Routine versus selective use of intraoperative angiography during thromboembolectomy for acute lower limb ischemia: analysis of outcomes

Background: The success of thromboembolectomy for acute lower limb ischemia depends on the complete removal of all thromboembolic material accessible to the Fogarty catheter. Intraoperative arteriography can be used during arterial thromboembolectomy as a guide for extension of procedure to ensure complete clearance of the arterial tree and distal patency. However, it is still matter of debate if intraoperative angiography should be routinely performed in all cases or only in selected cases, depending on intraoperative findings, when the surgeon suspects an incomplete desobstruction.

Methods: Details of 380 thromboembolectomies in 361 patients with acute lower limb ischemia due to native vessel occlusion were prospectively recorded over a 12-year period in a central hospital vascular unit setting. The relevance of intraoperative angiography was retrospectively analyzed. The procedures were divided into two groups: group A, when intraoperative angiography was performed in selected cases (selective angiography), and group B, when angiography was performed as a routine procedure in all cases (routine angiography). Thrombectomy and embolectomy cases were separately analyzed.

Results: "On-table" angiography was used in 57 (26.4%) of 216 cases in group A and in all 164 cases (100%) of group B. Included in this study were 225 embolectomies and 155 thrombectomies of native vessels. After thrombectomy, the adoption of routine intraoperative angiography (group B) resulted in a statistically significant higher intraoperative reintervention rate than did selective intraoperative angiography (group A) (53.4% vs. 29.9%; p < 0.05). Also, after embolectomy extension of procedure, the rate was higher in group B than in group A (17% vs. 9.2%), but it did not reach statistical significance (p > 0.05). Considering the overall casuistic, at 24 months after thromboembolectomy, group B resulted in a lower incidence of reocclusion in comparison with group A (p < 0.05), whereas there was no statistical difference between the two groups in terms of amputation (p > 0.05) or of mortality (p > 0.05). Considering separately patients treated by embolectomy and by thrombectomy, reocclusion rate at 24 months was lower in group B than in group A, after thrombectomy and after embolectomy, with a statistical significance (p < 0.05). Amputation rate at 24 months was similar in group A and group B after embolectomy (10.7% vs. 8.9%; p > 0.05). After thrombectomy, there was in group B a slight advantage in comparison with group A, although not reaching statistical significance (31.3% vs. 46.2%; p > 0.05). There was no difference in mortality rate according to treatment group.

Conclusion: Routine use of intraoperative angiography influences outcome after thromboembolectomy for lower limb acute arterial occlusion. Routine use of intraoperative angiography, compared with selective use, results in higher rate of extension of the procedure for residual lesion and in a lower reocclusion rate at 24 months.