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Complications - Transfemoral Fogarty balloon catheter embolectomy in embolic occlusion of the left external iliac artery—Vascular Surgery

vascular surgery
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Anatomy Perioperative management Technique Complications Evidence Total Video

  1. Intraoperative complications

    Intimal tears and dissections, vascular perforation

    • Cause: typically overly aggressive handling during the arterial embolectomy manuever with the Fogarty catheter
    • Clinical picture: persistent ischemia
    • Mandatory: intraoperative angiography to check the circulation after embolectomy maneuvers
    • Persistent residual stenoses indicate the need for repeat thromboembolectomy, endovascular dilation, or treatment of vascular lesions (e.g., stenting in dissection of the iliac artery)
    • Prevention: Perform Fogarty maneuvers delicately and with feeling

  2. Postoperative complications

    Secondary bleeding, hematoma

    • Causes: technical errors such as suture line failure; slipped off ligatures; inadequate hemostasis; also needle track bleeding; iatrogenic vascular lesions; surgery under concomitant antiplatelets
    • Management: emergency surgery in active and hemodynamically significant bleeding
    • Liberal indication for evacuation of hematomas as a breeding ground for infection and also possible cause of compression of other structures (compartment
    • Prevention: careful dissection, subtle hemostasis

    Repeat occlusions

    • Cause: persisting stenosis, intraoperative vascular lesion, recurrent embolism.
    • Clinical picture: renewed deterioration of perfusion
    • Diagnostics: angiographic work-up
    • Management: repeat thromboembolectomy, endovascular dilation, or treatment of vascular lesions or necessary repair of the arterial axis; if necessary, local catheter-guided thrombolysis in occlusions far peripherally in the distal arteries of the lower leg.
    • Also: prompt work-up and treatment of embolic foci

    In persistent or recurrent limb ischemia with initially preserved residual perfusion, the limb findings may deteriorate and progress rapidly with increasing thrombosis (appositional thrombi) with increasing threat to limb viability!

    Wound infection

    • Diagnosis: Local findings, lab panels, fever
    • Management: if unavoidable, reopen the wound; swab; debridement; possibly NPWT, AST-specific antibiotics
    • Prevention: careful atraumatic, anatomically correct surgical technique, subtle hemostasis, avoidance of injury to the lymphatics 

    Compartment syndrome

    • Cause: Reperfusion after complete or incomplete ischemia results in damage to the capillary membrane with increased permeability and soft tissue edema, increasing the pressure in muscle compartments with tissue death.
    • Clinical signs: see red flags
    • Diagnostic work-up: Clinical picture, see Red Flags; assess objectively by intracompartmental pressure measurement (borderline pressure between 30 and 50 mmHg over 6 hours, as well as pressure readings above 50 mmHg, are pathologic).
    • Management: immediate dermatofasciotomy with complete longitudinal fascia cleavage in all muscle compartments, followed later by dermatotraction via alloplastic skin graft or NPWT, split-thickness skin graft.

    Red flags - Clinical warning signs in compartment syndrome

    Pathognomonic signs:

    • Painful soft tissue swelling of the muscle compartment with reduced elasticity (early symptom)
    • Pain on passive stretching of the affected muscle
    • Intense, analgesic-refractory rest pain (ischemic pain)
    • Sensory impairment and motor deficits (paralysis of the tibialis anterior muscle with weakness of the extensor muscles of the lower leg)

    Clinical P‘s of compartment syndrome:

    • Pressure (swelling and impaired elasticity)
    • Pain out of proportion
    • Pain with passive stretching
    • Paresthesia (affection of the nerves passing through the compartments)
    • Paresis or Palsy (motor weakness)
    • Pulses present! Pulselessness is not considered a classic symptom!
    • Pink skin color (shiny marbled skin)

    Lymphatic fistula, lymphocele

    • Risk: Access via the inguinal region predestined for injury to lymphatics
    • Diagnosis: clinical local findings
    • Treatment: nonsurgical management of lymphoceles, bearing in mind the risk of infection; lymphatic fistulas should be drained long-term without suction, or, after ruling out infection, by injection of fibrin glue or revision surgery with ligation (methylene blue, surgical loupes), very rarely by plastic surgery
    • Prevention: Protect the lymphatics during the approach, sweep lymphatic tissue anteromediad

    Persistent lymphedema

    • Manual lymphatic drainage and in case of adequate arterial perfusion (!) consistent compression treatment