Acute aortic occlusion from a cardiac embolus.

Abstract

A 28-year old man with dilated cardiomyopathy on the heart transplant list presented with acute bilateral leg pain with progression to complete paralysis. He had been recently hospitalized for management of chronic atrial fibrillation and anticoagulated with Coumadin (INR, 1.8). Physical examination showed absent bilateral femoral pulses and ankle Doppler signals. He also had an absent right wrist pulse with a normal left wrist pulse. The patient was immediately heparinized and taken to the operating room. After exposure of both femoral arteries, the aorta was catheterized from the left femoral artery and an aortogram was performed. This demonstrated a large embolus completely occluding the distal aorta below the origin of the inferior mesenteric artery, which was patent and provided collateral circulation to the legs (A, Cover). Through a transverse arteriotomy, retrograde left femoral embolectomy was performed using a #5 Fogarty catheter with retrieval of substantial thromboembolic material and return of pulsatile flow. Next, the balloon catheter, under fluoroscopic guidance, was inflated in the left common iliac artery with 50% contrast-saline solution for radiographic visualization (B, left). With the left leg thus protected by balloon occlusion, retrograde embolectomy was performed through the right femoral artery with similar retrieval of embolus and thrombus and return of a strong femoral pulse (B, right). Following bilateral antegrade embolectomies of the superficial and deep femoral arteries, the transverse arteriotomies were closed. A completion aortogram was performed which demonstrated wide patency of the previously occluded aortoiliac segment and no evidence of residual thrombus (C). Acute aortic occlusion is a surgical emergency. It may be either embolic or thrombosis of preexisting aortoiliac atherosclerosis. Reported mortality for acute embolic occlusions ranges from 31% to 40%.1Surowiec S.M. Isiklar H. Sreeram S. Weiss V.J. Lumsden A.B. Acute aortic occlusion of the aorta.Am J Surg. 1998; 176: 193-197Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar, 2Littooy F.N. Baker W.H. Acute aortic occlusion—multifaceted catastrophe.J Vasc Surg. 1986; 4: 211-216PubMed Scopus (50) Google Scholar, 3Dossa C.D. Shepard A.D. Reddy D.J. Jones C.M. Elliott J.P. Smith R.F. Ernst C.B. Acute aortic occlusion. A 40-year experience.Arch Surg. 1994; 129: 603-607Crossref PubMed Scopus (71) Google Scholar More than 75% of these patients present with lower-extremity paresis or paralysis.2Littooy F.N. Baker W.H. Acute aortic occlusion—multifaceted catastrophe.J Vasc Surg. 1986; 4: 211-216PubMed Scopus (50) Google Scholar The optimal treatment is rapid bilateral transfemoral embolectomy to restore inflow to the extremities. With the availability of intraoperative imaging, we believe that fluoroscopy guidance is a useful adjunct to standard “blind” embolectomy. This allows more accurate assessment of the degree and location of the thrombus or embolus, protection of the contralateral iliac artery from inadvertent embolism during ipsilateral embolectomy, and evaluation of the completeness of the embolectomy.