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Cardiac Causes of Acute and Chronic Limb Ischemia

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Critical Limb Ischemia

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Abstract

Acute limb ischemia occurs from an abrupt interruption of blood flow to an extremity, usually because of embolic or thrombotic vascular occlusion. It can also result from trauma and dissection. With an embolic occlusion, a cardiac origin is the source of emboli in 80–90 % of cases, usually in the setting of atrial fibrillation/flutter or acute myocardial infarction (O’Connell and Quiñones-Baldrich, Semin Vasc Surg. 22(1):10–16, 2009). The presence of rheumatic or prosthetic cardiac valves, endocarditis, and cardiac tumors (such as left atrial myxoma) is also associated with increased risk of embolic events. Furthermore, paradoxical embolism of venous thrombi through an intra-atrial communication (such as an atrial septal defect (ASD) or patent foramen ovale (PFO)), or less commonly an intraventricular communication, is also encountered in some patients. Hence, this chapter discusses cardiac causes of limb ischemia including dissection.

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References

  1. Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, et al. ACC/AHA 2005 guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic). J Am Coll Cardiol. 2006;47(6):1239–312.

    Article  PubMed  Google Scholar 

  2. Falluji N, Mukherjee D. Critical and acute limb ischemia: an overview. Angiology. 2014;65(2):137–46.

    Article  PubMed  Google Scholar 

  3. Walker TG. Acute limb Ischemia. Tech Vasc Interv Rad 12:117–29.

    Google Scholar 

  4. O’Connell JB, Quiñones-Baldrich WJ. Proper evaluation and management of acute embolic versus thrombotic limb ischemia. Semin Vasc Surg. 2009;22(1):10–6.

    Article  PubMed  Google Scholar 

  5. Fuster V, Rydén LE, Cannom DS, et al. ACC/AHA/ESC 2006 Guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation. 114(7): e257–354.

    Google Scholar 

  6. Lloyd-Jones DM, Wang TJ, Leip EP, Larson MG, Levy D, Vasan RS, et al. Lifetime risk for development of atrial fibrillation: The Framingham Heart Study. Circulation. 2004;110:1042.

    Google Scholar 

  7. Frost L1, Engholm G, Johnsen S, Møller H, Henneberg EW, Husted S. Incident thromboembolism in the aorta and the renal, mesenteric, pelvic and extremity arteries after discharge from the hospital with a diagnosis of atrial fibrillation. Arch Intern Med. 2001;161:272–6.

    Google Scholar 

  8. Menke J, Lüthje L, Kastrup A, Larsen J. Thromboembolism in atrial fibrillation. Am J Cardiol. 2010;105(4):502–10.

    Article  PubMed  Google Scholar 

  9. Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA. 2001;285(22):2864–70.

    Article  CAS  PubMed  Google Scholar 

  10. Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest. 2010;137(2):263–72.

    Article  PubMed  Google Scholar 

  11. January CT, Wann LS, Alpert JS, Calkins H, Cleveland JC Jr, Cigarroa JE, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014;28. pii: S0735-1097(14)01740-9.

    Google Scholar 

  12. Connolly SJ, Ezekowitz MD, Yusuf S, Eikelboom J, Oldgren J, Parekh A, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med. 2009;361(12):1139–51.

    Article  CAS  PubMed  Google Scholar 

  13. Granger CB, Alexander JH, McMurray JJ, Lopes RD, Hylek EM, Hanna M. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2011;365(11):981–92.

    Article  CAS  PubMed  Google Scholar 

  14. Patel MR, Mahaffey KW, Garg J, Pan G, Singer DE, Hacke W. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med. 2011;365(10):883–91.

    Article  CAS  PubMed  Google Scholar 

  15. Holmes DR, Reddy VY, Turi ZG, Doshi SK, Sievert H, Buchbinder M. Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomised non-inferiority trial. Lancet. 2009;374(9689):534–42.

    Article  CAS  PubMed  Google Scholar 

  16. Asinger RW, Mikell FL, Elsperger J, Hodges M. Incidence of left-ventricular thrombosis after acute transmural myocardial infarction. Serial evaluation by two-dimensional echocardiography. N Engl J Med. 1981;305(6):297–302.

    Article  CAS  PubMed  Google Scholar 

  17. Delewi R, Zijlstra F, Piek JJ. Left ventricular thrombus formation after acute myocardial infarction. Heart. 2012;98(23):1743–9.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Chiarella F, Santoro E, Domenicucci S, Maggioni A, Vecchio C. Predischarge two-dimensional echocardiographic evaluation of left ventricular thrombosis after acute myocardial infarction in the GISSI-3 study. Am J Cardiol. 1998;81(7):822–7.

    Article  CAS  PubMed  Google Scholar 

  19. Gianstefani S, Douiri A, Delithanasis I, Rogers T, Sen A, Kalra S, et al. Incidence and predictors of early left ventricular thrombus after ST-elevation myocardial infarction in the contemporary era of primary percutaneous coronary intervention. Am J Cardiol. 2014;113(7):1111–6.

    Article  PubMed  Google Scholar 

  20. Küpper AJ, Verheugt FW, Peels CH, Galema TW, Roos JP. Left ventricular thrombus incidence and behavior studied by serial two-dimensional echocardiography in acute anterior myocardial infarction: left ventricular wall motion, systemic embolism and oral anticoagulation. J Am Coll Cardiol. 1989;13(7):1514–20.

    Article  PubMed  Google Scholar 

  21. Stratton JR, Resnick AD. Increased embolic risk in patients with left ventricular thrombi. Circulation. 1987;75:1004.

    Article  CAS  PubMed  Google Scholar 

  22. Meltzer RS, Visser CA, Fuster V. Intracardiac thrombi and systemic embolization. Ann Intern Med. 1986;104(5):689–98.

    Article  CAS  PubMed  Google Scholar 

  23. Delewi R1, Zijlstra F, Piek JJ. Left ventricular thrombus formation after acute myocardial infarction. Heart. 2012;98(23):1743–49.

    Google Scholar 

  24. Cabin HS, Roberts WC. Left ventricular aneurysm, intraaneurysmal thrombus and systemic embolus in coronary heart disease. Chest. 1980;77(5):586–90.

    Article  CAS  PubMed  Google Scholar 

  25. Nixon JV. Left ventricular mural thrombus. Arch Intern Med. 1983;143(8):1567–71.

    Article  CAS  PubMed  Google Scholar 

  26. Jugdutt BI1, Sivaram CA. Prospective two-dimensional echocardiographic evaluation of left ventricular thrombus and embolism after acute myocardial infarction. J Am Coll Cardiol. 1989;13(3):554–64.

    Google Scholar 

  27. Weinstein L, Schlesinger JJ. Pathoanatomic, pathophysiologic and clinical correlations in endocarditis (second of two parts). N Engl J Med. 1974;291(21):1122–6.

    Article  CAS  PubMed  Google Scholar 

  28. Baddour LM, Wilson WR, Bayer AS, Fowler VG Jr, Bolger AF, Levison ME, et al. Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America. Circulation. 2005;111(23):e394–434.

    Google Scholar 

  29. Vilacosta I, Graupner C, San Román JA, Sarriá C, Ronderos R, Fernández C, et al. Risk of embolization after institution of antibiotic therapy for infective endocarditis. J Am Coll Cardiol. 2002;39(9):1489–95.

    Article  PubMed  Google Scholar 

  30. Mügge A, Daniel WG, Frank G, Lichtlen PR. Echocardiography in infective endocarditis: reassessment of prognostic implications of vegetation size determined by the transthoracic and the transesophageal approach. J Am Coll Cardiol. 1989;14(3):631–8.

    Article  PubMed  Google Scholar 

  31. Prendergast BD1, Tornos P. Surgery for infective endocarditis: who and when? Circulation. 2010;121(9):1141–52.

    Google Scholar 

  32. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin 3rd JP, Guyton RA, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63(22):e57–185.

    Article  PubMed  Google Scholar 

  33. Molina JE, Edwards JE, Ward HB. Primary cardiac tumors: experience at the University of Minnesota. Thorac Cardiovasc Surg. 1990;38 Suppl 2:183.

    Google Scholar 

  34. Tazelaar HD, Locke TJ, McGregor CG. Pathology of surgically excised primary cardiac tumors. Mayo Clin Proc. 1992;67(10):957.

    Article  CAS  PubMed  Google Scholar 

  35. Odim J, Reehal V, Laks H, Mehta U, Fishbein MC. Surgical pathology of cardiac tumors. Two decades at an urban institution. Cardiovasc Pathol. 2003;12(5):267.

    Article  PubMed  Google Scholar 

  36. Livi U, Bortolotti U, Milano A, Valente M, Prandi A, Frugoni C, et al. Cardiac myxomas: results of 14 years’ experience. Thorac Cardiovasc Surg. 1984;32(3):143–7.

    Article  CAS  PubMed  Google Scholar 

  37. Reynen K. Cardiac myxomas. N Engl J Med. 1995;333(24):1610–7.

    Article  CAS  PubMed  Google Scholar 

  38. Coley C, Lee KR, Steiner M, Thompson CS. Complete embolization of a left atrial myxoma resulting in acute lower extremity ischemia. Tex Heart Inst J. 2005;32(2):238–40.

    PubMed  PubMed Central  Google Scholar 

  39. Chiba K, Abe H, Kitanaka Y, Makuuchi H. Left atrial myxoma complicated with an acute upper extremity embolism. Ann Thorac Cardiovasc Surg. 2012;18(4):391–4.

    Article  PubMed  Google Scholar 

  40. Bhan A, Mehrotra R, Choudhary SK, Sharma R, Prabhakar D, Airan B. Surgical experience with intracardiac myxomas: long-term follow-up. Ann Thorac Surg. 1998;66(3):810–3.

    Article  CAS  PubMed  Google Scholar 

  41. Edwards FH, Hale D, Cohen A, Thompson L, Pezzella AT, Virmani R. Primary cardiac valve tumors. Ann Thorac Surg. 1991;52(5):1127–31.

    Article  CAS  PubMed  Google Scholar 

  42. Gowda RM, Khan IA, Nair CK, Mehta NJ, Vasavada BC, Sacchi TJ. Cardiac papillary fibroelastoma: a comprehensive analysis of 725 cases. Am Heart J. 2003;146(3):404.

    Article  PubMed  Google Scholar 

  43. Sun JP, Asher CR, Yang XS, et al. Clinical and echocardiographic characteristics of papillary fibroelastomas: a retrospective and prospective study in 162 patients. Circulation. 2001;103:2687–93.

    Article  CAS  PubMed  Google Scholar 

  44. Klarich KW, Enriquez-Sarano M, Gura GM, Edwards WD, Tajik AJ, Seward JB. Papillary fibroelastoma: echocardiographic characteristics for diagnosis and pathologic correlation. J Am Coll Cardiol. 1997;30:784–90.

    Article  CAS  PubMed  Google Scholar 

  45. Kerut EK, Norfleet WT, Plotnick GD, Giles TD. Patent foramen ovale: a review of associated conditions and the impact of physiological size. J Am Coll Cardiol. 2001;38(3):613–23.

    Article  CAS  PubMed  Google Scholar 

  46. Hagen PT, Scholz DG, Edwards WD. Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc. 1984;59(1):17–20.

    Article  CAS  PubMed  Google Scholar 

  47. Hugl B, Klein-Weigel P, Posch L, Greiner A, Fraedrich G. Peripheral ischemia caused by paradoxical embolization: an underestimated problem? Mt Sinai J Med. 2005;72(3):200–6.

    PubMed  Google Scholar 

  48. Miller S, Causey MW, Schachter D, Andersen CA, Singh N. A case of limb ischemia secondary to paradoxical embolism. Vasc Endovascular Surg. 2010;44(7):604–8.

    Article  PubMed  Google Scholar 

  49. Chen WJ, Kuan P, Lien WP, Lin FY. Detection of patent foramen ovale by contrast transesophageal echocardiography. Chest. 1992;101(6):1515–20.

    Article  CAS  PubMed  Google Scholar 

  50. Tobis J, Shenoda M. Percutaneous treatment of patent foramen ovale and atrial septal defects. J Am Coll Cardiol. 2012;60(18):1722–32.

    Article  PubMed  Google Scholar 

  51. Furlan AJ, Reisman M, Massaro J, Mauri L, Adams H, Albers GW, et al. Closure or medical therapy for cryptogenic stroke with patent foramen ovale. N Engl J Med. 2012;366(11):991–9.

    Article  CAS  PubMed  Google Scholar 

  52. Parissis H, Soo A, Al-Alao B. Intra aortic balloon pump: literature review of risk factors related to complications of the intraaortic balloon pump. J Cardiothorac Surg. 2011;6:147.

    Article  PubMed  PubMed Central  Google Scholar 

  53. Vales L, Kanei Y, Ephrem G, Misra D. Intra-aortic balloon pump use and outcomes with current therapies. J Invasive Cardiol. 2011;23(3):116–9.

    PubMed  Google Scholar 

  54. Kantrowitz A, Wasfie T, Freed PS, Rubenfire M, Wajszczuk W, Schork MA. Intraaortic balloon pumping 1967 through 1982: analysis of complications in 733 patients. Am J Cardiol. 1986;57(11):976–83.

    Article  CAS  PubMed  Google Scholar 

  55. Alderman JD, Gabliani GI, McCabe CH, Brewer CC, Lorell BH, Pasternak RC, et al. Incidence and management of limb ischemia with percutaneous wire-guided intraaortic balloon catheters. J Am Coll Cardiol. 1987;9(3):524–30.

    Article  CAS  PubMed  Google Scholar 

  56. Al-Attar N, Roussel A, Khaliel F. Extracorporeal membrane oxygenation (ECMO). ESC Council Cardiol Pract. 2013;11(22).

    Google Scholar 

  57. Zangrillo A, Landoni G, Biondi-Zoccai G, Greco M, Greco T, Frati G, et al. A meta-analysis of complications and mortality of extracorporeal membrane oxygenation. Crit Care Resusc. 2013;15(3):172–8.

    PubMed  Google Scholar 

  58. Taglieri N1, Galiè N, Marzocchi A. Acute hand ischemia after radial intervention in patient with CREST-associated pulmonary hypertension: successful treatment with manual thromboaspiration. J Invasive Cardiol. 2013;25(2):89–91.

    Google Scholar 

  59. Rose SH. Ischemic complications of radial artery cannulation: an association with a calcinosis, Raynaud’s phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia variant of scleroderma. Anesthesiology. 1993;78(3):587–9.

    Article  CAS  PubMed  Google Scholar 

  60. Mangar D1, Laborde RS, Vu DN. Delayed ischaemia of the hand necessitating amputation after radial artery cannulation. Can J Anaesth. 1993;40(3):247–50.

    Google Scholar 

  61. Khakha RS, Ali T, Chong P, Gerrard D, Leopold P. Embolisation of Angio-Seal™ device: an unusual case of post-cardiac catheterisation limb ischaemia. Ann R Coll Surg Engl. 2011;93(5):e41–2.

    Article  CAS  PubMed  Google Scholar 

  62. Teso D, Karmy-Jones R. Distal embolism of percutaneous arterial closure device resulting in critical limb ischemia. J Vasc Interv Radiol. 2010;21(10):1487–8.

    Article  PubMed  Google Scholar 

  63. Hagan, P, Nienaber C, Isselbacher E, et al. The international registry of acute aortic dissection (IRAD) new insights into an old disease. JAMA. 2000;283(7):897–903.

    Google Scholar 

  64. Nusair M, Abuzetun J, Khaja A, Dohrmann M. A case of aortic dissection in a cocaine abuser: a case report and review of the literature. Cases J. 2008;1:369.

    Article  PubMed  PubMed Central  Google Scholar 

  65. Fann JI, Sarris GE, Mitchell RS, Shumway NE, Stinson EB, Oyer PE, Miller DC. Treatment of patients with aortic dissection presenting with peripheral vascular complications. Ann Surg. 1990;212(6):705–13.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  66. Sutton MS, Oldershaw PJ, Miller GA, Paneth M, Williams B, Braimbridge M. Dissection of the thoracic aorta. A comparison between medical and surgical treatment. J Cardiovasc Surg (Torino). 1981;22(3):195–202.

    Google Scholar 

  67. Slater EE, DeSanctis RW. The clinical recognition of dissecting aortic aneurysm. Am J Med. 1976;60(5):625–33.

    Article  CAS  PubMed  Google Scholar 

  68. Cambria RP, Brewster DC, Gertler J, Moncure AC, Gusberg R, Tilson MD, et al. Vascular complications associated with spontaneous aortic dissection. J Vasc Surg. 1988;7(2):199–209.

    Article  CAS  PubMed  Google Scholar 

  69. Steingruber I, Chemelli A, Glodny B, Hugl B, Bonatti J, Hiemetzbeger R, Jaschke W, Czermak B. Endovascular repair of acute type B aortic dissections: midterm results. J Endovasc Ther. 2008;15(2):150–60.

    Article  PubMed  Google Scholar 

  70. Khan IA, Nair CK. Clinical, diagnostic, and management perspectives of aortic dissection. Chest. 2002;122(1):311–28.

    Article  PubMed  Google Scholar 

  71. Patel AY, Eagle KA, Vaishnava P. Acute type B aortic dissection: insights from the international registry of acute aortic dissection. Ann Cardiothorac Surg. 2014;3(4):368–74.

    PubMed  PubMed Central  Google Scholar 

  72. Gargiulo M, Massoni CB, Gallitto E, Freyrie A, Trimarchi S, Faggioli G, Stella A. Lower limb malperfusion in type B aortic dissection: a systematic review. Ann Cardiothorac Surg. 2014;3(4):351–67.

    PubMed  PubMed Central  Google Scholar 

  73. Trimarchi S, Segreti S, Grassi V, Lomazzi C, Cova M, Piffaretti G, Rampoldi V. Open fenestration for complicated acute aortic B dissection. Ann Cardiothorac Surg. 2014;3(4):418–22.

    PubMed  PubMed Central  Google Scholar 

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Authors and Affiliations

  1. Division of Cardiothoracic Surgery, The University of Tennessee Medical Center, Knoxville, TN, USA

    Raymond A. Dieter III MD

  2. Cardiovascular Disease, University Cardiology, The University of Tennessee Medical Center, Knoxville, TN, USA

    Tjuan L. Overly MD & Madhur A. Roberts MD

  3. General Surgery, University of Tennessee Medical Center, Knoxville, TN, USA

    Juan J. Gallegos Jr. MD

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  1. Raymond A. Dieter III MD
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  2. Tjuan L. Overly MD
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  3. Madhur A. Roberts MD
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  4. Juan J. Gallegos Jr. MD
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Editors and Affiliations

  1. Loyola University Medical Center, Maywood, Illinois, USA

    Robert S. Dieter

  2. Northwestern Medicine Central DuPage Hospital, Glen Ellyn, Illinois, USA

    Raymond A. Dieter, Jr

  3. The University of Tennessee Medical Center, Knoxville, Tennessee, USA

    Raymond A. Dieter, III

  4. West Virginia University, Charleston, West Virginia, USA

    Aravinda Nanjundappa

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Dieter, R.A., Overly, T.L., Roberts, M.A., Gallegos, J.J. (2017). Cardiac Causes of Acute and Chronic Limb Ischemia. In: Dieter, R., Dieter, Jr, R., Dieter, III, R., Nanjundappa, A. (eds) Critical Limb Ischemia. Springer, Cham. https://doi.org/10.1007/978-3-319-31991-9_12

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