After the blue toe: Prognosis of noncardiac arterial embolization in the lower extremities

Kvilekval, Kara H.V.; Yunis, Jonathan P.; Mason, Robert A.; Giron, Fabio

doi:10.1016/0741-5214(93)90418-l

Cited by 13 publications

(10 citation statements)

References 11 publications

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“…9,10 Historically, open surgical treatment of embolizing aortic lesions has been viewed as the safest treatment modality because of the ability to control and prevent potential further visceral or extremity embolization during aortic manipulation. 1,3,11 However, an analysis by Keen et al 11 of 100 patients with atheroembolism managed with open surgical techniques demonstrated a significantly high periprocedural mortality rate among patients with a suprarenal aortic source. Because this disease typically portends an overall poor prognosis with associated significant comorbidities, affected patients are often not ideal candidates for open surgery, making an endovascular option quite attractive except for the unusual patient with minimal risk.…”

Section: Discussionmentioning

confidence: 99%

“…Diagnosis has been enhanced by imaging techniques such as computed tomographic (CT) angiography and transesophageal echocardiography (TEE) in addition to intravascular ultrasonography. The 2-year mortality and recurrence rates for patients with noncardiac arterial embolization to the viscera and lower extremities in a report by Kvilekval et al 1 was 17% and 15%, respectively. Subjects with supradiaphragmatic sources were disproportionately affected, with mortality and recurrence rates of 60% each.…”

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confidence: 90%

“…1–4 It is estimated that 20% of embolic events are secondary to noncardiac arterial embolization, with the most common source being the aorta. 1 Half of these lesions are related to aneurysmal disease; the other half, historically termed cryptogenic, has frequently been localized to the aortic wall. Diagnosis has been enhanced by imaging techniques such as computed tomographic (CT) angiography and transesophageal echocardiography (TEE) in addition to intravascular ultrasonography.…”

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confidence: 99%

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Endovascular strategies for treatment of embolizing thoracoabdominal aortic lesions

Jeyabalan

Wallace

Chaer

et al. 2014

Journal of Vascular Surgery

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Objective Aortic sources of peripheral and visceral embolization remain challenging to treat. The safety of stent graft coverage continues to be debated. This study reports the outcomes of stent coverage of these complex lesions. Methods Hospital records were retrospectively reviewed for patients undergoing aortic stenting between 2006 and 2013 for visceral and peripheral embolic disease. Renal function, method of coverage, and mortality after stent grafting were reviewed. Results Twenty-five cases of embolizing aortic lesions treated with an endovascular approach were identified. The mean age was 65 ± 13 years (range, 45–87 years), and 64% were female. Sixteen (64%) patients presented with peripheral embolic events, six with concomitant renal embolization. Five patients presented with abdominal or flank pain, and two were discovered incidentally. Three patients had undergone an endovascular procedure for other indications within the preceding 6 months of presentation. Nineteen patients had existing chronic kidney disease (stage II or higher), but only three had stage IV disease. Of the eight patients tested, four had a diagnosed hypercoagulable state. Eight of the patients had lesions identified in multiple aortic segments, and aortic aneurysm disease was present in 24%. Coverage of both abdominal and thoracic sources occurred in eight patients, whereas 17 had only one segment covered. Minimal intraluminal catheter and wire manipulation was paired with the use of intravascular ultrasound in an effort to reduce embolization and contrast use. Intravascular ultrasound was used in the majority of cases and transesophageal echo in 28% of patients. Two patients with stage IV kidney disease became dialysis-dependent within 3 months of the procedure. No other patients had an increase in their postoperative or predischarge serum creatinine levels. No embolic events were precipitated during the procedure, nor were there any recurrent embolic events detected on follow-up. The 1-year mortality rate was 25%. Conclusions Endovascular coverage of atheroembolic sources in the aorta is feasible and is safe and effective in properly selected patients. It does not appear to worsen renal function when performed with the use of specific technical strategies.

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Section: Discussionmentioning

confidence: 99%

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confidence: 90%

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confidence: 99%

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Endovascular strategies for treatment of embolizing thoracoabdominal aortic lesions

Jeyabalan

Wallace

Chaer

et al. 2014

Journal of Vascular Surgery

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“…Uncommonly, atheroembolism may present with damage to other systemic organs (pancreas, gallbladder, spleen, prostate, or skeletal muscles). Although all of these phenomena may be self-limited, there is a relatively high risk of permanent organ damage and mortality (17% in one series) [6]. The multiplicity of findings in atheroembolism syndrome may result in diagnostic confusion with other disorders such as endocarditis and vasculitis.…”

Section: Opinion Statementmentioning

confidence: 98%

Embolism from the aorta: Atheroemboli and thromboemboli

Tunick

Kronzon

2001

Curr Treat Options Cardio Med

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To date, there are no evidence-based data to support specific drug therapy for a patient with atheroembolism. It makes sense to use HMG CoA (3-hydroxy-3-methylglutaryl coenzyme A) reductase inhibitors (statins) in any patient with atherosclerosis, as these drugs have been shown to reduce the risk of myocardial infarction and stroke, and have a theoretical benefit on plaque stabilization. Surgical treatment should be considered for patients with abdominal aortic or popliteal artery aneurysms and downstream atheroembolism. There are case reports of atheroemboli in patients worsening after given warfarin or heparin. For this reason, some institutions are reluctant to prescribe these drugs for patients with atheroemboli or thromboemboli from aortic plaque. However, the incidence of this complication is quite low. Anticoagulation probably should be stopped if a patient develops atheroembolism. Similarly, the current state of knowledge does not allow for selecting specific pharmacologic intervention in patients with thromboemboli from aortic plaque. Statin therapy does make sense, as these drugs theoretically stabilize plaques and prevent plaque hemorrhage, thrombosis, and subsequent embolization. Unstable aortic plaques may develop superimposed thrombi (red thrombi on pathologic examination), easily seen as mobile elements on transesophageal echocardiography. Therefore, it is possible that anticoagulation with warfarin might prevent embolic events in these patients. For this reason, we are often in the position of recommending warfarin therapy for patients with emboli and severe atheromas seen on transesophageal echocardiography, especially when superimposed mobile thrombi are seen. There are small series in the literature that indicate the potential benefit of warfarin. However, until a large multicenter randomized clinical trial is done, the use of warfarin can not be definitively recommended. Antiplatelet agents, although safer than warfarin (less risk of hemorrhage), have not been proven beneficial in patients with thromboembolism from the aorta. Surgery (endarterectomy) of the aortic arch is a very risky procedure that should not be performed routinely, but may be used in highly selected patients.

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“…Die Vorraussetzungen zur Ausbildung von Thromben in der deszendierenden Aorta sind neben Aneurysmen vor allem Wandunregelmäßigkeiten auf dem Boden lokaler Dissektionen mit der Ausbildung von ulzerogenen Plaques. Insgesamt 40-50% der nicht kardial bedingten Embolisationen sind auf solche Läsio-nen der thorakalen oder abdominellen Aorta zurückzuführen [1,8,21]. Darü-ber hinaus können kleine segmental veränderte Aortensegmente sowie prominente Atherome zur Ausbildung von intraluminalen Thromben führen.…”

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Intravasale Raumforderungen der thorakalen Aorta

Ockert

Schumacher

Böckler

et al. 2004

Chirurg

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Aortic intraluminal mass lesions of the thoracic aorta are rare disorders with a wide range of differential diagnoses. Generalized hypercoagulation or vascular endothelial disorders have been proposed as the main etiological factor. The risk of catheter-related thrombus development or embolization after interventional procedures is as high as 17%. Malignancies of the aorta are somewhat rare. In some cases, the specific source of the thrombus could not be determined. Mainly, intraluminal tumors of the thoracic aorta become evident through peripheral embolization. Modern diagnostic tools are able to identify the structure and location of intravascular formations. Therapy options are influenced, due to the heterogenic entity, by the individual risk to the patient and the pathology of the thrombus.

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After the blue toe: Prognosis of noncardiac arterial embolization in the lower extremities

Cited by 13 publications

References 11 publications

Endovascular strategies for treatment of embolizing thoracoabdominal aortic lesions

Endovascular strategies for treatment of embolizing thoracoabdominal aortic lesions

Embolism from the aorta: Atheroemboli and thromboemboli

Intravasale Raumforderungen der thorakalen Aorta

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