Delayed thromboembolectomy for subacute limb ischemia

Abstract

Arterial embolization frequently requires immediate operative intervention. Occasionally, embolic events produce subacute limb ischemia that may not be recognized as thromboembolic in origin. In October 1988, a prospective policy to attempt thromboembolectomy rather than infrainguinal bypass in all patients with delayed presentation of lower limb thromboembolism was initiated at our institution. Seven limbs in five patients were identified by history, physical examination, noninvasive study, and/or angiography as ischemic due to thromboembolism, which occurred from 3 to 10 weeks prior to presentation. Six of seven limbs were studied angiographically, and all seven were treated by femoral and/or popliteal thromboembolectomy with limb salvage. Six of seven limbs were restored to normal arterial hemodynamics as assessed by intra- and postoperative noninvasive study. One limb in a patient continued to have minimal residual occlusive disease that was recognized preoperatively. In all cases, chronic and fresh thromboemboli were found at surgery and confirmed by pathology. Chronic thromboembolism seems to be an underrecognized event. Limb salvage can be achieved readily even if extensive delay in diagnosis is present. Using preoperative angiography and intraoperative noninvasive techniques to measure the success of revascularization, as well as avoiding, when possible, complex infrainguinal reconstruction in these high-risk patients allows for an aggressive approach to limb salvage with gratifying results.