Aggressive treatment of acute limb ischemia due to thrombosed popliteal aneurysms

The absence of infra-popliteal runoff in patients with acute limb ischemia and thrombosed popliteal aneurysms carries a high risk of amputation. A combined treatment method involving thrombolysis and surgery is reported.

Information regarding six patients was reviewed. Ankle brachial indices and degree of ischemia were recorded. All patients underwent digital subtraction angiography. In five patients thrombus dissolution was achieved using a combination of mechanical and pharmacologic therapy. One patient was judged incapable of withstanding any delay in reperfusion and was treated with isolated limb perfusion using a thrombolytic agent. All patients underwent surgical revascularization. Follow-up (1-3 years) consisted of duplex examinations at 6 months and yearly thereafter.

Five patients had no measurable ankle brachial index (ABI), while one patient 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 peroneal, and five below knee popliteal arterial bypasses. Fasciotomies were performed in four of the six patients. There were no amputations. One patient developed a persistent foot drop. Two patients developed bypass grafts occlusions; one of which required therapy.

The pre-operative use of thrombolytic therapy is a safe and effective method to achieve limb salvage in this patient population. Patients must be capable of withstanding an additional period of ischemia allowing for reconstitution of distal runoff. Isolated limb perfusion is of use when a delay to reperfusion cannot be tolerated.