Thrombectomy for a presumed embolus to the brachial artery is best approached through a transverse incision one fingerbreadth distal to skin crease at the antecubital fossa (Fig. 132.1A). Mobilize the superficial veins. Incise the bicipital aponeurosis to expose the brachial artery. Begin sharp dissection of the brachial artery on its anterior surface and proceed to obtain circumferential proximal control. Continue the dissection distally until the brachial artery bifurcates into the radial and ulnar arteries. Place Silastic loops around the brachial, ulnar, and radial arteries (Fig. 132.1B). Loops can be placed in a double-looped or Potts fashion, or single-looped with the addition of small, atraumatic vascular clamps which are used for control once the embolus is removed.

On the anterior surface of the brachial artery use an 11-blade knife at a 45-degree angle to start a transverse arteriotomy. Once completely through the anterior surface of the arterial wall and into the lumen, extend the arteriotomy transversely with Potts scissors. Pass a Fogarty embolectomy catheter (Edwards Lifescience, Irvine, CA) in a retrograde fashion past the proximal extent of the thrombus, gently inflate the balloon to the point that there is a small amount of tension as the catheter is pulled back (Fig. 132.1C,D), then extract the thrombus. More than one pass might be needed to obtain brisk antegrade flow. Use the markings on the catheter to assess the distance needed to advance the catheter before inserting it into the vessel. To minimize bleeding from the vessel once the clot is removed, be ready to retract gently on the vessel loop as the catheter balloon approaches the arteriotomy site. Sizes of the catheters range from 2F to 7F with the corresponding maximal inflation diameters between 4 and 12 mm. Close the vessel with fine 6-0 or 7-0 polypropylene suture. Assess Doppler signals of the distal vessels.

If the blind passage of the Fogarty catheter does not yield satisfactory revascularization, perform an angiogram. If there is a significant amount of residual clot, reopen the arteriotomy. Place a sheath in an antegrade fashion toward the hand. Use intraoperative fluoroscopy to guide a 0.018-inch wire into the distal radial and ulnar arteries and use an over-the-wire Fogarty catheter to perform the thrombectomy. Inject small amounts of contrast as needed to assess progress of the thrombectomy. Once flow has been restored into the hand, remove the sheath and close the arteriotomy with interrupted sutures (Fig. 132.1E).