Upper-Extremity Thromboembolectomy

Indication:
Acute upper-extremity ischemia secondary to embolism or thrombotic event
Essential Steps:
1. Identify the likely site of obstruction, based on history and physical exam.
2. Obtain proximal and distal control.
3. Circumferential dissection of the brachial artery at the antecubital fossa.
4. Circumferential dissection of the origin of the radial and ulnar arteries.
5. Make arteriotomy (transverse vs longitudinal).
6. Catheter thromboembolectomy (avoid overdistension and repeated passes).
7. Artery closure (primary vs patch).
8. Asses distal perfusion.
9. Evaluated the arm for compartment syndrome.
Note these variation:
- The brachial artery can be exposed through a transverse or S-shaped skin incision overlying the antecubital fossa.
- Dissection of the origin of the radial and ulnar arteries is optional.

Complications:
- Bleeding
- Infection
- Ongoing ischemia
- Compartment syndrome
- Limb loss

Description of procedure:
The procedure was performed under local/axillary block/general anesthesia. With the patient in the supine position, the right/left upper extremity was prepped and draped in the usual steril fashion. The skin over the antecubital space was infiltrated with 1.0/0.5% lidocaine. A 5-cm skin incision overlying the antecubital fossa was then performed and deepened through the subcutaneous tissue and fat. The biceps aponeurosis was incised over he brachial pulse. The brachial artery was circumferentially dissected to its bifurcation into the ulnar and radial arteries. The patients was already receiving heparin anticoagulation. The brachial artery was controlled with silastic vessel loops and a transverse arteriotomy was performed. Clot was extruded and good inflow was established. The same was then performed to the radial artery. Thorough irrigation with heparinized saline was then performed. The arteriotomy was closed using 6-0/7-0 interrupted/running sutures. At the completion of the procedure, there was evidence of palpable pulse in the radial/ulnar arteries. The suture line was hemostatic. The wound was then irrigated with antibiotic solution and closed using 3-0 vicryl for the subcutaneous tissue and 4-0 monocryl for the skin.
The patient tolerated the procedure well and was transferred to the postanesthesia care unit in stable condition.