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.