Chapter 56 - Lower extremity arterial exposure Flashcards
vein that crosses over the proximal DFA
Lateral femoral circumflex
femoral nerve in relation to femoral artery
lateral and posterior
Lateral/distal approach to the DFA
1) starting 6-7 cm distal to the femoral pulse
2) parallel to sartorius (medial or lateral side)
3) dissect lateral to SFA and adjacent nerves
4) dissect between the vastus medialis and adductor longus
5) open raphe/fascia encountered
6) expose DFV and find artery deep to this
Nerves inside the Hunter canal
1) sensory saphenous nerve
2) motor nerve to vastus medialis muscle
Exposure of mid/distal SFA
1) knee flex 30 degrees
2) longitudinal incision parallel to anterior border of sartorius
3) avoid muscle blood supply from inferomedial edge
4) incision down to fascia lata
5) incise to expose sartorius
6) reflect muscle posteriorly to reveal Hunter canal roof
7) open fascia to expose SFA/FV
Medial exposure of proximal popliteal
1) leg rotated on bump at knee
2) distal third of medial thigh along anterior sartorius at lower edge of vastus medialis
2) fascia lata incised
3) sartorius retracted posterior
4) deep fascia entered inferior to vastus medialis
5) spare branch of the saphenous nerve
6) dissect fat pad close to the femur
Popliteal artery in relation to the vein
Anterior and medial
Finding the proximal popliteal artery using muscle landmark
Palpate adductor magnus tendon
artery pierces the tendon to enter popliteal space
Lateral exposure of proximal popliteal
Internally rotate leg and flex knee
1) incision in distal third lateral thigh
2) between iliotibial tract and bicep femoris
3) fascia lata incised posterior to where iliotibial tract joins lateral intramuscular septum
4) enter popliteal space between short head of biceps femoris and lateral femoral condyle
5) palpate neurovascular bundle in fat pad
6) do not injury common peroneal nerve
Posterior approach to mid popliteal
1) prone
2) foota nd ankle on pad to slightly flex knee
3) S-shaped incision from medial to lateral
4) small saphenous identified
5) deep fascia entered
6) avoid sural nerve
7) tibial nerve identified
8) identify neurovascular bundle
9) protect common peroneal nerve along the biceps femoris
10) retract apart two heads of gastrocnemius muscles to expose distal popliteal
Medial approach to mid popliteal requires division of these
1) tendinous attachments of medial head of gastrocnemius
2) division of sartorius tendon
reattach these
Medial exposure to distal popliteal
1) knee flexed
2) one finger inferior to medial border of tibia start incision
3) crural fascia entered to get into popliteal space
4) semimembranosus tendon divided
5) medial head of gastrocnemius retracted posteriorly to reveal neurovascular bundle
6) dissect out artery
Lateral exposure to distal popliteal
1) supine with leg internally rotated and knee flexed
2) longitudinal incision over head of fibula and extend distally
3) common peroneal nerve identified posterior to tendon of biceps femoris
4) divide tendon to reach fibula
5) detach attachments to the fibular head
6) remove proximal third of figula
7) identify popliteal artery
AT exposure proximal and middle 1/3
1) vertical incision on anterolateral calf centered over planned anastomosis
2) palpate cleft between tibialis anterior and extensor digitorum longus on lateral calf with foot and ankle relaxed
3) incision over cleft 2-3 cm distal to figular head
4) avoid injury to peroneal nerve
5) blunt dissect to separate muscle bellies of tibialis anterior and extensor digitorum longus
6) Identify AT artery and vein in the cleft of the interosseous membrane
7) vessels line just on top of the interosseous membrane
Distal AT exposure
separate tendons of extensor hallucis longus and extensor digitorum longus
Options to tunnel an AT bypass
1) laterally subcutaneously through thigh then passing knee between the midpoint of the lateral femoral condyle and anterior to head of fibula
2) through interosseus membrane
3) through anterior shin/tibia
TPT exposure
1) below knee pop exposure
2) divide soleus 1 finger posteror to tibial attachment
3) mobilize TPT vein first
4) peroneal artery is more deep and turns lateral
Mid PT exposure
1) 1-2 finger posterior to edge of tibia or via GSV harvest
2) enter deep fascia and take soleus off tibia
3) PT vein superior to artery, isolate
Distal PT exposure
1) incision posterior to tibia and anterior to Achilles tendon
2) encounter artery and vein
Two exposures to the mid peroneal pros and cons
Anterior to PT - more veins
Posterior to PT - peroneal nerve encountered
Lateral approach to the mid distal peroneal
Lateral incision along fibula
take out fibula
incise fascia
Course of the AT artery at the ankle
1) lateral border of extensor hallucis longus
2) pass beneath inferior extensor retinaculum –> dorsalis pedis
3) runs parallel and immediately lateral to extensor hallucis longus tendon
4) runs between first and second metatarsal
5) gives deep plantar branch between heads of first itnerosseous muscle
6) connects with lateral plantar branch of PT
Course of PT artery at ankle
1) found between flexor digitorum longus and flexor hallucis longus
2) enters foot after coursing beneath flexor retinaculum
3) travels with tibial nerve
4) divides into medial and lateral plantar arteries
Exposure of DP
1) foot in relaxed position
2) longitudinal incision over DP just distal to extensor retinaculum
3) parallel and immediately lateral to extensor hallucis longus tendon
4) Dorsal branch of peroneal nerve (can be divided)
5) incision of deep fascia to identify artery
6) preserve division into lateral and medial tarsal arteries
7) preserve all branches
Exposure of inframalleolar PT and plantar artery
1) flex knee and elevate foot
2) Curvilinear skin incision between medial malleolus and calcaneus
3) deepen tissue down to flexor retinaculum
4) divide fat pad and deep fascia
5) identify artery between flexor digitorum longus superiorly and flexor hallucis inferiorly
6) abductor hallucis can be divided to expose lateral plantar artery
Exposure of obturator foramen
1) retroperitoneal exposure
2) dissection medial to EIV and posterior to pubic ramus
3) dissect obturator internus muscle
4) identify obturator membrane
5) tunnel through anterior medial portion of membrane
Tunnelling obturator bypass
Between adductor longus and brevis anteriorly and adductor magnus posteriorly
Obturatory artery and nerve in relation tot he obturator membrane
Neurovascular in posterior-lateral position
Tunnel via anterior-medial
Course of the GSV
1) medial aspect of dorsal pedal venous arch
2) anterior to medial malleolus
3) cross tibia at junction of distal and middle third of calf
4) posteriormedial to femoral condyle at knee
5) medial ascension in thigh parallel to medial edge of sartorius
6) joins common femoral vein 4cm below inguinal ligament
GSV lies close to this nerve
Saphenous nerve
anterior to GSV in calf
Patency and infection with skip incisions vs continuous incision
VQI showed no difference
exposure of SSV
vertical incision posterior to lateral malleolus after ultrasound mapping
percentage of SSV that ascends into thigh without joining popliteal
25%
Deep vein harvest steps
1) bump under knee with external hip rotation and flexed knee
2) longitudinal incision in thigh along border of sartorius
3) sartorius reflected laterally
4) incise fascia overlying abductors to expose SFA adn FV
5) preserve deep femoral vein; don’t leave stump
