ORAL BOARDS Flashcards
CEA Indications
asymptomatic patients with carotid stenosis of more than 60%, and (2) symptomatic patients with a history of recent transient ischemic attack (TIA) or amaurosis fugax and ipsilateral carotid stenosis of more than 50%.
CEA Pre-op
*The use of aspirin (81-325 mg/day) or clopidogrel (75 mg/day)
*statins
*Perioperative imaging may consist of a duplex scan alone, provided that the quality control aspects of the noninvasive vascular laboratory have been verified and the surgeon can evaluate both the technical adequacy and the original data of the study. Additional imaging may consist of magnetic resonance angiography, computed tomography (CT) angiography, or conventional catheter-based angiography.
*Evaluation of cardiac risk is recommended by clinical profiling or in select patients through use of noninvasive stress testing.
*Evaluation of vocal cord function should be performed in patients with a history of prior CEA.
*Prophylactic antibiotics are advisable.
*Nasotracheal intubation and mandibular subluxation should be considered for exposure of the distal internal carotid artery (ICA).
*Intraoperative arterial line monitoring of blood pressure is recommended.
*Intraoperative cerebral monitoring may be used to indicate a need for a carotid shunt.
CEA Risks
Stroke
*The performance of a technically perfect operation is the most important variable in stroke prevention.
*Perioperative antiplatelet therapy is an evidence-based adjunct to diminish risk of stroke.
*Cranial nerve (CN) injury
*Hematoma
*Restenosis
*Recurrence of stenosis is more common in women and small arteries.
*Patch angioplasty is an evidence-based adjunct to diminish risk of restenosis.
CEA Technique
-The patient is positioned at the edge of the table of the affected side.
-The neck is extended, and the head is turned to opposite the side of the intended incision and placed upon a soft rubber ring
-Elevation of the shoulders with a shoulder roll to enhance neck extension
- Ultrasound is used to mark the location of the bifurcation
-The upper chest, lower face, and lower ear are prepped and draped.
- A timeout is performed
- An incision paralleling the anterior border of the SCM muscle is made and extended just inferior to the lobe of the ear at its distal end. This posterior displacement of the incision, one fingerbreadth below the angle of the jaw
-The incision is deepened through the platysma muscle, and the investing layer of the deep cervical fascia is opened on the anterior border of the SCM muscle
-The anterior border of the SCM muscle is mobilized, and the muscle is separated from the underlying vascular sheath by a sharp dissection on its medial border. The spinal accessory nerve, which may cross from beneath the SCM at the superior aspect of the wound, is at risk of injury if the SCM is subjected to excessive traction.
-The SCM muscle is retracted posteriorly, the carotid sheath is identified; The internal jugular vein is dissected along its medial border in the central part of the field and retracted posteriorly with the SCM muscle. This maneuver requires division of the common facial vein. The common facial vein is divided, as well as other medially coursing branches, and the internal jugular vein is mobilized laterally. The ansa hypoglossi lies over the carotid artery and can be divided with impunity.
- The common carotid artery is isolated using sharp dissection before manipulation of the atherosclerotic bifurcation. The vagus nerve should be identified and protected. Once the common carotid artery is freed from the surrounding tissue, it is encircled with tape away from the bifurcation area.
-The ECA is isolated just above the bifurcation, which is never grasped, and encircled with tape. The superior thyroid artery requires isolation when it branches directly from the common carotid artery.
- The ICA is isolated next. The hypoglossal nerve trunk crosses the ICA at a variable distance from the bifurcation and often courses medial enough such that the ICA can be thoroughly exposed without having to manipulate the nerve. However, mobilization of the hypoglossal nerve from lateral to medial is sometimes required, necessitating division of the occipital artery at the lateral border of the field. The ICA should be controlled 1 cm beyond the visible extent of atheromatous disease and encircled with tape.
Heparin (75-100 units/kg) is administered intravenously. The ICA is clamped with a bulldog clamp where it is visibly normal, followed by clamping of the common carotid artery and the ECA using angled vascular clamps. An arteriotomy is made on the anterolateral surface on the common carotid artery and extended to the ICA beyond the atheromatous plaque with Potts scissors.
A shunt is advanced into the ICA, and free retrograde flow is confirmed The shunt is then temporally occluded to prevent continued blood loss, and the proximal end is placed into the lumen of the common carotid artery. The shunt should be placed under direct vision after aspiration of blood in order to minimize the risk of inadvertent embolization of debris from the operative field through the lumen of the shunt. The angled vascular clamp is removed, the shunt advanced into the common carotid artery, and tapes with rubber tourniquets are made snug around the shunt. The average size of a shunt that fits into the distal ICA is 10 Fr (2.5-mm lumen). An 8- or 12-Fr shunt can be used for smaller or larger vessels, respectively. Flow through the shunt should be assessed after placement with a Doppler flow probe.
- The atheromatous plaque is separated from the carotid artery by dissection in the layer between media and adventitia, revealing the distinct pinkish color of the limiting adventitia. A Freer or Penfield elevator is the most useful instrument. Optical magnification (×2.5-×3.5) provides accurate visualization. Forceps are used to retract the vessel wall as the plaque is pushed away. The dissection is started in the common carotid artery. The plaque is completely divided just proximal to the lowest extent to the arteriotomy. Scissors are used to cut the plaque at the point of separation, leaving a smooth proximal edge in the common carotid artery. The plaque is then separated from the ECA by an eversion technique. Separation of the plaque from the ICA is the most critical maneuver. As the end of the plaque is approached, a transition is made to a more superficial layer in the intima media so that the plaque comes away and leaves a firm attachment of the intima layer. Microscissors may be used to cut into the edge of the most distal end of plaque to assist in feathering of the plaque. If the transition at the distal endpoint is not smooth, the distal intima can be secured by use of 7-0 polypropylene tacking sutures. Flooding the artery with saline irrigation exposes remaining loose fragments, which can be removed with forceps.
A patch is sewn into place with 6-0 polypropylene sutures secure the patch at the distal end, with initial sutures carefully placed in the ICA using the smallest possible amount of the vessel wall, which is consistent with security of the arteriotomy closure.
- Before final closure of the arteriotomy, the shunt is removed, the common carotid artery and ICA are clamped, and all three vessels are flushed to remove debris from the arteriotomy site. The common carotid artery can be digitally occluded after the shunt is removed and before clamp placement. The arteriotomy closure is completed, and flow is restored first to the ECA and subsequently to the ICA. The flow dynamics of the completed repair are evaluated by ultrasound.
- Hemostasis should be assessed, including the patch anastomosis, jugular vein, ligated common facial vein, and SCM muscle. A Valsalva maneuver can be performed to assess the integrity of the jugular vein. Protamine is administered. A 7-Fr Jackson-Pratt drain may be placed and removed the next day. The platysma is closed with a 3-0 absorbable suture, and the skin is approximated with a 4-0 subcuticular suture. If the patient received general anesthesia, the surgical nurse and instrument table should remain sterile and the patient should remain in the operating room until the presence of any neurologic finding that might warrant reexploration is excluded.
Distal Exposure of the ICA
In the case of distal disease, exposure of the upper cervical segment of the ICA can be achieved by mandibular subluxation. General anesthesia with nasotracheal intubation is required for this approach. The mandibular condyle on the side to be operated is subluxed and transfixed with transnasal or oral wiring.
Exposure of the common carotid artery and the ICA and mobilization of the hypoglossal nerve proceed as described earlier.
Division of the posteriorly belly of the digastric muscle allows exposure of the ICA within 2 cm of the skull base (Fig. 6-4). Care should be taken to ligate small branches of the jugular vein that cross the anterior surface of the ICA. The lower edge of the parotid gland is retracted superiorly during this maneuver.
Higher exposure of the ICA is obtainable by dividing the stylohyoid ligament, as well as stylohyoid, stylopharyngeus, and styloglossus muscles to permit removal of the styloid process. (exposure above C1) Confining dissection to the periadventitial tissue of the ICA minimizes risk of injury to the glossopharyngeal nerve.
Lateral mandibulotomy exposure above C1 (can avoid mandibular subluxation- need to wire jaw shut with that for 3 months post-op)
CEA post-op Care
Patients are usually discharged the day after their operation, but at home blood pressure monitoring is advised.
*Patients are monitored with an arterial line to assess fluctuations in blood pressure in the postanesthesia care unit for a period of at least 2 hours. If medications are required to maintain normal blood pressure, the patient should be transferred to the intensive care unit for overnight monitoring. Avoidance of significant hypertension is important.
*Patients are usually kept on bed rest on the day of operation and encouraged to ambulate the next day.
*Clear liquids are recommended the day of operation in the unlikely event of a need to return to the operating room. Patients are allowed to resume a regular diet the next day.
*One dose of a cephalosporin or, in the case of a penicillin allergy, vancomycin is given before the operation and continued for 24 hours (e.g., Cefazolin 1 gm IV q8h; Vancomycin 1 gm IV q12h).
*Discomfort from the neck incision is usually minimal, and patients often discontinue narcotics in favor of over-the-counter analgesics after the first day.
*Life-long aspirin (81-325 mg/day) is recommended. Additional intraoperative and postoperative antiplatelet agents (e.g., low-molecular-weight dextran) may be added at the surgeon’s discretion, particularly in patients who have not received preoperative aspirin or clopidogrel.
*A postoperative duplex scan at 1 month and repeated at an annual interval is an appropriate follow-up strategy.
*Patients should be referred for atherosclerotic risk reduction therapy—including administration of an angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, or both and a statin agent—and where appropriate for antihypertensive therapy.
Post-op complications
Cardiac Complications
Stroke
Cerebral Hyperperfusion Syndrome
Nerve Injury
Bradycardia
Hematoma
Periincisional Hypesthesia
Carotid Restenosis
CEA Post-op Complications
Arrythmia
Bradycardia
Bradyarrhythmia is a common event attributed to manipulation of the carotid sinus. Atropine is administered if bradycardia is persistent or is associated with hypotension. Lidocaine may be administered into the area of the carotid sinus nerve at the time of operation but may be associated with reflex hypertension.
CEA Post-op Complications
Nerve Injury
Nerve Injury
Transient deviation of the tongue toward the side of operation may result from injury or traction on the hypoglossal nerve. Transection of the hypoglossal is rare and may require urgent repair. In this instance patients may have difficulty swallowing and with speech articulation. Aspiration precautions may be appropriate. In most patients with postoperative tongue deviation resolution occurs within 48 hours, because edema rather than frank nerve injury is the usual mechanism. A brief course of steroids and elevating the head of the bed often facilitates resolution.
Injury to the vagus nerve may result in either temporary or permanent hoarseness. Trauma to the marginal mandibular branch of the facial nerve results in drooping at the corner of the mouth. Injury to the superior laryngeal nerve may cause fatigability of the voice and impairment in phonation. Damage to the spinal accessory nerve is uncommon but may result in shoulder dysfunction and neck weakness. Suspicion of a CN injury warrants consultation with an otolaryngologist.
CEA Post-op Complications
CHS
Cerebral Hyperperfusion Syndrome
The complication of cerebral hyperperfusion syndrome occurs in less than 1% of cases but carries a mortality rate of more than 30%. Hyperperfusion syndrome can cause severe headaches, seizures, neurologic deficits, and ultimately death from cerebral hemorrhage. It may manifest 3 to 6 days after CEA. Risk factors include high-grade ipsilateral stenosis (>90%), contralateral carotid occlusion, recent history of stroke, and severe postoperative hypertension. Of these risk factors, only postoperative hypertension can be controlled. Therefore large fluctuations in blood pressure are best managed in the intensive care unit with appropriate vasopressors or vasodilators. Complaints of headache should not be dismissed.
CEA Post-op Complications
Cardiac
Cardiac Complications
Although the stress of CEA is low, most patients have evidence of cardiovascular disease and are at risk for myocardial ischemia or cardiovascular-related death. Whereas a postoperative electrocardiogram is appropriate, routine assessment of cardiac isoenzymes is not.
CEA Post-op Complications
CVA
Stroke
Although CEA is intended to prevent stroke, stroke is a recognized complication. A patient who presents with a neurologic deficit upon emergence from anesthesia or soon thereafter should be promptly reexplored. The most common cause of this event is thrombosis at the operative site. A minor, transient, or both types of deficits should prompt urgent duplex or CT angiography. Embolization of platelet debris with a patent reconstruction is the most common cause.
Post-op Complications
Hematoma
Peri-incisional hypesthesia
Carotid Restenosis
Hematoma
Postoperative wound hematomas occur in about 5% of patients. Of these, a small fraction requires evacuation. An expanding hematoma in the neck must be treated expeditiously to avoid airway compromise.
Periincisional Hypesthesia
Patients may complain of numbness of the ear lobe if the greater auricular nerve has been injured. More frequently, patients experience diminished sensation in the region of the neck incision because of interruption of cutaneous cervical nerves. Typically, this resolves over several months.
Carotid Restenosis
Most restenoses are asymptomatic and occur within 2 years of primary surgery because of intimal hyperplasia. The risk can be minimized by routine use of patch angioplasty. Additional recommendations include smoking cessation and atherosclerotic risk factor reduction. Reoperation is undertaken for the same indications as primary operation.
Eversion Technique following exposure
It is essential to mobilize the distal ICA circumferentially, well beyond the plaque, to the level where the uninvolved artery achieves a bluish hue. The clamp should be placed on the normal ICA beyond the endpoint or transition zone of the plaque to facilitate eversion and allow examination of the endpoint of the endarterectomy. It is also important to clear all periadventitial tissue away from the ICA to allow adequate eversion of the ICA. This can be performed after transection of the ICA and allows much of the dissection to be done with the ICA “out of the wound,” thus minimizing the risk of cranial nerve injury.
After administration of heparin, the ICA is clamped using Yasargil neurosurgical clips. Then the ECA and common carotid artery are dissected and clamped. The ICA is then transected obliquely at its origin using an 11 blade and dissecting scissors and is freed from remaining periadventitial tissue. The ICA should be divided at the bifurcation or carotid bulb, not in the proximal ICA (Fig. 7-1). If the proximal ICA is divided, it makes the subsequent anastomosis more technically challenging. The arteriotomy is extended along the medial side of the ICA for 1 to 2 cm (Fig. 7-2). The arteriotomy in the common carotid artery is extended for a similar distance. At this stage, the ICA should be fully mobilized and anchored only by the distal ICA Yasargil clip.
Eversion CEA of the ICA is then performed. A dissection plane is first identified on the proximal ICA. The adventitia is then peeled off the plaque (Fig. 7-3). As the eversion proceeds, fragments of plaque that remain on the arterial side of the adventitia are removed. The plaque is not extracted from the artery; rather the adventitia is peeled off the stationary plaque, much like peeling a glove from a hand. As the adventitia is peeled off, the plaque begins to “feather out” where it ends before separating from the adventitia. A small rim of residual plaque may be seen after removal of the bulk of the plaque, which is removed as a spiral to minimize the risk of dissection plane of the distal normal intima. Irrigation with heparinized saline removes residual debris and provides a clearer view of residual strands on the intimal surface of the ICA. A critical part of this operation is good visualization of the distal endpoint of the endarterectomy. If not clearly visible, the Yasargil clamp should be moved more cephalad on the ICA.
Two technical problems are possibly encountered at this stage:
*Lack of a distal end point. When the ICA is inverted, the plaque may not “feather out” but instead may become continuous with the distal intima. This is analogous to endarterectomy of the superficial femoral or iliac arteries. The surgeon must stop the endarterectomy before the ICA is out of reach at the skull base. The ICA with its plaque may be transected, and often the distal endpoint is secure. If this does not occur, the plaque may be tacked with 7-0 or 8-0 polypropylene sutures or a common carotid artery to ICA bypass may be performed.
*Unstable distal endpoint. After successful endarterectomy, there may be concern that the intima is separating from the distal ICA, which could dissect after reestablishing flow. Tacking (Kunlin) sutures, made with 7-0 or 8-0 polypropylene, may be used to secure the distal intima.
Endarterectomy of the Common Carotid Artery
Endarterectomy of the common carotid artery is performed using an endarterectomy spatula or elevator. A plane is identified between the plaque and the adventitia. The plaque is transected proximally with either Metzenbaum or Potts scissors or a No. 15 blade just beyond the ECA origin and, if required, the ECA is everted in a similar fashion to that used for the ICA. In rare cases, the plaque is confined within the ICA or does not involve the common carotid artery. However, in our experience, failure to endarterectomize the common carotid artery predisposes the patient to a higher incidence of restenosis, usually in the common carotid artery. It is also easier to suture to an endarterectomized common carotid artery.
The technical problem possibly encountered at this stage is extensive plaque in the common carotid artery. With such situations, it may be necessary to extend the arteriotomy proximally on the common carotid artery to perform a more extensive endarterectomy. This results in a size mismatch between the common carotid artery arteriotomy and the ICA origin. Because the common carotid artery is wide enough to accommodate primary closure without undue narrowing of its lumen, primary closure of the common carotid artery arteriotomy can be performed with 6-0 polypropylene. The ICA can then be sewn to its origin, which results in a Y-shaped suture line.
Anastomosis of the Internal to the Common Carotid Artery
The ICA is reanastomosed to its origin on the common carotid artery with a continuous 6-0 polypropylene suture using a parachute technique (Fig. 7-4). The anastomosis has the advantage of being performed in the center of the incision, not at its most cephalad extent. It is difficult to narrow the lumen. Before completion of the anastomosis, the clamps are released and the artery is irrigated with heparinized saline. After release of the clamps, flow is confirmed by Doppler insonation or Duplex imaging of both the ICA and the ECA.
Technical problems may be encountered at this stage:
*No flow in the ECA. Lack of ECA flow implies a problem with the endpoint of the dissection and likely occlusion of the ECA, which in some patients may result in jaw or masseter muscle claudication. The “counsel of perfection” is to reexplore the ECA. However, if the operation has been difficult and a shunt required, wiser counsel suggests matters be left alone.
*No flow in the ICA. Reexploration is mandated when there is no ICA flow, even if the patient is not experiencing a neurologic deficit.
*ICA thrombosis. An emergent situation is thrombosis, and reexploration is mandated. “Red” thrombus usually results from thrombosis of the ICA and the endpoint must be evaluated and revised, as needed. A No. 2 or No. 3 Fogarty embolectomy catheter may be used to carefully retrieve a thrombus, but catheter length should be measured to avoid causing a carotid-cavernous sinus fistula. In most circumstances retrograde flow from the ICA flushes the thrombus out, and catheter extraction is not necessary. If “white” thrombus is found, aberrant platelet aggregation may be the cause and a technical issue often may not be identified. Replacement of the endarterectomized ICA with a vein interposition graft may be considered along with use of a more potent antiplatelet agent, such as low-molecular-weight dextran. Heparin-induced thrombocytopenia should be excluded.
Shunting During Eversion Carotid Endarterectomy
The placement of shunt during eversion CEA is not more difficult than when performed during a conventional CEA, and any conventional shunt may be used, such as a Javid, Sundt, or Pruitt-Inahara shunt. The ICA is transected and an eversion CEA is performed expeditiously. The shunt is then inserted and secured with a shunt clamp or balloon (Fig. 7-5). The distal end of the shunt can also be inserted before endarterectomy in the rare circumstance that the ICA plaque is so short that transection of the ICA and performance of an arteriotomy along the medial aspect of the ICA allows easy access to the distal ICA. The proximal end is then inserted into the common carotid artery and secured, usually before performing an endarterectomy. When the shunt has been inserted, flow is confirmed by Doppler insonation. Endarterectomy of the common carotid artery can then be performed. Finally, the ICA is anastomosed to its origin on the common carotid artery around the shunt and the shunt is removed before completion of the anastomosis.
Carotid- Subclavian bypass Technique
The patient is positioned at the edge of the table of the affected side.
-The neck is extended, and the head is turned to opposite the side of the intended incision and placed upon a soft rubber ring.
-Elevation of the shoulders with a shoulder roll to enhance neck extension. EEG neuromonitoring.
-The upper chest, lower face, and lower ear are prepped and draped.
- A timeout is performed
- Supraclavicular incision extending from the clavicular head of the SCM laterally and raise subplatysmal flaps
- Identify the jugular vein and expose the common carotid artery- careful to avoid vagus nerve
- divide and reflect the scalene fat pad cephalad- ligate thoracic duct if identified
- identify and preserve the phrenic nerve then divide the anterior scalene to expose the subclavian artery
- Heparinize 80-100u/kg and wait for ACT >250
- Clamp proximal and distal subclavian artery and perform end-side anastomosis with ringed ePTFE
- Clamp graft, open flow to the arm
- Tunnel graft retrojugular
- clamp proximal and distal common carotid artery and perform end-side anastomosis. Flushing maneuvers prior to completion
- Open flow from proximal carotid through graft, followed by distal carotid
- Interrogate with doppler
-place drain
- Close platysma and skin once hemostasis is achieved
Carotid- Subclavian Transposition
The patient is positioned at the edge of the table of the affected side.
-The neck is extended, and the head is turned to opposite the side of the intended incision and placed upon a soft rubber ring.
-Elevation of the shoulders with a shoulder roll to enhance neck extension. EEG neuromonitoring.
-The upper chest, lower face, and lower ear are prepped and draped.
- A timeout is performed
- Supraclavicular incision extending from the clavicular head of the SCM laterally and raise subplatysmal flaps
- Identify the jugular vein and expose the common carotid artery- careful to avoid vagus nerve
- divide and reflect the scalene fat pad cephalad- ligate thoracic duct if identified
- identify and preserve the phrenic nerve then divide the anterior scalene to expose the subclavian artery
- isolate subclavian artery as far proximally into the mediastinum as safely possible
- Heparinize 80-100u/kg and wait for ACT >250
- Clamp proximal subclavian artery proximally to vertebral, place stay sutures with pledgets prior to transection
- Clamp distal subclavian artery
- Transect the SCA and extend stay sutures across the artery, ensure adequate hemostasis
- Free SCA circumferentially and mobilize toward CCA (anterior or retro to IJ)
- clamp proximal and distal common carotid artery, make longitudinal arteriotomy and perform end-side anastomosis. Flushing maneuvers prior to completion
- Open flow from proximal carotid through SCA, followed by distal carotid
- Interrogate with doppler
- Close platysma and skin once hemostasis is achieved
Carotid- Carotid Bypass Technique
-The patient is positioned in the table midline
-The neck is extended, elevation of the shoulders with a shoulder roll to enhance neck extension
- Ultrasound is used to mark the location of the bifurcation
- EEG neuromonitoring applied
-The upper chest, lower face, and lower ear are prepped and draped.
- A timeout is performed
- An incision paralleling the anterior border of the SCM muscle is made
-The incision is deepened through the platysma muscle, and the investing layer of the deep cervical fascia is opened on the anterior border of the SCM muscle
-The anterior border of the SCM muscle is mobilized
-The SCM muscle is retracted posteriorly, the carotid sheath is identified; The internal jugular vein is dissected along its medial border and retracted posteriorly with the SCM muscle
- The common carotid artery is isolated using sharp dissection. The vagus nerve should be identified and protected. Once the common carotid artery is freed from the surrounding tissue, it is encircled with tape away from the bifurcation area
- This is repeated on the contralateral side
- Create graft tunnel with blunt finger dissection retroesophageal (or between esophagus and trachea) aided by NGT
- Pass the graft and systemically heparinize with 80-100 u/kg hep and wait for ACT >250
- Clamp one CCA, perform end-side anastamosis, flushing maneuvers prior to completion, clamp graft and open flow to CCA
- perform contralateral anastamosis in end-side manner, vigourous flushing prior to completion
- open the graft and CCA
- obtain hemostasis, leave a drain, close platysma and skin
Treatment of thoracic duct injury
Fluid shows high TG (more than 100mg/dl) with low cholesterol (less than 200 mg/dl)
- antibiotics, drainage
- MCTG diet
- NPO with TPN x 2 weeks
- VATs thorascopic ligation of right thoracic duct via Right thorascopic approach
Spider embolic protections
0.014-0.018
3-7mm basket
For the SRU consensus, what cutoff values are use for PSV and ratio in carotid stenosis?
50-69% PSV 125-230, EDV 40-100, ratio 2-4
>70% to near occlusion PSV >230, EDV >100, ratio >4
near occlusion high/low/undectec
Society of radiologists in ultrasound
What is the Washington criteria?
normal ICA PSV 125 EDV 125 EDV >140
Transfemoral- CAS
- procedure performed under conscious sedation with squeaky toy in the contralateral hand for periodic neurochecks
- US- guided percutaneous access to R CFA
- heparinize w 80-100 u/kg, confirm ACT > 250 before arch manipulation
- Using wire and catheter, I would traverse the arch, exchange for a pigtail, perform arch aortogram in LAO projection
- exchange for stiff wire and track a 7fr x 90cm sheath into teh aortic arch by the origin of the innominate artery
- use angled catheter and wire to select inominate and subsequently select the CCA
- perform carotid angiogram, exchange for rosen wire, track sheath into CCA
- perfrom 2 view cerebral angiogram ensuring no bubbles and low pressure injection
- cross the stenosis and place embolic protection device into the distal ICA
- predilate lesion with 3mm balloon to create a channel
- deploy a self expanding stent sized to the CCA
- post dilate with a 5mm balloon
- completion 2 view cerebral angiograms
- recapture the filter, perform a neurologic exam and close the access
Can you ligate Carotid?
If have carotid back pressure > 50mmHg
balloon in ICA, remove wire, connect to a-line tubing
Sign of ischemia on EEG
Slowed waves, frequencies
Pre-op work-up for EVAR
Hx surgery (abdominal surgery*** right hemicolectomy, IMA patent=bad- left colon relies on IMA–> high risk of colonic ischemia 50%, open surgery with IMA reimplantation , left hemicolectomy=fine)
cardiac clearance
basic labs
Counsel Risk modification- tobacco cessation
Counsel risks and benefits
Size aorta for endograft repair (diameter at and 1cm below renals, iliacs, length of aneurysm to bifurcation, length from lowest renal to iliac bifurcation)
EVAR Technique- AAA
After induction of general anesthesia, position the patient supine
Prep and drape the patient from nipples to knees
Perform Timeout
Access the bilateral CFA with pre-close technique under US guidance with 8Fr sheaths
Systemically heparinize the patient with 80-100u/kg heparin
Exchange starter wires for stiff wires positioned in the proximal aorta
Exchange for appropriately sized large bore sheaths
Advance bifurcated endograft to L1-L2
Perform angiogram to mark renals through pigtail in contralateral groin
Deploy endograft to contralateral gate
Cannulate contralateral gate, Confirm true lumen by spinning pigtail in graft main body and repeat angiogram to confirm appropriate graft positioning
Reinsert stiff wire, perform retrograde angiogram to mark iliac bifurcation, use marker pig to size contra limb length
Advance sheath with introducer into contra gate
Position contra limb, retract sheath and deploy
Complete deployment of main body
Select and deploy ipsi limb extension in similar fashion to contra limb
Balloon proximal, distal and overlap of stents
Completion angiogram
Satisficed, I would close the groin with pre placed suture and reverse heparin, and use manual pressure until hemostasis
Complete extremity exam following completion
Open AAA Technique- Tube Graft- Transperitoneal Incision
After induction of general anesthesia, position the patient supine
Prep and drape the patient from nipples to knees
Perform Timeout- discuss allergies, antibiotics, surgical plan
Perform midline incision from xiphoid to pubis
The peritioneal cavity is entered
Omni Retractor is placed (self retaining retractor)
The grater omentum and transverse colon are reflected cephalad with moistened towels
THe small bowel is retracted to the patients right and packed
The ligament of trietz is identified and divided- retractors are adjusted
THe RP is incised exposing the aorta
the aorta is isolated to renal veins proximally and bifurcation distally
The neck of the aneurysm is isolated and circumferential control obtained with umbilical tape
Distal control obtained (iliacs or distal aorta), IMA isolated and controlled
Systemically heparinized
Clamps applied Distally then proximal- alerting anesthesia
The aneurysm sac is incised, and extended with mayo scissors
Clot is evacuated
Backbleeding lumbars oversewn
Tube graft sewn in proximally with 3-0 prolene
Clamps moved down to graft, anastamosis evaluated
Distal graft sew in with 3-0 prolene- flushing maneuvers prior to completion
Clamps released one leg at a time
Hemostasis evaluated, Doppler interrogation of distal flow
IMA evaluated for re-implantation
Aneurysm sac closed
RP closed
Midline closed
Open Infrarenal AAA Retroperitoneal Approach
After induction of general anesthesia, position the patient in the lateral position with the left side up at 60 degree angle, both arms on armboards and supported. Bed flexed at patients flank.
Prep and drape in the standard fashion
Perform Timeout- discuss allergies, antibiotics, surgical plan
*Standard
- incision made over the 11th rib incision carried from posterior border axillary line to abdominal midline 5cm below umbilicus
Incision carried down through subQ
External oblique muscle, aponeurosis, Left anterior rectus sheath divided. left rectus divided
Divide internal oblique and transversus abdominus
divide transversalis fascia and enter RP space down to but not violating Gerotas fascia
(accidentally entered peritoneal cavity? - running 3-0 vicryl repair
I would approach the aorta from a retro-renal plane (unless retroaortic renal vein)
Ureter identified and swept towards midline
Identify renal artery ( should be cephalad to vein) and used to follow back to aorta
Renal lumbar vein identified and ligated
Aorta exposed from renals to bifurcation
Plan to control Left iliac with clamp and Right iliac with a balloon from within
IMA isolated and controlled
Extraperitoneal Exposure of the EIA
Incision made 2cm above and parallel to the inguinal ligament
Extending from lateral rectus sheath to a point 2cm cephalad to ASIS
Superficial epigastric and Circumflex iliacs ligated in subcutaneous layer
External and Internal aponeurosis are divided, internal oblique muscle fibers are split
Transversus muscle and transversalis fascia are opened in the lateral wound
Entry to RP is gained laterally by stripping peritoneum from anterior abdominal wall
PEritoneal cavity retracted superiorly
External iliac exposed in center of wound
Care to avoid injury to deep circumflex iliac and inferior epigastric
RP Exposure of the Iliac arteries
After induction of general anesthesia, position the patient in the supine position with ipsilateral hip elevated 10 degrees on rolled sheet.
Entire abdomen and flank prepped and draped
Perform Timeout- discuss allergies, antibiotics, surgical plan
oblique skin incision is begun at lateral border of the rectus muscle 3cm above the inguinal ligament and extended to midaxillary line halfway between subcostal margin and iliac crest
wound carried down through subcutaneous tissue
superficial epigastric and circumflex iliac arteries is performed
Aponeuroses of external and internal oblique muscles are divided
muscle fibers of internal oblique are split parallel to wound axis
transversus abdominus and transversalis fascia are opened in lateral half of wound gaining access to the RP
RP space is entered in wounds lateral aspect (peritoneum may be fused to tranversalis fascia in midline)
peritoneum stripped from lateral pelvic wall and retracted medially to expose the psoas muscle and iliac vessels on the medial side of the muscle
ureter left attached to posterior peritoneal surface and retracted into medial wound
EIA identified in lower wound and traced proximally to identify common and internal iliac arteries
Proximal exposure can be gained to the terminal aorta
Spleno-renal bypass
after entering the peritoneum…
left colon mobilized by incising its lateral peritoneal attachements and developing plane between left colon mesentary and the anterior surface of gerotas fascia
after the colon has been reflected to the level of the splenic flexure the spleen is mobilized by incising spleno phrenic and splenorenal ligaments
plane between pancreas and gerotas fascia developed allowing the spleen and distal pancreas to be developed anteriorly and medially
splenic artery identified near superior border of pancreas
central portion of splenic artery dissected and mobilized (to avoid kinking)
pancreatic branches divideed with silk suture
sufficient length of the splenic artery is isolated and mobilized
distal end divided and ligated (sufficient blood supply from short gastric and gastroepiploic arteries)
spatulated end-end anastomosis with L renal
Hepato-renal bypass
area of hepatoduodenal ligament exposed by retracting right lobe of liver superiorly and packing intestines and right colon inferiorly
hepatoduodenal ligament incised transversely near the superior wall of the duodenum
hepatic artery located on the left side of the common duct
artery mobilized and encircled with vessel loops on both sides of the GDA
bypasses can be anastomosed to side of hepatic artery or proximal to, distal, using the GDA.v
End to end vs End-side
ES preferred: to preserve flow through hypos, accessory renal, patent IMA
ABF Technique AIOD
After induction of general anesthesia, position the patient supine
Prep and drape the patient from nipples to knees
Perform Timeout- discuss allergies, antibiotics, surgical plan
Perform bilateral CFA cutdowns, obtain proximal and distal control
Perform midline incision from xiphoid to pubis
The peritoneal cavity is entered
Omni Retractor is placed (self retaining retractor)
The grater omentum and transverse colon are reflected cephalad with moistened towels
THe small bowel is retracted to the patients right and packed
The ligament of trietz is identified and divided- retractors are adjusted
THe RP is incised exposing the aorta
the aorta is isolated to renal veins proximally and bifurcation distally
Bilateral infrainguinal tunnels are created
The aorta is isolated
Distal control obtained (iliacs or distal aorta), IMA isolated and controlled
Systemically heparinized
Clamps applied Distally then proximal- alerting anesthesia
The aorta is transected
Distal aorta stump oversewn in 2 layers
Bifurcated graft sewn in proximally with 3-0 prolene
Clamps moved down to graft, anastamosis evaluated
Limbs tunneled
End-side anastamosis CFA 5-0 prolene (less ischemic leg first)
Clamps released one leg at a time
Hemostasis evaluated, Doppler interrogation of distal flow
IMA evaluated for re-implantation
Aneurysm sac closed
RP closed
Midline closed
Colonic Ischemia
flex sig
bowel necrosis –> sigmoidectomy, diverting colostomy
Cant close Sternotomy
make sure graft is on medial aspect of ascending aorta
resect posterior aspect of sternoclavicular joint
remove subclavian bypass limb?
What to do pre-op if planning a median sternotomy?
heart cath (see if cabg needed)
what to do if coronary steal
consult cardiology to see if can treat native vessels
Type IV TAAA
Beveled proximal anastamosis
Type I-III TAAA
TEVAR from normal aorta proximal to Celiac distally
single lung ventilation
Left heart bypass
diaphragm incised laterally
resect rib if needed
CTD- need individual bypasses to viscerals
Spinal drain management
initial 24h: drain open, no more than 10cc/h, MAP >90, ICP < 12
24-48h post-op: clamp trial 4h, monitor for neuro changes, if stable–>
liberalize MAP goals > 70, wean pressors as able
> 48H postop: if stable neuro exam >24 from cap, remove drain
antiplatelets started 7 days after LD
anticoagulation 3 days after
Ax-pop bypass
lateral supra-geniculate pop exposure
- leg internally rotated, flexed at knee
- longitudinal incision made in distal 1/3 of thigh between bicep femoris and IT tract
- fascia lata incised posterior to junction of IT tract and lateral intermuscular septum
- space between short head of biceps femoris and lateral femoral condyle is opened
- vessels found posterior to femur
- popliteal vein retracted posterior with tibial and peroneal nerves
- pop artery is isolated
Ax-profunda
Lateral Approach to the profunda
- vertical incision along lateral border of the sartorious
- incicion carried through fascia lata
- sartorius is mobilized along lateral border and reflected medially
- inciison carried through fascia between vastus medialis and adductor longus
- rectus femoris reflected laterally
- exposes lateral femoral circumflex
- identifya nd protect branches of fem nerve
- ligate circumflex vein to isolate profunda
Obturator bypass
RP Approach
Curvilinear transverse incision made 4cam above and parallel to the inguinal ligament
Muscles of anterior abdominl wall divided
EO split in direction of fibers
IO, transversus abdominaus, transversalis fascia divided up to teh edge of the rectus sheath
Access to RP space gained through lateral wound by separating peritoneum from transversalis fascia
Peritoneum and contents retracted medially with ureter
Iliac vessels found along medial border of psoas
grafts usually lie anterior to EIA
Obturator foramen is palpated under superior ramus of pubic bone
bypass created centrally to avoid neuro bundle
medial portion of obturator memebrane found by incising endopelvic fascia and bluntly separating underlying obturator internus and levator ani muscle fibers
opening made on medial aspect of obturator membrane
curved tunneler passed through the opening and routed behind the pectineus and adductor muscles into the thigh
btought through adductor magnus muscle, through adductor hiatus to reach Ak-pop
Options for in-line aortic reconstruction
PTFE
Rifampin soaked dacron
NAIS
Cryograft
Aortic Stump closure
2 layer closure
Anterior Spinal ligament reinforcement
omental pedicle flap: passed in a retrocolic manner through an avascular section of the mesocolon to cover the aortic stump. A large sump drain is placed in the retropperitoneal space.
Friable Aortic Stump Reinforcement
If the aortic stump tissues are friable, they may be reinforced with autogenous tissue consisting of strips or pledgets of abdominal wall or prevertebral fascia, if available. Other autogenous materials, such as endarterectomized occluded aortoiliac or hypogastric arterial segments or saphenous vein pledgets, can be used to prevent the sutures from tearing through friable aortic tissue.
Location of obturator vessels
Where to tunnel bypass
neurovascular bundle lie superolaterally
anteromedially
Thoracobifemoral bypass
Three specific indications have evolved. The first indication is the rare situation of a hostile abdomen, usually after either extensive previous operations or radiation in the periaortic region. Circumstances including inflammatory bowel disease or abdominal wall deficiencies can enter into this decision. In such patients, aortic inflow from the left chest may be less traumatic than an abdominal exploration. The second indication is for repeated failure of abdominal aortic grafting. As a general rule, failure after a single aortofemoral bypass is appropriately managed with another intraabdominal aortic graft. After two failures, one may reasonably consider moving to the thoracic aorta for inflow. Finally, the thoracofemoral bypass has been useful for patients with multiple failed extra-anatomic bypasses. They include patients with axillopopliteal and axillofemoral grafts having had multiple graft thrombectomy operations.
The patient is positioned to maintain adequate surgical access to both femoral arteries. The pelvis is left reasonably flat, with a rotation of the thorax to about 30 degrees.
A thoracotomy incision is made in the sixth or seventh intercostal space and brought across the costal cartilage for several centimeters onto the abdominal wall. Remove 1 or 2 centimeters of costal cartilage with the curved Mayo scissors for a less painful closure. After the thoracic cavity is entered, the diaphragm is incised for several centimeters in a radial fashion. Later, the bypass graft will pass through this short incision.
Left lung retraction with either conventional retractors or selective deflation with a double-lumen endotracheal tube is followed by incision of the inferior pulmonary ligament to expose the aorta. The aorta is circumferentially dissected above the diaphragm to allow placement of a bypass graft several centimeters above the diaphragmatic hiatus. Avoid placing the anastomosis too close to the diaphragm to prevent kinking. A nasogastric tube allows identification of the esophagus by palpation during this dissection, and an silicone elastic sling is left around the aorta for control should the side-biting aortic clamp be dislodged.
Tunnels are formed from the retroperitoneum just beneath the costal cartilage incision to the left groin. This process is aided by transecting the left inguinal ligament and is achieved with blunt bimanual index finger dissection. Remarkably, finger dissection with both hands usually provides enough length for this tunnel (Figure 2). The tunnel is beneath the lateral abdominal musculature but extraperitoneally along the anterior or midaxillary line (Figure 3). After systemic anticoagulation with heparin, the proximal aortic anastomosis is performed after partial occlusion of the aorta. Selection of just the right J-shaped clamp from the instrument tray can require some experimentation. Patients are well served with a ring-supported 10-mm graft, but 8- or 12-mm ringed grafts may be used, depending upon patient size. Suture with 3–0 or 4–0 polypropylene or polytetrafluoroethylene is appropriate. Chest tube drainage for 1 or 2 days is instituted after standard closure of the thoracotomy.
Rifampin dosage
60 mg/ml solution (1200 mg rifampin powder in 20 ml sterile saline) x 15min
Conduits for medium sized graft infections
saphenous
jugular
cryo
bovine carotid
hypogastric artery
SFA with in-situ replacement with PTFE
SMA embolectomy
Base of the Mesentery
- after peritoneal cavity is entered, the peritoneal contents are rapidly evaluated, noting the extent of bowel necrosis
- frankly necrotic bowel is resected
- the transverse colon and omentum are elevated, intestines wrapped in moist towels and retracted to the patients right
- a horizontal incision is made in the peritoneum at the base of the transverse mesocolon, extending from the the duodenal-jejunal junction towards the patients right
- middle colic artery is identified in the transverse mesocolon and traced proximally to locate its origin from the SMA
- Sma between middle and right colic is readily identified and isolated, careful to preserve jejunal branches
- (pancreas retracted superiorly to expose more proximal artery)
- proximal and distal control
- heparinze if not alreaady
- transverse arteriotomy
- fogarty balloon embolectomy proximally and distally
- close arteriotmy with interrupted prolene
- doppler interrogation
- inspect bowel
- consider 2nd look (close with abthera)
Retrograde SMA bypass
Exposure of the Aorta or Common Iliac Artery
The proximal anastomosis can be positioned on the proximal right common iliac artery, the infrarenal aorta, or the proximal left common iliac artery. The preference is to position the heel of the graft on the distal aorta and the toe on the right common iliac artery. However, the choice is contingent on the anatomic course of the graft and the degree of atherosclerotic involvement in the vessels. The inflow vessels are exposed by incising the retroperitoneal tissue over the midinfrarenal aorta and extending the incision over the course of the designated common iliac artery. The inflow vessels are dissected to allow clamp application, and it is not necessary to circumferentially dissect the aorta or common iliac vessels. Although the proximal anastomosis is performed in an end-to-side fashion, it may not be possible to use a partial occluding vascular clamp.
Exposure of the Superior Mesenteric Artery
The superior mesenteric artery is exposed by incising the ligament of Treitz and the other peritoneal attachments and then retracting the duodenum to the patient’s right side (see Fig. 40-1, C). As the base of the mesentery is dissected laterally from left to right, the superior mesenteric artery is the first structure to be encountered and is a sizable vessel.
Tunneling the Bypass Graft and Anastomoses
Either a 6- or a 7-mm-diameter Dacron graft is a suitable conduit, although a comparable externally supported ePTFE graft is a reasonable alternative to minimize the risk of kinking. The proximal anastomosis is usually performed first, although some surgeons have proposed the opposite to simplify the process of tunneling the graft and to obtain the optimal configuration. The distal anastomosis can be performed in either an end-to-end or end-to-side fashion, but the anatomic course of the graft may be more favorable if distal anastomosis is performed in an end-to-end manner. The graft should be tunneled so that it forms a gentle curve or C loop between the two anastomoses as it traverses caudal to cephalad and posterior to anterior. It is imperative that the graft does not kink and that the anastomoses are tension free.
Closure
The retroperitoneal tissue over the aorta, the ligament of Treitz, and the peritoneum over the superior mesenteric artery are reapproximated to exclude the graft from contact with the intestine. In addition, a segment of the omentum can be mobilized to cover the graft.
Supraceliac mesenteric bypass
Operative Technique for Antegrade Bypass
Position
For antegrade aortoceliac or aortosuperior mesenteric artery bypass, the patient is positioned supine. The distal pulses are interrogated with continuous wave Doppler, and the operative field, including the chest, abdomen, groin and both lower extremities, is prepared in the standard fashion.
Incision
Either a midline or a bilateral subcostal incision can be used, because the anatomic structures that need to be exposed during the procedure are all along the axial skeleton. The major advantage of the midline incision is that it is somewhat easier and faster to close. The major advantage of the bilateral subcostal incision is that it provides the most optimal exposure to the upper abdomen and is helpful in larger individuals.
Exposure of the Aorta
The supraceliac aorta is exposed by incising the left triangular ligament of the liver (Fig. 40-2). Care should be exercised during this step to avoid injuring the vena cava or hepatic veins that serve as the lateral extent of the dissection. The left lateral segment of the liver is then folded back and retracted to the patient’s right. Exposure is facilitated by using a self-retaining Bookwalter retractor with a large round ring and by positioning four medium or deep right-angled retractor blades throughout the length of the bilateral subcostal incision. Placing the patient in a significant amount of reverse Trendelenburg also facilitates exposure by allowing the visceral structures to “fall away” from the operative field. The gastrohepatic ligament is then incised. Care should be exercised, because a replaced left hepatic artery from the left gastric artery may course through the ligament. The esophagus and stomach are then retracted to the patient’s left with the assistance of a retractor blade. The esophagus can usually be identified by the presence of a nasogastric tube or transesophageal echocardiography probe. The median arcuate ligament is subsequently incised along the longitudinal axis of the aorta, and both lateral crus of the diaphragm are incised horizontally. The pleural cavity is occasionally entered, which necessitates a chest radiograph in the immediate postoperative period to confirm that the lungs are fully expanded. The posterior peritoneum is then incised, and the supraceliac aorta exposed. Approximately 6 cm of the supraceliac aorta should be dissected free to facilitate aortic clamping. It is not necessary to dissect the aorta circumferentially.
The celiac axis is exposed by dissecting caudal along the anterior surface of the aorta (Fig. 40-2). This requires incising the remaining fibers of the diaphragm and the dense, fibrous neural tissue know as the celiac ganglion that surrounds the proximal celiac artery. This is facilitated by incising the fibers with electrocautery between the jaws of a right-angled clamp. The stomach and viscera can be retracted inferiorly either manually or with a malleable retractor. The preferred technique is to dissect the origin of the celiac axis and its proximal branches circumferentially. Approximately 3 cm of the celiac artery along with its proximal branches should be exposed to facilitate constructing an end-to-end anastomosis and oversewing the proximal remnant, after the vessel is transected. The proximal branches of the celiac artery, including the splenic and left gastric arteries, occasionally need to be sacrificed to facilitate the anastomosis. This is rarely of clinical significance since the orifice of the celiac artery was already occluded or severely stenotic, and because the stomach and spleen have a rich collateral network. Alternatively, the distal anastomosis can be performed to the common hepatic artery in an end-to-side manner. This is facilitated by dissecting the common hepatic, proper hepatic, and gastroduodenal arteries circumferentially along the lesser curve of the stomach in the proximal porta hepatis. Although the dissection is somewhat easier, it is more difficult to properly orient the graft.
Exposure of the Superior Mesenteric Artery
A suitable segment of the superior mesenteric artery can be exposed using a variety of techniques, as detailed previously. In a preferred approach, the artery is dissected immediately caudal to the inferior border of the pancreas (see Fig. 40-1, A). The vessel is approached either through the lesser sac by incising the gastrocolic ligament or through the gastrohepatic ligament by retracting the lesser curve of the stomach inferiorly. A longitudinal incision is made in the retroperitoneum immediately below the inferior border of the pancreas to expose the artery. This can be facilitated by retracting the stomach superiorly and the small bowel and transverse colon inferiorly using the malleable retractor blades. The retroperitoneal tissue overlying the superior mesenteric artery and vein can be retracted with two Weitlander self-retaining retractors oriented at 90 degrees relative to each other. It can be somewhat challenging to find the superior mesenteric artery in patients with a significant amount of retroperitoneal fat. Identifying the adjacent superior mesenteric vein or tracing the middle colic artery retrograde can be helpful. Approximately 2 cm of the artery should be exposed to facilitate construction of the anastomosis, but caution should be exercised because multiple branches of the artery at this level are easily injured. Alternatively, the superior mesenteric artery can be exposed at the root of the transverse mesocolon (see Fig. 40-1, B). The transverse colon is elevated, and the proximal mesentery incised horizontally. Finally, the superior mesenteric artery can be approached along its left lateral surface. The ligament of Treitz and other peritoneal attachments are incised (see Fig. 40-1, C), followed by completely mobilization of the duodenum’s fourth portion. The superior mesenteric artery is surrounded by fatty tissue at this level. Arterial or venous branches will rarely be encountered when the artery is approached along its left lateral surface.
Tunneling The Bypass Graft
After the superior mesenteric artery is exposed, a retropancreatic tunnel is created using gentle, bimanual finger dissection between the exposed supraceliac aorta and the superior mesenteric artery. This step should be performed with caution, because the tunnel courses adjacent to the superior mesenteric vein, deep to the splenic vein, and near their confluence with the portal vein. A straight aortic clamp or red rubber catheter can be passed through the tunnel and left in place until it is necessary to pass the limb.
Proximal Aortic Anastomosis
The proximal anastomosis to the supraceliac aorta is performed as the next step (Fig. 40-3). Before occluding the aorta, the patient is systemically heparinized (100 units per kilogram of body weight) and given 25 g of mannitol as both an antioxidant and a diuretic. A bifurcated Dacron graft with a body diameter of 12 mm and limb diameters of 7 mm may be used. However, grafts of this size are not universally available and can be substituted with those measuring 12 × 6 or 14 × 7 mm. Both ePTFE and autogenous femoral vein are acceptable substitutes. Aortic control can usually be achieved with a partial occluding clamp, such as a Lambert-Kay clamp that has been modified with a locking device that secures the tips. When it is not possible to partially occlude the aorta because of calcification or atherosclerotic involvement, two straight aortic clamps can be used. Completely occluding the aorta is less optimal, although the time to complete the anastomosis is usually less than 15 minutes.
An arteriotomy is made along the longitudinal axis of the aorta, and the graft is spatulated so that the limbs of the graft are oriented on top of each other, in contrast to the case of an aortobifemoral graft in which the limbs are oriented side by side. The anastomosis is performed with a 3-0 nonabsorbable, monofilament suture, and 5-0 sutures with felt pledgets are used as necessary for suture line bleeding. The body of the graft should be as short as possible, with the heel of the anastomosis essentially being the start of the inferior limb to the superior mesenteric artery. A short graft body is necessary because the distance between the aortic anastomosis and the celiac anastomosis is quite short. A limited endarterectomy of the aorta is occasionally necessary, but creating an aorta that is thin and will not hold sutures should be avoided. The proximal anastomosis can be challenging in large patients. Exposure of a large segment of aorta is helpful, as is the placement of retracting stay sutures in the aortotomy, parachuting the anastomosis or placing interrupted sutures.
Distal Anastomoses
The anastomoses to the celiac artery and the superior mesenteric artery are performed in sequence. The cephalad limb of the graft is used for the celiac anastomosis, whereas the caudal limb is tunneled deep to the pancreas. Vascular control of the branches of the celiac artery is obtained with microvascular clamps or vessel loops, whereas proximal control of the celiac artery is obtained with a right-angled clamp. The celiac artery is transected, and the stump is oversewn with a 4-0 nonabsorbable, monofilament suture. The distal celiac artery is spatulated to account for any size discrepancy between the native artery and graft, and the anastomosis performed using a 5-0 suture. The anastomosis to the superior mesenteric artery is configured in an end-to-side manner using a 5-0 suture. Upon completion of the anastomoses, the target arteries and their branches are interrogated with continuous wave Doppler to confirm adequacy of visceral perfusion.
Closure
The retroperitoneal tissue over the superior mesenteric artery anastomosis is closed with interrupted 3-0 absorbable sutures, whereas the proximal aortic anastomosis is not covered. The bilateral subcostal or midline incision is then closed using standard technique.
Splenectomy
Upon entry into the abdominal cavity, dissection is performed with blunt and sharp technique and with the surgeon’s hand following the convex surface of the organ, leading to identification of the peritoneal attachments.
The spleen is gently grasped and displaced medially toward the incision. The avascular peritoneal attachments and ligaments are incised with an electrocautery or Metzenbaum scissors. These suspensory ligaments are avascular except for the gastrosplenic ligament, which contains the short gastric vessels. In patients with portal hypertension, any ligaments may have vessels that should be ligated.
Attention is then turned to the hilum, where the splenic artery and veins are identified, carefully dissected, doubly ligated with 0 nonabsorbable suture (eg, silk), and transfixed with 2-0 silk suture ligatures. To avoid injury to the pancreas, the dissection is carried out at the hilum in close proximity to the spleen.
Next, the short gastric vessels are identified and ligated. In hypotensive patients, the short gastric vessels usually do not bleed, nor does the splenic bed.
In the case of elective splenectomy, the first step is transection of the ligamentous attachments, including the splenophrenic ligament at the superior pole and the splenocolic and splenorenal ligaments at the inferior pole. This may be accomplished with blunt dissection, an electrocautery, or, in conditions where the ligaments are thickened, Metzenbaum scissors.
After the ligamentous attachments are transected, the gastric vessels that run from the spleen to the greater curvature of the stomach are ligated and divided. A Lembert suture is placed in the gastric wall in a seromuscular fashion to avoid the complication of gastric fistulization when one is unable to identify the source of bleeding from the stomach.
After these maneuvers are completed, the spleen is delivered into the wound with blunt dissection of the posterior attachments. To keep from entering the splenic vein, care should be taken not to divide the posterior attachments too far medially. It is also important to avoid axial rotation of the spleen before securing the splenic vessels with vascular loop or clamps; such rotation may lead to disruption of the splenic artery or vein.
Dissection is carried out at the hilum in close proximity to the spleen to avoid injury to the pancreas. Individual ligation of the splenic artery or arterial branches and the splenic vein or venous branches is generally preferable. This is accomplished by means of double ligation and transfixation with nonabsorbable suture ligatures.
In the case of a markedly enlarged spleen (severe splenomegaly), it is often preferable to place a vascular loop or vascular clamp on the splenic vessels (see the image below) and double-ligate the vessels with heavy nonabsorbable suture. One may then proceed with suture ligation using a transfixed technique. This approach avoids slipped-off sutures and helps prevent postoperative bleeding.
After removal of the spleen, hemostasis is obtained and confirmed in a systematic fashion through careful inspection of the left subphrenic area, the greater curvature of the stomach, and the short gastric vessel area, as well as the splenic hilum. Inspection of these areas is facilitated by proper retraction of the stomach and small bowel to allow clear visualization of the left upper quadrant and surgical bed. Attention is then turned to the surgical field to check for active bleeding. Any active bleeding is identified and hemostasis achieved.
Replaced R hepatic arises from?
SMA
Replaced L hepatic arises from?
left gastric (courses through gastrohepatic ligament)
CMI Triad
CMI Velocities
food fear, weight loss, postprandial abdominal pain
Celiac: PSV >200cm/s = >70% stenosis, EDV > 55cm/s = >50%
OR: retrograde hepatic artery flow specific for significant celiac dz
SMA: PSV >275cm/s = >70% stenosis, EDV > 45cm/s = >50%
First line for CMI
endovascular (femoral approach, tour guide sheath)
Exposure of celiac
Divide triangular ligament to mobilize left lobe of liver
Divide gastrohepatic ligament to enter the lesser sac
Retract liver to right with a self-retaining retractor
Push esophagus left (use NGT to assist with identification)
Divide peritoneum overlying crura to identify celiac vessels
Typically trace common hepatic artery backwards to identify celiac artery
Watch out for the left gastric vein as it crosses the celiac artery as it drains the lesser curve of the stomach into the portal vein.
About half of the time, the phrenic artery takes an origin from the celiac artery and must be controlled during exposure.
To expose the supraceliac aorta, divide the median arcuate ligament and separate the left and right crura from each other.
You can trace most of the proximal celiac distribution right at the origin, and through this exposure you get access to the origin of the SMA if you mobilize the superior border of the pancreas. The neck of the pancreas and the splenic vein cross the anterior of the SMA, obscuring the rest of the mid and distal SMA from the superior approach.
Operative Strategies for AMI
Resect frankly necrotic bowel and contain gross spillage. Once you revascularize the bowel, compromised-appearing bowel may improve and not need immediate resection. Thus the first step is only damage control, to remove anything completely unsalvageable that is making the patient sick, or anything causing gross contamination of the operative field. The key is you’re not doing anything definitive with the bowel as your first step.
Revascularization. SMA embolectomy is the initial management of choice for embolic disease. Thrombotic disease, on the other hand, may be more challenging to treat by embolectomy alone, and frequently are treated with a bypass. (More to come on these procedures).
Re-assess bowel viability. Clinical status permitting, 20-30 minutes should be taken to fully assess the results of the revascularization before proceeding with resection. Perfusion can be assessed by many methods, including clinically, by Doppler, pulse oximetry (a.k.a. photoplethysmography), fluorescein fluorescence, etc. The take home is to give the bowel enough time to be perfused before going ahead with resection.
Proceed with temporizing or definitive bowel repair. Resection, leaving in discontinuity, primary anastomosis, diversion, etc. All of these are options on the table, but the key here is that all of the previous steps occur before addressing the bowel.
Consider second-look laparotomy. Many times, bowel may look questionable even after revascularization and thorough re-assessment. To preserve the most bowel length, it may be reasonable to leave borderline bowel alone at the index operation and do a “second look” to fully reassess the bowel, especially after the patient has benefited from aggressive resuscitation in the ICU.
Endovascular approaches to acute mesenteric ischemia have been described but data is limited. Exploratory laparotomy and embolectomy should be preferred management
Options for Revasc
And what are some of my options for constructing a bypass?
Short retrograde aorto-SMA bypass:
This bypass takes is origin off of the aorta just below the SMA, anastomosing typically end-side onto the SMA just below its origin in order to bypass ostial or very proximal disease. This is a relatively quick bypass, with only one field of dissection directly from the aorta below the SMA onto the proximal-mid SMA. The length of the bypass is very short, limiting concerns with kinking or twisting of the bypass. However, this may not always be feasible, as SMA disease often coexists with significant aortic disease. Additionally, the other bypasses described have better reported patency.(Scali et al. 2019)
Long retrograde R iliac-SMA bypass (“C-loop”):
This bypass originates from the right common iliac artery, which presents a number of distinct advantages over an aorto-mesenteric bypass. First, using the iliacs avoids the hemodynamic consequences of an aortic cross-clamp, which may be contraindicated depending on your patient’s medical condition. Second, you can avoid showering, causing dissection, or otherwise injuring your clamp sites if you have significant disease in the mesenteric segment of the aorta, which is common in patients with chronic mesenteric ischemia. The graft should be tunneled in a gentle C-loop towards the SMA to avoid kinking or twisting. The proximal anastomosis is performed end-side on the iliac artery, and the distal can be performed either end-end or end-side depending on the anatomy of the disease. Especially when using prosthetic in a contaminated field, you can consider taking an omental flap to wrap or cover the prosthetic.
Antegrade supraceliac aorta-SMA bypass:
This bypass originates from the supraceliac aorta. If revascularization of both celiac and SMA is planned, a bifurcated graft can be selected. A side-biting aortic clamp can be used to mitigate the hemodynamic effect of an aortic cross-clamp. The tunnel to the SMA is created with gentle finger dissection in a retropancreatic plane, taking care to avoid injury to the SMV.
Also: ROMS, endo
SMA Exposure Lateral
- mobilize the 4th portion of the duodenum by dividing the ligament of Trietz
- SMA is isolated in the tissues cephalad to the duodenum
- proximal exposure enhanced by retracted the inferior border of the pancreas to the level of the left renal vein
Endovascular Repair
In most cases access to the superior mesenteric artery can be gained through a retrograde femoral approach. Antegrade left brachial artery access is favored for an acutely angulated mesenteric artery, an excessively narrow or tortuous distal aorta or iliac arteries, or occlusive and long segment lesions of the visceral vessels (Figs. 41-7 and 41-8). Some studies have reported more frequent stent dislodgement21 and mortality22 through a femoral approach because of greater catheter manipulation.
A 5-Fr introducer sheath is first placed in the access artery, and a pigtail catheter is used to perform an aortogram. A lateral view demonstrates the origins of the celiac artery and the superior mesenteric artery and the presence and extent of stenosis. Anteroposterior views are used to assess the collateral circulation, as well as the origin of the inferior mesenteric artery. Selective magnified views complete the initial angiogram.
If endovascular treatment is selected, the 5-Fr sheath is exchanged for a long guiding 6-Fr sheath to allow better support and pushability to catheterize and cross the lesion. A brachial artery cutdown can be performed if a larger sheath is required to prevent access site complications. Systemic heparin (80-100 units per kilogram of body weight) is given, and an activated clotting time greater than 240 sec is maintained during the procedure. From a femoral approach the target vessel may be accessed using a hydrophilic 0.035-inch angled wire and a preshaped catheter such as a Cobra 2 or Sos II. At times a simple angled glide catheter will suffice. If the lesion is difficult to cross, 0.018- or 0.014-inch wires should be considered. After the wire placement has crossed the lesion, the catheter is advanced beyond the lesion and its position within the lumen is confirmed by an angiogram performed through the catheter. The extent of the lesion is assessed, and distal embolization and arterial dissection are excluded.
When the severity of stenosis is uncertain, a mean pressure gradient can be measured across the lesion to confirm a hemodynamically significant lesion (>10 mm Hg). If the lesion is occlusive or nearly occlusive, predilation should be performed with a 1.5- to 2.5-mm coronary balloon. In severely calcified or eccentric lesions with thrombus, a distal embolic protection device can be deployed.
A stiff wire, such as an Amplatz wire (Cook Medical, Bloomington, Ind.) is then placed across the lesion to track larger balloons or stents. Severely calcified, eccentric, occlusive, or dissected lesions are primarily stented. Ostial lesions should be stented using a balloon-expandable stent (5- to 7-mm diameter) with 1 to 2 mm extending into the aorta. A simple angioplasty can be performed on straightforward atherosclerotic lesions, and a stent can be placed for residual stenosis (>30%) or a residual pressure gradient.
Completion angiography in lateral and anteroposterior views is performed. Occasionally, because of wire or catheter manipulation, vasospasm may be present, and selective intraarterial infusion of nitroglycerin (200 mcg) or papaverine (30 mg) is used to reverse the spasm. The presence of dissection or embolization is also assessed, and if present, an attempt to retrieve the embolic particles can be made using a suction export catheter. If unsuccessful, focal thrombolytic therapy should be pursued. Emergent open revascularization should be pursued if ischemic bowel is suspected. Delay in treatment results in propagation of a clot and progressive intestinal infarction. Vessel rupture can also occur, particularly if the vessel is severely calcified. A covered stent, such as the iCast, can be used to seal the rupture site. Dislodged or fractured stents should be removed using a snare or grasping forceps, followed by an angiogram to rule out traumatic vessel dissection or perforation.
Postoperative Care
*Procedure-related complications range from 0% to 29%.23 Therefore all patients should be admitted for 24-hour observation and hydration after angioplasty and stenting of the superior mesenteric or celiac artery.
*Clopidogrel should be initiated at an oral loading dose of 300 mg and continued at 75 mg daily for 1 month. Daily aspirin (81 or 325 mg) should be initiated and continued indefinitely.
*Complaint of abdominal pain or tenderness should be assessed with duplex or computed tomography imaging.
*Urine output and creatinine should be monitored, because renal embolization can occur during the procedure.
*Patients can be fed the day after the procedure.
*A baseline duplex of the treated vessel should be obtained before discharge, every 6 months for 1 year, and annually thereafter.
Complications
*Morbidity and mortality. Over the last 10 years, numerous reports have documented excellent technical results (82%-100%) with low morbidity and 30-day mortality rates of less than 5%.23
*Access site complications. Most common early complications are related to the access site, including a hematoma or pseudoaneurysm, brachial sheath hematoma, access artery thrombosis, or retroperitoneal hematoma. A recent report of local complications of percutaneous brachial access noted a local complication rate of 6.5%, although complications occurred more frequently in females (11.5% vs 2.7%).24,25 Aspirin lowered the risk, whereas oral anticoagulation was associated with an increased risk of hematoma.
*Embolization. Wire and catheter manipulation during the procedure can result in particle embolization into the renal arteries or lower extremities, and splenic infarction has been reported after celiac artery intervention.26
*Acute superior mesenteric artery thrombosis. Early complications can result in acute mesenteric ischemia, including symptomatic thrombotic occlusion because of unrecognized arterial dissection or arterial injury and stent thrombosis.27 Reperfusion hemorrhage is rare.28
*Long-term patency. Cumulative patency over 3 years is reported between 44% and 88%. Sarac and associates reported a 1-year patency, a primary assisted patency, and a secondary patency of 65%, 97%, and 99%, respectively.22 Atkins and colleagues reported a primary patency of 58% and a primary assisted patency of 65% at 1 year.29 The most recent report of midterm patency notes a 3-year primary patency of 57% and a secondary patency of 92%.24
*Recurrent stenosis. Patients with recurrent stenosis may be treated with repeat angioplasty and stenting. The use of cutting balloons has not been shown to be superior in the treatment of restenosis. Although longitudinal follow-up is necessary, the use of covered stents provides an alternate treatment strategy (see Fig. 41-6).
Omnilink stent
Contraindications to EVLT
When to treat?
GSV >12mm width raises concern for incomplete obliteration
Superficial GSV unlikely to be pushed down with tumescence - could cause staining or thermal injury to the skin
GSV tortuosity may limit the ability to pass a catheter and sufficiently ablate the vein
Acute superficial vein thrombosis.
after failure of conservative therapy with 3months compression 30-40mmHg
EHIT
EHIT Grade Description Treatment
1 Extension to SFJ
None
2 Extension into deep system <50% of lumen diameter
Close observation (repeat US 1 weeek) vs anticoagulation
3 Extension into the deep system >50% of lumen diameter Anticoagulation x 3 months
4 Occlusion of the femoral or popliteal vein
Anticoagulation x 3 months
Risks of EVLT
EHIT
Bruising
Thermal Injury
Nerve injury
Fistula (GSV- External pudendal)
Sclerotherapy Risks
Hyperpigmentation is probably the most common complication (11-80%), but only a small percentage persist up to a year (1-2%). Incision and drainage of the thrombus 2-4 weeks after treatment may reduce hyperpigmentation.
New appearance of fine red telangiectasias (AKA telangiectatic matting) is related to underlying vessel injury in 5-57% of patients and can persist up to 1 year (1%).
Cutaneous necrosis is rare (<1%) and results from extravasation of sclerosing agent, injection into dermal arteriole, reactive vasospasm or excessive cutaneous pressure.
DVT and cutaneous nerve injury are also rare.
1 in 5000 neurological event (Superficial–>Deep–>PFO–> Brain)
Allergy to sclerosant
Acute cellulitis
Criteria for treatment of perforator
The clinical criteria most often used to as an indication for treatment is >350ms of deep to superficial reflux, diameter greater than 3.5mm and near a healed or active ulcer.
Virchow’s Triad
venous stasis
hypercoaguable state
endothelial injury
Risk factors for DVT
Prior DVT
Surgery
Trauma
Travel
Immobility
Malignancy
OCPs
Dabigatran Reversal
Xa-inhibitors Reversal
Dabigitran - Idarucizumab.(Glund et al. 2019)
Edoxaban, apixiban and rivaroxaban - andexanet alfa.(Connolly et al. 2019)
Nonspecific with some effect on other DOACs - PPC, Factor 7, and activated PPC.(Cuker et al. 2019; Kearon et al. 2016)
Warfarin Induced Skin Necrosis
This occurs shortly after initiating warfarin and presents with purple, cool, painful toes and punctate areas of necrosis and petechiae. Treatment includes immediate cessation of warfarin and transition to LMWH, normalization of INR with Vit K and FFP.
PE C/I to thrombolysis
Age >75
Intracranial neoplasm
Intracranial/spinal surgery or trauma with the last 2 months
History of hemorrhagic stroke
Active bleeding or known bleeding disorder
Non-hemorrhagic stroke within the past 3 months.
PTS grading
Villata
PTS
people get swelling, heaviness, pain. There is a very unique symptom, which is venous claudication, which is almost pathonogmonic of post-thrombotic syndrome with venous outflow obstruction. It’s this pain which has a bursting tense quality in the calf on exertion, which does settle on stopping, but it takes a lot longer than arterial claudication. So sometimes people will take half an hour to get better and the leg has to be elevated. So that’s venous claudication and that’s often the most disabling symptom. But of course, people can develop the same clinical complications than you can with any venous disease—skin changes, lipodermatosclerosis, venous leg ulceration, et cetera. Those are the summery of symptoms for PTS, seen in up to 50% but probably closer to 25% of proximal DVT.
Pregnant Patient and placenta previa
A rather challenging and unique patient would be a pregnant patient with a DVT and placenta previa. Anticoagulation is contraindicated in placenta previa and in addition, an infrarenal IVC filter is also contraindicated, so she would require a suprarenal IVC filter.
Phlegmasia Cerulea Dolens
What is it, how to treat?
The reason it happens is almost certainly a profound obstruction of venous outflow. So the venous blood in the leg cannot escape. You get this cycle of worsening pressure, leaking of fluid from the capillaries, increasing pressure on the soft tissues. Then that starts to threaten tissue perfusion and potentially if it’s bad enough this will threaten the actual arterial profusion of the leg as well. Presentation often includes iliofemoral DVT with non-palpable pulses and loss of sensation with out improvement on anticoagulation and elevation. Endovascular early thrombus removal is the first line with fasciotomies, with open thrombectomy as back up for salvage
SVC Syndrome
Angioplasty and stenting are first line treatment for benign etiology.(Rizvi et al. 2008; Sheikh et al. 2005) Angioplasty alone may be sufficient, but stenosis refractory to angioplasty may require stenting. SVC syndrome with failed endovascular management in reasonable operative candidates can undergo open reconstruction with large diameter prosthetic graft or spiral vein graft.(Doty, Flores, and Doty 1999) However, restenosis in open repair can be as high as 15%.(Kalra, Sen, and Gloviczki 2018; Sfyroeras et al. 2017)
SVC syndrome secondary to malignancy, bronchogenic or lymphoma, is often most effectively treated with palliative radiotherapy with good response.(Talapatra et al. 2016) Endovascular or open recannalization is often reserved only for those with severe symptoms refractory to radiation or chemotherapy.
Lymphedema
primary dysfunction of the lymphatic channels or the secondary result of a disease that results in the destruction of lymphatic flow. Causes of secondary lymphedema include filariasis, which is endemic to parts of South America.
Lymphedema Stages
The management of lymphedema is determined primarily on its clinical stage at presentation.(Grada and Phillips 2017) The staging for lymphedema is as follows:
Lymphedema Stage Description Symptoms
0 Sub-clinical No swelling, heaviness or discomfort
1 Spontaneous Reversible Swelling improved with limb elevation
2 Spontaneous Irreversible Pitting and swelling, not improved with elevation
3 Lymphostatic elephantiasis Skin hardening, non-pitting edema, verrucas changes, recurrent infection
Lymphedema Diagnosis
On physical exam, a classic finding is Stemmer’s sign, which is a thickened skin fold at the based of the second toe/finger. The sign is positive when the tissue is hardened and cannot be lifted.(S. G. Rockson et al. 1998; Stanley G. Rockson 2019)
Lymphedema is most often diagnosed based on clinical presentation and physical exam. Lymphoscintography can be used to confirm the diagnosis in complex presentations and would demonstrate dermal back flow, absent or delayed transport, crossover filling, absent or delayed visualization of lymph beds.
Lymphedema Treatment
Treatment is best initially managed with combined decongestive therapy (CDT) which includes an intensive reductive phase (4-8wks), followed by life long maintenance, often with specific compression garments.(Grada and Phillips 2017) CDT in the setting of heart failure has been reported to lead to volume overload.(Lawenda, Mondry, and Johnstone 2009)
In extreme cases, after CDT therapy has been instituted for at least 6 months and the patient has persistent refractory symptoms, surgery may be used for reconstruction or debulking
EVLT Technique
Leg prepped and draped in sterile fashion
Under ultrasound guidance administer local anesthesia to the skin overlying the GSV
Access the vein with a micro
Advance laser through a point 2cm distal to SFJ
Administer tumescent anesthesia along the vein (1cm deep to skin surface)
Withdraw laser while activated 1-2mm/sec
Withdraw laser and sheath
Apply compression bandage
Obtain duplex in 72h to evaluate for successful ablation
What is in tumescent, what is its purpose?
heat sink
compresses vein
local anesthesia
40ml 1% lidocaine with epi
10ml sodium bicarb
450ml normal saline
safe amount: 35mg/kg
EVLT C/I
SVT
Acute DVT
Venous aneurysm
ABI < 0.9
Vein <2mm or >20mm, tortuous proximal segment
