Resultados do tratamento das oclusões arteriais agudas de membros em hospital universitário – estudo retrospectivo
Results of treatment of acute occlusions of limb arteries at a university hospital - retrospective study
Caroline Teodoro; Matheus Bertanha; Flavia Potsch Camara Mattos Girard; Marcone Lima Sobreira; Ricardo de Alvarenga Yoshida; Regina Moura; Rodrigo Gibin Jaldin; Winston Bonetti Yoshida
Background: Acute arterial occlusions (AAO) in limbs have been increasing in parallel with population longevity. Objective: To assess risk factors, limb salvage rates, and survival of patients with AAO treated at a University Hospital. Methods: Retrospective cohort study of consecutive patients. Outcomes included: patency, symptoms, comorbidities, Rutherford category, arteries occluded, postoperative complications, and 30-day limb salvage and mortality rates. Results: Medical records were evaluated from 105 patients, predominantly males (65.7%), with ages ranging from 46 to 91 years. Etiology: thrombotic (54.3%), embolic (35.2%), and undefined (10.5%). About 2/3 of the patients were assessed as Rutherford category II or III. Associated symptoms: pain (97.1%), coldness (89.5%), pallor (64.7%), sensory loss (44.7%), paralysis (30.5%), anesthesia (21.9%), edema (21.9%), and cyanosis (15.2%). Associated comorbidities: hypertension (65.0%), smoking (59.0%), arrhythmias (26.6%), dyslipidemia (24.0%), and diabetes (23.8%). The distal superficial femoral-popliteal segment was the most affected (80%). Thromboembolectomy with a Fogarty catheter was performed in 73.3% of cases (81.0% of embolic cases, 71.9% of thrombotic cases, and 54.5% of cases with undefined etiology) and was the only treatment used in 41 cases (39.05%), among which there were 11 reocclusion, 20 amputations, and 14 deaths. Arterial reocclusion was more frequent in thrombosis cases (12.9%, p = 0.054). Within 30 days of treatment, total mortality was 14.6%, and 19.8% of cases underwent major amputation, which was less frequent among Rutherford Class I patients (p = 0.0179). Conclusion: Treatment of AAO was primarily performed by thromboembolectomy with a Fogarty catheter, either alone or in combination with other treatments, achieving amputation and complication rates compatible with the best results in the literature and were progressively lower in less advanced Rutherford categories.
1 Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG. Inter-society consensus for the management of peripheral arterial disease (TASC II). J Vasc Surg. 2007;45(1, Suppl. S):S5-67.
2 Creager MA, Kaufman JA, Conte MS. Clinical practice. Acute limb ischemia. N Engl J Med. 2012;366(23):2198-206.
3 Costantini V, Lenti M. Treatment of acute occlusion of peripheral arteries. Thromb Res. 2002;106(6):V285-94.
4 Bergqvist D, Troeng T, Elfstrom J, et al. Auditing surgical outcome: ten years with the Swedish Vascular Registry--Swedvasc. The Steering Committee of Swedvasc. Eur J Surg Suppl. 1998;581(581):3-8. PMid:9755403.
5 Karapolat S, Dag O, Abanoz M, Aslan M. Arterial embolectomy: a retrospective evaluation of 730 cases over 20 years. Surg Today. 2006;36(5):416-9.
6 Fogarty TJ, Cranley JJ, Krause RJ, Strasser ES, Hafner CD. A method for extraction of arterial emboli and thrombi. Surg Gynecol Obstet. 1963;116:241-4. PMid:13945714.
7 Rossi FH, Izukawa NM, Oliveira LA, et al. O valor atual da trombólise na oclusão arterial aguda do membro inferior. J Vasc Bras. 2003;2:129-40.
8 Mandelli NCB, Nhuch C, Fontes PR, et al. O uso da estreptoquinase no tratamento da oclusão arterial aguda pós-cateterização da artéria femoral em crianças com menos de 10 kg. J Vasc Bras. 2007;6(1):42-9.
9 Pitta GBB, Silva CRA, Medeiros JD, et al. Isquemia grave de membros inferiores por arterite por HIV. J Vasc Bras. 2011;10(4):319-24.
10 Duda NT, Tumelero RT, Tognon AP. Tratamento percutâneo das oclusões arteriais agudas periféricas. Rev Bras Cardiol Invasiva. 2005;13:301-6.
11 Rutherford RB. Clinical staging of acute limb ischemia as the basis for choice of revascularization method: when and how to intervene. Semin Vasc Surg. 2009;22(1):5-9.
12 Antusevas A, Aleksynas N. The surgical treatment of acute ischemia of the lower limb. Medicina (Kaunas). 2003;39(7):646-53. PMid:12878818.
13 de Donato G, Setacci F, Sirignano P, Galzerano G, Massaroni R, Setacci C. The combination of surgical embolectomy and endovascular techniques may improve outcomes of patients with acute lower limb ischemia. J Vasc Surg. 2014;59(3):729-36.
14 Davies B, Braithwaite BD, Birch PA, Poskitt KR, Heather BP, Earnshaw JJ. Acute leg ischaemia in Gloucestershire. Br J Surg. 1997;84(4):504-8. PMid:9112902.
15 Yeager RA, Moneta GL, Taylor LM Jr, Hamre DW, McConnell DB, Porter JM. Surgical management of severe acute lower extremity ischemia. J Vasc Surg. 1992;15(2):385-91.
16 Borioni R, Garofalo M, Albano P, et al. Thromboembolectomy with a Fogarty catheter. Our clinical experience. Minerva Cardioangiol. 2000;48(4-5):111-6. PMid:10959147.
17 Aune S, Trippestad A. Operative mortality and long-term survival of patients operated on for acute lower limb ischaemia. Eur J Vasc Endovasc Surg. 1998;15(2):143-6.
18 Ouriel K, Shortell CK, DeWeese JA, et al. A comparison of thrombolytic therapy with operative revascularization in the initial treatment of acute peripheral arterial ischemia. J Vasc Surg. 1994;19(6):1021-30.
19 Working Party on Thrombolysis in the Management of Limb Ischemia. Thrombolysis in the management of lower limb peripheral arterial occlusion--a consensus document. Working Party on Thrombolysis in the Management of Limb Ischemia. Am J Cardiol. 1998;81(2):207-18. PMid:9591906.
20 Comerota AJ, Weaver FA, Hosking JD, et al. Results of a prospective, randomized trial of surgery versus thrombolysis for occluded lower extremity bypass grafts. Am J Surg. 1996;172(2):105-12.
21 Comerota AJ, Davidovic L, Hanna K, Courtney KL, Shlansky-Goldberg RD. Phase 2, randomized, open-label study on catheter-directed thrombolysis with plasmin versus rtPA and placebo in acute peripheral arterial occlusion. J Drug Assess. 2019;8(1):43-54.
22 McNamara TO, Dong P, Chen J, et al. Bleeding complications associated with the use of rt-PA versus r-PA for peripheral arterial and venous thromboembolic occlusions. Tech Vasc Interv Radiol. 2001;4(2):92-8.
23 Yoshida W, Rollo H, Lastoria S, et al. Tratamento das oclusões arteriais agudas com doses baixas de estreptoquinase: resultados iniciais. Cir Vasc Angiol. 1989;5:27-33.
24 Darwood R, Berridge DC, Kessel DO, Robertson I, Forster R. Surgery versus thrombolysis for initial management of acute limb ischaemia. Cochrane Database Syst Rev. 2018;8(8):CD002784.
25 Eliason JL, Wainess RM, Proctor MC, et al. A national and single institutional experience in the contemporary treatment of acute lower extremity ischemia. Ann Surg. 2003;238(3):382-9.
26 Blaisdell FW, Steele M, Allen RE. Management of acute lower extremity arterial ischemia due to embolism and thrombosis. Surgery. 1978;84(6):822-34. PMid:715701.
27 Pimenta REF, Yoshida WB, Rollo HA, et al. Heparin induced thrombocytopenia in a patient with acute arterial occlusion. J Vasc Bras. 2016;15:138-41.
28 Dormandy J, Heeck L, Vig S. Acute limb ischemia. Semin Vasc Surg. 1999;12(2):148-53. PMid:10777242.
29 Working Party on Thrombolysis in the Management of Limb I. Thrombolysis in the management of lower limb peripheral arterial occlusion - A consensus document. J Vasc Interv Radiol. 2003;14:S337-49.