Management of Common Femoral Artery Thrombosis
For common femoral artery thrombosis, initiate immediate anticoagulation with unfractionated heparin and proceed urgently to hybrid revascularization combining surgical endarterectomy with endovascular treatment of any associated inflow or outflow disease. 1
Immediate Medical Management
Start anticoagulation immediately upon clinical diagnosis with intravenous unfractionated heparin (bolus 5000 IU or 70-100 IU/kg, followed by continuous infusion adjusted by aPTT or ACT) or subcutaneous low molecular weight heparin (enoxaparin 1 mg/kg twice daily) to prevent thrombus propagation and further embolization 1
Administer analgesia and intravenous fluids while preparing for revascularization 1
Place pulse oximetry on the affected foot to provide early warning of arterial obstruction or distal thromboembolism 2, 3
Monitor distal pulses, limb color, temperature, and sensation continuously to detect progression of ischemia 3
Diagnostic Imaging
Obtain urgent imaging to guide revascularization strategy, but do not delay treatment if the limb is immediately threatened 1:
Duplex ultrasound (DUS) is the fastest bedside option to confirm thrombosis and assess vessel patency 1, 2
CT angiography (CTA) from aorta through common femoral bifurcation identifies extent of disease and evaluates for multilevel involvement 1, 3
Digital subtraction angiography (DSA) or MRA are alternatives based on local availability 1
Revascularization Strategy
Hybrid revascularization is the recommended approach for common femoral artery occlusion requiring endarterectomy, particularly when combined with inflow and/or outflow disease amenable to endovascular therapy 1:
Surgical endarterectomy is preferred for the common femoral artery because endovascular approaches may adversely affect profunda femoris artery pathways, which are critical collateral vessels 1, 4, 3
Common femoral endarterectomy achieves primary patency rates of 78.5% at 7 years 4, 3
Hybrid procedures should be performed in a one-step modality when possible 1
If surgical treatment is required, perform it ideally in a hybrid room with capacity for completion angiography and initiation of local lysis if residual clot is visualized 1
Timing of Intervention
Urgency depends on limb viability assessment 1:
Immediately threatened limb (complete sensory loss and loss of motor function): Emergency revascularization required 1
Salvageable limb (sensory loss limited to toes with mild-to-moderate muscle weakness): Urgent revascularization required 1
Viable limb (no sensory loss, normal motor function): Medical management with anticoagulation and follow-up may be considered in highly selected cases 5
Special Considerations
When Endarterectomy Alone May Suffice
In highly selected patients with chronic limb-threatening ischemia and isolated common femoral artery disease, isolated endarterectomy without concomitant infrainguinal revascularization can be effective 6:
This approach is most successful in patients with WIfI stage 1-3 disease 6
WIfI stage 4 is a significant predictor of need for subsequent infrainguinal bypass 6
The profunda femoris artery can provide adequate collateral flow if patent 6
Catheter-Directed Thrombolysis
Consider catheter-directed thrombolysis or mechanical thrombectomy if there is absent distal runoff to restore tibial vessel patency before definitive surgical repair 1:
This approach is particularly useful when thromboembolism has compromised distal vessels 1
Limb salvage rates correlate directly with the number of available runoff vessels 1
Must be followed by treatment of the underlying common femoral artery lesion 1
Post-Revascularization Management
Continue anticoagulation unless contraindicated 1
Investigate etiology of thrombosis with Holter-ECG, echocardiogram, and aortic imaging to identify embolic sources requiring anticoagulation 1
Consider prothrombotic syndromes (antiphospholipid syndrome, vasculitis) if clinically suspected 1
Initiate statin therapy, which improves outcomes after revascularization 1
Structured follow-up may improve functional outcomes 1
Critical Pitfalls to Avoid
Do not perform primary stent placement in the common femoral artery unless salvaging a suboptimal result from balloon dilation, as this compromises profunda femoris pathways and future surgical options 1, 3
Do not delay revascularization for extensive imaging if the limb shows signs of immediate threat (complete sensory and motor loss) 1
Do not attempt revascularization after 10-12 hours of severe ischemia if the limb shows signs of irreversible damage (absent arterial and venous Doppler signals with extensive motor deficit), as this may lead to systemic complications from reperfusion injury or recurrent thrombosis 1, 5
Monitor for compartment syndrome and rhabdomyolysis post-revascularization by checking creatinine kinase and myoglobin levels, as elevated levels indicate risk of amputation, kidney failure, and mortality 1