Perimalleolar and pedal thromboembolectomy and bypasses to treat distal embolization during aortoiliac aneurysm repairs

Objectives Lower extremity embolization occurs during aortoiliac aneurysm repair and may require major amputation when distal arteries are occluded. Because nonoperative treatments are often ineffective, we evaluated an aggressive operative approach. Methods In the past 11 years, we performed 328 endovascular and 350 open aortoiliac aneurysm repairs. Excluding cases of embolization to iliac, femoral, popliteal, and more proximal tibial vessels, which were treated in a standard fashion, foot ischemia severe enough to produce cadaveric, pregangrenous, or gangrenous skin changes occurred from more distal embolization after seven endovascular and three open aortoiliac aneurysm repairs. Six of these 10 patients underwent thromboembolectomies of both their dorsalis pedis and perimalleolar posterior tibial arteries ≤4 hours of their original operation. In the other four patients, treatment was delayed 7 to 10 days. Because of progressive foot ischemia, arteriography was performed. From these results, four bypasses (3 autologous vein, 1 polytetrafluoroethylene graft) were performed to the transverse metatarsal arch, dorsalis pedis, perimalleolar peroneal artery, or perimalleolar anterior tibial artery. Results Patency and limb-salvage rates for both thromboembolectomy and bypass procedures were 100% at a mean follow-up of 3.0 years (range, 5 months-8 years). Conclusions Perimalleolar and foot artery thromboembolectomy and bypasses to arteries as distal as the metatarsal arch can be effective treatment for distal embolization from aortoiliac aneurysm repair. Even when cadaveric, pregangrenous, or gangrenous lesions are present, distal arteriography and operative treatment (thromboembolectomy or bypass) may be indicated to successfully salvage the foot.