SURGICAL-MANAGEMENT OF ATHEROEMBOLIZATION

Purpose: Atheroembolization may cause limb loss or organ failure. Surg ical outcome data are limited. We report the largest series of atheroe mbolization focusing on patterns of disease, surgical treatment and ou tcome. Methods: One hundred patients (70 men), mean age 62 +/- 11 year s, operated on for lower extremity, visceral, or nonthoracic outlet up per extremity atheroemboli were identified prospectively and monitored over a 12-year period. The atheroembolic source was localized by use of a combination of computed tomography scanning (n = 55), arteriograp hy (n = 93), duplex scanning (n = 25), transesophageal echocardiograph y (n = 6), and magnetic resonance imaging (n = 4). Occlusive aortoilia c disease (47 patients) and small aortic aneurysms (20 patients; mean aneurysm size 3.5 +/- 0.8 cm) were the most common source of atheroemb oli. Imaging studies revealed 12 patients with extensive suprarenal ao rtic thrombus. Correction of the embolic source was achieved with aort ic bypass (n = 52), aoaoiliac endarterectomy and patch (n = 11), femor al or popliteal endarterectomy and patch (n = 11), infrainguinal bypas s (n = 3), extraanatomic reconstruction (n = 6), graft revision (n = 3 ), upper extremity bypass (rt = 11), or upper extremity endarterectomy and patch (n = 3). Results: All four deaths within. 30 days and all s even deaths within the first 6 months after operation were among the 1 2 patients with suprarenal aortic thrombus. The cumulative survival pr obabilities for all patients at 1, 3, and 5 years were 89%, 83%, and 7 3%, respectively. After operation, nine patients required major leg am putations and 10 required toe amputations. Renal atheroemboli led to h emodialysis in 10 patients. Recurrent embolic events occurred in five of 97 patients monitored for a mean of 32 months. All five recurrences occurred in the first 8 months after operation. Three patients with r ecurrent emboli had suprarenal aortic disease, one of whom had undergo ne axillofemorofemoral bypass. Four of 15 patients receiving postopera tive warfarin anticoagulation had development of recurrent embolism. O nly one patient not receiving postoperative warfarin had a recurrent e vent (p < 0.05 by Fisher exact test). Conclusion: The atheroembolic so urce is the aorta or iliac arteries in two thirds of patients who unde rwent operation. Computed tomography scanning of the aorta is a useful diagnostic technique. The source of the emboli can be eliminated surg ically with low mortality or limb loss rates except when the suprarena l aorta is involved.