78 - Lower extremity embolectomy

Summary

With mortality and amputation rates remaining over 20%, thromboembolic arterial disease continues to be a major health problem despite improvements in patient care. While embolic sources are primarily cardiogenic in 80%–90% of cases, other causes include atheroemboli from large vessels, tumors, paradoxical emboli, and aneurysmal debris. Classically, patients have a history of atrial fibrillation, myocardial infarction, or a prosthetic heart valve. The majority of emboli affect the lower extremity, most commonly in the femoropopliteal system, and occlude distal flow and collateral pathways by typically lodging at the bifurcations of vessels such as the femoral bifurcation.

Patients with thromboembolism of the extremities present with one or more of the “six classic P's of limb ischemia”: pain, pallor, paresthesia, paralysis, pulselessness, and poikilothermia (cold limb). Since each patient has a critical window before irreversible tissue damage occurs, the duration of symptoms is important. Six hours is commonly considered to be the span before such damage begins. It cannot be overemphasized that immediate referral to a vascular surgeon is absolutely paramount if a patient presents with acute limb ischemia, as delays in triage or unnecessary imaging can ultimately compromise limb salvage. Diagnosis can usually be made by history and physical examination, though certain cases may require duplex ultrasonography or arteriography prior to definitive treatment.

The algorithm for treating patients with acute thromboembolism can be quite complex and takes into account duration and severity of ischemia, presence of pre-existing peripheral vascular disease, history of prior vascular surgery, and therapeutic modalities available to the treating surgeon.