Prepare the whole limb and lower abdomen and contralateral side to mid-thigh
Because you don’t know exactly where problem is
You can evaluate your success (foot in transparent plastic bag)
Embolectomy via Fogarty balloon catheter placed through a proximal arteriotomy
Sizes 2-7 available (Fogarty)
Check balloon with saline first
Catheter passed in 10cm increments
Gentle inflation
Resistance free withdrawal
Repeat until no more clot, and good back flow
Back flow not a reliable sign though
Heparinize distally 5000 IU in 250mL
Can use intraoperative direct arterial infusion of urokinase (50,000-250,000 units) in settings where cleared proximal disease but might be left with some stagnant thrombosis which can’t clear
For an aortic bifurcation saddle embolus
Will often do bilateral femoral cut-downs, clamp both sides and clear
To avoid forcing trash down one side
Always do arteriogram on completion
Femoral Embolectomy
Setup and Positioning
Fogarty size 3 or 4 for Femoral
Sizes 2-7 available – 2 – smallest
Check the balloon
Prepare both limbs and lower abdomen completely (can wrap feet in transparent plastic bags)
E.g. If you identify an aortic bifurcation saddle embolus will need to do bilateral femoral cut downs, clamping both sides before starting to clear so trash doesn’t get thrown down one side
Thigh abducted, knee on pillow
NB: Mid-inguinal point – ASIS Pubic Symphysis
Femoral Artery
NB: Mid-point of the inguinal ligament; ASIS to Pubic Tubercle
Femoral Nerve
Incision and Control
Longitudinal skin incision at mid-inguinal point
Divide skin, subcutaneous tissue
Superficial & deep fascia, vascular sheath
May come across superficial branches of GSV/ Femoral Artery
Control Common femoral artery, superficial femoral artery, PFA individually with vascular loops
Encircle vessels by working medial to lateral under vessels with right angles
Avoid damage to Femoral Vein
Identify PFA as the one with the branches
Embolectomy
Before opening – 5000 IU heparin (take into account body weight, renal function)
Just above bifurcation make
Transverse cut if artery normal & unlikely to need to re-construct
Longitudinal if diseased, will often need to close with patch to prevent stenosis
Transverse arteriotomies are more predisposed to flaps & you are limited with the size of the cut you can make (therefore problematic in small vessels)
Longitudinal arteriotomies: More prone to stricturing
Will accept up to 50% stenosis
Use size (3) 4 catheter mostly
Do proximal (common), then SFA then PFA
Catheter passed in 10cm increments, gentle inflation, resistance free withdrawal
Repeat until no more clot, good back flow
Check distal pulses
Check other side pulses
From here if placed distally
Generally can enter peroneal artery
If want ATA or PTA, make separate distal (below knee) incision
Closure and Considerations
Once finished
Flush with heparinized saline
Arteriogram can be done if facilities/ experience available but not if unexperienced in technique
Transverse arteriotomy closed with 4/0 or 5/0 Prolene
Consider about fasciotomy
Popliteal Embolectomy
Leg abducted, hip & knee flexed, externally rotated
Standard medial incision
Parallel to long axis of leg,
1 finger breadth posterior to medial border of Tibia
Approximately 10cm long, preserve LSV
Fat, fascia & deep fascia divided
Medial head of gastrocnemius mobilized & retracted posteromedially
Soleus taken down off tibia to expose Tibioperoneal Trunk
Get individual control (sometimes take ATV to aid dissection)