Thromboendarterectomy in Segmental Arteriosclerotic Thrombosis

Abstract

Thromboendarterectomy as described in 1947 by Joao Cid Dos Santos consists of the extirpation of a thrombus together with a portion of the endothelium. The advisability of this operation is based on the demonstration of the existence of a cleavage plane on the internal elastic lamina level, together with the possibility of administering anticoagulants later on, in order to avoid a new thrombosis on the operated segment. This is in accordance with the result of a previous arteriographic study permitting the demonstration of the segmentary character of the obstruction.This study points out our experience with the operation at the Vascular Diseases Service of the Lila Hidalgo Hospital and is intended to put forth the two factors that, in our judgement, greatly influenced the results obtained; i.e., patient selection and postoperative anticoagulant therapy. MATERIALIn each of our patients there was a history of a chronic ischemia syndrome, in which intermittent claudication was the chief complaint. Fifty per cent showed, in addition, trophic lesions of an ulcerative type or preexisting gangrene. In each of them, pre-and postoperative studies of the oscillometric readings and arteriograms (for the topographic diagnosis of lesions) were made, because only those patients with segmental lesions between the aorta-iliac bifurcation and the popliteal bifurcation were considered suitable for the operation. In some instances of iliac occlusion (figs. 1 and 2) the arteriographic study was completed by injecting the dye into the femoral artery-after previous dissection and puncturing of same-in the now of and against circulation to check the distal circulatory condition and the lower limit of the obstruction.Clinical and electrocardiographic checks were conducted to verify the cardiac status in order to discard the possibility of operation in patients with severe lesions, or take the necessary precautions in connection with the type of anesthesia and medication. TECHNIQUE . The first patients were treated according to the technique of continuous incisions along the length of the obstructed segment of Reboul,i which practice was abandoned promptly because it prolongs the operation. Thereafter the preferred technique was that of Joao Cid Dos Santosl 3 relative to discontinuous incisions.Once the cleavage plane was found and the thrombus dissected with the endothelium, the latter was cut obliquely on the level of the distal end, to avoid the necessity of fixing the thrombus with U-sutures according to the Kunlin and Leriche technique in order to prevent dissecting hematoma.Frequent irrigations were made of the operative area with 10 mg per cent of heparin solution, closing the arteriotomy with everting continuous suture made with Deknatel 5-0 silk. On our recent patients who had femoral occlusion, we successfully performed the Cannon and Barker2 technique.In the majority of our patients, especially those with iliac occlusion, we perform a lumbar sympathectomy, which, while increasing the velocity of circulation in the endarterecto...