Brachial embolectomy

1.The arm is usually more resistant to critical ischaemia therefore hand remains viable and surgery can be performed at earliest convenience not emergency.
2.Make a transverse incision 1cm distal to cubittal skin crease over the medial side of the forearm.
3.Make a longitudinal incision through fascia and bicipital aponeurosis
4.Identify the brachial artery (N(median)AV from medial to lateral) and venae comitantes.
5.Isolate the brachial artery proximally and sling to allow control, then follow the brachial artery distally to expose bifurcation into ulnar and radial (note may be trifurcation with deep interosseus artery) and sling distally.
6.Administer IV heparin at 100units/kg and then pull up and clip slings to drapes – no clamps on small arteries.
7.Make a transverse arteriotomy just proximal to bifurcation and assess inflow and backflow.
8.Perform a Fogarty balloon embolectomy proximally (size 3 or 4 proximally) until two clear passes and reassess inflow.
9.Similarly, perform a distal embolectomy (size 3) down each branch until two clear passes.
10.Flush with heparinized saline and assess resistance to flow.
11.Close the arteriotomy with 6/0 prolene continuous (begin at each apex and tie in middle). Release slings prior to tying to ensure do not narrow the artery
12.Drain and close