Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3711_Библиотеки_им_академика_М_И_Перельмана

I. Obstructive lesions

2. Proximal aortic thrombus B. Acute dissection C. Tumor obstruction

A. Iatrogenic

1. Surgery with legs in stirrups

A. Chemotherapy related B. Obstructing tumor

A. Essential thrombocytosis B. Protein C and S deciency syndromes C. Thrombotic thrombocytopenia

IX. Medication

In the younger, and particularly in the Marfan-type, patient, sudden severe pain and ischemic symptoms may develop as a result of aortic wall dissection. Such lesions may be of familial or hereditary origin. These lesions usually occur in the proximal or thoracic aorta with symptoms involving the chest, the abdomen, and the lower extremities. Similarly, spontaneous proximal thoracic aortic dissection and thrombus formation may lead to both thoracic aortic thrombosis and distal aortoiliac embolic situations.

also be the culprits. Kim etal. reported on four cases of acute aortic thrombus induced by chemotherapy [7]. Thrombosis of the abdominal aorta in congenital abrinogenemia has been reported by Sartori etal. [8].

Positional considerations are always present when patients are placed in unusual positions for major prolonged surgical therapy. When patients require prolonged stirrup positioning and control of the lower extremities for major pelvic tumor surgery, such as exenteration, we have been asked postoperatively to consult on these patients with aor­toiliac occlusive disease and loss of limb function or sensa­tion. In the recent years, additional nongynecologic surgical procedures have required the lower extremities to be placed in stirrups for surgeon positioning and appropriateness of the operation. The physician attempts to position the patient and legs in as neutral a position (not too high or too wide) as pos­sible and yet to be able to perform the necessary operation. Despite these prophylactic attempts, on an unusual occasion, the patient on awakening may be found to have “moribund” extremities. The physician may assume such nding was due to the positioning but, in fact, other factors may also be involved and should be investigated for– when possible and time permits.

hypertension, COPD, a history of cholesterol elevation, clau­dication, and a history of two cerebral strokes. A whole-body C-T (computerized tomography) scan demonstrated two aor­tic aneurysmal dilations with maximum diameter of 3.2cm (one thoracic and one abdominal) and an open aortoiliac system.

As soon as reasonable, after a decision regarding medical or vascular surgery intervention urgency is completed – which depends on the level of extremity discoloration and the patient’s medical condition– further diagnostic or ther­apy evaluation is undertaken. CTA, diagnostic studies, and intervention will be guided by and after the therapeutic approach elected has been determined. MRA studies and more esoteric coagulation prole studies may not be neces­sary or practical initially but obtained when conditions are more appropriate. Invasive catheter angiography will not be required nor practical in a large number of these acutely and very ill patients but assistive when conditions permit.

Recognition of the problem is primary in deciding the thera­peutic course to follow in these patients. When the patient is asymptomatic or has few complaints, the approach will be different from that for the patient who has morbid function­less and discolored extremities. Some of the options avail­able to treat these unfortunate individuals – depending on their condition– are outlined below.

I. History and physical– medication history II. Laboratory

Kaschwich etal. have outlined their approach and man­agement of acute aortic thrombosis after reviewing the litera­ture and report no improvement in mortality over the past 20 years [13]. When the endoaortic thrombus is causing recurrent or potentially catastrophic concerns, more aggres­sive therapy and intervention are indicated. Depending on the location of the thrombus and the patient’s condition, aggressive therapy will be initiated. This was done by Ha etal. after cardiac catheterization-associated aortic occlusion [14]. Siani etal. utilized the endovascular stent graft for a high-risk patient with a thoracic aortic medial thrombosis [4]. Verma et al. reviewed 88 patients with acute arterial occlusion and found 19 patients (mean age 41.2years and male/female ratio 1:2.1) with aortic mural thrombus. Ten of the patients had thoracic aorta thrombus and six had infrare­nal aortic thrombin origin [15]. Thoracic aortic lesions were treated with stent grafts (4), bare-metal stents (3), and antico­agulation (2). Three suprarenal lesions were treated with a trapdoor aortic thrombectomy and six infrarenal patients with aortobifemoral embolectomy, aortic stenting (2), surgi­cal thrombectomy (1), and anticoagulation alone (1). Four of the patients died due to these major thromboembolic insults (21%) [15].