Results of surgical management of acute thromboembolic lower extremity ischemia.
OBJECTIVE
Acute lower extremity ischemia secondary to arterial thromboembolism is a common problem. Contemporary data regarding this problem are sparse. This report examines a 10-year single-center experience and describes the surgical management and outcomes observed.


METHODS
Procedural codes were used to identify consecutive patients treated surgically for acute lower extremity embolization from January 2002 to September 2012. Patients presenting >7 days after onset of symptoms, occlusion of grafts/stents, and cases secondary to trauma or iatrogenic injury were excluded. Data collected included demographics, medical comorbidities, presenting clinical characteristics, procedural specifics, and postoperative outcomes. Results were evaluated using descriptive statistics, product-limit survival analysis, and logistic regression multivariable modeling.


RESULTS
The study sample included 170 patients (47% female). Mean age was 69.1 ± 16.0 years. Of these, 82 patients (49%) had a previous history of atrial fibrillation, and four (2%) were therapeutically anticoagulated (international normalized ratio ≥2.0) at presentation. Presentation for 83% was >6 hours after symptom onset, and 9% presented with a concurrent acute stroke. Femoral artery exploration with embolectomy was the most common procedural management and was used for aortic, iliac, and infrainguinal occlusion. Ten patients (6%) required bypass for limb salvage during the initial operation. Local instillation of thrombolytic agents as an adjunct to embolectomy was used in 16%, fasciotomies were performed in 39%, and unexpected return to the operating room occurred in 24%. Ninety-day amputation above or below the knee was required during the index hospitalization in 26 patients (15%). In-hospital or 30-day mortality was 18%. Median (interquartile range) length of stay was 8 days (4, 16 days), and 36% of patients were discharged to a nursing facility. Recurrent extremity embolization occurred in 23 patients (14%) at a median interval of 1.6 months. The 5-year amputation freedom and survival estimates were 80% and 41%, respectively. Predictors of 90-day amputation included prior vascular surgery, gangrene, and fasciotomy. Predictors of 30-day mortality included age, history of coronary artery disease, prior vascular surgery, and concurrent stroke.


CONCLUSIONS
Despite advances in contemporary medical care, lower extremity arterial embolization remains a condition that is associated with significant morbidity and mortality. Furthermore, the condition is resource-intensive to treat and is likely preventable (initially or in recurrence) in a substantial subset of patients.
Department of Vascular and Endovascular Surgery, Wake Forest School of Medicine, Winston-Salem, NC.
Kelly
K
Kempe
Department of Vascular and Endovascular Surgery, Wake Forest School of Medicine, Winston-Salem, NC.
Brett
B
Starr
Division of Public Health Sciences, Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, NC.
Jeanette M
JM
Stafford
Department of Vascular and Endovascular Surgery, Wake Forest School of Medicine, Winston-Salem, NC.
Arsalla
A
Islam
Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, NC.
Ashley
A
Mooney
Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, NC.
Emily
E
Lagergren
Department of Vascular and Endovascular Surgery, Wake Forest School of Medicine, Winston-Salem, NC.
Matthew A
MA
Corriere
Department of Vascular and Endovascular Surgery, Wake Forest School of Medicine, Winston-Salem, NC. Electronic address: medwards@wakehealth.edu.
Matthew S
MS
Edwards
D000046:Academic Medical Centers; D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical; D015897:Comorbidity; D018572:Disease-Free Survival; D017128:Embolectomy / Q000009:adverse effects / Q000401:mortality; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007511:Ischemia / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D007902:Length of Stay; D023821:Limb Salvage; D016015:Logistic Models; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009657:North Carolina; D010351:Patient Discharge; D012042:Registries; D012086:Reoperation; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013923:Thromboembolism / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D015912:Thrombolytic Therapy; D013997:Time Factors; D016896:Treatment Outcome; D058017:Vascular Grafting / Q000009:adverse effects / Q000401:mortality