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 Repair of abdominal aortic aneurysm Most abdominal aortic aneurysms are asymptomatic and le ss than 5% are suprarenal. Data from the UK small aneurysm trial suggests that at least in males surgical intervention is not required until the maximum trans- verse diameter of the aneurysm exceeds 5.5cm. Operative mortality for elective surgery is in the order of 3 \200 \2235% but that for ruptured aneurysms is in excess of 40%. Screening for aneurysm disease has been associated with a reduced mortality rate for rupture (MASS Trial) Preoperative pre paration (cid:142)(cid:3) Accurate imaging and diagnosis \200\224B mode ultrasound/CT scan/ MRI (cid:142)(cid:3) Preoperative blockade reduces left ventricular workload. Perioperative management (cid:142)(cid:3) Good intravenous access/intra-arterial pressure recording/urin ary catheter/central venous line or Swan Ganz (cid:142)(cid:3) Hematological status/biochemistry (cid:142)(cid:3) Cross match 4 \200\2236 units of blood for elective surgery and 10 units for rupture. Position Supine with the arms abducted to 90(cid:13) with a warming blanket appropri- ately applied. Approaches/incision Transperitoneal (cid:142)(cid:3) Midline xiphisternum to pubi s (cid:142)(cid:3) Transverse mid-abdominal. Retroperitoneal (cid:142)(cid:3) Left side usu ally (easier to mobilize the spleen) (cid:142)(cid:3) Hostile abdomen/stoma/horseshoe kidne y (cid:142)(cid:3) May be difficult to access right iliac. Endovascular (cid:142)(cid:3) Ac cess by exposure of the groin arteries. Transperitoneal (cid:142)(cid:3) Enter the peritone al cavity and perform a thorough laparotomy to exclude concomitant pathology. Displace the transverse colon superiorly, divide the liga ment of Treitz and displace the small bowel to the right between moist packs in a gut bag. ( \200\230Onion peel \200\231 the duodenum if an inflammatory aneurysm). (cid:142)(cid:3) Insert a fixed self-retaining retractor (Omnitract). Identify and retract/ divide the inferior mesenteric vein. Incise the posterior peritoneum from lower border of p ancreas to iliac arteries and identify the neck of the aneurysm (usually just below the lef t renal vein). (cid:142)(cid:3) Avoid incising the autonomic nerves (avoids sexual dysfunct ion in men) pass a sling around the left renal vein and lift it superiorly (take care \200\224bewa re of the tributaries to the lumbar veins). Dissect the neck of the aneurysm and the iliac arteries. This page intentionally left blank CHAPTER 12 Peripheral vascular surgery 418 (cid:142)(cid:3) Apply a supracoeliac clamp if aneurysm neck is juxtarenal. Heparinise the patient with 5000IU heparin intravenously and apply arterial clamps to the iliac arteri es and to the aorta. (cid:142)(cid:3) Open the aneurysm sac longitudinally away from the inferior mesenteric artery (IMA). Incise the proximal aorta transversely at the proposed anastomotic site. Remove the thrombus/ atheroma and oversew any backbleeding lumbar arteries with 3/0 Prolene. Control the IMA temporarily with a bulldog clamp if it is patent. There is often a distinct ring at the proximal neck. If the bifurcation is healthy it may be suitable for a tube graft, if not, use a bifurcated graft. (cid:142)(cid:3) Select a suitable graft (if a bifurcation graft ensure it is long enough f or the limbs to reach the groins) and suture it in position proximally end to end with 2/0 or 3/0 Prolene sutures taking good bites of the aortic wall. If the aortic wall is friable pledgelets of Dacron (from the redundant graft) can be incorporated in the anastomotic line . (cid:142)(cid:3) After completion of the anastomosis, clamp the graft and slowly release the proximal aortic clamp and check for suture line bleeding. Transfer the aortic c lamp to the graft below and close to the anasto- motic line and the flush graft with hepari nised saline. Now complete the lower anastomosis similarly (if a tube graft) or if a bifurc ation graft to either the iliac bifurcation (after opening iliac aneurysm) or to the juncti on of the common femoral arteries with the profunda and super- ficial femoral arteries (via retroperitoneal tunnels) after tying off the common iliac arteries. Complete the anastomos is to the iliac or femo- ral vessels with a 4/0 or 5/0 Prolene suture. Restore blood flow w ith slow release of the aortic clamps (warn the anesthetist in advance to avoid declamping shock). (cid:142)(cid:3) Next assess the adequacy of lower limb perfusion by visual inspection of t he feet/palpation of pulses. When adequacy of gut/limb perfusion and haemostasis has been s ecured plicate the aneurysm sac over the graft with an absorbable suture to prevent the for mation of an aortoduodenal fistula and repair the peritoneum with Vicryl. (cid:142)(cid:3) Close the abdomen in layers or with a mass suture using non- absorbable suture material. Retroperitoneal Position The left shoulder is elevated to 45(cid:13) with the pelvis flat. Incision Make an incision centered on the 11th/12th rib, beginning at the lateral edge of t he rectus sheath and curved laterally to the tip of the 12th rib. Procedure (cid:142)(cid:3 ) Divide the underlying abdominal muscles and expose the peritoneum. (cid:142)(cid:3) Devel op the retroperitoneal plane either anterior/posterior to the left kidney (anterior for most infrarenal aneurysms). For juxtarenal/ suprarenal aneurysms mobil ize the kidney anteriorly to allow an approach to the aorta behind the left renal artery. REPAIR OF ABDOMINAL AORTIC ANEURYSM1 419 (B) (A) Vena cava Vena cava (D) (C) Vena cava Vena cava (E) Fig. 12.11 Bifurcation graft CHAPTER 12 Peripheral vascular surgery 420 (cid:142)(cid:3) Divide the inferior mesenteric artery to allow more complete access. (cid: 142)(cid:3) If access to the right iliac artery is required extend the wound with division of the rectus muscle and/or make a separate right iliac fossa incision. (cid:142)(cid:3) Repair of the aneurysm and insert the graft as described above. Endovascular Preoperative assessment Same intervention criteria as for open repair (maximum diameter >5.5cm). (cid:142)(cid:3) Maximum transverse diameter >5.5cm (cid:142)(cid:3) Pro ximal neck diameter 16 \200\22330mm diameter(no thrombus/ plaque/calcification) (cid:142)(cid:3) Minimal iliac diameter 6 \200\2238mm (cid:142)(cid:3) Neck configuration n ot reversed cone and >15mm long (cid:142)(cid:3) Neck angulation <60(cid:13) (cid:142)(cid: 3) Evaluation of aneurysm by spiral CT scan, calibrated aortography (cid:142)(cid:3) Full a nesthetic preoperative assessment. Position Supine on an X-ray table/endovascular operating table under general/ epidural anesthesia and with a radio-opaque ruler placed below the ba ck to allow accurate assessment of deployment. Incisions Bilateral groin incisions either vertically or in the skin crease to expose and m obilize the femoral vessels (common femoral, profunda and super- ficial femoral) passing sl ings for control. Procedure ( \200\230TALENT \200\231 device) (cid:142)(cid:3) Exposed the groin vessels. Giv e 5000IU heparin intravenously and apply arterial clamps to the profunda and superficial femoral arteries bilaterally. Make bi lateral arterial punctures in the common femoral artery using an angiography needle and pas s a soft guide wire into the aorta via a 6F sheath placed in each common femoral artery. (cid:142)(cid:3) Insert a 5F pigtail catheter via the left common femoral into the supra- r enal aorta to allow peri-procedure imaging. Exchange the soft guide wire in the right femor al for a stiff Backup Meier wire and perform pre-deployment angiography to identify the ren al artery origins whose position is marked on the X-ray monitor screen. (cid:142)(cid:3) Insert the main part of the modular bifurcated device is inserted over the Backup Meier and carefully advanced into the suprarenal aorta having ensured correct align ment of the contralateral limb markers. Begin the deployment of the device slowly and caref ully to expose the suprarenal fixating bare stent and check the position of the renal arter ies again by angiography. (cid:142)(cid:3) Now slowly drag the stent caudally until the upper fabric markers lie just below the origins of the renal arteries and continue deployment opening the stent into the right iliac system and deploying the short contralateral limb. Carry out molding of the de ployed stent rings using the included balloon. REPAIR OF ABDOMINAL AORTIC ANEURYSM1 421 (cid:142)(cid:3) Now replace the left pigtail catheter with a stiff guide wire passed through the short limb of the stent graft (position checked by lateral views) and deploy th e second modular component of the stent graft system within the short limb with a satisfact ory overlap of the fabric markers. Mold the stent rings as before and iliac extensions if n ecessary. (cid:142)(cid:3) Carry out post implantation angiography to ensure no endoleaks. (cid:142)( cid:3) Repair the femoral artery insertion sites with 5/0 Prolene and close the wounds in layers. Postoperative follow-up Spiral CT scans and plain abdominal X-ray initially 3 monthly then annu- ally to check for integrity/displacement or stent fracture. CHAPTER 12 Peripheral vascular surgery 422 Embolectomy Aim to restore the circulation to the pre-occlusive state. It is often currentl y required in patients with advanced arteriosclerosis and underly- ing or medical comorbidi ty. It may be difficult to distinguish between embolus and thrombosis so preoperative angio graphy, although not always possible is the ideal and identifies the site, multiplicity and associ- ated vascular disease allowing planning of any necessary reconstruction. Embolecto my using a Fogarty catheter is not without its complications and injurious effects and care must be exercised in performing this procedure. Indications (cid:142)(cid:3) Loss of circulation due to embolus. (cid:142)(cid:3) Most are due to myocardial disease particularly atrial fibrillation and myocardial infarction but they may originate from in situ atheroma or thrombus (peripheral/ aortic aneurysm). Anesthesia Most embolectomies can be performed using local anesthesia with intravenous seda tion but GA may be occasionally required. Basic principles (cid:142)(cid:3) Expose an adequate length of artery to gain proximal and distal control of the vessel(s) and pass slings around them. (cid:142)(cid:3) Next administer 4000 \200\2235000IU heparin systemically and apply arteria l clamps. (cid:142)(cid:3) Open the artery through a longitudinal incision and check the artery lumen for visible embolic material. Check the balloon inflation/ deflation and introduce the uni nflated balloon catheter into the artery, advancing it with care as far as it will proceed without resistance. Gentle retrieval of the inflated balloon is then performed partially de flating the balloon on resistance to adjust for caliber (plaque or narrowing). Remove the r etrieved thrombus/embolus and flush the vessels with heparinised saline via a Tibbs cannula before closing the arteriotomy with either a continuous Prolene suture or patch angioplast y if there is a risk of narrowing. (cid:142)(cid:3) Use a single lumen/irrigating Fogarty catheter with a compliant balloon. N ormally a size 3F will be suitable for the axillary/brachial artery, 4F for the common/supe rficial femoral artery and 5F for the aortic bifurcation. Brachial embolectomy Position Supine with the affected arm extended on a board and the hand in a sterile/translucent bag. Incision Lazy S incision crossing the elbow joint to give access to the brachial artery and its trifurcation. This page intentionally left blank CHAPTER 12 Peripheral vascular surgery 424 Procedure (see Fig. 12.12) (cid:142)(cid:3) Deepen the incision to expose the artery dividi ng the biceps tendon if necessary. The median nerve may be in the vicinity so care should b e exercised as it sometimes lies superficial to the artery. (cid:142)(cid:3) Mobilize the artery and the trifurcation vessels passing slings around them for control. (cid:142)(cid:3) Make a vertical arteriotomy just above the trifurcation and proceed as abo ve passing a 3F Fogarty catheter down each of the vessels distally, ensuring that there is backbleeding by releasing the tension on the slings. Ensure there is also forceful forward flow by releasing the proximal clamp. If insufficient flow, pass the catheter proximally to retrieve clot and restore flow. (cid:142)(cid:3) Flush the vessels, reapply the clamps and close the arteriotomy with 6/0 Prolene. Femoral embolectomy Position Supine with both groins prepared and draped in case a crossove r graft is required and with the foot in a sterile translucent bag. Incision Vertical groin incision over the femoral artery. Procedure (cid:142)(cid:3) Expose and mobilize the groin vessels, passing slings around the m for control. Give systemic heparin and clamp the arteries. (cid:142)(cid:3) Fashion a vertical arteriotomy and remove obvious clot with forceps. Pass a 3F/4F Fogarty catheter distally in the SFA and profunda, as de- scribed above, to retriev e propagated clot and ensure good backflow on withdrawal of the inflated balloon, making se veral passes to ensure that all clot is removed. (You may require two catheters, the first will likely enter the tibioperoneal trunk and the second will be guided into the anterior t ibial.) (cid:142)(cid:3) Flush the vessels with heparinised saline and reapply the clamps. Pass a 4 F/5F Fogarty catheter into the aorta until forceful downflow is re-established, flushing th e vessel with heparinised saline. (cid:142)(cid:3) Before closure of the arteriotomy perform on table angiography to assess the distal vessels. If there is significant residual clot, instill 5mg of rTPA (Ante plase) and wait for 10min before reassessing and closing the arteriotomy with 5/0 or 6/0 Pr olene. EMBOLECTOMY1 425 (A) Hand in sterile bag Incision (B) Biceps tendon Median nerve Basilic vein Radial art. Ulnar art. 3Fg Fogarty catheter (C) (D) (E) Fig. 12.12 Brachial embolectomy CHAPTER 12 Peripheral vascular surgery 426 In the case of a Saddle embolus, fashion bilateral groin incisions and expose and control t he femoral vessels as above. Make an arteriotomy in the common femoral artery just above th e bifurcation and proceed as above to remove the propagated clot from the distal vessels an d proxi- mal inflow. Popliteal embolectomy Position Supine as for exposure of the infragenicular popliteal vesse ls. Procedure (cid:142)(cid:3) Expose and mobilize the popliteal artery and tibioperoneal trunk , controlling the vessels with slings. (cid:142)(cid:3) Make an arteriotomy in the popliteal artery opposite the origin of the ant erior tibial and proceed as described above using a 3F Fogarty catheter for the distal vess els and a 3F/4F catheter proximally. EMBOLECTOMY1 427 (B) (A) a Femoral b Popliteal (C) Fig. 12.13 Infrainguinal embolectomy CHAPTER 12 Peripheral vascular surgery 428 Aortoiliac occlusive disease The therapeutic options for treatment of aortoiliac disease in clude: Catheter based endovascular treatment by angioplasty with/ without intravascular ste nt placement has largely replaced operative treatment in localized iliac disease but patien t selection is of paramount importance and it is not appropriate in diffuse iliac disease. Extra-anatomic reconstruction may be the treatment of choice in high risk unfit patients wi th more limited disease not suitable for angio- plasty/stent. Aortobifemoral graft is the m ost durable and efficacious treatment and is indicated in patients with total infrarenal ao rtic occlusion, those with severe bifurcation disease or diffuse aortoiliac disease with cr itical ischaemia. The bifurcated graft can be sutured to the aorta either by an end-to-side technique or by an end-to-end suture after the aorta has been completely divided and the a ortic bifurcation oversewn. The pro- cedure may also be utilized in the treatment of comple x aortoiliac aneu- rysmal disease. End-to-end (cid:142)(cid:3) Better haemodynamically/less turbulence (cid:142)(cid:3) Lower false aneurysm rate (cid:142)(cid:3) Easier to cover with natural tissue in the aortic bed. End-to-side (cid:142)(cid:3) Avoids sacrifice of patent inferior mesenteric artery (cid:14 2)(cid:3) Appropriate in retention of aberrant renal artery. Incision Vertical midline/tran sverse centered on umbilicus or oblique. Bilateral longitudinal groin incisions centered on the mid-inguinal point. Procedure (cid:142)(cid:3) Expose the femoral vessels first, passing slings around them for control. Next expose the aorta, making a transverse incision 2cm above the umbilicus and e xtending to 2cm beyond the lateral border of the rec- tus sheath on both sides. (cid:142)(cid:3) Displace the omentum and transverse colon superiorly. Incise the posterior peritoneum on the left margin of the duodenum and displace it and the small bowel wrapped in a moist pack to the right in a gut bag. Expose the aorta, crossed by the left r enal vein and then expose the bifurcation and the iliac arteries. (cid:142)(cid:3) Mobilize the aorta and pass a tape/sling around it dividing lumbar vessels as necessary. Give the patient 5000IU heparin and cross-clamp the aorta and iliac v essels as necessary. If there is total occlusion of the aorta, transect the aorta and oversew the bifurcation wi th 3/0 Prolene. Now finger compress the aorta at the level of the renal vein to remove the clot and then apply the aortic clamp, flushing the stump with heparinised saline. AORTOILIAC OCCLUSIVE DISEASE1 429 (A) (B) Alternative iliac closure (D) (C) Fig. 12.14 Aortobifemoral graft CHAPTER 12 Peripheral vascular surgery 430 (cid:142)(cid:3) Select a Dacron bifurcation graft of an appropriate size and remove all bu t 2 \200\2233cm of the trunk (otherwise the legs may kink due to the sharp angle). Affect a n end-to-end anastomosis between the divided aorta and graft using continuous 3/0 Prolene u sing the parachute technique or beginning in the middle of the posterior wall. (cid:142)(cid:3) Apply a vascular clamp to the graft close to the anastomotic line and test the top, releasing the aortic clamp slowly and oversewing any obvious leak to ensure the j oin is watertight. (cid:142)(cid:3) Fashion retroperitoneal tunnels to the groins by finger dissection, follow ing the iliac artery to the common femoral in the groin and taking care not to tear the sma ll veins just above the inguinal ligament. (cid:142)(cid:3) Bring the limbs of the graft to the groins ensuring maintenance of the orientation of the limbs. (cid:142)(cid:3) Apply vascular clamps to the common femoral, superficial femoral and deep femoral arteries. Make a longitudinal arteriotomy in the common femoral artery just above t he bifurcation. Now apply gentle traction to the limb of the graft to draw out the crimping and trim the graft obliquely in order to affect and end-to-side anastomosis to the common femoral artery with continuous 5/0 Prolene. Having completed the first limb, vent the graft through the non-attached limb and flush the limb with heparinised saline before completing the 2nd limb anastomosis as for the contralateral side. Check there is adequate lower limb perfusion by visible inspection of the feet. For an end-to-side anastomosis of prosthetic graft it may be possible to gain control of th e aorta by application of a Satinsky clamp and a bulldog clamp to the inferior mesenteric a rtery, otherwise proceed as above. Make a longitudinal incision in the aorta, select a suit able bifurcated graft and trim the trunk as above cutting the graft obliquely to fashion a \200\230cobra head \200\231 and anastomose it to the aorta with a continuous 3/0 Prolene d ouble-ended vascular stitch, starting at the heel. When the suture line is complete, clamp the prosthesis close to the suture line and slowly release the aortic clamps. Fashion the r etroperitoneal tunnels and com- plete the femoral anastomoses as described above. Suture th e perito- neum over the graft with an absorbable suture and close the abdominal wound in la yers and the skin with a subcuticular suture or staples. This page intentionally left blank CHAPTER 12 Peripheral vascular surgery 432 Extra-anatomic bypass In these bypass procedures the prostheses pass through an anatomic pa thway significantly different from that of the native vessels they bypass and include: (cid :142)(cid:3) Axillofemoral \200\224unifemoral/bifemoral (cid:142)(cid:3) Femorofemoral (cid :142)(cid:3) Carotid-subclavian bypass (cid:142)(cid:3) Obturator bypass. Axillobifemoral graft (5 year patency 30 \200\22385%) Indications This is an appropriate pr ocedure in patients with aortoiliac disease and reasonable distal run off who are unfit for major aortic surgery. It may also be an option where direct abdominal reconstruction is pr ohibited by risk or a hostile abdomen, in patients with severe cardiac disease or morbid ob esity. In addition it is a mechanism of revascularisation of the limbs when an infected aor tic graft requires removal. Incisions Bilateral groin as for exposure of the femoral vessels and subclavian incision ce ntered on mid-clavicle approximately 10cm long. Position The donor arm abducted and supported on a board. Procedure (see Fig. 12.15) The procedure may be carried out under light general anesthesia or local anesthesia. (cid:142)(cid:3) Prepare the chest and lower abdomen and both groins. Expose the axillary artery via a subclavian incision as above by splitting the fibers of pectoralis ma jor and exposing the deltopectoral fascia. A self-retaining Travers retractor is inserted, the axillary artery identified below the deltopectoral fascia lying below the vein and brac hial plexus. (Exposure of the artery may be enhanced by dividing pectoralis minor). Divide the acromioclavicular branches and mobilize a 5 \200\2236cm segment of artery controlling i t with slings. The groin dissections are as for the exposure of the common, superficial and deep femoral a rteries. (cid:142)(cid:3) Make a small transverse incision over the 6 \200\2237th interspac e in the ante- rior axillary line to facilitate passage of the graft from the axilla to the groins. (cid:142)(cid:3) Give the patient 5000IU heparin intravenously and clamp the axillary artery. (cid:142)(cid:3) Select a suitable Dacron graft (approximately twice the diameter of the re cipient vessel \200\224usually 8mm). Tunnel the graft subcutaneously to the groins. EXTRA-ANATOMIC BYPASS1 433 (A) (B) (C) CFA (D) Brachial plexus CFV Ax. art LSV Ax. vein PFA SFA Proximal anastamosis CFA CFA (F) (E) CFV CFV LSV Dacron graft LSV SFA PFA SFA PFA Fig. 12.15 Axillobifemoral graft CHAPTER 12 Peripheral vascular surgery 434 (cid:142)(cid:3) Fashion a longitudinal arteriotomy and cut the graft obliquely and anastom osed end-to-side to the axillary artery using a continuous 5/0 Prolene suture beginning at one corner of the back wall and progressing continuously to the front. When the anastomosis is com- plete, clamp the graft just proximal to the suture line and release the clamps to restore blood flow to the arm. (cid:142)(cid:3) Next apply clamps to the common, superficial and deep femoral arteries, now apply gentle traction to the graft which is tailored and the limbs anastomose d to the common femoral artery on either side using an end-to-side technique with continuou s 5/0 Prolene, the cross limb of the graft being tunneled subcutaneously suprapubically. (cid:142)(cid:3) Having completed the anastomoses release the clamps ensure haemo- stasis a nd close the wounds in layers with a subcuticular suture or staples to the skin. Femorofemoral graft (5 year patency 60 \200\22380%) Indications (cid:142)(cid:3) Unilateral iliac occlusive disease not amenable to stenting. (cid:142)(cid:3) Patients with adequate circulation in one leg with patent iliofemoral vessels on the donor limb. The operation can be done under local anesthesia in unfit patients. It may be used as a lim b salvage procedure in patients with a patent profunda femoris artery on the symptomatic si de with rest pain but in the absence of gangrene. Exposure Expose the groin vessels bilaterally through vertical incisions. Procedure (see Fig. 12.16) (cid:142)(cid:3) Using finger dissection or a tunneling instrume nt fashion a subcutane- ous tunnel suprapubically between the two groin incisions and pass an 8mm Dacron graft through the tunnel from one side to the other (Fig. 12.16A). Alternativ ely, the graft can be taken from the common iliac to femoral artery (Fig 12.16B). (cid:142)(cid:3) Give the patient 5000IU heparin and apply vascular clamps to the common femoral artery and its branches on the donor side. (cid:142)(cid:3) Make a longitudinal incision in the common femoral artery and carry out an end-to-side anastomosis with a continuous 5/0 Prolene suture (Fig. 12.16C and D). (cid:142)(cid:3) Apply a vascular clamp to the graft adjacent to the completed anasto- mosi s and release the femoral clamps to restore circulation to the donor limb. (cid:142)(cid:3) On the ischaemic side make a longitudinal incision in the common femoral artery extending into the origin and first part of the profunda femoris. (cid:142)(cid:3) Tailor the graft obliquely applying gentle traction to reduce the crimp- i ng and fashion an end-to-side anastomosis with continuous 5/0 or 6/0 Prolene (Fig. 12.16E). (cid:142)(cid:3) Release the clamps and ensure haemostasis before closing the wounds in layers. EXTRA-ANATOMIC BYPASS1 435 (A) (B) Dacron graft tunneled via Cave of Retzius Iliofemoral graft (D) (C) (E) CFA CFA PFA PFA SFA SFA Fig. 12.16 Iliofemoral and femorofemoral graft CHAPTER 12 Peripheral vascular surgery 436 Iliofemoral/unilateral aortofemoral/iliopopliteal Indications Unilateral iliac occlusive di sease, not suitable for angioplasty or stent Incision In flank gently curved incision from costal margin to lateral edge of rectus sheat h and 2 \200\2233cm above the inguinal ligament. Distally vertical incision in the groin or lower thigh. Procedure (cid:142)(cid:3) Divide the external oblique in the line of its fibers, cut the i nternal oblique and transversalis in the line of the incision and using finger dissection o pen up the retroperitoneal space, displacing the peritoneum medially. (cid:142)(cid:3) Identify the aortic bifurcation, common and external iliac vessels and control them with slings. Insert a self retaining retractor. (cid:142)(cid:3) Select an appropriate graft (8mm Dacron/PTFE). Give the patient 5000IU heparin, clamp the appropriate vessels proximally and distally and make a longitudin al arteriotomy (aorta/iliac). (cid:142)(cid:3) Trim the graft obliquely and fashion an end-to-side anastomosis with continuous 4/0 or 5/0 Prolene. Clamp the graft just distal to the suture line and release t he vessel clamps. (cid:142)(cid:3) Tunnel the graft to the groin or popliteal incision, clamp the vessels pro ximally and distally and fashion an end-to-side anastomosis to the arteriotomy with continu ous Prolene. Close the wounds in layers. Carotid to subclavian bypass Indications (cid:142)(cid:3) Subclavian steal syndrome (cid:14 2)(cid:3) Occlusive disease of the proximal subclavian (cid:142)(cid:3) It may be a preoper ative requirement in endovascular stenting of thoracic aortic dissection or thoracic aortic aneurysm if stent placement is required to cover the orifice of the subclavian. Position Supine with the head turned to the opposite side and a pad under the shoulders. Incision 6 \200\2238 cm incision parallel to and 1 \200\2232cm above the medial third of th e clavicle. Procedure (see Fig. 12.17) (cid:142)(cid:3) Make a supraclavicular incision 2cm above the m edial end of the clavi- cle extending from the clavicular head of the sternomastoid. Divide the platysma and clavic ular head of the sternomastoid and dissect through the fascia and the scalene fat pad (take care to avoid the thoracic duct on the left). (cid:142)(cid:3) Identify the phrenic nerve on the scalenus anterior and preserve it. Divid e the scalenus anterior and locate the subclavian with the thyrocervical trunk and free it. The brachial plexus lies laterally in the wound. EXTRA-ANATOMIC BYPASS1 437 (A) Subclavian art. CCA (B) CCA Subclavian art. Fig. 12.17 Carotid-subclavian bypass CHAPTER 12 Peripheral vascular surgery 438 (cid:142)(cid:3) Expose the carotid artery in the medial aspect of the incision by retrac- tion of the sternal head of sternomastoid. Dissect anterior to the internal jugular vein, o pen the carotid sheath and mobilize the common carotid artery passing slings to control the vessel. (cid:142)(cid:3) Heparinise the patient with 5000IU heparin and apply clamps to the subclavian and then the carotid. (cid:142)(cid:3) Select a suitable Dacron graft and fashion the carotid anastomosis end-to- side first at right angles to the carotid. The graft is brought either anterior or posterio r to the jugular vein and clamped adjacent to the anastomosis the carotid clamps being remo ved to restore cerebral circulation. (cid:142)(cid:3) Now tailor the graft to length and cut it obliquely to match the arteri- o tomy in the subclavian artery and fashion an end-to-side anastomosis to the artery. (cid:142)(cid:3) Secure haemostasis and close the wound in layers. Obturator bypass Indications (cid:142)(cid:3) Graft sepsis localized to the groin (cid:142) (cid:3) Crush injury to the groin (cid:142)(cid:3) Infected femoral aneurysms in IV drug ab user. Position Supine with the entire leg prepared to allow abduction/lateral rotation. The groin wound is covered with an adhesive drape and the skin of the thigh is prepared. Procedure (cid:142)(cid:3) Expose the iliac vessels by a retroperitoneal approach. If there is no infection in the patent graft it may be used as the donor site (unlikely), otherwise use th e common iliac or aorta as a donor site. (cid:142)(cid:3) Locate the obturator foramen just posterior to the superior pubic ramus by following the obturator nerve along the pelvic brim. (cid:142)(cid:3) Reflect the peritone um from the external iliac towards the pubic ramus. Incise the obturator membrane anteriorally and medially to avoid the nerve and vesse ls. (cid:142)(cid:3) Expose the above knee popliteal artery via a vertical skin incision dis- p lace the sartorius posteriorly and mobilize the artery with slings. (cid:142)(cid:3) Tunnel a suitable graft to the supragenicular incision via the obturator foramen. Give the patien t 5000IU heparin and clamp the iliac vessel. (cid:142)(cid:3) Make a longitudinal arterioto my, cut the graft obliquely and fashion an end to side anastomosis with continuous 5/0 Prolene. When the anastomosis is complete clamp the graft adjacent to the suture line and release the iliac or aortic clamps ensuring the join is watertight. Fashion a similar anastomosis to the popliteal artery above the knee. (cid:142)(cid:3) Close the wounds in layers. This page intentionally left blank CHAPTER 12 Peripheral vascular surgery 440 Infrainguinal bypass Aims To restore the circulation to the lower limb affected by occlusiv e vascu- lar disease. Indications (cid:142)(cid:3) Crippling intermittent claudication \200\224the majority of cl audicants are managed by interventional radiological procedures or conservatively