Aggressive treatment of acute limb ischemia due to thrombosed popliteal aneurysms

Objective: The absence of infra-popliteal runoff in patients with acute lim b ischemia and thrombosed popliteal aneurysms carries a high risk of amputa tion. A combined treatment method involving thrombolysis and surgery is rep orted. Material and methods: Information regarding six patients was reviewe d. Ankle brachial indices and degree of ischemia were recorded. All patient s underwent digital subtraction angiography. In five patients thrombus diss olution was achieved using a combination of mechanical and pharmacologic th erapy. One patient was judged incapable of withstanding any delay in reperf usion and was treated with isolated limb perfusion using a thrombolytic age nt. All patients underwent surgical revascularization. Follow-up (1-3 years ) consisted of duplex examinations at 6 months and yearly thereafter. Resul ts: Five patients had no measurable ankle-brachial index (ABI), while one p atient had an ABI of 0.4. Initial angiography noted all patients to have no runoff in continuity to the pedal arch. Following thrombolytic therapy, an adequate bypass vessel was noted in all cases, with reconstitution of the plantar arch in five patients. Distal revascularizations included one peron eal, and five below knee popliteal arterial bypasses. Fasciotomies were per formed in four of the six patients. There were no amputations. One patient developed a persistent foot drop. Two patients developed bypass grafts occl usions; one of which required therapy. Conclusion: The pre-operative use of thrombolytic therapy is a safe and effective method to achieve limb salvag e in this patient population. Patients must be capable of withstanding an a dditional period of ischemia allowing for reconstitution of distal runoff. Isolated limb perfusion is of use when a delay to reperfusion cannot be tol erated. (C) 1998 Elsevier Science Ireland Ltd. All rights reserved.