Vascular Flashcards
EVAR
Choose appropriate endograft based on 3D reconstruction of CT scan
Expose the common femoral arteries bilaterally or place closure devices
Insert sheaths and catheters at level of renal arteries; perform abdominal and pelvic aortogram
Administer heparin
Insert main body of endograft just below renal arteries
Obtain wire access of contralateral side gate of endograft
Place contralateral iliac limb
Balloon angioplasty sealing zones and joints
Perform completion angiogram and assess for presence of endoleaks
Administer protamine to reverse heparin
Close arteriotomies and groin wounds or deploy closure devices, check distal pulses
Potential Pitfalls
Endoleak
Vascular injury
Distal embolism
Open AAA Repair
Midline abdominal incision
Reflect small bowel to right, transverse colon superiorly, insert self-retaining retractor
Dissect duodenum off of the aorta, and define proximal clamp site
Dissect distal aorta and proximal iliac arteries, taking care to avoid sympathetic nerves
Choose appropriate graft size, administer heparin (ACT goal of >250), furosemide, and mannitol
Clamp iliac arteries followed by proximal aorta
Open aneurysm sac opposite IMA, remove thrombus, and oversew back bleeding lumbar arteries
Sew in graft starting proximally, then distally, with monofilament suture
Reestablish blood flow through graft, administer protamine, obtain hemostasis
Close aneurysm sac and retroperitoneum over graft
Close abdomen, check distal pulses
Potential Pitfalls
Embolus to lower extremities
Significant aortoiliac occlusive disease (AIOD)
Aberrant venous anatomy
Ischemia–reperfusion injury to lower extremities
EVAR for rAAA
=/- Endovascular placement of aortic occlusion balloon catheter
Expose bilateral common femoral arteries (or insert percutaneous closure devices)
Introduce wires and sheaths
Perform aortogram
Systemic heparin
Main body of endograft inserted and deployed just below renal arteries
Contralateral limb inserted and deployed
Balloon angioplasty at proximal and distal fixation points
Completion angiogram
Confirm distal flow with doppler
Administer protamine
Close arteriotomies, check pulses, and close wounds
Potential Pitfalls Endoleak (type I or III) Embolism Dissection or rupture of iliac, femoral arteries Abdominal compartment syndrome Ischemic colitis
Lower Extremity Endovascular Intervention
Perform ultrasound-guided access of contralateral common femoral artery with a micropuncture kit
Perform aortography, lower extremity angiography
Heparinize patient, place appropriately sized long access sheath (e.g., 55 cm) over the aortic bifurcation into target extremity over a stiff wire (e.g., Amplatz)
Carefully cross the lesion of interest using appropriate wire/catheter combination
Pretreat lesion with adjunctive therapy (e.g., atherectomy) if necessary
Perform balloon angioplasty or stent placement
Perform completion arteriogram
Reverse heparin with protamine; remove access sheath or deploy closure device
Hold manual pressure until hemostasis is deemed satisfactory
Potential Pitfalls
Improper placement of arterial puncture resulting in inability to properly compress and increased likelihood of retroperitoneal hematoma or arterial pseudoaneurysm
Contralateral iliac artery occlusion not appreciate preoperatively
Iatrogenic arterial dissection from balloon angioplasty
Infrainguinal Bypass Graft with Nonreversed Greater Saphenous Vein
Expose inflow artery for proximal anastomosis and evaluate suitability for proximal anastomosis.
Expose target artery for distal anastomosis and evaluate suitability for distal anastomosis.
Expose saphenous vein (>3 to 3.5 mm diameter) of adequate length through skip incisions or endovein harvest. Ligate side braches with fine silk and divide. Ligate and divide vein distally and at saphenofemoral junction.
Prepare vein for bypass with gentle distension of heparinized saline and repair any leaks. Excise proximal valves under direct vision or reverse
Create bypass graft tunnel between donor and target arteries with blunt clamp or tunneling device. Place umbilical tape through tunnel.
Systemically heparinize (100 mg/kg)
Perform proximal anastomosis:
Clamp donor artery distally and then proximally.
Make arteriotomy.
Fashion proximal vein (spatulate) to match arteriotomy.
Perform beveled anastomosis with running 5-0 polypropylene suture.
Lyse valves in vein under arterial distension using valvulotome. Confirm pulsatile flow.
Bring graft through tunnel under arterial pressure. Avoid kinks. Confirm pulsatile flow.
Perform distal anastomosis:
Occlude target artery (clamps or pneumatic tourniquet).
Make arteriotomy.
Trim vein under distention and fashion to match arteriotomy.
Perform anastomosis with running 6-0 polypropylene suture.
Confirm flow through graft and outflow arteries with pulse exam and continuous wave Doppler.
Perform completion angiography and/or duplex ultrasonography.
Femoral thromboembolectomy
Systemic heparinization (PTT 2–2.5× baseline or Xa 0.3–0.7 units/mL) immediately when ALI diagnosed.
Book patient for hybrid operative suite if available.
The abdomen, both groins and both legs (circumferentially) are prepped into the operative field.
Vertical skin incision below the inguinal ligament over the femoral pulse. If no pulse is present, the vertical incision is made vertically just medial to the midpoint of the inguinal ligament.
Lymphatic channels should be ligated with silk ties, and arterial circumflex branches should be preserved.
The common femoral, superficial femoral, and profunda femoris arteries should be controlled circumferentially with elastic vessel loops.
The patient should be systemically heparinized further to an ACT of >250.
Vessel loops are secured and a transverse arteriotomy is made over the femoral bifurcation.
A 4F or 5F Fogarty embolectomy is passed proximally until it returns clean twice. This is repeated distally, down the superficial femoral and profunda femoris arteries.
Once inflow and outflow has been reestablished, the arteriotomy is closed with several interrupted 5-0 monofilament permanent sutures (such as Prolene).
The groin is closed in layers, femoral sheath, Scarpa’s, deep dermal, and subcuticular using absorbable suture.
Strong consideration should be given to four compartment fasciotomies on the operative side, particularly in a patient with no evidence of chronic peripheral arterial disease.
Carotid endarterectomy
Establish arterial line blood pressure monitoring and neurologic monitoring, position the patient with hyperextended neck facing away from side of interest
Incise the skin (anterior to sternocleidomastoid) and platysma, retract the sternocleidomastoid laterally, identify the internal jugular vein and ligate the facial vein
Expose the CCA, ECA, and ICA with sharp dissection and minimal manipulation, identifying and preserving the vagus and hypoglossal nerves
Administer heparin (100u/kg), clamp the ICA, CCA, and ECA, respectively. Note: if performing stump pressure measurements, clamp the CCA and ECA and transduce ICA pressures by sticking the CCA above the clamp; ICA pressure will transmit across stenosis
Make arteriotomy starting on CCA and extending to ICA; perform the endarterectomy
A shunt is placed into the ICA and CCA and secured with Rommel tourniquets. A Doppler is used to interrogate the shunt to ensure blood is flowing
Flush with heparinized saline, assess the end points of endarterectomy, place tacking 7-0 prolene sutures if needed
Perform patch angioplasty with bovine pericardial patch (or autogenous vein/dacron/ptfe), remove shunt, back bleed ICA and ECA, forward bleed CCA
Unclamp ECA, CCA, and ICA, respectively
Assure hemostasis; perform completion study (doppler, duplex) and give protamine sulfate
Place closed suction drain in subplatysma space; close incision in layers
Check neurologic status prior to leaving the OR
Potential Pitfalls
Cranial nerve injury
Perioperative stroke
Perioperative myocardial infarction
SMA Revascularization
Liberal midline incision and full abdominal exploration
Exposure of SMA by cephalad retraction of the transverse mesocolon, rightward retraction of the small bowel, and division of the ligament of Treitz
Obtain proximal and distal control of the SMA and administer systemic heparin
Perform an embolectomy via transverse arteriotomy and passage of a Fogarty catheter (4-5 Fr for proximal, 3-4 Fr for distal)
If inflow is reestablished, close the SMA utilizing a patch angioplasty if vessel narrowing is anticipated or transverse interrupted closure with prolene
If inflow fails to be reestablished, the etiology is likely SMA thrombosis and a retrograde SMA bypass should be performed
Create the distal anastomosis on the SMA first, ideally with reverse saphenous vein graft
Proximal anastomosis can be performed either on the infrarenal aorta or the iliac vessels
Assess bowel viability after 30 minutes using visual inspection, Doppler probe, and/or fluorescein
Potential Pitfalls
Failure to efficiently recognize the diagnosis
Not adhering to “damage control” principles
Resecting too much bowel at the index operation
Metabolic disturbances once the affected bowel has been revascularized
Endo Tx for CMI
Choose appropriate access site (femoral for retrograde access or brachial)
Insert sheaths and catheters- will need 6 Fr, ensure brachial big enough for that
Perform AP and lateral abdominal aortogram
Administer heparin
Obtain wire access of mesenteric vessel
Place long guiding catheter or long sheath into target vessel
Chose appropriate type and sized stent (consider IVUS to assist selection)- balloon expandable for origin stricture vs self expandable for distal tortuous segments
Treat addition mesenteric vessel as above if indicated
Perform completion angiogram
Surrender wire access and remove sheaths
Consider use of closure devices
Check distal pulses and monitor postoperatively
Potential Pitfalls
Access site complications
Inability to access target vessel
Distal embolization
Sx Tx CMI
Midline abdominal incision
Expose inflow vessel
1-Left medial visceral rotation for aortomesenteric endarterectomy
2-Through the lesser sac for antegrade bypass
3-Infrarenal aorta or iliac artery for retrograde bypass
Expose target (outflow) vessel
1-Through lesser sac for celiac
2-Root of mesentery for SMA
Confirm decision on number of vessels to revascularize
Choose appropriate bypass conduit including type and size
Systemically heparinize patient
Clamp inflow vessel, perform arteriotomy, and complete proximal anastomosis with running monofilament suture
—-Alternatively, clamp aorta and mesenteric vessels; perform trapdoor incision and endarterectomized flap
Clamp target vessel, perform arteriotomy, and complete distal anastomosis with running monofilament suture
—-Close trapdoor incision with running monofilament suture
Reestablish blood flow through graft
Assess mesenteric pulses and viability of the bowel
Obtain hemostasis, consider reversal of heparin
Close abdomen and transfer to ICU for postoperative care
Potential Pitfalls
Kinking of bypass graft
Ischemia–reperfusion injury to bowel
Significant aortoiliac occlusive disease (AIOD)
Thrombectomy/Thrombolysis for DVT
Prep widely including the full extent of the involved leg.
Use mechanical thrombolysis catheters.
May require overnight thrombolysis w/TPA and serial fibrinogen levels.
Adjunctive stenting may be necessary, especially in cases of May-Thurner syndrome.
Intraoperative duplex and drain placement if open surgery is required.
Compression/elevation/sequential compression devices in order to assure adequate inflow.
Potential Pitfalls
Adequate length of infusion catheter to cross the lesion.
Bleeding due to technical reason, anticoagulation, HIT, or DIC.
Importance of a technically perfect result.
AVF creation
Intraoperative ultrasound to mark course of cephalic or basilic veins
Antecubital incision through crease
Dissection of cephalic and median antecubital vein
Mobilization of cephalic vein with ligation of proximal branch
Dissection of brachial artery
Distention of the outflow vein and spatulation of orifice
5000 U heparin followed by vascular control of brachial artery and arteriotomy
Tension-free anastomosis with running 6-0 prolene
Confirmation of adequate access thrill and arterial biphasic Doppler signal at wrist
Potential Pitfalls
Injury to cephalic or median antecubital vein with skin incision
Excess tension on the outflow cephalic vein
Kinking or compressing the outflow vein with skin closure
Absence of a thrill in access
