Hybrid Surgical Approach for Acute Limb Ischemia: A Case Report and Management Algorithm

Acute limb ischemia (ALI) is a time-critical vascular emergency associated with high morbidity and amputation risk if treatment is delayed. Popliteal artery aneurysms (PAAs), though less common, represent an important and often underrecognized cause. We report a 67-year-old man who presented with sudden-onset severe leg pain, pallor, sensory loss, and motor deficit, consistent with Rutherford IIb ALI. Computed tomography angiography revealed a nearly thrombosed PAA with absent distal run-off. The patient underwent hybrid revascularization combining open thrombo-embolectomy with prosthetic interposition grafting, intra- and postoperative catheter-directed thrombolysis, and prophylactic four-compartment fasciotomies. Postoperatively, distal perfusion improved significantly, sensation fully recovered, motor function was nearly restored, and independent ambulation was achieved. This case highlights extensive distal embolization with absent tibial run-off, a condition in which isolated embolectomy is often inadequate. It illustrates the effectiveness of a hybrid surgical-endovascular strategy for limb salvage and underscores the importance of rapid imaging, urgent revascularization, adjunctive thrombolysis, and early fasciotomy. These principles are summarized in a practical management algorithm.