Department of Vascular Surgery, Ninewells Hospital, Dundee, UK.
School of Medicine, University of Dundee, Ninewells Hospital & Medical School, Dundee, UK.
Vasa. 2024 Sep;53(5):341-351. doi: 10.1024/0301-1526/a001147. Epub 2024 Sep 9.
The management of embolic acute limb ischaemia commonly involves determining aetiology and performing emergency invasive procedures. This detailed study aimed to determine the impact of manipulation of anticoagulation in the aetiology of emboli in acute limb ischaemia and determine the efficacy of primary anticoagulation therapy vs. invasive interventions. Data collection was conducted at a single institution on a cohort of patients presenting consecutively with embolic acute limb ischaemia over one year. Two groups were compared, one receiving anticoagulation as primary therapy with those undergoing invasive treatment as the internal comparison group. A likely haematological causation was identified in 22 of 38 presentations, related to interruption of anticoagulation in cardiac conditions, the majority atrial fibrillation (n=12), or hypercoagulable states (n=10). Limb salvage was pursued in 36 patients employing anticoagulation (n=19) or surgical embolectomy (n=17) as the primary therapy in upper and lower limbs (n=17 vs n=19 respectively). Despite delays often well beyond six hours and a range of ischaemic severity in both groups, 35 of 36 patients achieved full or substantive restoration of function with improved perfusion. Regarding anatomical distribution of arterial disease and therapy, three patients with multi-level disease proceeded to embolectomy following anticoagulation. Embolectomy was undertaken most often for proximal emboli and more profound paralysis. Anticoagulation and coagulopathy are commonly implicated in the aetiology of arterial emboli, with omission of effective anticoagulation in atrial fibrillation being associated in almost 1/3 of presentations. Whilst more profound limb paralysis and proximal or multi-level disease tended to be managed surgically, primary anticoagulation therapy alone or with a secondary embolectomy was effective across the spectrum of ischaemia severity and despite significant delays beyond guideline recommendations.
急性肢体缺血性栓塞的治疗通常包括确定病因和进行紧急有创手术。本详细研究旨在确定在急性肢体缺血性栓塞的病因中抗凝药物的调整的影响，并确定原发性抗凝治疗与侵入性干预的疗效。数据收集在一家机构进行，对一年内连续出现急性肢体缺血性栓塞的患者队列进行了研究。将患者分为两组，一组接受抗凝治疗作为主要治疗方法，另一组接受侵入性治疗作为内部比较组。在 38 例表现中，有 22 例可能存在血液学原因，与心脏疾病中断抗凝治疗有关，其中大多数为心房颤动（n=12）或高凝状态（n=10）。36 例患者采用抗凝治疗（n=19）或手术取栓（n=17）作为上肢和下肢的主要治疗方法（分别为 n=17 和 n=19）来保留肢体。尽管两组患者都存在明显的延迟，通常超过 6 小时，且缺血严重程度不一，但 36 例患者中的 35 例均实现了功能的完全或实质性恢复，灌注得到改善。关于动脉疾病的解剖分布和治疗，3 例多水平疾病患者在抗凝治疗后进行了取栓。取栓术最常用于近端栓塞和更严重的瘫痪。抗凝和凝血异常通常与动脉栓塞的病因有关，在近 1/3 的病例中，心房颤动患者的抗凝治疗被遗漏。尽管严重程度不一，且存在明显的延迟超过指南建议，但当存在更严重的肢体瘫痪和近端或多水平疾病时，手术治疗效果更好，原发性抗凝治疗单独或与继发性取栓术的效果一样好。
