Operative Revascularization for Trash Foot David O’Connor, Nicholas J. Gargiulo, III and Frank J. Veith Distal embolization of atherosclerotic debris to the foot is a serious and challenging dilemma. Most commonly it occurs during open and endovascular aortoiliac aneurysm repair, but it is also known to occur during lower extremity endovascular interventions as well as from material within femoral and popliteal artery aneurysms. If allowed to progress, prolonged ischemia to the foot can result in soft tissue gangrene, requiring major amputation. Given the relatively low incidence of this condition and lack of comparative treatment analysis, no clear consensus has emerged on the optimal treatment of this condition. However, certain aspects from the presentation as well as the characteristics of the embolic material can help guide therapy. Clinical Presentation and Diagnosis Trash foot develops from atherosclerotic debris embolizing either spontaneously or from manipulation of a diseased proximal vessel. Depending on the clinical setting and proximal vessel characteristics, the embolic material can consist of cholesterol crystals, organized thrombus, or fibrin–platelet aggregates. This material can lodge in the major branches of the foot, including the dorsalis pedis, lateral tarsal, or plantar arteries, as well as the digital arteries. Painful bluish discoloration of the toes on one or both feet can occur initially along with livedo reticularis. With extensive embolization and a prolonged time course, ulceration and gangrene can develop. Pedal pulses may or may not be present, depending on preexisting arterial insufficiency and the site of embolic occlusion. Prompt diagnosis is aided by strong clinical suspicion and the setting of presentation. Although not common, distal embolization to the lower extremities is a well-known complication of both open and endovascular aneurysm repair. This is thought to be caused by fragmentation of atheroma within the aorta during dissection or cross clamping during open repair or during the passage of wires and stent deployment with endovascular repair. Inadequate heparinization and in-situ thrombosis of the distal arterial circulation are other proposed mechanisms. Digital subtraction angiography of the involved extremity with anteroposterior and lateral views of the foot can diagnose the level of proximal occlusion. Potential target pedal vessels for embolectomy or bypass can be missed owing to the limited amount of blood flow to these areas. Duplex scanning of the pedal vessels can be helpful in circumstances of occlusions starting more proximally in the tibial regions that cannot be visualized by angiography. Medical Therapy and Thrombolysis Conservative therapy using intravenous heparin or systemic thrombolysis is often inadequate because the embolic material many times contains cholesterol, and a large amount of debris may be present. In addition, systemic thrombolysis is contraindicated in patients who develop embolization after recent surgery. Percutaneous intraarterial thrombolysis, which is considered an effective first-line treatment for acute limb ischemia, may be considered in patients with trash foot who do not come to the hospital with motor or sensory deficits. A high failure rate, however, has been noted, especially following aortoiliac aneurysm repair, and these patients are prone to hemorrhagic complications. Despite its limitations as primary therapy, intraarterial thrombolysis has been used as an adjunct to embolectomy. Following incomplete pedal embolectomy, Mahmood and colleagues infused 30,000 units of streptokinase in 20 mL of saline proximally and distally. This was followed by repeat pedal embolectomy, allowing complete thrombus removal and limb salvage in four limbs. Wyffels and coworkers salvaged 10 limbs using pedal embolectomy and intraoperative lysis, which was continued into the postoperative period through a catheter left at the level of the ankle. Adjunctive thrombolysis can also theoretically assist with digital microvascular and arteriolar thrombosis, though there is no conclusive evidence to support this. Only gold members can continue reading. Log In or Register to continue Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window) Related Related posts: Technical Aspects of Percutaneous Carotid Angioplasty and Stenting for Arteriosclerotic Disease In-Situ Treatment of Aortic Graft Infection with Prosthetic Grafts and Allografts Treatment of Acute Upper Extremity Venous Occlusion Intraoperative Assessment of the Technical Adequacy of Carotid Endarterectomy Stay updated, free articles. Join our Telegram channel Join Tags: Current Therapy in Vascular and Endovascular Surgery Aug 25, 2016 | Posted by admin in CARDIOLOGY | Comments Off on Operative Revascularization for Trash Foot Full access? Get Clinical Tree
Operative Revascularization for Trash Foot David O’Connor, Nicholas J. Gargiulo, III and Frank J. Veith Distal embolization of atherosclerotic debris to the foot is a serious and challenging dilemma. Most commonly it occurs during open and endovascular aortoiliac aneurysm repair, but it is also known to occur during lower extremity endovascular interventions as well as from material within femoral and popliteal artery aneurysms. If allowed to progress, prolonged ischemia to the foot can result in soft tissue gangrene, requiring major amputation. Given the relatively low incidence of this condition and lack of comparative treatment analysis, no clear consensus has emerged on the optimal treatment of this condition. However, certain aspects from the presentation as well as the characteristics of the embolic material can help guide therapy. Clinical Presentation and Diagnosis Trash foot develops from atherosclerotic debris embolizing either spontaneously or from manipulation of a diseased proximal vessel. Depending on the clinical setting and proximal vessel characteristics, the embolic material can consist of cholesterol crystals, organized thrombus, or fibrin–platelet aggregates. This material can lodge in the major branches of the foot, including the dorsalis pedis, lateral tarsal, or plantar arteries, as well as the digital arteries. Painful bluish discoloration of the toes on one or both feet can occur initially along with livedo reticularis. With extensive embolization and a prolonged time course, ulceration and gangrene can develop. Pedal pulses may or may not be present, depending on preexisting arterial insufficiency and the site of embolic occlusion. Prompt diagnosis is aided by strong clinical suspicion and the setting of presentation. Although not common, distal embolization to the lower extremities is a well-known complication of both open and endovascular aneurysm repair. This is thought to be caused by fragmentation of atheroma within the aorta during dissection or cross clamping during open repair or during the passage of wires and stent deployment with endovascular repair. Inadequate heparinization and in-situ thrombosis of the distal arterial circulation are other proposed mechanisms. Digital subtraction angiography of the involved extremity with anteroposterior and lateral views of the foot can diagnose the level of proximal occlusion. Potential target pedal vessels for embolectomy or bypass can be missed owing to the limited amount of blood flow to these areas. Duplex scanning of the pedal vessels can be helpful in circumstances of occlusions starting more proximally in the tibial regions that cannot be visualized by angiography. Medical Therapy and Thrombolysis Conservative therapy using intravenous heparin or systemic thrombolysis is often inadequate because the embolic material many times contains cholesterol, and a large amount of debris may be present. In addition, systemic thrombolysis is contraindicated in patients who develop embolization after recent surgery. Percutaneous intraarterial thrombolysis, which is considered an effective first-line treatment for acute limb ischemia, may be considered in patients with trash foot who do not come to the hospital with motor or sensory deficits. A high failure rate, however, has been noted, especially following aortoiliac aneurysm repair, and these patients are prone to hemorrhagic complications. Despite its limitations as primary therapy, intraarterial thrombolysis has been used as an adjunct to embolectomy. Following incomplete pedal embolectomy, Mahmood and colleagues infused 30,000 units of streptokinase in 20 mL of saline proximally and distally. This was followed by repeat pedal embolectomy, allowing complete thrombus removal and limb salvage in four limbs. Wyffels and coworkers salvaged 10 limbs using pedal embolectomy and intraoperative lysis, which was continued into the postoperative period through a catheter left at the level of the ankle. Adjunctive thrombolysis can also theoretically assist with digital microvascular and arteriolar thrombosis, though there is no conclusive evidence to support this. Only gold members can continue reading. Log In or Register to continue Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window) Related Related posts: Technical Aspects of Percutaneous Carotid Angioplasty and Stenting for Arteriosclerotic Disease In-Situ Treatment of Aortic Graft Infection with Prosthetic Grafts and Allografts Treatment of Acute Upper Extremity Venous Occlusion Intraoperative Assessment of the Technical Adequacy of Carotid Endarterectomy Stay updated, free articles. Join our Telegram channel Join
