Can you think of a really fat person presenting with acute lower limb ischemia? Think of someone whose thigh is twice as normal size. Of someone whose, the abdomen lies over the groins and you must pull it upwards with sticky tapes in order to be able to find the femoral arteries. This may become a nightmare. Even if you manage to find the femoral artery bifurcation, you will definitely struggle to perform a proper embolectomy. And even if you successfully perform it, you will probably end with severe wound infections which will keep your patient a long time in the ward. So, what can you do?
It is a difficult case indeed. Possibly, there may be a solution. Read below to find out what I think you can try.
First, WHAT NOT TO DO
- Do not pull the abdomen upwards. I know it is tempting to pull the fluffy abdomen away by sticking tapes and pulling it upwards. This way, you will have good view of the groin and will be able to perform a standard femoral bifurcation embolectomy. But, this is exactly what you must avoid!!! Let it the belly lie on the groins, obstructing you from where you planned to look for the femoral artery. One can ask: why should you do this? The answer is simple. If you make a formal skin incision on the groin, after the procedure the abdomen will lie over the wound and this will definitely lead to wound infection, or wound necrosis. Additionally, if you do not care about this possible outcome and are interested only in performing a nice femoral bifurcation embolectomy, you will find great difficulty to pass the Fogarty embolectomy catheter into the vessels, especially in the distal superficial femoral artery (SFA). Due to the large abdomen you may not be able to put the Fogarty catheter horizontally in the SFA and you may cause a posterior intima injury and a possible dissection..
- Do not make a standard femoral embolectomy on the femoral bifurcation. And this for the very simple reason that you cannot have a nice and good access on the femoral bifurcation due to the situation explained before.
And, WHAT TO DO?
So, what you must do? Let’s see:
- Make a vertical incision on the anterior thigh, underneath from where the abdomen that lays on the thigh ends. The incision must not go higher up, because after the end of the procedure, the incision will be under the folded abdomen. So, just an incision along the route of SFA up to where the abdomen skin on the thigh. Make straight deep cuts, without undermining the skin, until you face the fascia. Cut the fascia inline with the skin incision. Usually, the wound is deep enough with too much fat around. If the depth of the trauma is big enough and the self-retainer seems small ask for an abdominal self-retained retractor. Or even a Finnochieto retractor, or both. Now try to identify the SFA. If the artery is medially or laterally from where you are now, you can dissect accordingly at a subfascial space. After you identify the SFA dissect it free from the surrounding tissues and pass an elastic sling around for identification and potential traction of the artery if needed.
- Find and dissect the profunda femoris artery. From the same wound try to find the profunda femoris artery. It is usually on a deeper level than the SFA. Dissect free a part of it (usually you have divide some overlying veins before) and pass an elastic sling around it. Give heparin and prepare for the embolectomy.
- Perform SFA and profunda femoris embolectomy from two different arterial incisions. As explained before avoid the femoral bifurcation. In contrast, use two lower arterial incisions on the SFA and the profunda femuris, away from the abdomen that lies in front of you.
AND IF NEED A POPLITEAL EMBOLECTOMY?
In the unfortunate situation you will need a popliteal embolectomy follow the same concept. Avoid the bulgy calf muscle. Avoid the popliteal fossa. Go lower enough below the calf bulging and make an incision just on the posterior edge of the tibia at about the middle of the calf. Cut the skin, subcutaneous tissue, and the fascia. Under the fascia, it is only the soleus muscle between you and the posterior tibial artery. Be careful with the surrounding small veins (ligate or clip them if you need it), and the artery is there for you ready to get embolectomized. Believe it. It is much easier to perform an embolectomy of the posterior tibial artery rather than trying to do this on the popliteal artery into the popliteal fossa, on the scenario of a patient with a BMI of 50!!!