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184
Fig. 27.10: Doppler probe over the femoral artery
Fig. 27.11: Handheld Doppler checking the dorsalis pedis artery
Manipal Manual of Surgery
ABPI—Ankle Brachial Pressure Index
Normal ABPI >1
>1.30 Noncompressible
1.00–1.29 Normal
0.91–0.99 Borderline (equivocal)
0.41–0.90 Mild to moderate PAD
0.00–0.40 Severe PAD
Toe-ankle index
0.6 + 0.2 Normal
• In diabetic patients, ABPI may be increased due to
arteriosclerosis. In such patients, toe pressure is
measured. If toes are not available (postoperative
status),
transcutaneous oxygen tension (TcPO
should be measured instead.
• Normal toe pressure is 20–40 mmHg less than
ankle pressure.
• <30 mmHg of toe pressure is associated with
ischaemic symptoms.
• Foot ulcers heal only if toe pressure is >30–40
mmHg.
• When ankle pressure is <30 mmHg, gangrene may
be imminent.
Uses of Doppler probe
• To detect normal pulses in operation theatres
• To detect clinically nondetectable pulse in
peripheral vascular disease
• To measure BP (blood pressure) in ischaemic limbs
• To remeasure BP in the lower limb after exercise
to differentiate ischaemic claudication from neurogenic claudication
5. Duplex scan (Key Box 27.8)
• Duplex ultrasound involves using high frequency
sound waves to look at the speed of blood flow.
This is the investigation of choice today. Duplex
scan is a combination of Doppler and B mode
ultrasound (Fig. 27.14). B mode ultrasound is used
)
2
Fig. 27.12: Colour Doppler showing femoral artery and vein
Section II • General Surgery
Fig. 27.13: Colour Doppler showing atherosclerotic narrowing
Key Box 27.8
Duplex Imaging Scan
It yields both anatomic and blood flow information
No nephrotoxic contrast agent is used
It gives a triphasic wave pattern systolic, diastolic and
elastic recoil
Elastic recoil is absent in calcified arteries
Thus biphasic and monophasic wave patterns indicate
‘PAD’
Overall sensitivity of 92% and specificity of 99% in
occlusive cases
Limiting factors are extensive ulcers, calcification and
oedema of leg
Lower Limb Ischaemia and Popliteal Aneurysm
Fig. 27.15: CT angiogram showing narrowing of superficial
femoral artery
185
CFA—Common femoral artery; PRO—profunda; SFA—Superficial femoral artery;
Fig. 27.14: Duplex scan report of a patient with the PAD—the
number represents the velocity of blood flow in that artery
ATA—anterior tibial artery; PTA—posterior tibial artery
to obtain the image of the vessel, and Doppler is
used to evaluate the direction and velocity of the
blood flow of the vessel. Colour Duplex allows
for the assessment of blood flow direction. Red
colour indicates that the direction of blood flow is
towards the transducer, whereas blue colour
indicates that the direction of blood flow is away.
6. Computed tomography angiography (CTA)
• For all patients with chronic limb ischaemia, if
revascularisation is planned by surgical/interventional methods, CTA is done. Here, IV contrast–
iodine about 300–400 mg/mL is used. An average
of about 130 mL of contrast is used. Interpretation
of CTA is always based on the axial images. Hydration of the patient should be adequate, and creatinine
should be normal, or else renal failure may occur.
• Advantages of CTA: It gives the vascular anatomy,
collaterals, variations (if any), and reformation of
the vessels. The most important advantage of CTA
over duplex scan is to get the exact information of
the level of the block, length of occluded segment/
stenosed segment,
and distal run off (Figs 27.15 and
27.16).
• This forms the basis of revascularisation proce-
dures.
• CTA is the choice of investigation to assess intra-
thoracic vessels.
• Because of these advantages and the ease of
the procedure, conventional angiogram using
Seldinger’s technique (details given below) is not
done for limb ischaemia.
Fig. 27.16: Extensive narrowing of popliteal artery and branches
due to atherosclerosis—pictorial representation of a case of CT
angiogram
• Catheter angiography—a catheter is inserted into
an artery, and advanced to the area probable
blockade, contrast is injected and using DSA,
vessels are visualised. This is used more for
therapeutic purpose of thrombolysis or dilatation
of stenosed segment of the arteries.
7. Seldinger’s technique: Today it is done to assess cere-
bral circulation (percutaneous transfemoral method).
An incision is made in the upper thigh to expose the
femoral artery on the normal
side. A Seldinger needle
and guidewire are used to introduce the arterial
catheter, and a radiopaque dye is introduced after
placing the catheter into the aorta. It visualises the
entire aortoiliac segment and below. Since the
catheter is passed from femoral artery into the aorta,
it is also called the retrograde method. When conven-
tional angiogram is done, subtracting soft tissues,
Section II • General Surgery
186
Manipal Manual of Surgery
bones etc, improves the quality of the images. This
is called digital subtraction angiography (DSA).
DSA gives excellent pictures of the carotid and large
central vessels.
Complications of angiography
(Key Box 27.9)
• Contrast allergy, anaphylaxis, which can be
avoided by a trial injection.
• Paraplegia due to spasm of spinal arteries.
• Infection
• Renal failure
Key Box 27.9
Complications of Angiography
Thrombus
Rarely paraplegia
Arterial dissection
Unexpected infection/sepsis
Massive bleeding
Anaphylaxis
Remember as TRAUMA
Fig. 27.18: Distal formation at common femoral artery
(Courtesy: Dr Chandrakanth Shetty, Professor, Department of Radiology
and Imaging, KMC, Manipal)
8. Magnetic resonance angiography (MRA) (Figs 27.17
to 27.20)
• It is more popular than arteriography because of
no arterial puncture and no contrast-induced
nephropathy.
• It also has no radiation exposure.
• Unlike CTA, MRA is not affected by arterial
calcification.
• Gadolinium-enhanced MRA may visualise the
entire arterial tree and pattern, including small
pedal vessels.
• Patients with newly placed metallic implants are
advised to avoid undergoing MRA.
• MRA may overestimate the degree of stenosis
because of turbulence, and metal clips may cause
artefacts that mimic vessel occlusions.
Fig. 27.19: Right common iliac artery occlusion
Section II • General Surgery
Fig. 27.17: Left common iliac artery occlusion
Fig. 27.20: Right common iliac artery occlusion—another view
Lower Limb Ischaemia and Popliteal Aneurysm
187
TREATMENT OF PERIPHERAL ARTERIAL DISEASE
(TAO AND ATHEROSCLEROSIS)
• In all patients with peripheral vascular disease, the
following general measures must be taken which will
help in better perfusion of the lower limb tissues.
• Anaemia must be treated with haematinics and, if
necessary, blood transfusion. If ejection fraction is
low, drugs are given to improve cardiac output.
• Lifestyle modification of decreasing weight, avoid fat
rich food and control of diabetes
Principles (Key Box 27.10)
Key Box 27.10
Principles of Treatment
To relieve the pain
To arrest the progression of the disease
Medical treatment
Surgical methods
I. To Relieve the Pain
As already discussed, the pain is very severe and distressing. Some amount of pain relief may be obtained with:
Analgesics: Simple analgesics may not help these
patients. Paracetamol 650 mg 1 tablet 2–3 times a day,
Tramadol (50 mg) one tablet, 3 times a day. Narcotic
analgesics (used judiciously) in cases with rest pain.
Buerger’s position, by elevating the head-end of the
bed, causes venous congestion and reflex vasodilatation.
Buerger’s exercises by elevation and dependency of
the limb for a few minutes.
Heel raise by 1–2 cm, to increase claudication dis-
tance by decreasing the work load on the calf muscles.
II. To Arrest the Progression of the Disease
• Stop smoking: This is more beneficial
in TAO patients
than in atherosclerotic patients.
• Supervised walking on treadmill of 1 hour or more
three times a week as exercise program for 3
months
with control of diabetes and cessation of smoking will
improve claudication.
• Diet: Avoid fatty foods to reduce serum cholesterol.
This is more useful in patients with hyperlipidaemia.
• Avoid injuries.
III. Medical Management (Table 27.8)
Cilostazol
• Is the drug of choice in atherosclerotic occlusive disease.
• It is an antiplatelet drug and a vasodilator.
• It helps improve claudication symptoms.
• It helps stabilise atherosclerotic plaques.
• It is a selective inhibitor of phosphodiesterase type 3.
Aspirin/clopidogrel
75 mg/day of clopidogrel or 75 mg of aspirin is advised
to all these patients as an antiplatelet. It has been shown
to reduce the mortality rate due to cardiac events in
these patients.
IV. Surgical Procedures
• In TAO: Lumbar sympathectomy and amputations.
• In atherosclerotic arterial disease (aortoiliac disease
and femoropopliteal disease): Percutaneous transluminal angioplasty and bypass grafts.
. A. Lumbar sympathectomy is the indirect surgery
1
done for TAO patients since direct arterial surgery is
not possible (Key Box 27.11).
• Indications: Cutaneous ulcer and rest pain.
• Structures which may be confused for the lumbar
sympathetic trunk include:
. The genitofemoral nerve
1
2. Tendon strip of the psoas muscle
3. The lymphatic chain and fatty tissue
• By depriving sympathetic nerve supply to the lower
limb blood vessels, vasomotor tone is reduced,
Table 27.8 Medical management of peripheral vascular disease—drugs, dosage and their role
• Antiplatelet Aspirin 75 mg with or without clopidogrel 75 mg Decreases vascular death by 25%
• Antismoking Stop smoking
• Anticholesterol Statins 10 mg/per day—to decrease L
to at least 100 mg/dl. This drug will stabilise the important therapy in patients with
plaques dyslipidaemia
• Antihypertensives Decrease blood pressure to <130/85 mmHg ACE inhibitors, β-blockers
• Antidiabetes Glycosylated haemoglobin level of <7% Oral hypoglycaemic agents or insulin
• Antivasospasm (vasodilator) Cilostazol—50 mg twice a day (doubtful value) Inhibits platelet aggregation and is a direct
DL cholesterol Slow release niacin is emerging as an
Smoking cessation can decrease 10-year
mortality rate from 54% down to 18%
arterial vasodilator
Section II • General Surgery
188
Manipal Manual of Surgery
Key Box 27.11
Salient Features of Lumbar Sympathectomy
Transverse loin incision
Extraperitoneal approach, and it is a preganglionic
sympathectomy.
Lumbar sympathetic trunk is identified in the para-
vertebral gutter lateral to the psoas muscle as a cordlike structure.
2nd lumbar ganglion is large and has white rami
joining it.
Sympathetic trunk is divided below the first lumbar
vertebra and removed up to the 4th lumbar vertebra.
This is a preganglionic sympathectomy because fibres
supplying the vessels of the limb have their cell
stations in the sacral ganglia which are not disturbed.
which in turn reduces some amount of vasospasm.
Thus, rest pain improves and minor ulcerations
heal due to cutaneous vasodilatation. However, the
duration of the effect of lumbar sympathectomy is
not clear.
• Both sides may be done in one sitting. However,
during bilateral operation, the 1st lumbar ganglion
on one side should be spared since removal of both
ganglia may cause sterility due to paralysis of the
ejaculatory mechanism.
• One should be careful not to damage lumbar veins
which join the inferior vena cava.
B. Conservative amputations should be done if the
toes are gangrenous.
2
C. Below knee amputation
is the last resort. It is
indicated in severe rest pain cases in which all other
modalities of treatment have failed. The risk of
amputation after ten years of the disease is around
10%. Risk of amputation is more with patients
having ABPI of less than 0.5.
2. Surgery in atherosclerotic vascular disease:
• Avoid or treat risk factors (Key Box 27.12).
• The decision to revascularise the limb is taken after
an angiography. The success of reconstruction
depends on a number of factors (Key Box 27.13).
• Intermittent claudication alone is not an indication
for surgery. Rest pain and pregangrenous changes
in the limb are definite indications for reconstruction with acceptable mortality and morbidity.
• Surgery can be classified as surgery for aortoiliac
disease, ileofemoral disease and femoropopliteal
disease.
Key Box 27.12
Major Risk Factors for Atherosclerosis
Lipids: Dyslipidaemia
Inhalation of tobacco: Smoking
Pressure: Hypertension
Insulin deficiency: Diabetes
Disordered metabolism: Hyperhomocystinaemia
Remember as LIPID
Key Box 27.13
Prognostic Factors for Limb Revascularisation
Severity of the disease Site of occlusion
Presence of collaterals Age of the patient
Presence of diabetes Angina pectoris
Chronic smoking Fitness for anaesthesia
• Principle of reconstruction: Wide exposure to
allow safe control of vessels, proximal and distal
control inflow (proximal) and outflow (distal)
anastomosis in disease free area, careful selection
of graft depending upon site of surgery. Dacron
and ePTFE perform equally well in aortoiliac
bypass, but saphenous vein has superior patency
in infrainguinal bypass.
I. AORTOILIAC DISEASE
1
It is treated by bypass grafts or endarterectomy.
A. Bypass Grafts (Figs 27.21 and 27.22)
• Usually, it is bilateral and is treated with an aorto-
bifemoral graft to bypass the stenosis. The graft is
made from either teflon or dacron. It is also called a
Y-graft or trouser graft. It commonly has a 16 mm
trunk and two 8 mm limbs.
• In unilateral cases, a unilateral graft is applied.
Figs 27.21 and 27.22: Aortobifemoral graft (Courtesy: Dr Ganesh
Kamath, Professor and Head, Department of Cardiothoracic
Surgery, KMC, Manipal)
1
Lumbar veins, if cut accidentally, retract and cause troublesome bleeding from the inferior vena cava. Pressure packing, waiting for 3–5 minutes
and then ‘see and ligate’ should be the policy.
2
Section II • General Surgery
Students are advised not to tell this as a first treatment modality.
Lower Limb Ischaemia and Popliteal Aneurysm
189
The aorta is approached from a midline incision. The
posterior peritoneum is opened to expose the aorta with
2 vertical incisions, and the common femorals are
exposed in the groin. Before clamping the vessels,
heparin 5000 U is administered intravenously. End-toside of the graft to aorta above and femoral artery below
is done. Extra-anatomical bypass refers to any bypass
graft, autologous or otherwise, that is placed in a site
different to that of the arterial segment that is being
bypassed.
For example, axillo-bifemoral bypass in a case of
hostile abdomen (previous surgeries, mycotic
aneurysms, aortoenteric fistulae), obturator bypass
(hostile groin after radiation or previous surgery),
femoro-femoral bypass.
B. Aortoiliac Endarterectomy
They are usually not done.
Indications: Short segment, large artery such as aorta
and single artery.
Types:
• Open endarterectomy: An arteriotomy is done first
and the diseased intima, atheromatous plaque, and
thrombus are removed. An arteriotomy incision can
either be closed directly or with a vein patch graft to
close the defect to avoid narrowing.
• Closed endarterectomy is indicated in a longer-
diseased segment. In this procedure, after an
arteriotomy, a wire loop is used to strip out a core of
atheroma by introducing it through the lower arterio-
tomy and removing the atheromatous plaque from
the upper end. However, results of bypass graft are
better than endarterectomy. The modern tendency
is to do bypass graft.
II. ILIOFEMORAL STENOTIC DISEASE
A. Transluminal angioplasty: Any arterial stenosis can
be dilated in angioplasty. The technique can be repeated
if stenosis recurs. The procedure is done under local
anaesthesia and is indicated in poor-risk patients.
Ideally suitable for iliofemoral segment, not suitable
for stenosed vessels below knee. A balloon catheter is
inserted into the artery under local anaesthesia and is
inflated at high pressure around 30 seconds and
deflated. By inflation and dilatation 2–3 times, the
stenosed segment can be dilated. Complications include:
internal dissection, distal embolisation, thrombosis, and
even rupture of the vessel may occur.
B. Ilio-femoral bypass grafts: Generally recommended
when the diseased segment is beyond 15 cm in length.
Technique is similar to what is mentioned above.
• This can be repaired by a bypass graft which is sutured
to the normal common iliac artery above and to the
normal femoral artery below (Figs
27.23 and 27.24).
• In this procedure, a balloon catheter is inserted into
the artery and inflated. Its correct position is
confirmed by radiopaque markers which are present
in the balloon.
A summary of revascularisation surgery is given in
Key Box 27.14.
Figs 27.23 and 27.24: Iliofemoral graft by using reversed long
saphenous vein
Key Box 27.14
Summary of the Revascularisation Surgery
(Figs 27.25 to 27.31)
Aortoiliac disease Aortobifemoral or aortofemoral
moral graft and endarterectomy
Iliofemoral disease Iliofemoral bypass graft
Balloon angioplasty
Femoropopliteal disease Bypass graft
Profunda artery stenosis Profundoplasty
III. FEMOROPOPLITEAL OCCLUSION
• This is the most common site of obstruction in
atherosclerotic patients. This is treated with a graft
extending from the femoral artery above to the
popliteal artery below.
• Reversed autologous long saphenous vein is better
than other grafts because it is less thrombogenic. If it
is not reversed, the valves have to be disrupted using
a valvulotome. If the LSV is not available, try the SSV.
When no vein is available, try for synthetic grafts.
• Dacron graft and polytetrafluoroethylene graft
(PTFE) are commonly used grafts.
• In a few other occasions, small vessel bypass like
femoro-tibial artery bypass may also be done if the
diameter of the distal vessels is ≥3 mm.
• Success in the immediate post-operative period is
around 90%, but the 5-year patency is around 50%.
Section II • General Surgery
190
Manipal Manual of Surgery
BALLOON ANGIOPLASTY IN ATHEROSCLEROTIC ARTERIAL DISEASE (Figs 27.25–27.31)
Fig. 27.25: Plain radiograph with guidewire in the aorta Fig. 27.26: Narrowing of the right common iliac artery
Fig. 27.27: Balloon angioplasty of narrowed right common iliac
artery
Fig. 27.29: Mid-SFA showing narrowing Fig. 27.30: Balloon angioplasty Fig. 27.31: Postangioplasty image show-
(Courtesy: Prof Chandrakanth Shetty and Dr Praharsha, Resident, Department of Radiodiagnosis and Imaging, KMC, Manipal)
Section II • General Surgery
Fig. 27.28: Post-balloon angioplasty
ing restoration of lumen of mid-SFA
Lower Limb Ischaemia and Popliteal Aneurysm
191
Profunda Artery Stenosis
• Significant occlusion of the profunda is demonstrated
by oblique views in an arteriography. If there are no
significant vessels available below the stenosis for
reconstruction, profundoplasty is considered. It is
done using a patch of Dacron or vein to widen the
origin of the vessel after endarterectomy.
Complication of Surgery
Early Late
Hemorrhage Graft thrombosis
Limb ischemia Anastomotic pseudoaneurysm
Renal failure Sexual dysfunction
Intestinal ischemia Infection
Spinal cord ischemia Aortoenteric fistula
Urateric injury
ACUTE ARTERIAL OCCLUSION
• Sudden occlusion of an artery commonly occurs due
to an embolus. The source of the embolus is from the
heart or from an atheroma. Increased incidence of
road traffic accidents, fall, or war injuries are other
causes. Trauma to the artery also produces occlusion.
• Emboli from atheromatous plaques are called athero-
emboli. In most of these patients collaterals would
have developed, hence the limb ischaemia may not
be very critical.
EMBOLIC OCCLUSION
• This commonly occurs in the peripheral arteries (e.g.
common iliac, femoral, popliteal).
• An embolus is a foreign body to the bloodstream. It
gets lodged in a vessel and produces obstruction,
clinically manifesting as severe ischaemia or gangrene
and resulting in critical limb ischaemia (CLI).
• Atherosclerotic vascular disease, thromboangiitis
obliterans, acute embolic ischaemia, and even
diabetes, may present as CLI.
Causes/risk factors:
• Smokers, cardiac diseases, obesity, recent cardiac
surgery (Table 27.9)
Pathology
• As a result of sudden occlusion, blood supply to the
distal part is cut off resulting in rapid development
of tissue death and gangrene. Most of such patients
also have atherosclerosis. Tissue hypoxia followed
by release of superoxide radicals and thromboxanes
result in endothelial damage necrosis and gangrene
within a few hours (Fig. 27.32).
Clinical Features (Key Box 27.15)
• No previous history suggestive of intermittent
claudication.
Table 27.9
Causes of acute lower limb ischaemia
Acute lower limb ischaemia
Embolism
• Atrial fibrillation
Mitral stenosis
•
Myocardial infarction
•
Aneurysm
•
Atheromatous plaques
•
Emboli from myxoma of heart
•
Common sites
• Aortic bifurcation (saddle embolus)
Common femoral bifurcation
•
Popliteal trifurcation
•
• Emboli impact at branching points where arterial lumen narrows abruptly.
Thrombosis (causes)
• Polycythaemia rubra vera
Thrombocythaemia
•
Leukaemia
•
High oestrogen pill
•
Atheromatous
•
Common arteries affected
• External iliac
Profunda
•
Popliteal
•
Fig. 27.32: Pathogenesis of tissue damage
Section II • General Surgery
192
Key Box 27.15
Signs of Acute
Lower Limb Ischaemia
Peripheries are cold
Pallor of the limb
Poor capillary return
Positive Buerger’s test
Progressive paralysis
Pulses are absent
Pulse at ankle by Doppler—undetectable
Observe 7 Ps
Manipal Manual of Surgery
• Sudden dramatic symptoms which are described in
the form of 5Ps—Pain, Pallor, Paresis , Pulselessness,
Paraesthesia.
1. Pain is severe, unbearable, and of a burning or
bursting type.
. The limb is pale and cold, and superficial veins are
2
collapsed.
3. Paresis: Depending on the level of occlusion, the
function of the limb is lost. Movement of the toes
becomes difficult, followed by total paralysis.
4. Pulselessness: Characteristically, peripheral pulses
below the level of the embolism are not palpable.
5. Paraesthesia: Altered sensation in the limb.
• If left untreated, necrosis of the muscles followed by
gangrene of the limb may occur within a few hours
(6–24 hours).
• Cardiac examination may reveal signs of valvular
heart diseases.
Intravenous drug abuse remains a major risk factor for endocarditis and embolic complications.
Fig. 27.33: Critical limb ischaemia (CLI)
Fig. 27.34: CLI due to diabetes and atherosclerosis
A 75-year-old lady, known case of polycythaemia vera,
presented to the hospital with multiple gangrenous
patches of skin in the upper and lower limbs.
Conservative surgery was attempted by debriding the
gangrenous portion of the skin. Polycythaemia is also a
cause of gangrene.
Look also for evidence of emboli in other arteries—
refer to Table 27.10.
Investigations
• Peripheral circulation should be assessed by Doppler
Critical Limb Ischaemia (CLI) (Figs 27.33 and 27.34)
It is defined as persistently recurring ischaemic rest pain
requiring regular, adequate analgesia for >2 weeks or
ulceration or gangrene of the foot/toes with an ankle
pressure <50 mmHg or a toe systolic pressure <30 mmHg.
Table 27.10 Emboli in various arteries—symptoms, signs and effects
1. Leg Common femoral, popliteal Pain/pallor Gangrene/ischaemia
2. Brain Middle cerebral artery Minor or major TIA Stroke/hemiplegia
3. Retina Central retinal artery Amaurosis fugax Fleeting/permanent blindness
4. Intestine Superior mesenteric artery Postprandial pain, shock Intestinal ischaemia/gangrene
5. Kidney Renal artery Pain in loin, haematuria Renal ischaemia
6. Upper limb Brachial artery Pain, ulcer upper limb Gangrene
Section II • General Surgery
ultrasound, which is an excellent noninvasive
investigation to judge the severity, level, position, and
length of superficial femoral artery stenosis.
• Urgent duplex scan
• CT angiogram
Lower Limb Ischaemia and Popliteal Aneurysm
193
Treatment
I. Angioplasty: Percutaneous transluminal angioplasty
(PTA) is indicated in short stenotic lesions in a
large vessel (e.g. iliac and femoropopliteal lesions).
• First, the balloon catheter is introduced percuta-
neously over a guidewire across the lesion. Under
fluoroscopic control, the balloon is dilated until
satisfactory widening of the lumen is achieved.
• It is a relatively safe and simple procedure.
• Immediate intravenous infusion of heparin
(10,000 IU) is necessary to reduce extension of
the thromboembolism.
II. Emergency embolectomy is done under GA or
local anaesthesia either by a direct arteriotomy
incision and removal of the clot or by using a
Fogarty balloon catheter to remove the embolus
remotely (Figs 27.35 and 27.36).
• Embolectomy: Under local or general anaesthesia,
a transverse incision is given over the common
femoral artery. A Fogarty catheter is introduced
through the incision for about 1–2 cm and the
balloon is inflated.
• The catheter is then withdrawn, and the emboli
are removed. The procedure is repeated until
bleeding occurs. The catheter can be passed by
the ankle to remove distal emboli as well. Postoperatively, anticoagulants are continued.
III. Intra-arterial thrombolysis:
• It is indicated in acute or acute on chronic
ischaemia where in ischaemia is not so severe.
• Intra-arterial thrombolysis: A catheter is passed
into the ‘clot’ after performing arteriography and
t-PA (tissue plasminogen activator) is infused
through the catheter. Repeat angiogram check
films are taken to see the results, such as clot
lysis, revascularisation, etc.
• It will reopen the occluded lumen within
24 hours.
A B C
Fig. 27.35A to C: (A) Femoral artery is exposed in the groin, (B) Fogarty balloon catheter is introduced within femoral artery
(C) Embolectomy—clots (Courtesy: Dr Ganesh Kamath, Head, Department of CVTS, KMC Manipal)
Fig. 27.35D: Fogarty embolectomy Fig. 27.36: Management of acutely ischaemic limb
Section II • General Surgery