Evaluation and Management of Peripheral
Vascular Injury
Part 2

Annotation for Point P

A distal occlusion of the superficial femoral or popliteal artery or tibioperoneal trunk beyond the arterial repair on the completion arteriogram mandates reheparinization as indicated, reapplication of proximal and distal vascular clamps or vessel loops, and performing a 2-mm to 3-mm transverse arteriotomy distal to the arterial repair. Passage of appropriately sized Fogarty balloon catheters is performed until two successive passes have no return of thrombus. A second arteriogram using the catheter described previously is then performed through the arteriotomy site. If an interposition graft has been inserted, the 2-mm to 3-mm transverse arteriotomy is placed 1 cm proximal to the distal anastomosis. An arteriotomy site in the injured artery or in an interposition graft is closed with interrupted 6-0 or 7-0 polypropylene sutures.  When the distal arterial occlusion is present in either the anterior or the posterior tibial artery, it is unlikely that the transfemoral or transpopliteal passage of the Fogarty balloon catheter will enter the desired vessel unless the proximal peroneal artery is occluded with a separate Fogarty balloon as previously described.¹⁴ If one artery in the leg is occluded but the foot has at least one palpable pulse and is clearly viable, it is acceptable to leave the one vessel occluded without further intervention. Occlusion of two vessels mandates transpopliteal or transtibioperoneal embolectomy, especially in patients with significant blunt trauma to the lower extremity (shearing of collaterals). An embolectomy distal to the knee adds 1.5 hours to the operative procedure and is performed through a longitudinal incision 1 cm posterior to the posterior border of the tibia. The crural fascia is incised, the medial head of the gastrocnemius muscle is retracted posteriorly, and the tibial attachments of the soleus muscle are divided.³⁷ Full exposure of the distal popliteal artery and entire tibioperoneal trunk usually mandates division and ligation of the anterior tibial vein. All three vessels of the leg require catheter embolectomy through a distal popliteal transverse arteriotomy, as long as each vessel can be occluded with a bulldog clamp or vessel loop to allow for passage of the catheter into the desired vessel. If only the peroneal and posterior tibial arteries need to have an embolectomy, the transverse arteriotomy is made in the distal tibioperoneal trunk.