Acute limb ischemia (ALI) is a vascular emergency characterized by sudden reduction in arterial perfusion, potentially resulting in irreversible tissue damage, limb loss, and mortality if timely revascularization is not achieved. Surgical thrombectomy remains an important treatment option for restoring arterial blood flow, particularly in patients with acute thromboembolic occlusion. The choice of surgical access influences thrombus clearance, distal perfusion, and postoperative outcomes. Recent evidence has demonstrated the effectiveness of thrombectomy through the below-knee popliteal artery, particularly in selected patients with distal arterial occlusion [1].

Advances in mechanical and endovascular thrombectomy techniques have expanded treatment options for ALI, with encouraging technical success and limb salvage outcomes [2]. However, open surgical thrombectomy continues to play an important role, especially in patients requiring rapid restoration of blood flow or those with extensive thrombotic occlusion. Comparative evidence suggests that treatment outcomes depend on the severity of ischemia, thrombus characteristics, anatomical location, and selected revascularization technique [3].

Transfemoral thrombectomy provides direct access to proximal arterial segments and facilitates thrombus removal from major lower limb vessels. In contrast, the transpopliteal approach allows more direct access to distal arterial segments and may improve thrombus clearance in selected cases. Studies comparing open and percutaneous thrombectomy have demonstrated comparable limb-related outcomes in appropriately selected patients, highlighting the importance of individualized procedural planning [4].

Recent investigations have reported favorable procedural success with mechanical aspiration thrombectomy, although complications, distal embolization, and repeat interventions remain important considerations [5]. Contemporary clinical evidence has further emphasized the need to optimize revascularization strategies to improve limb salvage and reduce postoperative morbidity in patients with acute limb ischemia [6].

Therefore, the present study aimed to compare the clinical outcomes of transfemoral and transpopliteal approaches for lower limb arterial thrombectomy, with particular emphasis on technical success, restoration of distal blood flow, limb salvage, postoperative complications, reintervention, and mortality.

Study Design and Setting

This hospital-based retrospective comparative study was conducted in the Department of Vascular Surgery at Stanley Medical College Chennai. Medical records of patients who underwent lower limb arterial thrombectomy for acute limb ischemia over a 36-month period were reviewed.

Sample Size

A total of 100 patients who underwent lower limb arterial thrombectomy were included and divided into two groups according to the surgical approach:

• Group A: Transfemoral thrombectomy (n=50).
• Group B:Transpopliteal thrombectomy (n=50).

Inclusion Criteria

Patients aged 18 years and above who underwent surgical thrombectomy for acute lower limb arterial occlusion using either a transfemoral or transpopliteal approach were included. Patients with documented preoperative vascular assessment, operative findings, and postoperative clinical outcomes were considered eligible.

Exclusion Criteria

Patients with chronic limb ischemia without acute thrombosis, traumatic arterial injuries, primary endovascular thrombectomy, incomplete operative records, or unavailable postoperative outcome information were excluded.

Data Collection

Demographic and clinical information, including age, sex, smoking history, diabetes mellitus, hypertension, cardiovascular comorbidities, duration of ischemic symptoms, and Rutherford classification, was retrieved from hospital records. Preoperative arterial imaging findings, thrombus location, extent of arterial occlusion, and distal runoff status were documented.

Surgical Procedure

Surgical thrombectomy was performed using standard vascular surgical techniques under appropriate anesthesia. In Group A, arterial access was obtained through the common femoral artery, followed by thrombus extraction using a Fogarty balloon catheter. In Group B, access was obtained through the popliteal artery, allowing thrombus removal from the affected arterial segments. Completion assessment of arterial flow was performed using available intraoperative Doppler findings or angiographic imaging.

Outcome Assessment

The primary outcome was the requirement for reintervention within 12 months following thrombectomy. Secondary outcomes included technical success, operative duration, restoration of distal arterial perfusion, distal embolization, postoperative thrombosis, limb salvage, major amputation, postoperative complications, and mortality.

Technical success was defined as successful thrombus removal with restoration of arterial flow at completion of the procedure. Limb salvage was defined as freedom from major amputation of the treated limb.

Follow-up

Postoperative outcomes were evaluated using available hospital records and follow-up documentation at 30 days, 6 months, and 12 months. Clinical examination findings, distal pulse assessment, Doppler ultrasonography, recurrent ischemic events, and repeat interventions were recorded when available.

Statistical Analysis

Data were entered into Microsoft Excel and analyzed using SPSS version 25.0. Continuous variables were expressed as mean ± standard deviation, while categorical variables were presented as frequencies and percentages. The independent Student's t-test or Mann–Whitney U test was used for continuous variables, as appropriate. The Chi-square test or Fisher's exact test was applied to compare categorical variables. Kaplan–Meier survival analysis was used to assess freedom from reintervention and limb salvage when time-to-event data were available. Multivariable regression analysis was considered to adjust for differences in baseline ischemia severity and anatomical characteristics. A p-value <0.05 was considered statistically significant.

A total of 100 patients who underwent lower limb arterial thrombectomy for acute limb ischemia were evaluated, with 50 patients each in the transfemoral (Group A) and transpopliteal (Group B) groups. The groups were broadly comparable regarding demographic characteristics and associated comorbidities. The transpopliteal approach demonstrated higher technical success, improved distal arterial perfusion, and lower rates of reintervention and postoperative complications.

Table 1. Comparison of Demographic and Baseline Clinical Characteristics

Baseline demographic characteristics, comorbidities, ischemia duration, and Rutherford classification were comparable between the two groups (p>0.05).

Table 2. Comparison of Operative Characteristics and Technical Outcomes

The transpopliteal approach was associated with significantly shorter operative duration (p=0.003), reduced blood loss (p=0.009), and shorter hospital stay (p=0.016). Technical success and restoration of distal flow were numerically higher with the transpopliteal approach, although these differences were not statistically significant.

Table 3. Comparison of Postoperative Outcomes and Limb Salvage

Reintervention was significantly lower in the transpopliteal group (10.0% vs. 30.0%; p=0.012). Limb salvage at 12 months was numerically higher in the transpopliteal group (92.0% vs. 80.0%), but the difference did not reach statistical significance (p=0.084). Mortality rates were comparable between groups.

Table 4. Comparison of Overall Clinical Outcomes at 12 Months

The transpopliteal approach demonstrated significantly higher freedom from reintervention at 12 months (90.0% vs. 70.0%; p=0.012). Other clinical outcomes, including limb salvage, freedom from recurrent ischemia, and overall survival, were numerically favorable but did not differ significantly between groups.

The present retrospective comparative study evaluated the clinical outcomes of transfemoral and transpopliteal approaches for lower limb arterial thrombectomy in 100 patients with acute limb ischemia. The findings suggested that the transpopliteal approach was associated with shorter operative duration, reduced blood loss, fewer reinterventions, and improved postoperative recovery compared with the transfemoral approach.

The technical success rate was higher in the transpopliteal group (94.0%) than in the transfemoral group (84.0%), although the difference was not statistically significant (p=0.110). Shukuzawa et al. [7] emphasized the importance of selecting an appropriate revascularization strategy according to the anatomical location and extent of arterial occlusion. Similarly, Duvnjak [8] highlighted the continuing importance of open surgical thrombectomy in acute limb ischemia, particularly when rapid restoration of arterial perfusion is required.

The transpopliteal approach demonstrated significantly shorter operative duration (98.4 ± 21.6 vs. 112.6 ± 24.8 minutes; p=0.003) and reduced intraoperative blood loss (152.6 ± 58.4 vs. 185.4 ± 65.2 mL; p=0.009). These findings suggested potential procedural advantages in selected patients with distal arterial occlusion. Gornik et al. [9] emphasized that timely revascularization and individualized treatment selection are essential for improving clinical outcomes in acute limb ischemia. Mazzolai et al. [10] similarly recommended appropriate assessment of limb viability, anatomical characteristics, and patient-related factors when selecting revascularization techniques.

Reintervention within 12 months was significantly lower in the transpopliteal group compared with the transfemoral group (10.0% vs. 30.0%; p=0.012). Jarosinski et al. [11] reported that reintervention remains an important outcome following thrombectomy for acute limb ischemia, although their study primarily compared percutaneous and open approaches. These findings support the importance of evaluating long-term procedural durability rather than immediate technical success alone.

Limb salvage at 12 months was higher in the transpopliteal group (92.0%) than in the transfemoral group (80.0%), but the difference was not statistically significant (p=0.084). Maldonado et al. [12] demonstrated the feasibility of mechanical aspiration thrombectomy for acute lower extremity ischemia, highlighting the importance of successful revascularization in preventing limb loss. Herzig et al. [13] also examined contemporary endovascular treatment patterns and outcomes, emphasizing the clinical importance of procedural success and postoperative limb-related complications.

Postoperative thrombosis, recurrent ischemia, and distal embolization were numerically lower in the transpopliteal group, although these differences were not statistically significant. Shukuzawa et al. [14] discussed surgical revascularization strategies for acute limb ischemia, supporting the need for individualized selection of operative approaches according to arterial anatomy and thrombus distribution.

The study was limited by its retrospective design, relatively small sample size, and potential selection bias. Differences in arterial occlusion location, distal runoff, and ischemia severity could have influenced the observed outcomes. Furthermore, references [11–14] duplicate previously listed publications [4–7] and should be replaced with unique references before submission. Larger prospective studies are required to establish the comparative effectiveness of both surgical approaches.

The transpopliteal approach demonstrated shorter operative duration, reduced blood loss, shorter hospitalization, and lower reintervention rates compared with the transfemoral approach in the analysis. Although limb salvage and technical success were numerically higher, these differences were not statistically significant. The choice of surgical approach should be individualized according to arterial anatomy, thrombus location, and ischemia severity.

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11. Jarosinski M, Kennedy JN, Khamzina Y, Alie-Cusson FS, Tzeng E, Eslami M, et al. Percutaneous thrombectomy for acute limb ischemia is associated with equivalent limb and mortality outcomes compared with open thrombectomy. J Vasc Surg. 2024;79(5):1151-1162.e3. doi:10.1016/j.jvs.2024.01.014.
12. Maldonado TS, Powell A, Wendorff H, Rowse J, Nagarsheth KH, Dexter DJ, et al. Safety and efficacy of mechanical aspiration thrombectomy for patients with acute lower extremity ischemia. J Vasc Surg. 2024;79(3):584-592.e5. doi:10.1016/j.jvs.2023.10.062.
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14. Shukuzawa K, Ozawa H, Ohki T. Revascularization for acute limb ischemia. Jpn J Vasc Surg. 2024;33(4):199-204. doi:10.11401/jsvs.24-00014.