Subclavian (see Fig. 12.2B) Position As for carotid. Procedure (cid:142)(cid:3) Make a 10cm incision above medial half of clavicle and lateral t o the insertion of sternomastoid muscle. Deepen the incision by dividing clavicular head of sternomastoid, platysma and deep fascia to expose omohyoid and fat pad with lymph node whi ch is displaced superiorly. (cid:142)(cid:3) Identify the phrenic nerve lying in the anterior aspect of scalenus anterior and passing downward and medially, and protect it. Identify the brachial plexus an d protect it laterally. (cid:142)(cid:3) Divide scalenus anterior over a blunt instrument to reveal the subclavian artery and the suprascapular and internal mammary branches. EXPOSURE OF MAJOR BLOOD VESSELS1 387 (A) Hypoglossal nerve and ansa cervicalis Superior thyroid artery Carotid Common carotid art. ECA Vertebral Stump of facial vein Internal carotid art. Int. jugular vein (B) Phrenic nerve Divided scalenus ant. Subclavian Axillary Subclavian art. Fig. 12.2 Exposure of carotid and subclavian arteries CHAPTER 12 Peripheral vascular surgery 388 Distal subclavian/axillary artery (see Fig. 12.2B) Position As for Carotid. Procedure (cid:142)(cid:3) Expose the distal subclavian artery as for Subclavian extending the incision over the clavicle, divide the clavicle if necessary. (cid:142)(cid:3) Approach the proximal axillary artery via a 10cm incision below the middle third of the clavicle. (cid:142)(cid:3) Incise the skin and deep fascia to expose the fibers of pectoralis major, split them and insert a self retaining retractor. Define the axillary artery in the depth o f the wound. Exposure of the vessel may be aided by division or detachment of pectoralis mi nor from the coracoid process, the acromioclaviclar branches, if necessary, to allow full m obilization. Brachial artery (see Fig. 12.2C) Position Supine with the arm on table and the hand isolate d in a sterile translu- cent bag. Procedure (cid:142)(cid:3) In the upper arm by an incision placed along the medial border, just behind biceps muscle. Divide skin and deep fascia and retract biceps anteriorly and tr iceps posteriorly. The median nerve lies anterior and superior to the artery. (cid:142)(cid:3) Achieve exposure of the brachial artery at the elbow by an S-shaped incisi on in the anticubital fossa. Expose the bicipital aponeurosis and divide it to expose the b rachial artery and its bifurcation to radial and ulnar arteries, passing between brachiorad ialis and the flexor muscles. The median nerve and basilic vein are posteromedial to the ar tery. Radial artery (see Fig. 12.2C) Procedure (cid:142)(cid:3) Expose the radial artery via a ve rtical incision in the anterior aspect of the forearm. (cid:142)(cid:3) Expose it proximally by dissection between brachioradialis medially and flexor carpi radialis. (cid:142)(cid:3) Expose it at the wrist by a vertical incision beginning at the radial sty- loid. The cephalic vein lies above the deep fascia and the radial artery below it. (cid:142)(cid:3) Incise the deep fascia to expose the artery and its accompanying veins. Ulnar artery (see Fig. 12.2C) (cid:142)(cid:3) Expose the ulnar artery likewise via vertica l forearm incisions. (cid:142)(cid:3) Expose it proximally by dissection of pronator teres and the brachio- radialis laterally and the flexor digitorum. The artery is found between them. (cid:142)(cid:3) For exposure at the wrist make a similar vertical incision medial to flexo r digitorum and the ulnar styloid. The ulnar artery lies slightly deeper than its radial co unterpart, expose it as it passes below the flexor retinaculum. EXPOSURE OF MAJOR BLOOD VESSELS1 389 Divided biceps tendon Brachial art. Median nerve Radial art. Basilic vein Ulnar art. Fig. 12.2C Exposure of brachial artery CHAPTER 12 Peripheral vascular surgery 390 Exposure of the abdominal aorta (see Fig. 12.2D) Position Supine. Incision Long midline skirting umbilicus, transverse, or retroperitoneal. Procedure (cid:142)(cid:3) Place self retaining retractors (Balfour, Finochetti, Omnitract) in the wound. Lift the transverse colon out of the wound or pack it under the upper abdomen/lower thorax. Displace the small bowel to the right and wrap it in moist packs in a gut bag. (cid:142)(cid:3) Expose the coeliac axis after opening the lesser omentum to identify the diaphragmatic crura. Divide them to reveal the aorta and origin of the coeliac axis. Su pracoeliac approach can be used to gain rapid con- trol of the aorta in the case of aortic rupture. (cid:142)(cid:3) Expose the splenic artery by dividing the greater omentum along the lower border of the stomach. Retract the stomach proximally to expose the upper margin of the pan creas and the splenic vessels. (cid:142)(cid:3) Expose the superior mesenteric artery by careful caudal dissection along t he aorta utilizing the supracoeliac approach as described above. An alternative and quicker approach to the SMA is via the root of the small bowel mesentery. Displace the transverse colon upwards and, with the small bowel to the right, expose the SMA in the small bowel mes entery using the point at which the middle colic artery ascends in the transverse mesocolon as a guide. (cid:142)(cid:3) To expose the infrarenal aorta, renal arteries, and the aortic bifurcation identify the peritoneum overlying the aorta and divide it over the bifurcation upwards to the right of the inferior mesenteric artery, mobilizing the duodenum to the right (you may need to divide the inferior mesenteric vein to gain access). Identify the left renal vein a nd carefully mobilize it passing a sling around it. The vein can be lifted or divided to ex pose the renal vessels. (cid:142)(cid:3) To expose each common iliac, lift the overlying peritoneum and divide it t aking care to preserve the ureters and iliac veins (often adherent to the artery) and conti nue the exposure to the iliac bifurcation and origin of the internal iliac. Common/external iliac artery (see Fig. 12.2E) Incision Oblique incision in iliac fossa late ral to edge of rectus sheath. Procedure (cid:142)(cid:3) Deepen the incision and divide the abdominal wall muscles to exp ose the peritoneum which is displaced medially identifying the ureter and the iliac vessels . (cid:142)(cid:3) Insert deep self-retaining retractors to allow access. Expose the inter- nal iliac by encircling the common and external iliac arteries with slings and pulling the vessel laterally to allow exposure of the origin of the internal iliac. EXPOSURE OF MAJOR BLOOD VESSELS1 391 (D) Abdominal aorta (a) (b) (c) (E) Iliac vessels Internal iliac art. Common iliac art. External iliac art. Fig. 12.2 Exposure of (D) abdominal aorta and (E) iliac arteries CHAPTER 12 Peripheral vascular surgery 392 Common femoral/profunda femoris arteries (see Fig. 12.2F) Incision The surface marking for the common femoral artery is the mid inguinal point, halfway between the anterior superior iliac spine and the pubic tubercle. Make 10 \200\22312cm vertical incision two fingerbreadths lateral to pubic tu- bercle exten ding one third above and two thirds below the inguinal ligament or over the palpable femora l pulse. Feel for the pulsation with your fingers. If exposure of the long saphenous vein i s required use a lazy S incision curving medially over the vein. Procedure (cid:142)(cid:3) Incise the fat and fascia and insert a Travers retractor. Do not cut across lymph nodes and ligate lymphatics. Feel for the pulse and expose the femoral sh eath and incise longitudinally. (cid:142)(cid:3) Mobilize the artery using sharp dissection, ligating and dividing any small veins to allow exposure of the common femoral and the superfi- cial femoral arteries. Pass a Lahey clamp under each vessel and draw a sling around each. (cid:142)(cid:3) Expose the profunda by gentle traction on the slings around the above vess els and pass a sling around it. Expose the profunda further. Divide the small vein which cr osses it a short distance from its origin, this reveals the first bifurcation and the profu nda vein. Ligate it and divide it to allow dissection to proceed distally. Above knee popliteal artery (see Fig. 12.2G) Incision Longitudinal. Along the medial aspect of the lower thigh along the ante- rior border of Sartorius or over the previously marked long saphenous vein if a vein graft is contemplated. Procedure (cid:142)(cid:3) Deepen the incision through the subcutaneous fat to expose the Sartorius and retract it posteriorly to reveal the neurovascular bundle and popliteal fat p ad. The artery lies close to the bone and the nerve is some way away with the vein in-betwe en. (cid:142)(cid:3) Gently mobilize sufficient artery to gain proximal and distal control with plastic slings passed around it using a Lahey clamp. Below knee popliteal artery (see Fig. 12.2H) Incision Longitudinal over the medial aspect o f the calf along the border of gas- trocnemius 2cm below medial border of tibia. Procedure (cid:142)(cid:3) With the knee flexed, deepen the incision and incise the deep fa scia, sweep the fat pad and gastrocnemius away and retract it posteriorly. EXPOSURE OF MAJOR BLOOD VESSELS1 393 (F) Femoral Common femoral art. (a) Profunda femoris art. Long saphenous vein Common femoral vein (b) Superficial femoral art. Profunda vein Adductor hiatus (G) Above knee Popliteal art. Sartorius Tibia Peroneal art. (H) Below knee Ant. tibial art. Gastronemius/ soleus Post. tibial art. Fig. 12.2 Exposure of (F) femoral, (G) above knee, and (H) below knee arteries CHAPTER 12 Peripheral vascular surgery 394 (cid:142)(cid:3) Continue dissection between the medial head of gastrocnemius and the tibia to expose the neurovascular bundle. Expose the vein first, carefully lifting it away to al low access to the artery. Mobilize a suffi- cient length for anastomosis passing slings pro ximally and distally. Proximal exposure of the artery is improved by dividing the tendons o f sartorius, semimembranous, and gracilis. (cid:142)(cid:3) Divide soleal arch and detaching it from the medial border of the tibia di ssection distally will expose the origin of the anterior tibial artery and allow access to the tibioperoneal trunk. Crural vessels Anterior tibial artery (see Fig. 12.2I) Incision Over the anterior tibial muscles on the lateral aspect of the calf, lateral to the anterior tibial border. Procedure Dissect between the muscles in the line of their fibers to expose the artery lyin g deep on the interosseus membrane with the venae commi- tantes. Dissect and mobilize the a rtery. This is aided by good retraction with a self retainer. Posterior tibial artery Incision Longitudinal on the medial aspect of the distal calf centered over the junction of gastrocnemius and the Achilles tendon. Procedure (cid:142)(cid:3) Deepen the incision and divide the deep fascia, develop the plan e between gastrocnemius and soleus muscles to reveal the posterior tibial vessels and nerve o n the surface of soleus, separate the artery by careful dissection. (cid:142)(cid:3) Alternatively find the artery more superficially by incising the deep fascia and retinaculum behind the medial malleolus. Peroneal artery (see Fig. 12.2J) Incision (cid:142)(cid:3) Longitudinal over lateral aspect of distal leg, expose the fibula and remove a segment. The artery lies behind the fibula. (cid:142)(cid:3) Alternatively approach as for the posterior tibial artery, split the later al fibers of soleus/flexor hallucis longus to reveal the peroneal artery. EXPOSURE OF MAJOR BLOOD VESSELS1 395 (I) Anterior tibial (J) Peroneal Interosseus membrane Peroneal art. and venae comitantes Lateral view Fibula Fig. 12.2 Exposure of (I) anterior tibial and (J) peroneal arteries CHAPTER 12 Peripheral vascular surgery 396 Profundaplasty The profunda femoris is part of an extensive vertical collateral network fro m the internal iliac to the tibial vessels and remains relatively free of disease when the other lower limb arteries are affected by atheroscle- rotic occlusion. Indications (cid:142)(cid:3) Significant stenosis or occlusion of the origin or proximal po rtion of the deep femoral artery. (cid:142)(cid:3) Lower limb ischaemia with no possibility of femoropopliteal reconstruction. (cid:142)(cid:3) Adjunct to inflow procedure in multisegment disease (aorto- femoral/axillofemoral or femorofemoral graft). (cid:142)(cid:3) Limb salvage procedure in f ailed distal bypass. (cid:142)(cid:3) To aid healing of below knee amputation if profunda d iseased. Position of patient Supine. Procedure (see Fig. 12.3) (cid:142)(cid:3) Make a vertical incision over the common femoral artery, 5cm above the inguinal crease extending distally depending upon the length of the profunda to be expo sed. (cid:142)(cid:3) Expose and mobilize the common femoral, profunda femoris and superficial femoral arteries and pass slings around them (the superficial femoral should be mobilized a variable distance as the outer wall of the vessel may be used as a patch). Dis sect the profunda downwards dividing the small vein which crosses the primary stem to expos e the first bifurcation and the profunda vein which should also be divided. Continue dissec tion along the artery can be continued until a satisfac- tory length of the vessel is expos ed, and identify a soft portion for arteriotomy, controlling any muscular branches with sli ngs. (cid:142)(cid:3) Give the patient 5000 IU heparin and apply vascular clamps to the common femoral and profunda vessels. (cid:142)(cid:3) Make an arteriotomy in a soft portion of the common femoral artery and ext end it into the profunda. If there is occlusive atheroma proxi- mally perform a local endar terectomy securing the distal flap with tack- ing sutures of 6/0 Prolene. Check for forward and backward bleeding and close the arteriotomy with a patch (vein, Dacron, PTFE, tongue o f graft or adjacent SFA wall). (cid:142)(cid:3) Approach the mid portion of the profunda through an anterior thigh incision along edge of sartorius; retract it laterally to expose the super- ficial femoral artery. Retract the superficial femoral artery medially and incise the fascia deep to the v essel to expose the profunda deep to the 2nd and 3rd perforator branches. PROFUNDAPLASTY1 397 (A) Common femoral art. CFA Vein patch Femoral vein (B) Profunda vein Superficial femoral art. Profunda femoris art. SFA PFA (C) CFA SFA (D) Dacron graft PFA SFA CFA (E) PFA SFA SFA PFA Fig. 12.3 Profundaplasty. CFA, common femoral artery; PFA, profunda artery; SFA, superficia l femoral artery CHAPTER 12 Peripheral vascular surgery 398 Endarterectomy Most frequently utilized in the internal carotid artery. It basically consis ts of removing the core of atheromatous and/or thrombotic material caus- ing occlusion or s tenosis of the vessel. Indications Restoration of blood flow in an artery with either a short occlusion or stenosi s and in which the vessel is otherwise normal above and below the lesion. Heavily calcified vessels may not be suitable due to the risk of repeated vessel fracture and uncontrollable hemorrhage on application of clamps, but may be feasible using balloon occlusion catheters to gain control proximally and distally. Procedure (cid:142)(cid:3) Expose the diseased artery and gain proximal and distal control of the vessel with slings. (cid:142)(cid:3) Apply arterial clamps above and below the lesion following systemic antico agulation and the artery opened by a longitudinal incision along the length of the stenosed segment. (cid:142)(cid:3) Identify the plane of cleavage between the diseased and non-diseased zones of the arterial wall in the media and using a Watson-Cheyne dissector carefully separate t he atheroma from the vessel wall. Then loosen the atheromatous core above and below being e xtra vigilant distally not to leave a loose flap. Secure the distal intimal division point by tacking sutures of a fine monofilament suture placed in through the endarterectomised ar tery and out through the non-endarterectomised wall, anchoring the flap. Close moderate siz ed arteries with a continu- ous or interrupted Prolene suture. Use a patch angioplasty for smaller arteries or if there is a risk of vessel stenosis. ENDARTERECTOMY1 399 (A) (B) (C) Fig. 12.4 Endarterectomy CHAPTER 12 Peripheral vascular surgery 400 Carotid endarterectomy Aims (cid:142)(cid:3) Prevention of stroke by removal of the source of embolic material. (cid:142)(cid:3) Improvement in cerebral function by the removal of at heromatous occlusive material from the carotid bifurcation and origin of the inter- nal carotid artery . Indications Symptomatic carotid occlusive disease with: (cid:142)(cid:3) Transient ischaemi c attack (cid:142)(cid:3) Stroke with good functional recovery (cid:142)(cid:3) Reversible ischaemic neurological deficit (RIND) (cid:142)(cid:3) Amaurosis fugax (cid:142)(cid:3) >70 % symptomatic stenosis \200\224clear indication 40 \200\22370% stenosis \200\224if failed m edical treatment. Position Supine with the neck extended and head supported on a ring, pad placed longitudina lly between the shoulder blades and head turned toward the opposite side Anesthesia General or local anesthesia. (cid:142)(cid:3) Local anesthesia allows evaluation of tolerance to cerebral clamping with/without the aid of transcranial Doppler assessment but disadvan- tage is restlessness/agitation of patient and patient/surgeon anxiety. (cid:1 42)(cid:3) General anesthesia gives better control and the duration is unlimited. Incision (cid:142)(cid:3) Vertical parallel to the anterior border of sternomastoid, the le ngth is dependent on the location of bifurcation (X-ray, MRA). (cid:142)(cid:3) Oblique skin crease incision. Procedure (see Fig. 12.5) (cid:142)(cid:3) Have all instruments (clamps and shunt) ready an d available before the start. There are various shunts (Pruitt (balloon) Javid (clamps)) an d snugging devices (Rummel). (cid:142)(cid:3) Divide the platysma and incise the fascia. (cid:142)(cid:3) Expose and div ide the common facial vein and any anterior venous tributaries (facial vein is a useful mar ker of level of bifurcation). (cid:142)(cid:3) Enter the carotid sheath and carefully mobil ize the common carotid artery passing a sling around it, keeping manipulation of the bifurcation to a minimum to a void embolisation. If bradycardia ensues inject 1 \200\2232ml of 1% lignocaine into the tis sues between the internal and external carotid vessels. (cid:142)(cid:3) Mobilize the hypoglossal nerve and protect it with a sling. (cid:142)(cid: 3) Mobilize the internal carotid above the visible plaque and pass a sling. If there is a h igh bifurcation or access to the internal carotid is difficult, it can be improved by divis ion of the posterior belly of the digastric muscle. CAROTID ENDARTERECTOMY1 401 (B) (C) (A) ECA ECA ICA ICA STA STA CCA ICA CCA ECA (D) ICA (F) (E) ICA ECA ECA STA STA CCA CCA CCA Fig. 12.5 Carotid endarterectomy. CCA, common carotid artery; ECA, external carotid artery; ICA, internal carotid artery; STA, superior thyroid artery CHAPTER 12 Peripheral vascular surgery 402 (cid:142)(cid:3) Treat the external carotid and superior thyroid vessels similarly. (cid:14 2)(cid:3) Ask the anesthetist to give the patient 4000 \200\2235000IU heparin intrave- nously, wait a suitable time for circulation before applying the vascular clamps, cross-cla mping the internal carotid first to prevent debris entering it, followed by the common caro tid and external carotid. (cid:142)(cid:3) Make an incision in the common carotid and exten d it proximally to the palpable and visible limit of the diseased segment of the internal c arotid revealing healthy intima. (cid:142)(cid:3) Insert the shunt with great care (it is the authors \200\231 practice to r outinely shunt), beyond the diseased segment of the internal carotid and backbleed whilst releasing the internal carotid clamp and insert the backbleeding proximal end of the shunt into the c ommon carotid artery and secure it ensuring a haemostatic fit at both ends of the shunt. No w perform careful endarterectomy in the appropriate plane using a Watson-Cheyne dissector. Transect the atheromatous core proximally and distally with iris scissors before completing the endarterectomy by avulsion of the core from the external carotid origin. Separation of the upper end of the core may result in feathering of the intima with no need for securing tacking sutures. It may, however, also create a step in the intima. Secure this with 3 \200\2234 tacking sutures of 6/0 Prolene. Carry out meticulous removal of any fragments of intima from the endarterectomy site and close the endarterectomy with a patch angioplasty ( Dacron/Bovine pericardium/PTFE) with 6/0 Prolene. (cid:142)(cid:3) Before closing the anastomosis, remove the shunt, reapply the vascular cla mps and flush the anastomotic site with heparinised saline. Release the clamps on completio n of the anastomosis in the following order: external carotid, common carotid and internal carotid. (cid:142)(cid:3) Insert a suction drain and repair the carotid sheath and platysma with an absorbable suture, using staples or a subcuticular suture for the skin. Prophylaxis Give a single dose of antibiotic intravenously preoperatively. Postopera- tivel y give aspirin 75mg/day and/or clopidogrel 75mg/day. Complications (cid:142)(cid:3) Stroke (cid:142)(cid:3) Haematoma (cid:142)(cid:3) Hemorrhag e (cid:142)(cid:3) Cranial nerve Injury. Endovascular carotid stent This technique is presently experimental and largely performed b y or in conjunction with a vascular radiologist. Patient selection (cid:142)(cid:3) Symptomatic high grade stenosis (cid:142)(cid:3) Surgica l restenosis (cid:142)(cid:3) Hostile neck (burns/radiotherapy/high bifurcation) (cid:142)( cid:3) Possibly patients for CABG with concomitant carotid disease. CAROTID ENDARTERECTOMY1 403 Preparation Commence on clopidogrel 75mg/day prior to stent procedure. Procedure (cid:142)(cid:3) Prepare the groin as for arteriography and gain arterial access to the common femoral artery percutaneously via the groin. (cid:142)(cid:3) Administer 5000IU heparin via the arteriography sheath. Introduce a stiff guide wire (0.035) and advance it with care into the external carotid artery to allow place ment of a long sheath/catheter in the common carotid artery. Given the patient atropine and size the inter- nal carotid artery using a catheter sheath or externally placed coin for r eference. (cid:142)(cid:3) Pass a 0.014 wire across the stenotic segment in the internal carotid arte ry and pass a cerebral protection device along the wire and deployed to catch any debris. (cid:142)(cid:3) Pass a low profile balloon catheter of the appropriate size across the les ion with a 15 second inflation time, then exchange it along the wire for a self expanding s tent deployed to abolish the stenosis. (cid:142)(cid:3) Obtain post deployment angiograms and remove the cerebral protec- tion device and guide wires. CHAPTER 12 Peripheral vascular surgery 404 Excision of carotid body tumor Carotid body tumors are rare and may be extremely vascular. Their excision may rarely involve excision of the carotid bifurcation or sacrifice of the e xternal carotid artery. Handling of the tumor may result in significant haemodynamic upset and an experienced anesthesia is essen- tial. Dissection should proceed with great care. Preoperative preparation (cid:142)(cid:3) Accurate localization and diagnosis of the tumor by CT or MRI imaging. (cid:142)(cid:3) Vascular anesthetic pre-assessment. Position Supine with the head of the table slightly raised, the head supported on a ring an d extended to the opposite side away from the incision. A pad placed longitudinally between the shoulder blades. Incision Along the anterior border of the sternomastoid, from 2 \200\2233cm above its inser tion to two fingerbreadths below the angle of the jaw. Procedure (see Fig. 12.6) (cid:142)(cid:3) Expose the carotid bifurcation, preserve the gre ater auricular nerve. Dissect the internal jugular vein from the artery dividing the facial vein and anterior tri butaries and retract the muscle with a Travers retrac- tor. Dissect the internal jugular ve in from the artery carefully preserv- ing the vagus nerve in the groove between the artery and vein. (cid:142)(cid:3) Preserve the ansa cervicalis if possible and expose the common carotid pro ximally and the external and internal carotids distally passing slings around them. (cid:142)(cid:3) Identify and preserve the hypoglossal nerve which crosses the internal and external carotid vessels above the bifurcation. (cid:142)(cid:3) Begin with the external carotid side of the tumor and divide the plane bet ween the tumor and the vessel wall. Numerous tiny vessels from the tumor to the vessel wall often make this dissection bloody. Secure them with bipolar diathermy. As dissection proce eds proxi- mally, split the tumor along its midline. If the tumor completely surrounds the vessels divide it with diathermy to identify the plane, again on the external carotid side. It may be necessary to divide the external carotid to remove the tumor completely. (cid:142)(cid:3) Rarely when the tumor cannot be safely removed, as above, it may be necess ary to resect the carotid bifurcation and re-establish vascular continuity to the internal carotid by insertion of a vein/prosthetic graft (see Resection of aneurysmal internal carot id artery). EXCISION OF CAROTID BODY tumor1 405 (B) (A) Hypoglossal n. Tumor ICA ICA ECA ECA Int. jugular vein CCA IJV CCA (C) ECA ECA ICA (D) IJV ICA ECA CCA IJV (E) CCA ECA En-bloc with ECA Vein graft Shunt Resection carotid bifurcation Fig. 12.6 Excision of carotid body tumor. CCA, common carotid artery; ECA, external carotid artery; ICA, internal carotid artery; STA, superior thyroid artery CHAPTER 12 Peripheral vascular surgery 406 Aneurysmal internal carotid artery repair Aims (cid:142)(cid:3) To restore normal circulati on (cid:142)(cid:3) To prevent risk of rupture, embolus and/or thrombosis associated with aneurysmal disease of the vessel. Indications Established aneurysmal disease of the extracranial internal carotid artery in a patient fit for surgery. Preparation (cid:142)(cid:3) Vascular anesthetic preassessment. (cid:142)(cid:3) MRA or CT angiographic assessment of the extracranial vessels and the Circle of Willis. Position Supine with the head extended, supported on a ring and turned away from the side t o be operated upon with a pad placed between the shoulder blades. Incision Along the anterior border of the sternomastoid from two fingerbreadths below the a ngle of the jaw to just above the muscle insertion. Procedure (see Fig. 12.7) (cid:142)(cid:3) Expose the carotid vessels as in carotid endarte rectomy. Handle the aneurysm as little as possible to minimize the risk of dislodgement of any clot and subsequent embolisation. Control the vessels proximally and distally first, pa ssing slings around them. Either ligate the external carotid artery or suture closed from w ithin the opened aneurysm sac. (cid:142)(cid:3) Ask the anesthetist to give 4000 \200\2235000IU heparin intravenously and apply vascular clamps to the carotid vessels. Open the aneurysm longitudinally; the neck of the aneurysm is usually clearly defined. (cid:142)(cid:3) Insert a Javid shunt into the internal carotid and pass the shunt through an appropriate length of a synthetic graft (woven Dacron/PTFE), backbleed the internal caro tid through the shunt and insert the backbleeding shunt into the common carotid artery, app lying ring clamps and/or snuggers to keep it in place and secure haemostasis at either end of the shunt. (cid:142)(cid:3) Suture the graft end-to-end starting with the internal carotid and beginni ng the suture in the middle of the posterior wall, working around each side to the front wa ll. Complete a continuous suture line to the posterior wall of the common carotid artery le aving a small gap on the anterior wall incomplete. (cid:142)(cid:3) Clamp the common and internal carotid arteries and remove the shunt, flushing the graft with heparinised saline to remove clots and debris and complete t he anastomosis on the anterior wall of the common carotid. ANEURYSMAL INTERNAL CAROTID ARTERY REPAIR1 407 (cid:142)(cid:3) Release the clamps on the common carotid followed by the internal carotid securing haemostasis at the anastomotic lines as necessary. (cid:142)(cid:3) Plicate the op ened aneurysm sac around the synthetic graft using an absorbable suture, insert a suction drain and close the wound in layers with either staples or a subcuticular suture for the skin. (A) (B) ECA ECA ICA ICA ST CCA CCA CCA (D) (C) ICA ICA ECA Shunt ECA Dacron/ vein graft CCA Fig. 12.7 Aneurysmal internal carotid artery repair. CCA, common carotid artery; ECA, exter nal carotid artery; ICA, internal carotid artery; STA, superior thyroid artery CHAPTER 12 Peripheral vascular surgery 408 Sympathectomy Thoracic sympathectomy Aims (cid:142)(cid:3) To achieve permanent sympathetic blockade in the upper limb. (cid:142)(cid:3) No objective evidence for its use in pain syn dromes or Raynaud \200\231s disease (cid:142)(cid:3) Primary indication is hyperhidrosis (cid:142)(cid:3) Also used in facial f lushing/blushing(nerves of Kuntz) (cid:142)(cid:3) Less commonly \200\224upper limb Ischaem ia/post traumatic pain/rare cardiac arrhythmias (long QT syndrome) Options (cid:142)(cid:3) Endoscopic \200\224preferred option (cid:142)(cid:3) Open \200\224 transcervical/supraclavicular/transaxillary \200\224when endoscopic not feasible (pleural adhesions, previous thoracic surgery). Endoscopic (cid:142)(cid:3) 2nd and 3rd thoracic ganglia for supply to arteries and hands ( cid:142)(cid:3) 4th thoracic ganglion for eccrine axillary glands (cid:142)(cid:3) Possible to do bilateral. Take care to avoid azygos vein and tributaries on right and subclavian an d aortic arch on the left. Anesthetic General anesthesia with either a single or double lumen tube, the latter facilit ating collapse of ipsilateral lung to improve access to the chain. Position Supine with the arm(s) abducted to 90(cid:13), chest and axilla prepared and drape d. Procedure (see Fig. 12.8) (cid:142)(cid:3) Make a 10mm stab incision in the skin and subcut aneous tissues over the 4th intercostal interspace in the mid axillary line. Feel for the r ib and ask the anesthetist to deflate the appropriate lung if using a double lumen tube, in sert a Verres needle into the pleural cavity and instill 700cc of carbon dioxide. (cid:142)(cid:3) Insert a 10mm laparoscopic port via the midaxillary incision and introduce the video camera. (cid:142)(cid:3) Orient the anatomical structures. (cid:142)(cid:3) Now make a 5mm stab inc ision on the anterior chest wall over the 3rd intercostal interspace and insert a 23 gauge hypodermic needle under direct vision to act as a guide for the insertion of a 5mm laparosc opic port through which a diathermy hook is inserted. Using the hook and video telescope di splace the lung posteriorly to identify the thoracic sympathetic chain running below the pl eura over the necks of the ribs. (cid:142)(cid:3) Open the pleura over the 2nd rib (the subclavian artery courses over the t op of the 1st rib), elevate the chain and divide it using diathermy. Repeat the process ove r the 3rd and 4th ribs. SYMPATHECTOMY1 409 (A) 5mm port 3rd interspace midclavicular line 10mm port 4th interspace mid-axillary line (B) Subclavian art. Sympathetic chain 1st rib 2nd rib Lung 3rd rib Diathermy hook 4th rib Fig. 12.8 Endoscopic thoracic sympathectomy CHAPTER 12 Peripheral vascular surgery 410 (cid:142)(cid:3) To ensure obliteration of the nerves of Kuntz, if dealing with facial flus hing or blushing, apply diathermy to the periosteum of the dis- sected rib necks on either side of the divided chain. (cid:142)(cid:3) Verify haemostasis and evacuate the carbon dioxide asking the anaes- theti st to hand re-inflate the lung whilst re-expansion is confirmed on the video monitor. (cid:142)(cid:3) Remove the ports and close the wounds with absorbable sutures and steristrips to the skin Open supraclavicular approach Position Supine on the operating table under general anesthes ia, with feet down tilt and the head turned to the opposite side. Incision Make a short 10cm long incision above the medial one third of the clavicle. Procedure (cid:142)(cid:3) Deepen the incision and divide the clavicular head of sternomast oid. (cid:142)(cid:3) Identify the phrenic nerve running downwards from lateral to medial o n the surface of scalenus anterior and mobilize it passing a sling around it. Elevate the n erve and divide scalenus anterior to expose the subclavian artery which is retracted inferi orly. Palpate the first rib and expose Sibson \200\231s fascia. Divide the fascia and expos e the pleura which is pushed inferiorly and anteriorally to reveal the neck of the 1st rib and the stellate ganglion with the sympathetic chain palpable as a cord. Use good light and deep retractors to visualize the ganglion and the chain. Divide the stellate ganglion in i ts lower third to avoid a Horner \200\231s syn- drome, elevate the chain and dissect it as far inferiorly as is safe below the third ganglion. (cid:142)(cid:3) Ensure haemostasis and check for pneumothorax by asking the anaes- thetist to inflate the lungs before inserting a suction drain and closing the wound in layers with a subcuticular stitch for the skin Complications (cid:142)(cid:3) Horner \200\231s Syndrome (cid:142)(cid:3) Pneumothorax (cid :142)(cid:3) Neuralgia. Axillary transthoracic Avoid in patients with apical pleural adhesions. Better access to th e chain below the stellate ganglion than afforded by supraclavicular approach but first tho racic ganglion is not easily accessible. Position Lateral position with the arm supported to avoid brachial plexus traction. Incision Transverse incision in the axilla below the hair bearing zone in the line of the 3 rd rib and approximately 15cm long. SYMPATHECTOMY1 411 (A) (B) Brachial plexus Scalenus ant. (C) Divided scalenus ant. Brachial plexus Phrenic nerve Phrenic nerve Scalene fat pad (D) Sympathetic chain Brachial plexus Sibsons fascia divided Phrenic nerve Subclavian art. Stellate ganglion divided here (E) 1st rib 1st rib Scalenus ant. Subclavian art. Lung and pleura 2nd rib 3rd rib Fig. 12.9 Open supraclavicular cervical sympathectomy CHAPTER 12 Peripheral vascular surgery 412 Procedure (cid:142)(cid:3) Deepen incision through the fat of the axilla preserving the int ercosto- brachial nerve, identify and retract the long thoracic nerve (beware of injury to this if the wound is extended). (cid:142)(cid:3) Enter the thorax via the 2nd interspace or by excision of a portion of the 3rd rib inserting rib retractors to provide access. (cid:142)(cid:3) Displace the lung downwards and retract it to expose the sympathetic chain lying below the posterior pleura. (cid:142)(cid:3) Incise the pleura over the chain, elevate the chain and excise it to the desired level. (cid:142)(cid:3) Ensure haemostasis, insert a chest drain and allow the lung to re-inflate, approximate the ribs and close the periosteum and muscle with a Nylon suture an d the skin with a subcuticular absorbable suture. (cid:142)(cid:3) Perform a post operative chest X-ray to ensure no persistent pneumothorax and remove the chest drain at 24hrs. Lumbar sympathectomy (cid:142)(cid:3) Relatively minor role in the management of vascular d isease (cid:142)(cid:3) Maximal effects on blood flow in cutaneous arteriovenous anastomoses with small increase in tissue perfusion (cid:142)(cid:3) Results in alteration in extremity blood flow distribution and in pain impulse transmission Indications (cid:142)(cid:3) Causalgia \200\224if trial of LA blockade beneficial (cid:142) (cid:3) Ischaemic rest pain > ulcers \200\224ABPI >0.3/absent neuropathy/limited tissue loss (cid:142)(cid:3) Small shallow ulcers/single digit gangrene \200\224ABPI >0.3. Techniques ( cid:142)(cid:3) Phenol block/chemical sympathectomy (cid:142)(cid:3) Open surgical sympathe ctomy. Phenol block Useful in elderly/unfit patients and performed under image intensifier control . Position The patient lies on side with the side for injection uppermost. Procedure (cid:142)(cid:3) Prepare the area between the 12th rib and the iliac crest with a ntiseptic solution. Infiltrate two sites corresponding to the position of the 2nd and 3rd l umbar vertebrae with local anesthetic a few centimeters apart at the upper edge of quadratu s lumborum and insert a spinal needle via the skin bleb and direct towards the vertebral co lumn. (cid:142)(cid:3) When this is felt the needle is carefully marched forward tangentially and eased forward to penetrate the edge of the psoas sheath. Perform aspiration to ensure a blood vessel has not been penetrated and inject a few ml of dilute contrast medium slowly to ensure correct positioning of the needle. This is revealed by a satisfactory spread of c ontrast along the psoas sheath. SYMPATHECTOMY1 413 (A) (B) Aorta Vena cava Sympathetic chain Psoas (C) Peritoneum Lumbar vertebrae Sympathetic chain Psoas Fig. 12.10 Lumbar sympathectomy CHAPTER 12 Peripheral vascular surgery 414 (cid:142)(cid:3) If satisfactory spread is observed slowly inject 3 \200\2235ml of 6% pheno l in water into the space stopping after each milliliter for a minute or so, checking that the patient is comfortable. Repeat the process at the second site. Complications Neuralgia of upper thigh and groin. Surgical sympathectomy (see Fig 12.10) Position The anesthetized patient lies supine with a sandbag/padded rolls placed under the hip and thorax of the side to be operated on so that the interval between costal margin and iliac crest is opened and the table broken to 15(ci d:13). Incision Oblique/transverse incision from the edge of the rectus sheath to approxima tely the anterior axillary line, halfway between the anterior superior iliac spine and the 12th rib. Procedure (cid:142)(cid:3) Divide the musculofascial layers (external/internal ob lique/ transversalis) or split them in the line of their fibers. (cid:142)(cid:3) Develop the lateral plane between transversalis and the peritoneum with th e fingers and sweep the peritoneum towards the vertebral column. The ureter and gonadal ves sels are left attached to the posterior peritoneum. Identify the anterolateral edge of psoa s. (cid:142)(cid:3) Insert two deep retractors and feel for the sympathetic chain medial to ps oas, lying over the transverse processes in the groove between the muscle and the vertebral column (take care to avoid the more lateral genitofemoral nerve). (cid:142)(cid:3) On the left the chain lies adjacent to the aorta and on the right just beneath the edge of the vena cava (take care!) Pick up the chain with a nerve hook and remo ve at least 2 \200\2233 ganglia placing ligaclips on the rami communicantes and diminish an y bleeding with diathermy. (cid:142)(cid:3) Insert a suction drain and close the wound in layers with an absorbable suture to the muscle layers and subcuticular suture to the skin. This page intentionally left blank CHAPTER 12 Peripheral vascular surgery 416