PERIPHERAL EMBOLECTOMY by FRANK FORTY, M.B., B.S., F.R.C.S

Postgrad Med J: first published as 10.1136/pgmj.27.305.117 on 1 March 1951. Downloaded from "17

PERIPHERAL EMBOLECTOMY By FRANK FORTY, M.B., B.S., F.R.C.S. Surgeon, Edgware General Hospital

Peripheral arterial embolectomy ranks among powerful adjuncts in the surgical treatment of em- the longest established operations in vascular bolism, and measures which by thepmselves can surgery. The first successful case was in I91i, occasionally avert gangrene-have had the ten- when Labey removed an embolus from the dency of further encouraging a policy of optimistic common femoral artery. Jefferson (I925) reported temporization. the first successful case in Great Britain and Every case of peripheral arterial embolism Griffiths (I938) reported the first successful aortic should be regarded as an urgent surgical emer- embolectomy in this country. Numerous authors gency and conservative treatment should be have published large series of cases. Key (1936), adopted only as a pre-operative measure with in a series of 382 embolectomies performed in everything in readiness for immediate operation, Sweden, was able to report a cure with restoration except when advanced cardiac failure or severe de- of the circulation in 86 cases (22.5 per cent.). bility are absolute contraindications to any kind of Amputation was subsequently required in i8 per surgical intervention. cent. of the cases and 6o per cent. of the patients died in hospital. Symptoms

If embolectomy at the present time still carries The vast majority of emboli lodging in peri- by copyright. a high mortality and often fails to save the limb, pheral arteries are derived from endocardial delay in performance of the operation must be ac- vegetations or mural thrombi in the left side of the counted as the principal cause of these disappoint- heart. Every patient with endocarditis, mitral ing results. It has been repeatedly proven that stenosis or auricular fibrillation is threatened by early operation, undertaken within ten hours, is embolism. Any sudden disturbance ofthe circula- capable of yielding between 6o per cent. and 75 tion of a limb in such a patient should therefore be per cent. of good results, as compared with be- presumed to be due to an embolus and surgical tween io per cent. and 20 per cent. when operation help be made immediately available. Rarely, em- is delayed beyond the tenth hour. A close parallel bolism occurs in the absence of cardiac disease. in this respect between arterial embolism and per- Thrombus on-an atheromatous plaque in the aorta, http://pmj.bmj.com/ foration of a peptic ulcer leaps to the mind. Grey or in the wall of an aneurysm of the aorta, or of one Turner (1950) has recalled that Mikulicz quoted of the major peripheral arteries may be swept into 35 operations for perforated ulcer with 34 deaths and obstruct a more distal vessel. A normal heart as proof that this condition should always be should not, therefore, be assumed to exclude a treated surgically; this declaration of faith was diagnosis of embolism. justified only when early intervention became the Characteristically embolism is proclaimed by the

accepted rule. A similar obligation rests upon the sudden onset of severe, often excruciating, pain in on September 28, 2021 by guest. Protected physician or practitioner who is faced with an a limb. This is rapidly followed by loss of power arterial embolism. Every surgeon interested in of movement and of sensation, and by pallor and vascular surgery has cause to regret the wasted coldness of the skin, which may soon acquire a opportunities for successful embolectomy, due to marbled appearance with patches of violaceous hesitation and procrastination until gangrene is discoloration. At the same time the patient established and amputation inevitable. presents the picture of surgical shock. Whilst this In the majority of cases the diagnosis of em- dramatic onset is the rule there may be a more in- bolism is easy and is correctly made at the outset. sidious course with only tingling, numbness or Delay is due to an unjustifiable hope that spon- coldness of the limb at first. These symptoms, taneous restoration of the circulation will occur, which may be relieved by the application of heat, and consequent reluctance to submit to operation a recur at longer or shorter intervals. They are frail patient with serious cardiac disease. Para- presumably due to the detachment of minute doxically, the recent introduction of anticoagulant emboli. Any such symptoms, alone or in com- drugs and the recognition of the valuable effects of bination, especially in a cardiac patient, are a novocaine block of the sympathetic ganglia- warning of impending massive embolism. Postgrad Med J: first published as 10.1136/pgmj.27.305.117 on 1 March 1951. Downloaded from

I i8 POSTGRADUATE MEDICAL JOURNAL March 1951 Physical Examination cumstances of the resulting vasodilatation, release Inspection and palpation of the limb suffice to ofthe vasoconstriction provides valuable diagnostic confirm coldness, pallor and loss of sensation. information in some cases. If the pain and Systematic search for the lowest point of palpable ischaemia are relieved without a return of the peri- arterial pulsation reveals the site of the embolus. pheral pulse and of an appreciable oscillometric There may be localized tenderness at this point. index: mechanical blockage is certain, the im- Below it no pulse is palpable. The oscillometric proved circulation being solely from dilatation of index is similarly abolished below the embolus. collateral vessels. Contrariwise, if appreciable Oscillometry may therefore help in localization of oscillations return after sympathetic block the the embolus, but it is more useful in providing a patency of the main vessels is proven and the quantitative measure of recovery of the circulation ischaemia is evidently due to spasm. occurring either spontaneously, or as the result of Arteriography and sometimes venography should conservative or operative treatment. The great be performed if the diagnosis is still in doubt majority of emboli lodge at the bifurcation of an (Fontaine and Branzeu, 1939). In cases of em- artery; this knowledge, together with observation bolus the arteriogram is characteristic. The main of the level of loss of pulsation, usually suffices to vessel is normal above the obstruction, with an establish the localization of the embolus. even calibre and smooth outline. The shadow ter- minates like a cupola fitting the convex upper Differential Diagnosis limit of the embolus. No filling of the main Though characteristic of embolism, sudden vessels occurs below the embolus. In pure spasm severe pain in a limb, accompanied by pallor, loss the artery is seen to be reduced in calibre but re- of sensation and muscular power, coldness and mains permeable and its out'ine everywhere is absence of the peripheral pulses, is in no wise smooth. In cases of endarteritis the artery may diagnostic of this condition. In the presence of show an irregular outline and an uneven calibre. this clinical syndrome, embolism must always be The distal termination of the shadow lacks the postulated and preparations made to act on this cupola-like appearance characteristic of embolus,by copyright. assumption. At the same time an effort must be and in an early thrombotic lesion the obstruction made to exclude other causes of sudden ischaemia. to the lumen may be only partial. The collaterals Leriche (I947), in his lectures delivered at the are typically tortuous or corkscrew shaped. At the College de France in 1945, critically examined the same time there is likely to be filling of the main differential diagnosis in the light of numerous vessel beyond the thrombus. cases in which the expected embolus was proved to be absent, either by exploration at operation or Treatment autopsy, or by the clinical sequel. Postulating Given that the diagnosis of embolism has been established and the site ofthe embolus determined'. that an embolus, once diagnosed, must be operated http://pmj.bmj.com/ upon, he affirmed that the diagnosis must be the surgeon should proceed to expose the vessel based upon: with a view to embolectomy with the same con- fidence and promptitude as he opens the abdomen (i) The presence of cardiac disease capable of in a case of perforated peptic ulcer. furnishing an embolus. Embolectomy should not be regarded as a (2) The elimination of a venous thrombosis ac- difficult operation or one demanding specialized companied by acute, painful arterial spasm. knowledge of vascular surgery. Access to certain The elimination of an obliterative endarteritis (3) sites, notably the aortic bifurcation and the iliac on September 28, 2021 by guest. Protected with acute onset of ischaemic symptoms. vessels, presents certain problems, but these are (4) The elimination of a pure spasm such as may perfectly soluble in the light of general surgical ex- occur in hypertensive patients. perience. No special instruments are necessary, Leriche stresses that venous thrombosis may though arterial clamps are a convenience. provoke an acute arterial spasm, but that in such a case the limb is cyanotic rather than livid, and the Pre-Operative Treatment and Anaesthesia superficial veins congested rather than empty and Shock should be treated by injection of morphia, collapsed. k to I gr., which has the additional effect of Arterial spasm, whether secondary to a venous promoting peripheral vasodilatation. Preliminary thrombosis or idiopathic in certain cases of hyper- paravertebral sympathetic block has already been tension, will be abolished by novocaine infiltration referred to. If pre-operative arteriography is of the appropriate sympathetic pathways. Para- employed, the opportunity may be taken of in- vertebral block of the sympathetic chain should jecting io CC. of 2 per cent. novocaine into the therefore always be performed as a preliminary to artery as an additional means of vasodilatation. operation. Besides the beneficial effect in all cir- In any case this may be done as soon as the artery Postgrad Med J: first published as 10.1136/pgmj.27.305.117 on 1 March 1951. Downloaded from

March I1951I FORTY: Peripheral Embolectomy" lII is exposed. Appropriate measures should be taken At the site of the embolus pulsation in the to control fibrillation by digitalin. artery abruptly ceases, though in the larger vessels General, spinal and local anaesthesia have all a to-and-fro movement may be transmitted be- been used with success in embolectomy. The yond it. A spastic contraction often exists at the choice is largely a matter of individual preference level of the embolus. Below this the artery is in the light of the facilities available. General small and collapsed. The embolus itself can be anaesthesia skilfully administered is generally well felt as a rubbery swelling within the artery. born by cardiac patients and either this or spinal anaesthesia are essential if the intra-peritoneal route Haemostasis to the aortic bifurcation is to be followed. Em- The artery above and below the embolus and bolectomy on the more peripheral vessels can any major collaterals must be freed sufficiently to always be performed under local anaesthesia, permit the control of bleeding, either by slings of which is to be preferred in aged or frail patients tape or rubber secured by artery forceps, or by whose cardiac state is precarious. It can also be arterial clamps. Only the proximal clamp will be employed for the extra-peritoneal approach to the tightened until evidence is obtained that the terminal aorta and iliac vessels. secondary thrombus has been evacuated from the distal segment of the artery. Approach It is a general and important rule of vascular Incision ofthe Artery surgery that there should be wide exposure of the A longitudinal incision of i to 2 cm. is sufficient vessels concerned, sufficient to allow the necessary for removal of the embolus. Usually this will be manipulations for securing haemostasis above and made directly over the embolus. In exceptional below the site of operation. This applies par- situations it may be placed, for greater ease, either ticularly to the artery below an embolus, which is above or below the obstruction. In this connection likely to be occupied by a secondary ' tail ' throm- reference may be made to the method of ' retro- bus. Clamps or other means of haemostasis must grade embolectomy' advocated by Key and used therefore be placed at a sufficient distance below by Griffitbs (1938), for removal of emboli at theby copyright. the embolus to allow for complete extraction of the aortic bifurcation and in the iliac vessels. The thrombus. The works of Fiolle and Delmas (I921) incision is made in the common femoral artery and and of Henry (I945) should be consulted with the clot dislodged by retrograde probing or suction. regard to the exposure of individual vessels. This blind approach to the embolus is not without Access to the aortic bifurcation and common possibilities of damage to the intima, with the risk iliac vessels may be obtained either intra- or extra- of subsequent thrombosis, and it may be difficult peritoneally. The intraperitoneal route presents to make sure that the clot has been totally ex- the more familiar territory to the general surgeon tracted. Milking down the clot by digital com- and a wide and clear view of the vessels. It has the pression of the artery from the outside avoids the http://pmj.bmj.com/ disadvantage of being impracticable under local risk of trauma to the endothelium. The less anaesthesia and of requiring a Trendelenburg tilt elaborate dissection involved may make this the prejudicial to an embarrassed heart. The intra- method of choice when operating on very feeble peritoneal approach was used by Ewing (1950) in patients, but the precaution should be taken of ex- two cases of aortic embolectomy, and he stresses posing and temporarily obstructing the opposite its simplicity and refers to its use in several recent common femoral artery lest a portion of the clot cases reported by other authors. Murray be swept down into it,

(I943) on September 28, 2021 by guest. Protected reports on five cases in which the left extra- peritoneal approach was used. This approach is Removal of the Embolus also recommended by Leriche (I947). The in- The ease with which the embolus is removed cision is similar to that for an extensive lumbar depends partly on the time that has elapsed before sympathectomy and allows a simultaneous removal operation. In the first few hours the embolus lies of the sympathetic chain, including the first free in the arterial lumen and is extruded spon- lumbar ganglion. taneously as soon as the vessel is opened, or it may be swept out by the blood stream when the proxi- Recognition of the Embolus mal clamp or sling is momentarily released. In After exposure of the vessel it is usually easy to other cases, gentle milking of the vessel above the identify the site ofthe embolus. Exceptionally this incision dislodges the embolus. After a few hours may be found at another than the expected level, the embolus becomes adherent to the wall of the as when In embolus migrates distally-an oc- artery and probing or suction may be needed to currence which may result from successful vaso- liberate it. Later the clot becomes completely dilatation after pre-operative sympathetic block. fixed and irremovable, as was found by Griffiths Postgrad Med J: first published as 10.1136/pgmj.27.305.117 on 1 March 1951. Downloaded from 12 - POSTGRADUATE MEDICAL JOURNAL March I1951I I938) in one of his cases of aortic embolism then closed in layers. A soft rubber drain may operated upon 46 hours after the onset of the first be placed as a precaution against the formation of symptom. The secondary thrombus in the artery a haematoma. distal to the embolus must be removed for a good functional result to follow embolectomy. It may Causes of Failure of Embolectomy come away with gentle traction, or may need Various factors threaten the results of every retrograde milking of the distal segment of the operation of embolectomy. Of these, thrombosis artery. Griffiths (1938) has recorded a secondary is the commonest cause of failure. Pre-operatively, thrombus 39' in. in length, with terminal branches as the hours pass, thrombus extending distally so fine that they must have come from the arteries from the embolus progressively obliterates the of the foot. Only when free, though non-pulsatile, peripheral vessels. At first this secondary clot bleeding from the distal end of the artery shows lies free in the arterial lumen and, by traction, that the secondary clot has been removed will the milking or suction, can be removed at operation. distal clamp or sling be tightened in preparation Later the thrombus, like the embolus itself, for closure of the arterial incision. becomes adherent to the arterial wall. Its dis- lodgement then becomes either impossible, or if Closure of the Arterial Incision achieved, exposes a damaged intima, prone to Fine black silk (5 x o) mounted on round- become the starting point of a new thrombus as bodied atraumatic needles is the material of choice soon as the circulation through the vessel is for arterial suture, and should be made available restored. Frequently the sequel to this is gangrene in all operating theatres. Fine linen thread and and amputation. In other cases, the collateral fine chromic catgut mounted on intestinal needles circulation may be sufficient to ensure survival of are perfectly reliable substitutes. It is generally the limb, but the patient is crippled by claudication recommended that the suture material be vaselined pain as soon as he attempts to walk. Occasionally or paraffined. thrombosis starts on the suture line, even though A plain over and over continuous suture taking removal of the embolus appears to have left an all layers should be employed and care taken to see intact intima. by copyright. that accurate apposition of the intima is obtained. The introduction of anti-coagulant drugs-and A preliminary removal of the adventitia assures particularly of heparin-provides a powerful that none of this layer with its thrombogenic weapon with which to combat thrombosis, and its property will protrude within the lumen of the use in embolectomy, as in all vascular surgery, has artery. This also achieves a segmental sympa- become practically a routine. It is well to remem- thetic denervation which may be of value in ber, however, that the largest published series of countering spasm of the vessel, but to obtain this cases of embolectomy, with their very consider- effect the adventitia must be removed over a dis- able proportion of successes, date from the pre- tance of some io cm. If such a step is decided anticoagulant era, when coating of the suturehttp://pmj.bmj.com/ upon, it is most easily performed before the artery material with vaseline and irrigation of the wound has been clamped and incised. After removal of with sodium citrate solution were the only avail- the clamps a spurt of blood from the suture line able means of preventing coagulation. Then, as may need to be secured by an additional in- now, however, gentle handling, avoidance of all terrupted stitch. unnecessary trauma to the vessel and meticulous If the artery has been completely cleared of clot, suturing, together with early operation, were the pulsation will now be visible passing beyond the best assurances of success. incision into the previously inert distal segment of Hard and fast rules cannot yet be laid down on September 28, 2021 by guest. Protected the artery. The peripheral pulses will again for the use of heparin in arterial surgery, owing become palpable and colour and warmth will to the varying and unpredictable response to the return to the limb. Absence of these signs that drug by different individuals. A narrow margin the ischaemia has been relieved indicates the may separate insufficient and ineffectual dosage possibility of a second, more distal, embolus in from over-dosage with resulting severe haemorr- the artery. Several such cases of multiple emboli hage from the operation wound or elsewhere. in the same vessel have been reported since Key Frequent estimations of the coagulability of the (1923) first drew attention to them. A second blood are necessary. In operating theatre and arteriography should be made to confirm and ward this is best done by measuring the clotting locate the remaining embolus, which must then time of a drop of blood on a vaselined glass slide. be removed in the same way as the first. This method requires no special equipment or A patch of muscle or of fibrin foam may be specialized knowledge and gives sufficiently placed over the arterial incision as an added accurate results for practical purposes. The security against haemorrhage. The wound is normal clotting time, by this method, of 7-IO Postgrad Med J: first published as 10.1136/pgmj.27.305.117 on 1 March 1951. Downloaded from

Marchl 1951 FORTY: Peripheral EnmbolectomyvI2 121 minutes needs to be kept constantly lengthened to endarterial lesions as early as the tenth hour, not less than I5 minutes, and should not be whereas the embolus has in other instances been allowed to exceed 30 minutes. Continuous found lying free in contact with apparently normal administration in an intravenous drip infusion intima as late as the iith day (Ipsen) and the 28th provides the most convenient method of control- day (Nicolaysen, quoted by Leriche, I947). ling the dosage of heparin by regulation of the The operator who has the good fortune to inter- speed of the drip. About 400 mgms. of heparin vene early, as well as he who perforce arrives late will need to be administered in the first 24 hours. on the scene, must therefore be prepared to find Heparinisation should be maintained, with that after extraction of the embolus the intima diminishing doses, for at least 3 days. Should presents a hyperaemic, velvety, irregular surface severe haemorrhage occur, the effect of heparin is prone to initiate a post-operative thrombosis. In reversable by blood transfusion or the adminis- these circumstances he must decide whether sacri- tration of protamine sulphate. If a massive fice of the abnormal arterial segment by arteriec- haematoma should form in the wound, this should tomy may not be a preferable alternative to sutur- be reopened to remove the clots, whose presence ing the incision in the face of probable subsequent endanger the circulation of the limb and sound obliteration of the artery by thrombosis. This healing of the wound. question has been thoroughly examined by Leriche The administration of heparin should be started (1947). Arteriectomy suppresses the afferent, as soon as a diagnosis of embolus is made, vN ith sympathetic vasoconstrictor impulses initiated by the aim of limiting or preventing secondary adherence of thrombus to damaged intima and thrombosis in the interval preceding operation. thus allows the collateral circulation to fill the main This, combined with the vasodilatory effect of artery distal to the resected segment, whence a novocaine block, may, in the case of a patient who blood flow sufficient to prevent gangrene may be is a poor risk for operation, confer relative safety expected. This effect of arteriectomy has often upon a short period of observation for signs of been observed in cases of obliterative endarteritis spontaneous improvement in the circulation of and should be all the more effective in cases of the limb. The use of an anti-coagulant con- embolism, where the vessels of the limb are other- by copyright. currently with any surgical operation imperatively wise healthy. Leriche advises that the sympatheti- demands the most meticulous attention to haemos- colytic effect of arteriectomy should be reinforced tasis. Every recognizable bleeding point must be by novocaine infiltrations of the lumbar sympa- secured by ligature before the wound is closed. thetic chain. Nevertheless, in spite of every precaution, dan- Arnulf (1950) reports that more recently Dos gerous bleeding may necessitate the interruption Santos has proposed removal of the obstruction by of anti-coagulant therapy. endarteriectomy. in preference to arteriectomy. Statistics from numerous sources relating to This procedure, as modified and elaborated by the functional end results after embolectomy Reboul (1950), has proved its worth in cases of http://pmj.bmj.com/ reveal a high proportion of cases marred by post- chronic endarteritis obliterans, and is a resource to operative thrombosis of the vessel and terminating keep in mind when confronted by secondary ar- in amputation. Thus, Key reported 208 embolec- terial lesions resulting from an embolus. tomies with 133 deaths. Among the survivors there were 43 cures and 32 amputations. Inevitable Gangrene-Amputation The factors responsible for this post-operative As has already been indicated, failure to save as thrombosis are without doubt multiple, and the circulation of the limb still attends many of on September 28, 2021 by guest. Protected yet imperfectly understood. Four principal causes the operations performed for embolectomy. Once may, however, be discerned. gangrene is established and its extent clearly de- (i) Degenerative lesions of the arterial wall marcated there is no advantage in delaying am- initiated at the site of contact of the embolus. putation. If it is performed before infection (2) Retardation of the blood stream from complicates the issue the limb can be safely re- arterial spasm, fall of blood pressure and stenosis moved through healthy tissue close to the upper at the site of arterial suture. limit of the gangrene, with primary suture of the (3) Imperfect suturing. flaps. If, however, there is widespread degenera- (4) Disturbance of the coagulability of the tive disease of the arteries of the limb, amputation blood. will have to be performed at a higher level, e.g. Time, without doubt, is the principal factor in through the lower third of the thigh for gangrene determining adherence of clot to the intima and of the foot. The view recently expressed by the consequent occurrence of degenerative lesions Learmonth (1950) that ' the first amputation of the arterial wvall. That time is not the only should be the final one ' carries special weight with factor is shown by the exceptional finding of reference to frail individuals with a poor expecta- Postgrad Med J: first published as 10.1136/pgmj.27.305.117 on 1 March 1951. Downloaded from 122 POSTGRADUATE MEDICAL JOURNAL March I951

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FIG. 1.-Case I, (a) Pre-operative arteriogram. (b) Post-operative arteriogram. on September 28, 2021 by guest. Protected tion of life, as are so many of the patients suffering I9I8, but had not been under any medical treat- from embolism. ment since then. On examination. The left forearm and hand Illustrative Case Histories were cold and cyanotic. Finger movements were CASE i. Auricular fibrillation; embolus at bi- unimpaired. There was some loss of sensation in furcation of brachial artery; embolectomy; the fingers. The radial and ulnar pulses were recovery. absent at the wrist. The brachial artery was pul- J.C., male aged 52, was admitted to hospital on sating visibly in the cubital fossa. The heart was July 25, I950, with the history that at 7 a.m. on the in auricular fibrillation, was enlarged and there same day he suddenly felt faint and at the same was a pre-systolic murmur. A diagnosis of em- time his left forearm and hand went cold, numb bolism at the bifurcation of the brachial artery due and powerless. There was pain from the elbow to mitral stenosis and auricular fibrillation was downwards. Slight spontaneous improvement oc- made. curred a little later. The patient said that he had Treatment. Procaine block of the brachial suffered from rheumatic fever and endocarditis in plexus was induced forthwith. The forearm and Postgrad Med J: first published as 10.1136/pgmj.27.305.117 on 1 March 1951. Downloaded from Marclrh f95 FORTY: Peripheral Embolectomy I 23 hand became warm from the resulting vaso- had some intermittent claudication in the calf. dilatation. There was no return of the radial or Three weeks after the first onset of symptoms ulnar pulses. Oscillometry gave an index of 1 in there was a sudden recurrence of pain in the same the left forearm as compared with 4 on the sound foot and in the leg. The foot was now cold and side. At 3 p.m., eight hours after the occurrence of blue and the pain was not relieved by morphia. the embolism, the brachial artery was exposed under He was admitted to hospital on the following day general anaesthesia. There was a rubbery in- -September 23, 1950. Seven years previously the duration at its bifurcation; the radial artery was patient had been treated for a coronary throm- contracted and pulseless; the origin of the ulnar bosis. He had remained well during the artery was a little larger than that of the radial, intervening years. but did not pulsate. Pyelosil was injected into Examination. The toes of the right foot were the brachial artery, and arteriography showed a white. There were violaceous patches on the cupola-shaped arrest in the brachial artery just dorsum of the foot. There was an abrupt change above the level of the elbow joint. There was no from warm to cold at the junction of the middle filling of the radial artery, but the ulnar, radial and and lower thirds of the leg, and the limb was ulnar recurrent and interosseous arteries were anaesthetic below this level. There was some faintly visible (Fig. ia). The termination of the oedema of the lower leg, and the right calf brachial artery was incised for I cm. over the measured 2 in. more in circumference than the embolus, after placing proximal and distal clamps. left. The femoral pulse was easily palpable Red, recent looking thrombus presented and was throughout the thigh. The popliteal pulse was extracted in five fragments. It was slightly ad- exaggerated and expansile. The posterior tibial herent to the intima and the smaller fragments pulse was absent, but the dorsalis pedis artery were dislodged by probing. After release of the was felt to be beating strongly. On the left side clamps the artery bled from both ends. The open the femoral pulse was palpable in Scarpa's triangle. vessel was irrigated with heparin and the arterial The popliteal, posterior tibial and dorsalis pedis incision closed with a continuous 5 x o silk suture. pulses were absent. The oscillometric index in Arteriography was repeated, and showed con- the upper third of the leg on the right side was by copyright. tinuous filling of the radial artery and improved 3 compared with 9I on the left side. A systolic filling of the ulnar and interosseous arteries (Fig. murmur was audible over the right femoral and ib). A heparin intravenous drip was started dur- popliteal arteries. ing the operation, and the wound was closed with A diagnosis of popliteal aneurysm of the right drainage. leg and endatteritis obliterans of the left was Progress. There was serious bleeding from the made. The sudden ischaemia of the right wound during the night following operation, for extremity was attributed to the detachment of a which one pint of blood was transfused. fragment of mural thrombus from the aneurysm, Eighteen days after operation there was a with formation of an embolus which had been http://pmj.bmj.com/ sudden onset of pain in the tight side of the chest, arrested at the bifurcation of the tibio-popliteal with fever and blood-stained sputum. There were trunk into the posterior tibial and peroneal arteries, no signs of venous thrombosis in the legs and the both of which were thereby occluded. This point apparent pulmonary embolism was thought to is below the origin of the anterior tibial artery, originate in the right side of the heart and was which had remained patent, as shown by the treated by a further course of heparin. A fortnight strong pulsation in the dorsalis pedis.

after the embolectomy the colour, temperature, X-ray of the limb showed extensive calcification on September 28, 2021 by guest. Protected movements and sensation of the hand were normal. of the femoral and popliteal arteries, with expan- The oscillometric index had risen to 2 1 and the sion of the latter to a diameter of i1 in. In the radial pulse was palpable at the wrist. The left leg the popliteal artery was also calcified and patient looked and felt well when discharged from expanded to a diameter of I4 in. (Fig. 2, a and b.) hospital on August 29, 1950. Arteriography showed the expanded popliteal artery on the right to have a central channel of CASE 2. Arteriosclerotic foofliteal aneurysm; to -a in. diameter. The Wassermann reaction embolus at bifurcation of tibio-popliteal trunk; was negative. amputation. Management and Progress. As the embolism G.C., male aged 71 yrs. At the beginning of had occurred more than 24 hours previously and September I950 this man had a sudden attack of the foot was already beyond salvation, embolec- numbness and tingling in the right foot, which tomy was not contemplated. Treatment was became painful., This was relieved by immersion directed to efforts to limit the extent of the inevit- in hot water. After resting for a week he was able able gangrene. A para-vertebral sympathetic to return to his work as an accountant, though he procaine block was performed on September 25- Postgrad Med J: first published as 10.1136/pgmj.27.305.117 on 1 March 1951. Downloaded from POSTGRADUATE MEDICAL 114 JOURNAI, Alarch I95I

F1~G.2~ (S'2 t)X-r g tIi,s h S.:.gcIc1fiec *O-ltild-C r,s-. ()X ry O ILf lCg S:}.in c*cfepo.ta 11ICUrmi.' |.I) by copyright. http://pmj.bmj.com/ on September 28, 2021 by guest. Protected io cc. of i per cent. procaine being injected at the went a dry, mummifying gangrene and a similar level of each lumbar ganglion. This produced an patch of gangrene the size of a half-crown piece immediate sensation of warmth down the outer developed on the heel. The dorsalis pedis artery side of the leg, which felt warmer than on the conserved its strong pulsation. But for a patch opposite limb. The patient volunteered the of gangrene on the heel a Syme's amputation information that the foot warmed up during the would have been perfectly justifiable, and in a night. The next morning the leg was warm down younger man might still have been attempted. At to the level of the malleoli. The para-vertebral this patient's age, however, it was felt that the block was repeated the next day and an intra- advantages of early return to activity outweighed arterial injection of io cc. of 2 per cent. procaine those of retaining a longer stump, and a below- was made into the right femoral artery. knee amputation at the site of election was per- During the next three weeks the foot regained formed, without a tourniquet, on November i6. its warmth as far as the middle of the sole and to The equal anterior and posterior flaps were within an inch of the base of the toes on the sutured and the stump healed by first intention. dorsum. The tissues distal to this level under- Comment. Leriche (I949) refers to embolism Postgrad Med J: first published as 10.1136/pgmj.27.305.117 on 1 March 1951. Downloaded from

March 1951 FORTY: Peripheral Embolectomny 125 by copyright. Ori,

FIG. 3.-Photomicrograph of posterior tibial artery, showing normal structure and absence of thrombus. http://pmj.bmj.com/ resulting from an aneurysm as a condition seldom by radiography, leading to his discharge from the seen. He states that Key records only five Army on this account. During the past seven instances in his statistical surveys of embolism- months he had had three attacks of sudden pain and he reparts the only case which he has per- in the legs after walking short distances. This sonally observed. which was an embolism at chiefly affected the backs of the calves, which felt the brachial artery originating ' paralysed.' After each attack the pain persisted the bifurcation of on September 28, 2021 by guest. Protected from an axillary aneurysm. longer in the left leg than in the right. There had been no abdominal symptoms on any of these CASE 3. Embolus of unknown origin at bifurcation occasions. In other respects he had always been of femoral artery; embolectomy; gangrene of perfectly healthy. foot; amputation. Clinical examination. When seen in the ward History. W.W., male, aged 34, was admitted the patient was very restless and complained to hospital on the morning of February 23, 1946, loudly of severe abdominal pain, which radiated to with a tentative diagnosis of perforated peptic the left thigh. Examination of the abdomen ulcer. Whilst on his way to work on that day, revealed tenderness and muscular guarding, chiefly he was suddenly seized by violent pain in the in the left upper quadrant. Contractions of the epigastrium and left loin which caused him to anterior abdominal muscles coincided with spasms collapse in the street. Shortly afterwards he of pain. The pulse was regular at a rate of 88 per vomited and noticed numbness in the left leg. minute, the heart was not enlarged, and there were For the past foiur years he had suffered from epi- no cardiac murmurs, nor any evidence of cardiac gastric pain after meals and three years previously failure. The patient's excited demeanour was in the presence of a gastric ulcer had been revealed sharp contrast to that normally associated with Postgrad Med J: first published as 10.1136/pgmj.27.305.117 on 1 March 1951. Downloaded from

126 POSTGRADUATE MEDICAL JOURNAL March 1951 by copyright.

FIC. 4.-Photomicrograph of anterior tibial artery, showing organized thrombus, thickened intima, degenerated elastica and media and peri-arterial fibrosis. http://pmj.bmj.com/ perforation of a peptic ulcer and it was decided present in the distal part of the artery. The to keep him under observation. incision was closed with vaselined silk and the rn the evening of the same day circulatory wound closed. changes were observed in the left leg. From the Post-operative frogress. Dicoumarol was ad- knee to the middle of the foot the skin was ministered in daily doses of 300 mg. for the first cold and blanched. The distal part of the foot three days after operation. Circulation failed to and the toes were blue and insensitive. No return to the skin covering the distal half of the on September 28, 2021 by guest. Protected pulsation could be detected in any of the arteries foot and the lower 9 in. of the leg on the outer of the limb below the common femoral, which side, so that a below-knee amputation was per- was pulsating normally for about an inch below formed one month after the embolectomy. The Poupart's ligament. A diagnosis of embolus at patient has now been under observation for five the bifurcation of the left common femoral artery years. was made, and 15 hours after the onset of At no time were there any cardiac symptoms or symptoms the vessel was explored. irregularity of the pulse, nor any evidence of Operation. Under spinal anaesthesia the femoral further embolic phenomena. X-ray examination artery was exposed in Scarpa's triangle. The showed a normal heart shadow and no calcification embolus was recognized by distention and bluish of the aorta was visible. The Wassermann reaction discoloration of the artery, which was collapsed was negative. At the time of the patient's dis- and pulseless below the embolus. An incision charge from hospital hiis blood pressure was ! in. long was made in the artery immediately i6o/ Ioo mm. Hg. below the embolus, and the embolus dislodged Microscopical examination of the main vessels with a Volkmann's spoon. No thrombus was of the amputated limb showed a normal posterior Postgrad Med J: first published as 10.1136/pgmj.27.305.117 on 1 March 1951. Downloaded from

March i95i FORTY: Peripheral Embolectomy 127 tibial artery. The anterior tibial artery contained can justify persistence with non-operative measure an organized thrombus; the intima showed beyond 8 or io hours. After ti is interval embolec- marked thickening, the elastica and media were tomy is menaced by rapidly diminishing chances degenerate, and much peri-arterial fibrosis was of success, but with the use of heparin and sym- present. (Fig. 3, a and b.) The distribution of pathetic block the period for possible successes the gangrene was evidently related to the oblitera- may come to be appreciably extended. When tion of the anterior tibial artery, probably due to exploration reveals adherence of the embolus, a small fragment of the embolus carried distally secondary thrombosis or a damaged arterial lining, and arrested in this vessel. arteriectomy and perhaps disobliterative endarteriectomy offers the best hopes of conserving Conclusion limb, function and life. Decision is the keynote of success in the management of peripheral emboli. Embolism Acknowledgment should be assumed when, in the words of Hopkins I am indebted to Miss M. H. Shaw for the (I945), ' something sudden happens to a limb' photographs. in a patient with any cardiovascular disease liable to form detachable thrombi. Exceptionally BIBLIOGRAPHY arteriography may clinch a doubtful diagnosis. JEFFERSON, G. (1925), Brit. Med. J., ii, 985. Preparations must be made for operation at the KEY, E. (1923), Stirg. Gynaec. Obstet., 36, 309. earliest possible moment. Temporizing measures KEY, E. (1936), quoted by LERICHE, R. (see below). GRIFFITHS, D. LI. (I938), Lancet, ii, 1331. should only be considered when the cardiac state GREY TURNER, G. (1950), Brit. Med. j., Oct. 28, 1004. of the patient absolutely contraindicates operation LERICHE, R. (I947),' Les Embolies de l'Artere Pulmonaire et des Art&res des Membres,' Masson et Cie, Paris. -a rare contingency when it is remembered that LERICHE, R. (1949), 'Aneurysmes Arteriels et Fistules Arterio- most embolectomies can be performed under Veineuses,' Masson et Cie, Paris. FONTAINE, R., and BRANZEU, P. (1939), Lyotn C/.irurgical., local anaesthesia. In the interval between the 36, 652.

onset of symptoms and operation all possible FIOLLE, J., and DELMAS, J. (1921), 'Exposure of tise Deep- by copyright. Seated Blood Vessels.' measu.es should be employed to promote the HENRY, A. K. (1945), 'Extensile Exposure in Limb Surgery,' collateral circulation and to delay thrombosis. E. & S. Livingstone, Edinburgh. Occasionally such an improvement in the cir- EWING, M. R. (1950), Brit. J. Surg., 38, 149. MURRAY, G. (1943), Surg. Gynaec. Obstet., 77, 157. culation of the limb will follow sympathetic block, ARNULF, G. (1950), ' Chirurgie Arterielle,' Masson et Cie, Paris. and administration of heparin that postponement REBOUL, H., and LAUBRY, P. (1950), Proc. Roy. Soc. Med., 43, 547. of operation will be justified. Only iecovery of LEARMONTH, J. (I950), Lancet, i, 505. such degree that the peripheral pulses re-appear HOPKINS, P. (I945), Brit. Med. J., ii, 4117. http://pmj.bmj.com/ on September 28, 2021 by guest. Protected

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