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OBJECTIVES: Acute lower extremity ischemia secondary to thromboembolism is a common problem treated by vascular surgeons. Contemporary data regarding this problem are sparse. This report examines a 10 year single-center experience with acute lower extremity thromboembolism and describes the surgical management and outcomes observed.
METHODS: Consecutive patients treated surgically for acute lower extremity embolization from January 2002 to September 2012 were identified using ICD-9 and CPT codes. Iatrogenic cases and cases secondary to trauma were excluded. Demographic, co-morbidity, presentation, operative management, postoperative morbidity, and mortality data were abstracted from the electronic medical record. Data were examined using count (%), median or mean ± SD, and product-limit survival analysis.
RESULTS: The identified study sample included 170 patients. Mean age was 69 years, 47% of patients were female, and 80% were white. Eighty-two patients (49%) had a known history of atrial fibrillation and 4 (2%) had a warfarin associated INR ≥ 2.0. Eighty-three percent presented greater than 6 hours after symptom onset. Nine percent presented with a concurrent stroke. Femoral artery exposure for embolectomy was the preferred initial mode of treatment. Additional popliteal exposure for inadequate clearance of tibial occlusion was required in 4% of cases, 10% of cases employed a popliteal-only approach for isolated distal occlusions, and local instillation of thrombolytic agents was employed in 16% of cases. Fasciotomies were performed in 39% of cases. Unexpected return to the operating room occurred in 24% of cases. Eleven patients (6%) required bypass for limb salvage during the initial hospitalization. Amputation was required during the index hospitalization in 26 patients (15%) and following initial discharge in an additional 6 patients (4%). In-hospital or 30-day mortality was 18 percent. Median length of stay was 8 days. Thirty-four percent of patients required discharge to a skilled facility. Recurrent embolization occurred during follow-up in 23 patients (14%) at a median interval of 1.6 months. Amputation-free and overall survival estimates for the study sample at five years were 75% and 49%, respectively.
CONCLUSIONS: Despite advances in contemporary medical care, lower extremity arterial embolization remains a condition that is associated with significant morbidity and mortality. Furthermore, the condition is resource intensive to treat and could be prevented (either initially or in recurrence) in a substantial subset of patients.