Embolectomy

Recently Sir Thomas Lewis, eminent London heart specialist, made a special study of how an arm or leg dies when an embolus (floating clot) plugs a main artery which feeds blood to that limb. Competent heart specialists and surgeons generally see such blood-starved limbs too late to save them from gangrene and amputation. Last week, by chance, a Chicago doctor, Geza deTakats, in the American Journal of Surgery, and a Toronto doctor, Donald Walton Gordon Murray, in the Canadian Medical Association Journal, each gave explicit directions for locating such a destructive clot, removing it by surgery, thus saving the limb.

Drs. deTakats and Murray agree that speed of diagnosis and operation is essential. Says Dr. Murray: "Next to internal and external hemorrhage, embolism of the peripheral arteries is one of the most urgent surgical emergencies. Acute appendicitis, intestinal obstruction, perforated viscus, etc., while better treated at the first possible moment, usually will not be followed by the disastrous results from waiting six to eight hours that may be expected from neglect of an embolus for the same length of time."

If embolectomy is performed within ten hours after the clot cuts off circulation in a limb, Dr. deTakats finds that 40% of the cases will recover the use of the member. Operations done in the second ten-hour period will be successful in 14% of the cases; in the third ten-hour period, 8%. Dr. deTakats: "Embolectomy is futile after 48 hours or even before that if there is a manifest gangrene, or on patients in whom the underlying disease is apt to be fatal shortly, as in septic endocarditis or terminal cardiac decompensation." Dr. Murray: "There are few operations in surgery so eminently satisfactory in selected cases or attended by such potentiality for good as embolectomy for arterial embolus."

The patient usually has heart disease or may have recently undergone a major operation. A blood clot (thrombus) breaks loose from its anchorage, floats with the blood stream until it gets stuck in an artery. Most frequent sites of this plugging are the common femoral artery in the groin (39%) and the common iliac artery in the lower abdomen (15%). Embolus here stops circulation in the entire leg and foot. Other frequent sites for emboli are the brachial artery in the elbow, affecting the forearm and hand; the popliteal (10%), affecting the lower leg and foot; the aorta, affecting the entire body.

The instant an embolus seats itself like a valve in an artery, the victim usually feels an excruciating pain at that point. Simultaneously "the affected extremity becomes paralyzed, cold and pale, the pulses disappear, and in a few hours the skin becomes mottled with a bluish hue. . . . On the fingers and toes, or sometimes over prominent bones . . . dark blisters appear which may open and from which the gangrene spreads."

Dr. Murray's operation for embolus is to cut until he can handle the affected artery at the site of the plugging. Above and below the embolus he applies soft rubber-covered clamps to the artery. Over the embolus "a longitudinal incision, 0.5 to 1 cm. long, is made. The mass is expressed by the fingers without difficulty and the lower clamp is removed to allow return bleeding to flush the distal [away from the heart] segment and similarly the proximal [toward the heart] segment is flushed and the clamp reapplied. With fine oiled silk suture on arterial needles, the incision is closed, and the clamps are removed. ... If successful, the color, temperature, anesthesia and paralysis improve promptly."

If unsuccessful, the limb dies, according to Heart Specialist Sir Thomas Lewis, in this order: 1) the sense of touch in the fingers, which proceeds up the hand and arm 1 1/2 in. per minute; 2) the kinesthetic sense, by which a person knows how his arm lies in relation to his body; 3) muscular power; 4) sense of pain; 5) sense of temperature; 6) nerves which cause goose flesh.

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