The role of transthoracic echocardiography in embolic acute limb ischaemia

Lewis, A. A. M.; Kirk, G.; McKinley, A.; Blair, Paul; Harkin, Denis W.

doi:10.1007/s11845-009-0284-x

Cited by 4 publications

(5 citation statements)

References 9 publications

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“…Our data on embolectomy outcomes are similar to those in the literature, including studies dealing primarily with UE, 1,3,9,10 LE 11 and UE and LE 12–14 emboli. As noted, atrial fibrillation is a universally recognized risk factor.…”

Section: Discussionsupporting

confidence: 81%

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Demographic and echocardiographic predictors of anatomic site and outcomes of surgical interventions for cardiogenic limb emboli

et al. 2016

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We sought to determine if symptomatic cardiogenic limb emboli have a random distribution or if there are demographic or echocardiographic factors that predict site of embolization, limb salvage and mortality. Upper (UE) and lower extremity (LE) emboli were evaluated over a 16-year period (1996-2012). Demographic (age, gender, smoking, medical comorbidities) and echocardiographic data were analyzed to determine predictors of embolic site. All symptomatic patients underwent surgical revascularization. Limb salvage and mortality were compared with Kaplan-Meier analysis. A total of 161 patients with symptomatic cardiogenic emboli were identified: 56 UE and 105 LE. The female-to-male ratio for UE emboli (70%:30%) was significantly higher than for LE emboli (47%:53%, p=0.008). No other demographic factors were statistically different. Upper extremity patients were more likely to have atrial fibrillation (50% vs 29.8%, p=0.028), while LE patients had a higher percentage of aortic or mitral valvular disease or intracardiac thrombus (71.4% vs 52.5%, p=0.038). The 30-day limb salvage was higher for UE compared to LE (100% vs 88%, p=0.008). There was a trend toward higher 30-day mortality in the LE group (14% vs 5%, p=0.11). Survival at 1, 3, and 5 years were similar (UE: 62.2%, 44.2%, 35.3%; LE: 69.1%, 47.5%, 30.3%; p=ns). Upper extremity emboli are more frequent in women and patients with atrial fibrillation. Lower extremity emboli are more frequent in the presence of valvular disease or intracardiac thrombus, and are associated with increased 30-day limb loss and mortality. These findings suggest gender- and cardiac-specific differences in patterns of blood flow leading to preferential sites of peripheral embolization.

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Section: Discussionsupporting

confidence: 81%

“…The frequent need for fasciotomies and the approximately 5-15% amputation rate have been reported by others. [12][13][14] In contrast, the need for fasciotomies and amputations is rare in UE emboli. None was required in our series.…”

Section: Discussionmentioning

confidence: 99%

Demographic and echocardiographic predictors of anatomic site and outcomes of surgical interventions for cardiogenic limb emboli

et al. 2016

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“…TTE also remains a powerful tool to address other incidental cardiac findings. One study demonstrated that TTE used for investigation of ALI revealed that 19% of patients had significant cardiac abnormalities—including severe valvular lesions, systolic dysfunction and ventricular aneurysm 18 . This may also explain why patients hospitalised for ALI have higher subsequent MACE (major adverse cardiovascular events) and all‐cause mortality 12 …”

Section: Discussionmentioning

confidence: 99%

“…One study demonstrated that TTE used for investigation of ALI revealed that 19% of patients had significant cardiac abnormalities-including severe valvular lesions, systolic dysfunction and ventricular aneurysm. 18 This may also explain why patients hospitalised for ALI have higher subsequent MACE (major adverse cardiovascular events) and all-cause mortality. 12 Given significant atherosclerotic disease was the most common precipitant of ALI (54%), it would be prudent to exclude proximal large-vessel disease with CT angiography, and indeed, this is usually performed by the vascular surgeon.…”

Section: Cardiac Imagingmentioning

confidence: 99%

A retrospective analysis of the investigative practices of acute limb ischaemia presenting with an unknown aetiology

Nath

Reyaldeen

Mack

et al. 2021

ANZ Journal of Surgery

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Background: Acute limb ischaemia (ALI) is a limb and life-threatening condition with significant morbidity. There are currently no consensus recommendations for the investigative practices to determine the aetiology of ALI presenting without a known aetiology. We undertook a detailed analysis of all investigations performed to identify an underlying precipitant in those with unexplained ALI and formulated a suggested diagnostic algorithm for the evaluation of unexplained ALI. Methods: ALI cases presenting to a tertiary referral centre over a 3-year period were reviewed, and known aetiologies, and investigations undertaken to determine the underlying aetiology of unexplained ALI were obtained. Results: Unexplained ALI was found in 27 of 222 patients (12%), of which 21 (78%) had a cause for ALI established after further investigations. Six patients had no cause identified despite extensive work-up. Most patients with unexplained ALI had a cardioembolic source identified as the underlying cause (62%), and this included atrial fibrillation, infective endocarditis, cardiac myxoma and intra-cardiac thrombus. Other causes of unexplained ALI were detected by computed tomography (CT) imaging and included newly diagnosed significant atherosclerotic disease (19%), embolism from isolated proximal large vessel thrombus (10%) and metastatic malignancy (10%). There were no cases attributed to inherited thrombophilias, myeloproliferative neoplasms or anti-phospholipid syndrome. Conclusion: Among patients with unexplained ALI, the majority had a cardioembolic source highlighting the importance of comprehensive cardiac investigations. A subset of patients had alternative causes identified on CT imaging. These data support the use of a collaborative and integrative diagnostic algorithm in the evaluation of unexplained ALI. 1 Cardiac mass 1 Combined recent vascular intervention and trauma 1

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“…Most commonly the cause is embolic or thrombotic [13,14]. The Rutherford classification [15] provides a common language when discussing severity of acute and chronic limb ischaemia.…”

Section: Acute Lower Limb Ischaemiamentioning

confidence: 99%

Anaesthesia for vascular emergencies

Ellard¹,

Djaiani

2012

Anaesthesia

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SummaryPatients presenting with vascular emergencies including acute aortic syndrome, ruptured thoracic or abdominal aortic aneurysms, thoracic aortic trauma and acute lower limb ischaemia have a high risk of peri-operative morbidity and mortality. Although anatomical suitability is not universal, endovascular surgery may improve mortality and the results of ongoing randomised controlled trials are awaited. Permissive hypotension pre-operatively should be the standard of care with the systolic blood pressure kept to 50-100 mmHg as long as consciousness is maintained. The benefit of local anaesthesia over general anaesthesia is not definitive and this decision should be tailored for a given patient and circumstance. Cerebrospinal fluid drainage for prevention of paraplegia is often impractical in the emergency setting and is not backed by strong evidence; however, it should be considered postoperatively if symptoms develop. We discuss the pertinent anaesthetic issues when a patient presents with a vascular emergency and the impact that endovascular repair has on anaesthetic management. In-hospital mortality after open repair of ruptured abdominal aortic aneurysm (rAAA) approaches 40-50% with total mortality, including pre-hospital deaths, closer to 80% [1][2][3]. Traumatic thoracic aortic injury is often immediately fatal with a 30-40% mortality in those who arrive alive to hospital and an overall mortality of 90% [4]. Thirty-day mortality rates are > 50% following ruptured thoracic aneurysm [5], 13% for acute type B dissection [6] and > 25% following embolectomy for acute limb ischaemia [7,8].We define a 'vascular emergency', for the purpose of this review, as an acute condition requiring intervention within hours, involving the descending aorta and its main lower limb branches. Specific pathologies meeting these criteria include acute aortic syndrome, ruptured thoracic and abdominal aneurysms, traumatic injuries of the thoracic aorta and acute lower limb ischaemia. Pathology involving the ascending aorta or aortic arch that is generally managed by cardiac surgeons is excluded.This review aims to discuss the optimal anaesthetic management to minimise morbidity and mortality and the impact of a move towards endovascular repair. An English language electronic search using Medline and Embase databases identified relevant scientific literature from the last 10 years and was supplemented with a manual search of reference lists from reviewed articles. Overview of vascular emergenciesAcute aortic syndrome Acute aortic syndrome consists of three interrelated conditions: penetrating atherosclerotic ulcer; intramural haematoma; and aortic dissection. Penetrating athero-

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The role of transthoracic echocardiography in embolic acute limb ischaemia

Abstract: Transthoracic echocardiography seldom identifies a cardiac embolic source, but identifies many patients with severe incidental cardiac abnormalities, suggesting cardiology screening of these patients remains important.

Cited by 4 publications

References 9 publications

Demographic and echocardiographic predictors of anatomic site and outcomes of surgical interventions for cardiogenic limb emboli

Demographic and echocardiographic predictors of anatomic site and outcomes of surgical interventions for cardiogenic limb emboli

A retrospective analysis of the investigative practices of acute limb ischaemia presenting with an unknown aetiology

Anaesthesia for vascular emergencies

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