What is it?

The main artery running down your bad leg is blocked near the knee. The leg is starved of blood. This causes pain, infection and even loss of the limb. The blockage in the artery is because of a blood clot. This has formed in the artery, or has floated down in the bloodstream from your heart or another blood vessel upstream. The loose type of blood clot is called an embolus. Either way, it is essential to try and get the blood clot out. Taking out the clot is called an embolectomy. If the clot came from upstream, and the leg is healthy, the operation usually works very well. If not, the artery may well clot up again, and the leg is at risk of getting worse. You may need special tests and possibly bigger operations. As a first step, the embolectomy is absolutely necessary to save your leg.

The Operation

You may have a general anaesthetic and be asleep for the whole operation, or have an injection in your back, (epidural) or groin and be heavily sedated. Either way you will not remember anything about the operation. A cut is made into the skin in the groin and thigh. Sometimes a cut is made on each side to catch any clot slipping into the artery of the other leg. The artery is opened. Then a special plastic balloon is slid down the artery. The clot is then pulled out through the opening in the artery. The opening in the artery is stitched up. The surgeon checks the blood is flowing down the artery once more. Finally the skin is stitched up. If the operation is not done soon after the blocking (occlusion) of the artery it might be that the surgeon will have to make a couple of cuts on the skin and the underling fat and supportive tissue (fascia) on each side of your leg below the knee. The cuts are called fasciotomies. This is done because the leg gets very swollen when the blood flows through it again (perfusion) after a long time of non-perfusion. The swelling can compress the tissues of the leg to the point that it will destroy them. The fasciotomies release the pressure and allow the leg to recover. In most cases, the fasciotomies heal on their own relatively quickly and the areas of the cuts are covered again with skin. You should plan to leave the hospital about five to seven days after the operation provided the leg is healthy. If you have fasciotomies you might need to stay longer.

Any Alternatives

If you do nothing, the problems you are having with your limb will surely get worse and you will most certainly to lose your leg. Drugs and antibiotics by themselves will not work. Another option is for the radiologists to pass a fine tube through the skin into your bloked (occluded) artery and introduce a solution of blood thinners into the artery to dissolve the clot. This might work for some selective cases but not everyone. Injections into the nerve in your back which controls the arteries will not help. The doctors are aiming to save your leg by doing the planned operation. Sometimes, if the leg is beyond recall, it is better to go ahead with an amputation (removal of the part of the leg that doesn't have proper blood supply). Sometimes a more complex operation is needed to deal with a narrow artery.

Before the operation

You will have come to the hospital as an emergency. Check that you have a relative or friend who can come with you to the hospital, take you home, and look after you for the first week after the operation. Sort out any tablets, medicines, inhalers that you are using. Keep them in their original boxes and packets. Bring them to the hospital with you.

On the ward, you may be checked for past illnesses and may have special tests to make sure that you are well prepared and that you can have the operation as safely as possible. Please tell the doctors and nurses of any allergies to tablets, medicines or dressings. You will have the operation explained to you and will be asked to fill in an operation consent form.

After - In Hospital

You may have a fine, thin plastic drip tube in an arm vein connected to a plastic bag on a stand containing a salt solution or blood. You will have dressings on your wounds and possibly fine plastic drainage tubes in the nearby skin connected to plastic containers. These drain any residual blood or other fluid from the area of the operation. You may be given oxygen from a face mask for a few hours if you have had chest problems in the past. The wound is a bit painful and you will be given injections and later tablets to control this. Ask for more if the pain is not well controlled or if it gets worse. A general anaesthetic will make you slow, clumsy and forgetful for about 24 hours. The nurses will help you with everything you need until you are able to do things for yourself. Do not make important decisions during this time.

You will be given blood thinners initially into one of your veins or with an injection into your skin. These will be replaced gradually with blood thinner tablets that you can take by mouth (orally). The blood thinners are given to prevent the artery from getting clotted again.

You will most likely be able to get out of bed with the help of the nurses the day after the operation despite some discomfort. You will not do the wound any harm, and the exercise is very helpful for you. The second day after the operation you should be able to spend an hour or two out of bed. By the end of four days you should have little pain. It is important that you pass urine and empty your bladder within 6 to 12 hours of the operation. If you cannot pass urine, let the doctors and nurses know. They will take steps to correct the problem. Each wound has a dressing which may show some staining with old blood in the first 24 hours. You can take the dressings off after 48 hours. There is no need for a dressing after this unless the wound is painful when rubbed by clothing. There may be stitches or clips in the skin. The wounds may be held together with just stitches underneath the skin that are dissolvable and do not need to be removed. Any plastic drainage tube is taken out after about two days or so.

There may be some purple bruising around the wound which spreads downwards by gravity and fades to a yellow colour after two to three days. This is expected and you should not worry about it. There may be some swelling of the surrounding skin which also improves in two to three days. After 7 to 10 days, slight crusts on the wound will fall off. Occasionally minor matchhead sized blebs (blisters) form on the wound line, but these settle down after discharging a blob of yellow fluid for a day or so. You can wash as soon as the dressings have been removed but try to keep the wound area dry until the stitches/clips come out. If there are only stitches under the skin, try to keep the wound dry for a week after the operation. Soap and warm tap water are entirely adequate. Salted water is not necessary. You can shower or bath as often as you want.

If you have fasciotomies, they will be cleaned and redressed regularly and their healing will be closely monitored. Try to keep them clean and dry while the healing is in progress. You will be told when it is safe to wash the area of the fasciotomies.

You will be given an appointment to visit the outpatient department for a check-up about one month after you leave the hospital. The nurses will advise about sick notes, certificates etc.

After - At Home

You are likely to feel very tired and need to rest two or three times a day for two weeks or more. You will gradually improve so that by the time two months have passed you should be able to return completely to your usual level of activity. You can drive as soon as you can make an emergency stop without discomfort in the wound, i.e. after about three weeks. You can restart sexual relations within two or three weeks when the wound is comfortable enough. You should be able to return to a light job after about six weeks and any heavy job within 12 weeks.

Possible Complications

If you have this operation under general anaesthetic, there is a risk of complications related to your heart and lungs. The tests that you will have before the operation will make sure that you can have the operation in the safest possible way and will reduce the chances for such complications.

If you have an anaesthetic injection in the back, there is a very small chance of a blood clot forming on top of your spine which can cause numbness or pins and needles in your legs. The clot usually dissolves on its own and this solves the problem. Extremely rarely, the injections can cause permanent damage to your spine.

It is important to know that the chances of dying during or after a femoral embolectomy can be up to 25% especially if you are elderly and you have a serious cardiac disease.

Complications are rapidly recognised and dealt with by the surgical staff. If you think that all is not well, please let the doctors and nurses know.

Sometimes there is some bleeding under the wounds which causes more severe bruising. This usually settles down. It is possible to have more bleeding in the area of the operation and this may require another operation to stop it. The fact that you are going to be given blood thinners increases the chances of bleeding after the operation.

Sometimes the blood in the artery clots. This usually needs a second operation to clear the blockage. The next steps to deal with this will be discussed with you. Wound infection is sometimes seen. This settles down with antibiotics in a week or two. Sometimes fluid builds up under the wounds. This settles down.

Overall there is a 2% chance that something will go wrong when the balloon is passed into your artery to remove the clot:

• the balloon can go the wrong way and get into the wall of the artery
• an aneurysm (weak area of the wall of the artery that gradually gets bigger like a balloon and might burst) can be created
• a communication between the artery and a nearby vein can be accidentally created.
  It might be possible to fix these conditions with an operation but it might also be that they will result in you losing your leg.

As we said, if you have fasciotomies they will most likely heal on their own. There is however a chance that the fasciotomies will need one or more further minor operations to clean any unhealthy or necrotic (dying) tissue. If the fasciotomies don't heal satisfactorily you may need another operation to cover them with skin grafts that are taken from another part of your body.

Aches and twinges may be felt in the wound for up to six months. Occasionally there are numb patches in the skin around the wound which get better after two to three months.

This operation is generally quite successful if performed within six hours of the artery becoming blocked (occluded). After this six-hour period, the chance of success are reduced as time goes by.

General Advice

As with all operations involving the blood vessels this operation should not be underestimated. Your recovery depends on the state of the other arteries in the legs, but is usually relatively quick and good. You should never smoke after the operation. These notes should help you through your operation. They are a general guide. They do not cover everything. Also, all hospitals and surgeons vary a little. If you have any queries or problems, please ask the doctors or nurses.