PREOPERATIVE DIAGNOSIS: Right iliac artery occlusion and threatened limb.

POSTOPERATIVE DIAGNOSIS: Right iliac artery occlusion and threatened limb. TITLE OF

OPERATION: Thrombectomy of right external iliac and profunda femoris artery with vein patch profundoplasty.

INDICATIONS: The patient is who is status post right external iliac artery angioplasty and stent placement by Dr. 10/14/2010. She has been doing well but developed signs of an occlusion over the weekend. She presented to the Emergency Room with severe pain on the day of surgery and was found to have a cold, pulseless foot. She was brought to the operating room now for attempted limb salvage.
FINDINGS: Operative findings included a moderate amount of clot within the external iliac. The superficial femoral artery was completely occluded At the completion of the procedure there was excellent flow noted through the profunda femoris artery with dramatic improvement in the color of the leg and foot.
PROCEDURE: The patient was brought to the operating room and placed in the supine position. Following IV sedation she was prepped and draped in the usual sterile fashion using ChloraPrep. A Foley catheter was placed by Nursing staff prior to prep. After infiltration of local anesthetic an oblique incision was made in the right groin overlying the superficial femoral artery. This was carried down through skin and subcutaneous tissue. The femoral sheath was incised and calcified superficial femoral artery was identified. This was used to trace the common femoral artery up proximally as well as the profunda femoris artery. Approximately 2 cm proximal to the bifurcation the common femoral artery appeared to be quite pliable. The patient was systemically heparinized. Vessel loops were placed around the vessels and an oblique incision was made in the common femoral artery and carried onto the profunda femoris artery in anticipation of potential cross femoral bypass or patch angioplasty. There was no back bleeding noted from any vessel at this point. A 4 French Fogarty was then placed into the profunda femoris artery where a small amount of clot was removed and excellent retrograde flow was noted. Gentle probing within the superficial femoral artery allowed us to gain entrance into the lumen and a Fogarty was placed to a distance of approximately 2 cm and very hard formed thrombus was removed. The catheter would progress no further at this point. Attention was turned toward the inflow. Resent was obtained with the inflow. The 4 French Fogarty was advanced to a point of resistance at about 30 cm. The balloon was inflated and the catheter was then withdrawn. A small amount of thrombus was extracted. Sequential passive Fogarty yielded additional bits of dark thrombus. There appeared to be an area of resistance approximately 70 cm. The catheter was gently advanced through this region. The catheter was then inflated, pulled back, and again a moderate amount of thrombus issued forth. The artery was then flushed with heparinized saline solution retrograde and the catheter was then passed proximally. At this point the catheter was passed to its full length and gently withdrawn and a small amount of thrombus was recovered. There was no resistance noted at 70 cm and excellent pulsatile flow was re-established. An additional pass of the catheter yielded no further thrombus. The artery was then flushed with heparinized saline and clamped. At this point we were confident that the arterial inflow had been re-established. The saphenous vein was identified and the ascending circumflex branch was ligated proximally and distally and the intervening segment measuring approximately 1 cm was harvested for vein patch. The vein was then split using Potts scissors under 3.0 magnification and the arteriotomy was closed with running 6-0 Prolene under 3.0 power magnification. The profunda femoris was back bled and excellent flow was noted. As noted above the arteriotomy could be carried onto the profunda and the profundoplasty was performed in this fashion. Excellent antegrade flow was noted through the common femoral artery. Prior to tying the final sutures the arteries were flushed with heparinized saline solution and final sutures tied down. Clamps were removed and excellent pulse was noted. Excellent flow was noted through the common femoral artery and through the profunda femoris artery. The wound was irrigated with Ancef solution and closed in layers using running 3-0 Vicryl for the femoral sheath, 3-0 Vicryl for the subcutaneous tissue, and subcuticular 4-0 Vicryl for the
skin. This was followed by Steri-strips, dry sterile dressing, and Tegaderm. The patient tolerated the procedure well and was brought back to the Recovery Room in stable condition.