Journal of Vascular Surgery

Retrograde Direct Thrombectomy with Distal and Pedal Access using Fogarty Catheter
in Acute limb Ischemia
--Manuscript Draft--

Manuscript Number:

Full Title: Retrograde Direct Thrombectomy with Distal and Pedal Access using Fogarty Catheter
in Acute limb Ischemia

Short Title: Retrograde Direct Thrombectomy in Acute limb Ischemia

Article Type: Clinical Paper

Section/Category:

Corresponding Author: Muzakkir Amir, M.D.

Hasanuddin University
Makassar, South Sulawesi INDONESIA

Corresponding Author Secondary

Information:

Corresponding Author's Institution: Hasanuddin University

Corresponding Author's Secondary

Institution:

First Author: Muzakkir Amir, M.D.

First Author Secondary Information:

Order of Authors: Muzakkir Amir, M.D.

Mulawardi ., MD

Tito Armando, MD

Order of Authors Secondary Information:

Opposed Reviewers:

Author Comments:

Additional Information:

Question Response

<b><font color=cornflowerblue>Clinical True

Practice Guidelines</b> (Recent, relevant
guidelines from any society or
group)</font><br>
I have included a short paragraph in the
discussion (or in the introduction) placing
this study into appropriate perspective
with the most recent clinical practice
guidelines, where a relevant guideline
exists.

Funding Information:

Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation
Cover Letter

Dr. Muzakkir Amir, MD

Department of Cardiology and Vascular Medicine,
Faculty of Medicine, Hasanuddin University,
90245, Makassar, Indonesia
+62811312706
muzakkir@unhas.ac.id

August, 28th 2022

Dear Editor of the Journal of Vascular Surgery

I would like to submit a new manuscript entitled “Retrograde Direct Thrombectomy

with Distal and Pedal Access using Fogarty Catheter in Acute limb Ischemia” to be
considered for publication as an original article in the Journal of Vascular Surgery.

In this manuscript, we present a 63-year-old male with acute limb ischemia Rutherford
IIa. Percutaneous transluminal angioplasty was performed but ALI presentation remain existed
because of the thrombus that present in anterior and posterior tibial artery was not completely
removed. So we decide to perform open thromboembolectomy with forgarty catheter. We used
distal and pedal access which dorsalis pedis artery and posterior tibial artery at the ankle level.
After the retrograde passage of the guidewire the embolus was completely removed.

We believe that our manuscript will be of great interest to the readers of your journal
because it proposes a valuable knowledge on ALI. I confirm that this manuscript is original
and is not under consideration by any other journal. All authors approved the manuscript and
this submission.

We thank you for receiving our manuscript and considering it for review. We appreciate
your time and look forward to your response.

Sincerely,

Dr. Muzakkir Amir, MD

Manuscript Click here to view linked References

Retrograde Direct Thrombectomy with Distal and

Pedal Access using Fogarty Catheter in Acute limb
Ischemia
Muzakkir Amir, MD1, Mulawardi, MD2,Tito Armando, MD1
1Department of Cardiology and Vascular, Medical Faculty of Hasanuddin University, Makassar, Indonesia 2Department
of Vascular surgery, Medical Faculty of Hasanuddin University, Makassar, Indonesia

Abstract
Acute Limb Ischemia (ALI) is a critical condition caused by embolic ischemia or thrombotic occlusion in limb
arteries. The incidence is approximately 1.5 cases per 10 000 persons per year. Surgery techniques advancement has
been developed but remain shown serious complications. Within 30 days post-operation, 15 % of ALI cases result in
amputation. The mortality rate in one year is approximately 20 %. 1 Rapid evaluation and management are mandatory
in patient with ALI with surgery and endovascular approach as limb salvage options. Difficulty on complete removal
thrombus with femoral access thrombectomy and endovascular treatment remain existed, especially in below-the-
knee arteries. Retrograde thrombectomy surgery with distal and pedal access could be a new option for below the
knee arterial occlusion but publication and case reports about this technique is limite. Here, we report a case of 63 y.o
man with acute limb ischemia Rutherford IIa. Percutaneous transluminal angioplasty was performed but ALI
presentation remain existed because of the thrombus that present in anterior and posterior tibial artery was not
completely removed. So we decide to perform open thromboembolectomy with forgarty catheter. We used distal and
pedal access which dorsalis pedis artery and posterior tibial artery at the ankle level. After the retrograde passage of
the guidewire the embolus was completely removed.

Introduction
Acute limb ischemia is treathening condition
with incidence rate is approximately 1.5 cases
per 10 000 persons per year.1 This condition can
develop due to embolism or traumatic occlusion
in the arteries. Cardiac origin is most common
cause for embolic arterial occlusion and usually
associated with atrial fibrillation. Regardless of
development of endovascular or open surgical
revascularization, limb loss has been shown to
occur in approximately 15% of cases during
hospitalization and death occurred in
approximately 20% of cases within 1 year.1
Limb salvage with open thromboembolectomy
commonly performed with femoral artery
approach with fogarty balloon catheter insertion.
Purposed for rapid and effective removal of
massive thromboembolic materials. However, it
is difficult to completely remove the thrombus
present within the tibial artery, mostly anterior
tibial artery (ATA), because of the
difficulty of passage of the embolectomy catheter or
guidewire into the tibial artery.2
Distal pedal access and retrograde passage of the
guidewire is a novel option to overcome this
disadvantage. Here, we report 1 case with ALI treated
first with Percutaneous transluminal balloon
angioplasty for antegrade access but not completely
removing the clot in distal arteries. So we decided to
do open thromboembolectomy with direct posterior
tibial artery cutdown and distal pedal access.
Case Description
A 63-year-old man came to emergency room with
pain at left foot since 4 days before admission and
worsened since 1 day before. Color change on the left
foot also developed (Figure 1). Computed
tomographic angiography revealed total occlusion of
the left popliteal artery and all crural arteries
suspected with embolus (Figure 2). Echo doppler
vascular showed no flow from superficial femoral
artery (SFA). Patient was diagnosed with acute limb
ischemia with Rutherford classification IIa based on
clinical manifestation, motoric and sensoric
impairment.

Figure 1. Patient’s limb appearance first time Figure 2. Computed tomographic angiography
admitted to ER. Discoloration of left foot was seen. (CTA) of lower extremities depicts a total occlusion
of the left distal common femoral artery and
popliteal artery.
The patient was deemed to be risky for
thrombolysis because of high risk bleeding;
therefore, we made an percutaneous
transluminal angioplasty (PTA) on left femoral
artery in purpose to make proximal access and
flow to posterior tibial artery was opened after
balloon angioplasty. Pain still remain after PTA
with no changes in clinical manifestation with
desaturated SpO2 57% value at left foot. So we
decided to perform open thromboembolectomy
with direct insision to posterior tibial artery Figure 3. Angiographic result after angioplasty
(PTA) and dorsalis pedis artery (DPA) under showed slow flow from popliteal artery to PTA.
local anesthesia. A 3F fogarty balloon catheter
was inserted and directed retrogradely to PTA
and DPA then inflated to trap and retrieve a
moderate amount of embolus (Figure 2).
Completion angiogram showed complete
revascularization with no residual embolus from
the left SFA to DPA (Figure 3). Patient showed
Figure 4. Amount of thrombus was retrieved from
good result one day after surgery, relieved inserted 3F Fogarty catheter directly to PTA and
symptoms and peripheral O2 saturation. DPA retrogradely.

Figure 5. Control Angiogram after thrombectomy
showed revascularization in PTA and DPA
Discussion
The acute limb describes the sudden
deterioration in the blood supply to a limb
leading to acute ischaemia and threatened
viability.4 The most common causes of ALI are
embolism, thrombosis of native arteries or
reconstructions, peripheral arterial aneurysm,
dissection, and traumatic arterial injury. The
ischaemia is graded clinically according to the
Rutherford ALI classification system.3 Optimal
treatment (endovascular, open, or combined)
method for ALI remains unclear.
Thromboembolectomy balloon catheter allows
rapid and effective removal of massive
thromboembolic material. However, open
thromboembolectomy shows the highest
mortality rate mainly caused by the underlying
heart disease such as congestive heart
failure, acute myocardial infarction, followed by
pulmonary thromboembolism.5,6
Endovascular intervention for ALI
includes catheter directed thrombolysis (CDT)
as well as percutaneous aspiration
thrombectomy (PAT). While effective, CDT has
the potential to increase the risk of major
bleeding and stroke. In addition, the patient must
be monitored in a critical care unit and usually
requires multiple visits to the operating room.
The clinical results of PAT have also been
favorable. However, PAT is labor-intensive and
can result in dissection or perforation during the
procedure. It is also relatively ineffective if the
thromboembolic material is chronic and organized.2
In patients with ALI presenting with absent
femoral pulse ipsilateral to the ischemic limb, believe
the best treatment method is cutdown of the femoral
artery bifurcation and balloon catheter
thromboembolectomy. conventional open
thromboembolectomy cannot always completely
remove the thromboembolism. Conventional open
thrombectomy via femoral approach or endovascular
intervention cannot always completely remove
thromboembolism. Up to 30 % of procedures may
demonstrate residual thrombus in a large fraction of
vessels on an angiogram especially on distal
thromboemboly. The essential step is the
advancement and crossing of the guidewire through
the lesion. It should be performed carefully without
causing an intimal flap. However, procedural failure
occurs in up to 20 % of the cases, even when
performed by experienced surgeons 1,2
Endovascular technique has its own limitations
with regard to removal of the entire thromboembolism
in ALI cases. The advancement and crossing of the
guidewire through the lesion is an essential step. It
should be performed carefully without causing an
intimal flap. Unfortunately, the guidewire cannot
always be passed all the way through the thrombus
due to difficulty in finding the orifice of the ATA or
PTA. Therefore, procedural failure occurs in up to
20% of the cases even when the procedure is
performed by experienced surgeons.3 The clear
indication for our proposed technique of adjunctive
retrograde pedal access for open thrombectomy is the
failed antegrade revascularization via the femoral
route due to failed passage of the guidewire into the
ATA or PTA, presence of dissecton flap, or
perforation.2 As novel option, retrograde surgical cut-
down direct thrombectomy could be an effective
method to deal with this problem, especially when the
embolic lesion is found in BTK arteries. The
indications for our proposed technique include the
following: 1) failure of guidewire passage into BTK
arteries, 2) incomplete revascularization with a poor
flow rate of ATA and PTA on angiogram, 3) no flow
detected by intraoperative bedside sonography after
revascularization, and 4) thrombotic occlusion of
BTK arteries documented by preoperative
sonography. 1,2.
This method also have procedure
complication. The most worrisome complication
of retrograde access is local artery trauma. Our
technical tip to prevent this problem is to use a
0.014-in guidewire and sheathless technique.
Although performing retrograde recanalization
using small-sized sheaths, there is an increased
risk of local vessel trauma and postprocedural
thrombosis. Moreover, we can achieve
hemostasis at the DPA or distal PTA by simply
removing the wire, without external
compression.2
Specific technical tips for a successful
retrograde DPA or PTA access include the use of
ultrasound sonographic guidance. The first step
is identifying the target artery by finding the
intima using power Doppler. The next step is to
push the small-bore needle until blood comes out
or double-wall puncture could be useful. Later,
wire insertion using a sheathless approach is
needed to avoid local vessel injury. The last step
is an externalization of the wire through femoral
level using a snare. We believe this retrograde
improves the timely recanalization rate and
allows the surgeon to repeat the embolectomy
safely or to guide subsequent management if the
thrombus remains as shown in a completion
angiogram.2,4,5
Although the development of
endovascular treatment showed evidence of good
outcomes in BTK thrombotic occlusion even
with a retrograde method.(2,6,7,8) direct surgical
thrombectomy for ALI maybe considered as the
better treatment. Aside from the optimal
assessment of blood flow, the endovascular
approach could not remove the 8. thrombus
completely as with open surgery. The residual
thrombus might become a distal embolic
occlusion, which may increase the risk for
amputation or may adhere to the vessel wall after
balloon angioplasty, which could be a risk for
critical limb-threatening ischemia. There was no
better way other than direct removal of the
thrombus. 2,4
Summary
Retrograde surgical thrombectomy could be a salvage
procedure for incomplete antegrade thrombectomy or
below the knee arterial occlusion.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of
interest with respect to the research, authorship,
and/or publication of this article.
References
1. Li Y, (2021) Retrograde Surgical Cut-down
Direct Thrombectomy as a Salvage Procedure
for Acute Limb Ischemia With Below the Knee
Thrombotic Occlusion: a Case Series. Chang
Gung Memorial Hospital, Research Square.
2. Cho, S., Lee, S. H., & Joh, J. H. (2020).
Complete Revascularization of Acute Limb
Ischemia With Distal Pedal Access. Vascular
and endovascular surgery, 54(1), 69–74.
3. Hamady, M., & Müller-Hülsbeck, S. (2020).
European Society for Vascular Surgery (ESVS)
2020 clinical practice guidelines
on the management of acute limb
ischaemia.
4. Mcmonagle, Morgan & Stephenson, Mathew.
(2014). Vascular and Endovascular Surgery At
A Glance.
5. Karnabatidis D, Spiliopoulos S, Tsetis D,
Siablis D. Quality improvement guidelines for
percutaneous catheter-directed intraarterial
thrombolysis and mechanical thrombectomy for
acute lower-limb ischemia. Cardiovasc
Intervent Radiol. 2011;34(6): 1123-1136.
6. Hill SL, Donato AT. The simple Fogarty
embolectomy: an operation of the past? Am
Surg. 1994;60(12):907-911.
7. Adam DJ, Beard JD, Cleveland T, et al. Bypass
versus angioplastyin severe ischaemia of the leg
(BASIL): multicentre, randomised controlled
trial. Lancet. 2005;366(9501):1925-1934
8. de Donato G, Setacci F, Sirignano P, Galzerano
G, Massaroni R, Setacci C. The combination of
surgical embolectomy and endovascular
techniques may improve outcomes of patients
with acute lower limb ischemia. J Vasc Surg.
2014;59:729-36.
Application for Publication

Journal of
Vascular Surgery
Publications
Application for Publication

Manuscript Title: Retrograde Direct Thrombectomy with Distal and Pedal Access using
Fogarty Catheter in Acute limb Ischemia

AUTHORITY OF THE CORRESPONDING AUTHOR. The authors designate Muzakkir Amir as the corresponding author and
give this person the authority to submit this form, the manuscript text, figures, tables, and all other accompanying files
to the Journal of Vascular Surgery Publications. The authors also authorize the corresponding author to communicate
with the Editorial Office and the Publisher regarding the submission, peer-review, revision, and publication of this
manuscript on behalf of the authors.

CORRESPONDING AUTHOR RESPONSIBILITY . The corresponding author confirms that they and the co-authors have read
and agreed to follow the policies of the Journal of Vascular Surgery Publications. The corresponding author also
confirms that they and the co-authors have approved the manuscript files, disclosed all relevant conflicts of interest,
and verified their contributions and conflicts on this form prior to submission. The corresponding author is responsible
for serving these same functions for the revision and resubmission of this work.

NOTE: Please include the names of the corresponding author and the post-publication corresponding author on the
title page of the manuscript.

Originality of Research. Please select one option.

☒ COMPLETELY ORIGINAL . The authors certify that this manuscript is original, has been written by the stated
authors, has not been published previously, and is not under consideration for publication by another journal.

☐ FOLLOW UP. This work is a follow up from a previously published study. It contains a patient cohort that has
been reported previously.
Please provide a link to the original publication, cite the original study in the manuscript, and list the
increase in the number of patients and follow up time below.
Link:
% Increase in Patient number: % Increase in follow up time: years

☐ OTHER. Parts of the work or patient data included in this manuscript have been previously published. The
authors have disclosed this information explicitly in the manuscript. In addition, the authors have received approval
to submit previously published data from the Editor-in-Chief. If you select this option, detailed description of the
previously published information below:
Authorship Responsibility and Contributions to Authorship. The authors must use the contributions
table to indicate their involvement in the creation of this manuscript. It is important that a box is checked in each
authorship category, otherwise the person will not qualify for authorship and the manuscript will be returned to the
authors for correction.

The boxes for “Approval” and Accountability” must be checked for ALL authors. If an author declines to
approve or be accountable for the work, they may not be included as authors.

CRITERIA REQUIRED FOR AUTHORSHIP. Authors must have contributed in all four categories.

Research including study design and conception; data collection; or data analysis and interpretation
1
Manuscript including writing the manuscript or providing critical revisions that are important for the
2 Development intellectual content
Approval of the final version of the manuscript files submitted to the Journal
3
Accountability Agreement to be accountable for all aspects of the work in ensuring that questions related to
4 the accuracy or integrity of any part of the work are appropriately investigated and resolved

CONTRIBUTIONS TABLE.
Authors Must have contributed in
All 4 Categories
1 2 3 4 Other
Research Manuscript Approval Accountability (Optional)
List 2 initials for each author (Select one or more) Development (Select) (Select)
(example: AS, BP). (Select one or
In the case of two authors with both)
the same initials, please use

Obtaining Funding
Statistical Analysis
their middle initial to Agreement to be
differentiate between them
Critical Revision
Conception and

Approval of the
Data Collection
Interpretation

(example: JEB, JTB).

Accountable
Analysis and

Manuscript

Manuscript
Writing the

Author Last Name Initials

Design

Amir MA X X X X X X
Mulawardi M X X X X X
Armando TA X X X X

You may add more rows if needed.

Overall responsibility. Click or tap here to enter text. assumes overall responsibility and guarantees the
scientific integrity of the work as a whole.

Optional Authorship Designations:

☐ SHARED FIRST AUTHORSHIP: Check this box if two authors participated equally and should share "first authorship”.
List these as first and second authors.

SHARED SENIOR AUTHORSHIP: If two authors participated equally and should share "senior authorship” enter their initials
here:

Conflict of Interest Disclosure

EACH author must disclose all relevant financial and nonfinancial potential conflicts of interest with respect to this
manuscript. Potential conflicts of interest include, but are not limited to:
1. A financial contribution to the author or the authors’ institution from a company or organization that might
benefit (or lose) financially from the results, conclusions or discussion presented in the manuscript
Examples include: Royalties, Patents (or patents pending), fees for consulting, fees for speaking
when organized by a corporate sponsored speakers’ bureau, funds for a member of the author’s staff
or family

2. Ownership of stocks, shares or options in a company or organization that might benefit (or lose) financially
from the results, conclusion or discussion presented in the paper/letter

3. A commercial interest in the form of a relationship with an entity producing, marketing, re-selling, or distributing
health care goods or services consumed by, or used on, patients

4. Other potential conflicts include:

a. an academic association or antagonism with someone whose interest might be affected by the paper
b. membership in a special interest group whose interests might be affected by the paper
c. other strong convictions that might have affected what was written

List conflicts of interest for EACH author below. If there are no conflicts of interest, please state "The authors
have no competing interests" in the space below.

Example:
All authors has no conflicts of interest.
Role of Sponsors
Each author must disclose the name and involvement of all entities that provided financial support for this work.
Please list the funding (grant, scholarships, donated devices, etc.) and describe the involvement of each sponsor in
the:
1. Study design; collection, analysis, and interpretation of data;
2. Manuscript writing
3. The decision to submit the manuscript for publication
4. Any other involvement in the creation of the manuscript (Artwork, critical revision, etc.)

Example:
This work was self-funded and no sponsors were involved in the decision to submit the manuscript for
publication.

Clinical Trial Registration

The International Committee of Medical Journal Editors (ICMJE) requires that clinical trials be registered in a public
trials registry at or before the time of first patient enrollment as a condition of consideration for publication. The ICMJE
accepts registration in any registry that is a primary register of the WHO International Clinical Trials Registry Platform
(ICTRP) or in ClinicalTrials.gov. Please review the following information and select the option that describes your
submission.

A CLINICAL TRIAL is defined by the ICMJE as any research project that prospectively assigns people or a group of
people to an intervention, with or without concurrent comparison or control groups, to study the cause-and-effect
relationship between a health-related intervention and a health outcome.
A. HEALTH-RELATED INTERVENTIONS are those used to modify a biomedical or health-related outcome;
examples include drugs, surgical procedures, devices, behavioral treatments, educational programs, dietary
interventions, quality improvement interventions, and process-of-care changes.
B. HEALTH OUTCOMES are any biomedical or health-related measures obtained in patients or participants,
including pharmacokinetic measures and adverse events.

☐ This submission meets the criteria for a clinical trial, and the study has been registered in a public trials registry as
required by the Journal of Vascular Surgery Publications.
The registration number is: Click or tap here to enter text.
☒ This submission is not a clinical trial. It has not been registered in a public trials registry.
☐ This submission meets the criterial for a clinical trial, but it has not been registered in a public trials database. If
you select this option, please provide a detailed explanation for why this study has not been registered in a public
trials registry.
Off Label Drugs and Devices
The authors must make a meaningful disclosure regarding their discussions of off label or unapproved drugs or
devices.

☐ This study does include off label drugs and/or devices.

The specific names of the products discussed are: Click or tap here to enter text.

☒ This study does not include off label drugs and/or devices.

The corresponding author confirms that they and the co-authors believe that this form and all accompanying files
describe truthful facts. The corresponding author also certifies that they and each co-author have participated to a
sufficient degree to take public responsibility for this manuscript, that their contributions and relevant conflicts of
interest are accurately and completely reported on this form.

Signed,

Muzakkir Amir, MD

*Date 8/28/2022

*(Please update for revised manuscripts and certify all statements in this manuscript are true.