VASCULAR Flashcards
EVAR
A line Nipples to toes Bilateral femoral cutdown's Heparinized Bilateral ilial femoral sheets placed Captures place in the aorta and renal arteries marked Aortogram performed Verify Lanks internal iliac arteries Body of the Integraph inserted over stiff wire and deployed just below the renal arteries
Contralateral Gay is opened and cannulated - stiff wires introduced
Contralateral lamb is introduced over the wire and docked into the main body and deployed
Balloon angioplasty performed the Upper and lower fixation sites as well as graft junctions
Smooth out any wrinkles in the graft
Completion angiography
Confirm exclusion of AAA and evaluate for endoleak
Wires and sheets are removed
arteriotomiesclosed
flow confirmed to distal arteries
Protamine administered
groin wounds closed
Distal extremity pulses are checked
Open AAA
Prep Nipples to toes
Midline laparotomy
Transverse bowel retracted cephalad
Small bowel retracted to the patient’s right
Reset the duodenum off of the aorta
Expose the aorta blow the renal arteries
Expose bilateral common iliac arteries
Left renal vein maybe divided if needed for exposure to the aorta
Diuresis if the patient can tolerate
Administer heparin for activated clotting time of 250
Clamp lax then aorta– Alert anesthesia
Enter aneurysm ( at the level of the IMA)
evacuate clot
ligate lumbars
So the proximal graft in place
ligate lumbar if there is could back bleeding from it
Re-implant IMA if there is port back bleeding
(careful, may just ligate if completely included – already dependent on collateral)
So in proximal graft then distal graft
Back bleed clot and debris
Stage reperfusion of legs
Reverse heparin
Close the aneurysm sac over the graft
Check distal extremity pulses
Close the abdomen
AAA
Supraceliac Clamp
Divide the lesser omentum
Divide falciform ligament
Devide L hepatic triangular ligament
Push stomach and liver to the right
Divide left crus
Retract esophagus to left (or right?)
Compress aorta against spine or clamp.
Distal control of iliacs - with incison of peritoneum over lying them
5,000 of Heparin is now given
ACT drawn
Pack transverse colon cephlad and small bowel to the right.
Take down ligament of treitz, follow it up in avascular vein, see renal vein, lift it up, and Aorta just below
the 3/4th portion of the duodenum is releflected off of the aorta.
the retroperitoneum over Aorta is divided
infra-renal clamp placed
(and supraceiliac removed)
Avascular plane developed at the level of the IMA - at this level the aneurysm sac is opened - cell saver used to evac contents
IMA flow is noted and encircled.
Proximal then distal graft is anast.
Reassess IMA:
No backflow do not need to re-implant
Brisk backflow do not need to re-implant
Modest backflow less than 40 mmHg - need to re-implant
Back flush graft
Check pulses
Reverse hep
Protamine one mg per 100 units of heparin
Retroperitoneal exposure
For midline incision
Inside the spinal renal ligament spinal phrenic ligament
Take down the the splenic flexure
Gain entry to the retroperitoneum from the lateral aspect of the sigmoid – white line of told
Plane is then bluntly developed between the spleen, pancreas, colon mesentery and
Anterior to Gerota’s does fashion
Complete access to: Aorta from celiac access to bifurcation Left kidney Left adrenal gland Left ureter
Right-sided retroperitoneal exposure
Extended Koker
Medial rotation of colon duodenum
Incise the mesentery of the small intestine until the ligament of Treitz is reached
Gaines exposure to: Infrarenal aorta Inferior vena cava Head of the pancreas Entire duodenum Right kidney Right ureter Adrenal gland
Carotid endarterectomy key moves
EEG - monitor
Anterior SCM Platysma flaps Strap muscles Facial vein Carotid sheath In circle vessels Administer heparin A CT Clamp: ICE is NICE check EEG changes Shunt enarterectomy Feather leading edge Tack down edge Bovine pericardial patch Flush respective arteries Release clamps: EC CC IC
Popliteal aneurysm
1– 2 cm posteromedial and parallel to the tibia A 10- to 12-cm longitudinal skin incision was performed .
fascia was incised and the popliteal space was entered.
retracting the gastrocnemius muscle posteriorly and laterally.
semimembranosus and semitendinosus muscles were retracted to further facilitate the exposure.
The popliteal vessels were identified.
A 2-cm segment of the most distal popliteal artery was sharply dissected.
Attention was then directed to the groin.
A vertical curvilinear skin incision overlying the right common femoral artery was made extending down the upper medial thigh along the preoperatively mapped GSV.
The incision was deepened through the subcutaneous tissues with electrocautery. The encountered lymphatics were ligated and divided. The common femoral artery was then exposed and sharply dissected circumferentially. The dissection was extended proximally to the inguinal ligament and distally to include the superficial femoral and profunda femoris arteries.
The common femoral, superficial femoral, and profunda femoris arteries were encircled with silastic vessel loops. Minor branches of the common femoral artery were identified and spared.
The GSV was then identified. The vein was exposed from the saphenofemoral junction to the mid/ lower leg through one continuous incision/ multiple incisions separated by skin bridges. Dextran– heparin– papaverine solution was infused into the GSV through a blunt needle that was placed in a side branch in the most distal aspect of the vein. The GSV was harvested and its tributaries ligated with 3-0 silk ties.
The above-knee popliteal artery was then exposed through the bed of the harvested GSV. The skin incision above the knee was deepened through the subcutaneous tissue, exposing the adductor tendon anteriorly and the sartorius muscle posteriorly. The fascia between these two muscles was incised and the popliteal fossa entered. A self-retaining retractor was placed deeper in the wound and the popliteal artery was palpated and exposed. A 2-cm segment of the proximal popliteal artery was sharply dissected. A tunnel was then created using a Zepplin/ Kelly weck/ Gortex tunneler. The tunnel was subcutaneous/ subfascial parallel to the course of the GSV to the level of the exposed popliteal artery. The patient was given 5000 U of heparin intravenously. The GSV was transected at the saphenofemoral junction and its stump suture ligated with 2-0 silk sutures. The distal end was double ligated and transected. The common femoral artery, profunda, and superficial femoral artery were clamped. A longitudinal arteriotomy in the common femoral artery was performed and extended with Pott’s scissors for 1 cm. The vein was then reversed and its distal end was incised along its posterior wall/ incorporating a side branch creating a T junction shape. The proximal anastomosis was constructed between the spatulated vein and the femoral arteriotomy with a running 5-0/ 6-0 prolene suture. Prior to completing the suture line, back-bleeding, forward-flushing, and irrigation of the anastomosis with heparinized solution was performed. The anastomosis was then completed and checked for hemostasis, which was adequate. The flow through the vein was checked and was pulsatile. The end of the vein was ligated with a 2-0 silk tie. The vein was rechecked for hemostasis. The vein was then passed distended through the tunnel, avoiding any twists. The popliteal artery was then suture ligated proximal and distal to the aneurysm using 2-0/ 3-0 silk/ prolene sutures.
Attention was then focused on the construction of the distal anastomosis. A Yasargil clip was applied on the popliteal artery at the level of its trifurcation. The popliteal artery was transected distal to the ligature. The distal end was incised along its anterior surface for 1 cm. The vein was then transected at the appropriate length. An end-to-end anastomosis was then performed between the distal end of the vein bypass and the popliteal artery using 5-0/ 6-0 prolene sutures. Prior to the completion of the anastomosis, forward-bleeding of the graft and back-bleeding of the tibial arteries was performed. The sutures were then tied and the clamps released. A 20-gauge angiocatheter was then introduced into the vein graft near the proximal anastomosis and an intraoperative arteriogram was performed. This revealed a widely patent anastomosis and no evidence of filling defects or kinks. The angiocatheter was removed and its puncture site repaired with a 6-0 prolene suture. The suture lines and wounds were then rechecked for hemostasis. There were good Doppler signals/ palpable pulses in the foot and a good augmentation of the signal with compressing and releasing the vein graft. The wounds were all irrigated with antibiotic solution. The subcutaneous tissue in the groin wound was closed in two layers of 3-0 Vicryl sutures. The fascia overlying the sartorius muscle and in the popliteal space was approximated with 3-0 Vicryl sutures. The skin was closed with staples. The patient tolerated the procedure well and was transferred to the postanesthesia care unit in stable condition.
Additional study to get with crecendo TIA patient
Head CT
with complete occlusion of contralateral side what do you need to do when doing CEA
shunt!
