Sibiul Medical nr 4_2007.p65

STUDII CLINICE ÇI DE LABORATOR
FACTORII DE RISC PENTRU PIERDEREA MEMBRULUI INFERIOR
DUPÅ EMBOLECTOMIE DIN OCLUZIA ARTERIALÅ ACUTÅ
RISK FACTORS FOR EARLY LOWER LIMB LOSS AFTER EMBOLEC-
TOMY FOR ACUTE ARTERIAL OCLUSION
L. Kiss, U. Metzger*, R. Kiss, N. Sârbu, S. Ilie**, E. Låpådatu***, R. Cojan****
Clinica Chirurgie I – Sibiu
*CHU ZÜRICH – Triemli Klinik
**Clinica ATI – Sibiu
*** Clinica de UrgenÆå – Spitalul de UregenÆå Petroçani
**** Clinica Cardiologie I – Sibiu
REZUMAT
Au fost studiaÆi 200 de pacienÆi cu scopul identificårii
factorilor de risk privond pierderea extremitåÆilor distale
dupå embolectomie arterialå. Au fost obÆinute date de la
65 de pacienÆi, care au suferit amputaÆii majore sub 30 de
zile dupå amputaÆie datele fiind comparate cu un lot control
de 65 de bolnavi. Studiul a aråtat creçterea riscului de
amputaÆie la bolnavii suferind de 2 sau mai mult de 2
infarcte miocardice, cei cu ischemie cronicå, în caz de
simptomatologie de duratå, sau la cei cu insuficienÆå
cardiacå postoperatorie. Riscul amputaÆiei a fost redus la
cei cu infarct miocardic acut çi cu tratament cu heparinå
(L.M.H.). În concluzie se poate spune cå riscul amputaÆiei
precoce dupå embolectomie sau trombectomie arterialå
poate fi apreciat prin aspecte clinice multiple.
Cuvinte cheie: embolectomia, pierderea extremitåÆii
distale, anticoagularea postoperatorie
ABSTRACT
To identify risk factors for lower limb loos after
arterial embolectomy a cohort of 200 patients was studied
between. Detaliled data were obtained for 65 patients who
underwent a major amputation within 30 days of
embolectomy and for 65 mathced controls. The
amputation risk was increased in patients whit two or more
myocardial infarctions, long duration of simptoms, chronic
ischaemia or postoperative heart failure. Reduced risk
were found in association with acute myocardial infarction
and postoperative anticoagulation with L.M.H.. We
conclude that the risk of early amputation after arterial
embolectomy or thrombectomy can be predicted by
several clinical charactristics.
Key words: embolectomy, lower limb loss,
postoperative anticoagulatoin.
The poor outlook after conventional embolectomy,
with on amputation risk of 20 – 40 percent, and a
postoperative mortality rate of 15 – 48 percent, remains a
major challenge in vascular surgery. The risk of
amputation after acute embolectomy may be related to
the:
• Duration of symptoms
• Degree of preoperative ischemia
• Preexistence peripheral atherosclerosis
• Anatomical level of oclusion
• Recurrence of embolism or thrombosis
• Degree of haemoconcentration and heart failure.
PATIENTS AND METHODS:
Study population: This investigation was conduced
as a nested case – control study in a population based
cohort of patients who underwent thromboembolectomy
for acute arterial oclusion between 1986 – 2006. The
cohort comprised 200 individual with a first episode of
acute arterial oclusion. Cases were defined as all patients
in the cohort who underwent a major amputation of the
foot, leg or thigh within 30 days of embolectomy or
thrombectomy for a first episode of acute arterial oclusion
in the lower extremity. Detaliled data were obtained for
65 patients who underwent a major amputation within 30
days of embolectomy and for 65 matched controls (32%).
Pathient characteristics: ECG and information on Hgb
and creatinine were avaible in laboratory records.
Preoperative and postoperative anticoagulation treatment
was recorded on a day – to – day supervision form for the
period of in patients care. Preoperative heparin was usually
administered in a dose of 5000 units just before clamping
of the vessel, and this dose was therefore chosen as the
minimum level of expasure. A distinction between arterial
embolism and thrombosis, however interesting, could not
be made retrospectively from the available data.
The preoperative factors studied were:
• History of miocardial infarction
• History of angina pectoris
• Presence of cardiac arrhythmia other than atrial
fibrillation
• Atrial fibrillation
• Heart failure
• Diabetes
• Symptoms of chronic ischaemia
• History of cerebrovascular lesion
• Oral anticoagulation treatment
• Maliignant disease
The preoperative factors studied included:
• Acute myocardial infarction
• Cerebrovascular lesion within the 30 days before
embolectomy
• Acute heart failure on admissiun
„Sibiul Medical“ Volum 19 Nr. 4/2007 73