OT notes · General Surgery

Balloon (Fogarty) embolectomy of limb artery

Usual anaesthesia
General, spinal, epidural or local infiltration (local is often enough for femoral or brachial exposure)
Position
Supine; arm on an arm board for brachial approach
Setting
emergency

Operative note template for balloon catheter embolectomy of a limb artery (femoral, popliteal or brachial approach), with a filled example for a femoral embolectomy for acute leg ischaemia in atrial fibrillation.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • clot left behind, needing further embolectomy, angiography or bypass
  • injury to the artery (tear, dissection, rupture) from the balloon, needing repair or a vein graft
  • compartment syndrome after blood flow returns, needing fasciotomy
  • bleeding and groin haematoma while on heparin
  • lymph leak (lymphocele) and groin wound problems
  • numbness from saphenous nerve injury (popliteal approach)
  • loss of the limb (amputation) if the limb is not salvageable
  • further clots from the heart or aorta

Pre-operative details for this operation

  1. Time of onset of symptomsdate and clock time; hours of ischaemia at incision
  2. Limb findingspulses present / absent at each level, colour, temperature, sensation, muscle power, calf tenderness
  3. Likely sourceAtrial fibrillationRecent myocardial infarctionAortic or other arterial sourceThrombosis on diseased arteryECG finding
  4. Heparin startedbolus and infusion, time started, APTT
  5. ImagingNone, clinical diagnosisDuplexCT angiogram
  6. Blood testsCBC, platelets, coagulation, chemistry panel
  7. Consent coversembolectomy, possible bypass, possible fasciotomy, possible amputation

Anaesthesia and position

  1. AnaesthesiaLocal infiltration with monitoringSpinalEpiduralGenerallocal anaesthetic drug, strength and total volume
  2. PositionSupine (femoral or below-knee popliteal approach)Supine, arm out on arm board (brachial approach)groin and medial below-knee incisions are made with the patient supine
  3. Prepboth groins and the whole leg to the toes (leg approach); fluoroscopy available

Operative findings

  1. Approach usedCommon femoralBelow-knee poplitealBrachial at elbow
  2. Artery at exposurepulse above the clot (water-hammer or absent), wall soft or diseased
  3. Clot retrievedfrom which vessels, amount, fresh embolus or old thrombus
  4. Inflow after proximal passPulsatilePoor
  5. Back-bleeding from distal vesselsGoodPoor
  6. Completion checkAngiogram satisfactoryResidual clot in tibial / forearm vessels: further actionDoppler only
  7. Limb at endcolour, warmth, pulses or Doppler signals, compartments soft or tense

Procedure (steps)

  1. IncisionLongitudinal groin incision over CFA, below inguinal ligamentMedial below-knee incision behind tibiaTransverse incision below antecubital crease
  2. Exposure and controllymphatics ligated, femoral sheath opened; CFA, SFA and profunda (or brachial, radial, ulnar) looped
  3. Clamps appliedpatient on heparin; extra bolus if given (dose, time)
  4. ArteriotomyTransverse, near bifurcationLongitudinal (diseased artery, for patch)No. 11 blade and Potts scissors
  5. Distal passescatheter size (French), vessel, length inserted by catheter markings, number of passes, clot retrieved
  6. Profunda passes (femoral approach)catheter size, number of passes
  7. Proximal (inflow) passcatheter size, inflow achieved
  8. End pointfor example no clot on two consecutive passes and good back-bleeding
  9. Heparinised saline flush distallyDone
  10. Arteriotomy closurePrimary, interrupted polypropylenePatch angioplasty (vein / prosthetic)suture size
  11. Clamp release orderfor example CFA, then profunda, then SFA
  12. Completion angiogram or Dopplerfindings; over-the-wire catheter or popliteal exposure if residual clot
  13. FasciotomyNot needed: compartments softDone: which compartments and incisions

Closure, drains and dressing

  1. Haemostasis on heparinwound checked with anticoagulation running
  2. Wound closurelayers, suture material; skin sutures or staples
  3. DrainNoneClosed suction
  4. Dressing

Specimens and implants

  1. ClotSent for HPENot sent
  2. Patch (if used)vein, or prosthetic patch with make, size, lot and sticker
  3. Fogarty catheters usedsizes and number

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Anticoagulationheparin infusion to continue: time to restart, APTT checks
  2. Limb checkscolour, warmth, pulses or Doppler, sensation and movement at set intervals
  3. Compartment syndrome watchwrite the signs the nurse must report and whom to call
  4. Groin woundhaematoma while on heparin
  5. Reperfusion bloodsserum chemistry and creatinine; urine output
  6. Source work-upECG, echocardiogram (transoesophageal if needed), CT of aorta, thrombophilia screen as indicated
  7. Long-term anticoagulation planto be decided with physician once the source is known
  8. Follow upwound review at 3 weeks; duplex at 6 months, then yearly

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mrs. K.L., 62 years, with rheumatic heart disease and atrial fibrillation, presenting 6 hours after sudden pain, pallor and coldness of the right leg, absent right femoral and distal pulses, sensation reduced over the foot, power normal.

Case details

Date: 17/09/2026. Emergency right femoral balloon embolectomy. Emergency OT.

Onset of symptoms 11:00. Seen in casualty 16:10. In OT 17:05. Incision 17:25. Closure completed 18:40.

Surgeon: Dr A. (MS 3rd-year resident), consultant Dr B. present. Assistant: Dr C. (MS 1st-year resident).

Anaesthetist (monitoring and standby): Dr D. Scrub nurse: Sr E.

Indication and pre-op

Acute embolic ischaemia of right leg, 6 hours. Right femoral, popliteal and pedal pulses absent, foot pale and cold, sensation reduced over dorsum, power normal, calf soft. Left leg normal.

ECG: atrial fibrillation, rate 104/min. No imaging done (clinical diagnosis, time saved).

IV heparin bolus and infusion started in casualty at 16:30 as per unit protocol. APTT sent.

Hb 11.4 g/dl, platelets 2.1 lakh, creatinine 0.9 mg/dl, K 4.2 mmol/l.

Consent: general and procedure-specific consent (embolectomy, possible bypass, fasciotomy, and risk of amputation) taken in Marathi from patient, husband present.

Blood group B positive, 2 units cross-matched. WHO checklist sign in and time out done. Inj cefazolin 2 g IV at 17:10.

Anaesthesia and position

Local infiltration with 15 ml of 1% lignocaine without adrenaline (150 mg; weight 60 kg). Anaesthetist monitoring.

Supine. Both groins and whole right leg to toes painted with povidone-iodine and draped, foot in sterile transparent bag. C-arm available.

Findings

Water-hammer pulse in upper right CFA, no pulse at bifurcation. Artery wall soft.

Fresh embolus at CFA bifurcation extending into SFA and profunda. Long propagated clot from SFA and popliteal.

Pulsatile inflow after proximal pass. Good back-bleeding from SFA and profunda after clearance.

Completion angiogram: SFA, popliteal and all three tibial vessels patent to the ankle.

Foot pink and warm at end, strong DP and PT Doppler signals. Calf compartments soft.

Procedure

Longitudinal right groin incision starting 1 cm below the inguinal ligament over the CFA. Lymphatics ligated. Femoral sheath opened.

CFA, SFA and profunda dissected and looped with Silastic loops. Crossing lateral circumflex vein preserved.

Patient on heparin infusion. Atraumatic clamps applied.

Transverse arteriotomy in CFA near bifurcation with No. 11 blade, extended with Potts scissors. Embolus seen and removed.

No. 4 Fr Fogarty catheter passed down SFA to about 60 cm by catheter markings, balloon inflated gently while withdrawing: long clot removed. Repeated until two passes returned no clot.

No. 3 Fr Fogarty passed into profunda: small clot removed, then two clean passes.

No. 4 Fr Fogarty passed proximally into iliac artery: no clot, brisk pulsatile inflow.

Distal vessels flushed with heparinised saline.

Arteriotomy closed with interrupted polypropylene (Prolene) 6-0 after flushing proximally and distally.

Clamps released in order: CFA, profunda, then SFA.

Completion angiogram through CFA: findings as above. Below-knee popliteal exposure not needed.

Calf compartments soft: fasciotomy not needed.

Closure

Haemostasis checked with heparin running.

Groin closed in layers with absorbable polyglactin 910 (Vicryl). Skin with staples. No drain. Dry dressing.

Specimens and implants

Embolus and clot sent for HPE. No patch or implant.

Fogarty catheters used: 4 Fr x 1, 3 Fr x 1.

End of procedure

Ischaemia time about 7 hours from onset to reflow. Estimated blood loss 250 ml. Contrast 15 ml.

Mop, needle and instrument counts correct, confirmed by scrub nurse.

No intra-operative complications.

Shifted to surgical ICU. Pulse 96/min irregular, BP 128/80 mmHg. Right foot warm, DP and PT Doppler present.

Post-op orders

Heparin infusion to continue as per unit protocol, with APTT checks as per protocol.

Right foot colour, warmth, Doppler, sensation and movement checked with each set of ICU observations, frequency as written by the consultant.

Inform surgeon at once if calf pain or swelling increases, or foot becomes numb or cold.

Serum electrolytes and creatinine tonight and tomorrow morning. Record urine output.

Cardiology referral: echocardiogram (transoesophageal if needed) to look for left atrial clot, rate control, long-term anticoagulation plan.

Wound review at 3 weeks; arterial duplex at 6 months.

Signature

Dr A., JR-3, General Surgery. Reg. no. ________. 17/09/2026, 18:55.

Must document for this operation

  • Time of onset, time of reflow and the limb state before surgery (sensation, power, calf). Ischaemia time decides the risk of compartment syndrome and limb loss, and is the first thing asked in any audit or complaint.
  • Heparin: when it was started and whether extra doses were given in theatre. Post-op bleeding and re-occlusion are both judged against the anticoagulation given.
  • Catheter sizes, vessels passed, number of passes and the end point used. Artery injury or residual clot is traced back to these details.
  • Completion angiogram or Doppler findings and the state of the foot at the end. They show whether revascularisation was complete and give the baseline for ward checks.
  • Compartments checked and fasciotomy decision. Missed compartment syndrome after reperfusion is a common cause of limb loss and litigation.
  • The likely source of the embolus and the plan to find it. Without treating the source, further emboli are likely.

Common mistakes in these notes

  • Writing 'embolectomy done, good flow' with no catheter sizes or vessels cleared.
  • Not recording the time of onset and time of reflow.
  • No note on calf compartments at the end.
  • Not writing the local anaesthetic volume and strength when done under local.
  • No plan for anticoagulation and source work-up in the post-op orders.

Indian practice and paperwork

  • NABH expects the operative note to be written before the patient leaves recovery, and post-op care to follow a written plan. (NABH 5th ed., COP.14(e) and (f))
  • The consent must name the added procedures that may be needed (bypass, fasciotomy). An extra procedure not covered by consent is defensible only if it was needed to save life or health and could not wait (Samira Kohli v. Dr Prabha Manchanda, Supreme Court, 2008). ((2008) 2 SCC 1)
  • If a prosthetic patch is used, NABH asks that its batch and serial number be written in the record, the OT master logbook and the discharge summary. (NABH 5th ed., MOM.10(d))

Sources

  • Scott-Conner CEH, ed. Scott-Conner & Dawson: Essential Operative Techniques and Anatomy. 4th ed. Lippincott Williams & Wilkins (Wolters Kluwer); 2014, Ch 132, Peripheral Embolectomy (Amin PB, Nicholson R), pp. 716-720.
  • Bell RH Jr, Kaufman DB, eds. Northwestern Handbook of Surgical Procedures. Landes Bioscience; 2005, Ch 103, Lower Extremity Thrombectomy/Embolectomy (Eskandari MK), pp. 308-310.
  • Moran B, Mittal R, Lord A, eds. Farquharson's Textbook of Operative General Surgery. 11th ed. CRC Press; 2026, Ch 4A, Surgery of the skin and subcutaneous tissue (Lamba S, Asirvatham E): local anaesthesia dose only, pp. 43.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Table 1: cefazolin 2 g IV (3 g if 120 kg or more). Table 2: vascular procedures: cefazolin. Start within 60 min before incision; duration under 24 h. www.ashp.org/-/media/assets/policy-guidelines/docs/therapeutic-guidelines/therapeutic-guidelines-antimicrobial-prophylaxis-surgery.pdf
  • Farquharson 11e, Ch 4A, printed p. 43 (pdf 58): lidocaine maximum 3 mg/kg plain, up to 7 mg/kg with adrenaline 1 in 200,000.

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

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