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Concomitant embolism of popliteal arteries
(Portuguese PDF version)

Edvaldo de Souza,1 Ricardo Tsutomu Suzuki,2 Flavio Roberto Cavalleiro de Macedo Ribeiro,3 Marcus Vinicius X. Veloso4

1. M.D. Specialist in Angiology and Vascular Surgery. Vascular Surgeon, Hospital Santa Marcelina, Itaquaquecetuba, SP, Brazil.
2. Specialist in Angiology and Vascular Surgery. Vascular Surgeon, Hospital Santa Marcelina, Itaquaquecetuba, SP, Brazil.
3. Vascular Surgeon, Hospital Santa Marcelina, Itaquaquecetuba, SP, Brazil.
4. Coordinator of the department of surgery, Hospital Santa Marcelina, Itaquaquecetuba, SP, Brazil.

Correspondence:
Edvaldo de Souza
Rua Rio Negro, 48
CEP 08577-210 - Itaquaquecetuba, SP, Brazil
Phone: +55 (11) 4645.4200
E-mail: ed@predialnet.com.br

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ABSTRACT

The authors report on an uncommon case of simultaneous acute ischemia of the lower extremities resultant from an arterial embolism of cardiogenic source. The diagnosis of the arterial occlusion was demonstrated by arteriography and the source of the embolus was confirmed by the echocardiogram. The thromboembolectomy was carried out soon after the patient was admitted in the emergency room presenting with reversion of lower extremities ischemia.

Key-words: ischemia, lower extremities, embolism.

J Vasc Br 2004;3(4):397-400

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Most of the cases of lower limb ischemia are resultant from arterial thromboembolisms that have cardiac origin or also of arterial thrombosis caused by atherosclerotic lesions or aneurysms. Less frequent causes of lower limb ischemia are trauma, aortic dissection and foreign body embolism. Acute cases should be managed urgently, otherwise irreversible tissues ischemia may occur. The patient's history, physical examinations and electrochardiogram findings may reveal the etiology of the ischemic event; an echodardiogram, however, would show the exact location of the intracavitary thrombus.^1-6

The first diagnose of arterial occlusion reported is from 1628, and the first embolectomy was performed in 1911. A large number of cases submitted to embolectomy have been reported since then, but they still have high mortality and morbidity postoperative rates. After the Fogarty catheter started to be used, in 1963, the outcomes of surgeries have had a progressive increase, especially with the increased offer of treatment alternatives.^2,4-11

CASE REPORT

A 58-year-old black male patient was admitted in the emergency room reporting sudden onset of pain in both lower limbs, below knee, lasting for four hours and being more intense in the left limb. Two days before, the patient had had a precordial discomfort, received clinical treatment and was discharged.

Cardiac failure and arterial hypertension were managed daily with digoxin 0,25 mg, captopril 75 mg, furosemide 80 mg and aldactone 50 mg. He presented psychomotor agitation, did not cooperate with the clinical examination and heart beats were irregular on auscultation. The electrocardiogram revealed atrial fibrillation.

The left foot movements were paralised and the right foot had paresis. Pain was more intense in the left limb and there was the presence of a thermal gradient since the upper third of the legs. The findings of pulse examination of lower limbs is shown in Table 1.

Table 1 - Findings of pulse examination of lower limbs.

Pulses	Femoral	Popliteal	Foot	Posterior tibial
Right	4+/4+	2+/4+	Absent	Absent
Left	4+/4+	Absent	Absent	Absent

The examination performed with portable Doppler revealed the absence of flow in the popliteal artery and in the distal arteries of the left lower limb and right foot.
The thorax x-ray showed bilateral basal lung infiltration, radiopacity of the lungs base and increased heart area.
Findings of laboratory tests are summarized in Table 2.

Table 2 - Laboratory test findings

Tests	Findings
Glucemia Urea Creatinine Sodium Potassium Creatinine phosphokinase Glutamic-oxaloacetic transaminase (SGOT) (lactic dehydrogenase) Blood count Platelets Leukocytes Prothrombine time (PT) Prothrombine activity (PA) International normatization ratio (INR) Activated partial thromboplastine time (APTT)	227 mg/dl 34 mg/dl 1.3 mg/dl 134 mmol/l 3.8 mmol/l 724 U/l (mb fraction - 52 U/l) DHL 166 U/l 948 U/l Hb = 16.4 g/dl, Ht = 52.8% 131,000/mm3 14,700 (small toxic granule) 13 seconds 100% 1 33%

A bilateral popliteal-femoral topography confirmed the diagnosis of acute arterial occlusion of lower limbs. Due to the hypothesis of embolism of cardiogenic origin and to the imminence of the limb becoming not viable, there was an indication for surgery of vascular exploration. In the surgical unit, a percutaneous bilateral femoral arteriography was performed, which revealed the obstruction of the right popliteal artery at the level of the knee-joint and of the upper third of the left popliteal artery. (Figures 1 and 2).

Figure 1 - Right femoral percutaneous arteriography showing the obstruction of the popliteal artery at the level of the knee joint.

Figure 2 - Left femoral percutaneous arteriography showing the obstruction of the popliteal artery in the upper third.

The surgical approach of the popliteal arteries was performed in the lower third of the thigh, and the thromboembolectomy was proceeded, allowing thrombi to be removed. At the end of the surgical procedure, we observed clinical signs of the compartmental syndrome in both legs, so a fasciotomy of the four compartments was immediately performed, bilaterally. The patient had pulses recovered in both legs, and was later kept in systemic anticoagulation.

The patient was referred to the Intensive Care Unit and in the fourth day developed dyspnea, ventricular fibrillation and was hemodynamically unstable. Electric cardioversion, orotracheal intubation with mechanical ventilation and use of vasopressors were required. The echocardiogram showed a severe diffuse myocardial injury of the left ventriculum (LV), mild tricuspid insufficiency, slight mitral insufficiency, pulmonary arterial hypertension and intracavitary thrombus (11 x 8 mm) adhered to the apex of the LV, with an ejection fraction of 36%.

In the sixth day of ICU admission, another event of ventricular fibrillation was reverted, and after three days the patient developed refractory cardiogenic shock to the vasopressors, dying in the 10^th admission day.

DISCUSSION

Treatment of peripheral arterial embolism, either conservative or surgical, has a high mortality rate because it reaches patients with high operative risks.

Bilateral and concomitant ischemia of lower limbs are usual signs of an episode of embolism and are rarely secondary to a systemic factor of low perfusion. Peripheral arterial embolism has a cardiac origin in 88 to 90% of cases and, in general, it occurs in patients with atrial fibrilation or recent myocardial infarct. The abdominal aortic aneurysm, the ulcerous atherosclerotic plaques with thrombus and, the paradoxal embolism are potentially responsible for embolism events. Currently, with the possibility of making early diagnoses and treating acute ischemia and thrombosis events, the limb salvage is possible in most cases.^1,2,4,5

The case we reported here is an uncommon case of concomitant embolism of cardiogenic origin in both lower limbs. Cases reported in the literature usually refer to unilateral embolisms of lower limbs. This case is important because of the clinical suspicion of bilateral embolism and its confirmation with the arteriography. Due to the patient's clinical condition, which did not allow the collaboration with the physical examination, and as symptoms were increased in the left side, the diagnosis of ischemia in the right side could have been delayed, increasing the risk of limb loss.³

The diagnosis about the source of the embolus was made in the postoperative period with the transthoracic echocardiogram, because the thrombus was in the interior of the LV; so the transesophagic echocardiography was not necessary.

The surgical thromboembolectomy is the treatment of choice for the management of arterial embolisms of lower limbs. It has the advantages of a simple treatment, which does not require much technical hospitalar sophistication. In our case, the revascularization was very fast and suitable to the urgency of the sensitive-motor ischemia, what would increase the limb salvage rate, according to the literature.

Treatment with fibrinolitic drugs is an alternative that can be used in cases of peripheral arterial embolism, although there is not a comparative study that demonstrates its efficacy. They may also cause some complications, especially hemorrhagic events. Another inconvenient is the delay of the surgical treatment. In the case reported, the patient presented neurological symptoms that indicated anoxia of peripheral nerves clinically classified as acute ischemia, which indicate the immediate risk of limb loss.^4,5,8,11,12

The preoperative fibrinolysis is an important and additional treatment in case residual thrombi are found in the control arteriography, especially when distal emboli can not be accessed with the Fogarty catheter. ⁶

Since 1985, different techniques for thrombi aspiration have been developed, presenting positive technical results in patients with arterial embolism in the lower limbs. Limb salvage and mortality rate were 94% and 3,9%, respectively. It has then become a radiological alternative to the thromboembolectomy, mainly in the distal segment of the femoral and popliteal arteries and leg arteries. This method may be combined with the in situ fibrinolysis, especially in the management of atherosclerotic arteries.^6,9,10,11

Fasciotomy was performed in the present case because of the compartimental hypertension installed in the patient's legs soon after surgery. It may have been a result of the ischemia caused by the lack of collateral circulation distal to the arterial obstruction showed in the arteriography. In these cases, the fasciotomy should be performed at the right moment, otherwise serious metabolic consequences may even antecipate death.⁴

The postoperative anticoagulation is an important measure to avoid the embolism recidivation, especially when intracavitary thrombus are present. In general, no significant bleeding is observed in this type of treatment.⁵

The cause of death is according to the literature. It resulted of a serious miocardiopathy that originated the embolus end evolved to arrhythmia and cardiogenic shock, which did not accept the clinical treatment.^2,4,6

COMENTS

The peripheral arterial embolism of lower limbs should lead to the suspicion of concomitant occlusion of other segments; a careful and detailed clinical examination would be very important to make an early diagnosis.

REFERENCES

1. Fernandez BB. An unusual presentation of simultaneous bilateral popliteal artery embolism: a case report. Angiology 1998;49:573-6.

2. Martin P, King RB, Stephenson CBS. On arterial embolism of the limbs. Br J Surg 1969;56:882-4.

3. Hurwitz MM. The too-subtle signs of occlusive arterial disease. Geriatrics 1972;27:42-53.

4. Greep JM, Aleman PJ, Jarrett F, et al. A combined technique for peripheral arterial embolectomy. Arch Surg 1972;105:869-74.

5. Papasoglou O, Antoniades A, Giacoustides E, et al. Surgical treatment of acute arterial obstruction of the extremities: an analysis of 75 cases. J Cardiovas Surg 1974;15:560-4.

6. Beck F, Duchemin JF, Streichenberger T, et al. Embolies des membres inférieurs: traitement par embolectomie chirurgicale. J Mal Vasc 1996;21 Suppl A:72-5.

7. Oglietti J, Abelleyra J, Vaccario A, et al. Tratamiento quirúrgico e las embolias arteriales. Pren Méd Argent 1969;56:1777-80.

8. Amery A, Deloof W, Vermylen J, et al. Outcome of recent thromboembolic occlusions of limb arteries treated with streptokinase. BMJ 1970;4:639-44.

9. Starck EE, McDermott JC, Crummy AB, et al. Percutaneous aspiration thromboembolectomy. Radiology 1985;156:61-6.

10. Murray JG, Brown AL, Wilkins RA. Percutaneous aspiration thromboembolectomy: a preliminary experience. Clin Radiol 1994;49:553-8.

11. Gabrielle F, Cercueil JP, Tatou E, et al. Embolies dês membres inférieurs: traitement par thrombo-aspiration percutanée. J Mal Vasc 1996; Suppl A:76-82.

12. Rutherford RB, Baker JD, Ernst C, et al. Recommended standards for reports dealing with lower extremity ischemia: revised version. J Vasc Surg 1997;26:517-38.