who cannot withstand major intraabdominal

surgery [5,6]. LoGerfo et al [5] reported that they performed four axillobifemoral bypass grafts for acute aortic occlusion with myocardial infarction and that all of the patients died. Of the four patients in our series who underwent this procedure, all had severe cardiac disease and were at high risk for laparotomy; yet they tolerated the extraanatomic procedure well. We believe that this technique provides a relatively safe and expedient means of reestablishing flow to the lower extremities in an adverse clinical setting in patients with acute aortic thrombosis. It equals in significance the basic advance of transfemoral embolectomy that occurred two decades ago in the management of acute aortic embolic saddle occlusion. We formulated a plan for the management of patients with acute aortic occlusion that provides a high degree of successful reestablishment of flow with low morbidity and mortality. As soon as the clinical diagnosis is made, the patient is heparinized and brought to the operating room where the. following steps are taken. (1)The patient is prepped and draped for a possible axillobifemoral bypass. (2) Both groins are opened and simultaneous bilateral distal angiograms are obtained by way of the common femoral arteries to assess runoff. Profundaplasties may be necessary to assure adequate outflow. (3) Bilateral aortofemoral embolectomies with Fogarty catheters are attempted. If the catheters pass easily, clot is removed and inspected. The characteristic

TABLE I Data on Six Patients With Acute Aortic Occlusion Case no.

Age(yr) & Sex

Cardiac Disease

1

55 M

Myocardial infarction

1 week s/p carotid endarterectomy

Not done

76 M

None

Complete aortic occlusion Not done

81 F

Atrial fibrillation; CHF (?) Myocardial infarction CHF

5

87 M

CHF

6

62 M

CHF

71 F

CHF = congestive

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Recent Surgery

5 days s/p colostomy closure 5 days s/p cholecystectomy and common duct exploration None

Aortography

Not done

Operations

Complications

Transfemoral thrombectomy (died in OR during procedure) Transfemoral balloon catheter embolectomy and profundaplasty Axillobifemoral bypass with profundaplasty Axillbbifemoral bypass

Complete aortic occlusion

Axillobifemoral

bypass

Thrombosed aortic aneurysm

Axillobifemoral

bypass

CHF; transient renal failure

Minor wound infection Arrhythmias; transient renal failure: axillary hematoma None

heart failure; OR = operating room; s/p = status post.

The American Journal of Surgery

Acute

grayish, trabeculated appearance of embolus of cardiac origin may be noted. (4) If forceful pulsatile flow is reestablished, the arteriotomies are closed and angiography is performed to assess the adequacy of the reconstruction. (5) If the catheters cannot be passed, or if embolectomy fails to restore or maintain normal pulsatile flow, axillobifemoral bypass is performed. Summary

Acute aortic occlusion is most often seen in elderly patients with advanced cardiac disease. The management of these patients has been facilitated by the use of extraanatomic bypass. Over the past 2 years, six patients aged 55 to 87 years presented to our medical center with acute aortic occlusion, three after major operative procedures. One patient had a thrombosed abdominal aortic aneurysm; in the other five patients differentiation between saddle embolus and thrombosis of the distal aorta was impossible. There was one operative death. Four of the other five patients underwent axillobifemoral bypass and one underwent aortofemoral thrombectomy. All survived, and none required amputation.

Volume 138, August 1979

Aortic Occlusion

Two of the three patients who underwent preoperative aortography developed transient renal failure postoperatively. Aortography is of little value in diagnosis and is probably contraindicated in acute aortic occlusion. Our recommendation for operative management includes (1) preparation of the patient for possible axillobifemoral bypass, (2) angiography of distal runoff via both femoral arteries, (3) attempt at bilateral aortofemoral embolectomy with Fogarty catheters, and (4) axillobifemoral bypass if embolectomy fails to restore normal pulsatile flow. References Bell JW: Acute thrombosis of the subrenal abdominal aorta. Arch Surg95: 681, 1967. Danto LA, Fry WJ, Kraft RO: Acute aortic thrombosis. Arch Surg 104: 569, 1972. Matolo NM, Cheung L, Albo D. Lazarus HM: Acute occlusion of the infrarenal aorta. Am J Surg 126: 788. 1973. Jannetta PJ, Roberts B: Sudden complete thrombosis of an aneurysm of the abdominal aorta. N Engl J Med 264: 434, 1961. 5. LoGerfo FW, Johnson WC, Corson JD, Vollman RW, Weisel RD, Davis RC, O’liara ET, Nabeth DC, Mannick JA: A comparison of the late patency rates of axillobilateral femoral and axillounilateral femoral grafts. Surgery 81: 33, 1977. 6. Mannick JA, Williams LE, Nabseth DC: The late results of axillofemoral grafts. Surgery68: 1038, 1970.

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Management of acute aortic occlusion.

SCIENTIFIC PAPERS Management of Acute Aortic Occlusion Sharon 6. Drager, MD, New York, New York Thomas S. Riles, MD, New York, New York Anthony M. Im...
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