Peripheral Vascular Surgery

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1

Peripheral Vascular System

  • Refers to a closed system of blood vessels that transports blood away from the heart (left ventricle) to the body's tissues, & then back to the heart again (right atrium)
  • Arteriole blood transported AWAY from the heart and to the body's tissues
  • Venous blood transported TO the heart
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Blood Vessels

  • (Aorta), arteries, arterioles, capillaries, (exchange of nutrients & waste fluid around the cells in the capillary beds), venules, veins, (Vena Cava)
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Tunica Adventitia

  • Outer layer of connective tissue
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Tunica Media

  • Middle, thickest, layer
  • Includes elastic fibers & smooth muscle fibers that completely encircle the artery
  • Responsible for vasoconstriction & vasodilation
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Tunica Intima

Inner lining of the endothelium

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Blood Vessel Structure (Vein)

  • Composed of same three layers with different thicknesses
    • Middle layer poorly developed with less smooth muscle tissue
  • The lumen of vein is larger than the artery
  • BP with vein is low and blood must work against gravity to return to the heart
  • Equipped with flap-like VALVES that close if blood backs up into the vein
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Arterial System

  • (Left ventricle), ascending aorta, right and left aortic sinuses, right and left coronary arteries
  • 3 major arteries emerge from the aortic arch: Brachiocephalic, left common carotid, & left subclavian
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Brachiocephalic

  • Supplies arm & head
    • Bifurcated into the right subclavian & right common carotid
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Venous System

  • Internal jugular veins (drain brain & meninges, face & neck), right and left subclavian, brachiocephalic veins, superior vena cava, right atrium of the heart
  • External jugular veins drain superficial structures of the face and the scalp
  • Upper extremities drained by the cephalic & basilic veins
  • Abdomen & thorax drained by brachiocephalic (drains head, neck, arms, upper thorax) & azygous veins
  • Lower extremities divided into two groups: superficial & deep
    • Names correspond to the arteries
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Doppler Probe

  • Measures blood flow to the peripheral artery
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CT, MRI, Ultrasound

  • Detection/evaluation of the carotid artery atherosclerosis & thoracic/abdominal aortic aneurysm
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Angiography

  • Diagnosis and evaluation of vascular disease
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Plethysmography

  • Determines variations in blood volume present in, or passing through, extremity
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Phleborheography

  • Diagnosis of deep vein thrombosis
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Vascular Instrumentation

  • Balfour Retractors (Aortic procedures)
  • Weitlaner
  • Hemoclip appliers
  • DeBakey forceps, Ring forceps
  • Potts scissors, Tenotomy Scissors
  • Rubber Shods
  • Right Angle
  • 30cc & 60cc syringes
  • Vascular Clamps (Bulldogs, Profunda)
  • Vascular dilators/catheters
  • Vessel loops/umbilical tape
  • Castroveigo needle holder
  • Sutures: 6-0 or 7-0 (3-0mor 4-0 for the aorta)
    • Double-armed for anastomosis***
  • Silk ties and suture used for ligation
  • Doppler ultrasound
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Biological & synthetic Grafts

  • Grafts used to bypass vascular obstruction or reconnect vessels
    • May be straight or Y-shaped
  • The autogenous saphenous vein is material of choice for distal bypass of the lower extremity
    • May be used in reverse, non-reversed, in situ
  • Synthetic grafts may be made of polyester (Dacron) or polytetrafluoroethylene (PTFE) (Gore-Tex)
    • Dacron is porous and requires pre-clotting
      • Typically used above the knee
    • Some grafts are antibiotic-impregnated (impervious-no need to pre clot)
    • Gore-Tex serves as a framework for tissues ingrowth
      • Used across the knee joint
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Operative Pathology of PVD

  • S/S of peripheral arterial DX is determined by location and degree of obstruction, rapidness of developing obstruction, presence/absence of collateral channels
    • Initial symptoms: Pain from muscle ischemia and Claudication (cramping/aching)
    • Pain brought on by exercise and relieved by rest
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Acute Arterial Occlusion

  • S/S: (4 P's) Painful, paresthetic, pale, pulseless
  • Constant pain in extremity even at rest
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Arteriosclerosis Obliterans

  • Generalized DX affecting arterial system involving the formation of atheroma within the lumen of the artery that restricts blood flow
    • 2 main areas of early involvement: aortic bifurcation & distal superficial femoral artery
  • TX: Smoking cessation, control of hypertension & diabetes, weight reduction exercise, diet management
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Arterial Embolism

  • May consist of blood clots, fat, air, or tumor
  • Embolus circulates through vessels until becoming logged & blocking blood flow to the extremity or organ
    • Approx 80% affect the lower limbs
  • Underlying source usually heart disorders
  • TX: Angiography (stable pt), anticoagulants or enzyme therapy (unstable PT)
  • Surgical removal involves an incision into affect artery to remove thromboembolic material and restoration of blood flow
    • Uses balloon-tipped Fogarty catheter
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Abdominal Aortic Aneurysm

  • Usually diagnosed when the patient is asymptomatic
  • S/S: severe abdominal & back pain with abdominal mass (=rupture)
    • Commonly ruptures into retroperitoneal space
  • Aneurysm also occurs femoral, popliteal, or iliac arteries
  • DX: CT, ultrasound, aortic angiography
  • TX: resection with synthetic graft replacement
    • PT assessed for CAD before aneurysm repair
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Peripheral Vessel Angiography

  • PTCA
  • Balloon selection/size is essential and based on angiographic measurements
    • Too small: under dilation & restenosis
    • Too Large: Dissection of vessel
  • Most common approach is VIA ipsilateral femoral artery
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Endartectomy

  • Excision of thickened, atheromatous tunica intima of the artery
  • Advantages: PT own vessel preserved, no foreign material introduced, procedure more hemodynamically sound
  • Most commonly performed on carotid artery
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Carotid Endartectomy

  • Transient cerebral ischemia
  • Pieces of plaque break away from the common carotid or internal carotid artery and are flushed upstream blocking blood flow to the brain
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Carotid Endartectomy (ITEMS NEEDED)

  • Equipment & Supplies: ESU, Suction, Doppler, Carotid Set (major vascular set), Minor set, hemoclips/appliers
  • Anesthetic and positioning: General; supine with head turned away from the affected side
  • Prep and drape: Prep from the lower ear across the midline of neck to just below the clavicle; square-off towels with thyroid sheet and 3/4 sheet over the feet
  • Post-op complications: Stroke, SSI, hemorrhage
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Carotid Endartectomy Operative Procedure

  • Typical procedural sequence to all endarterectomies after exposure of vessel
    • Vessel dissected free from surrounding tissue
    • Right-angle clamp placed under vessel; vessel loop fed into the clamp, around vessel & clamped with shod
    • (Systemic heparin administered)
    • Vascular clamps applied to vessel proximally and distally
    • Arteriotomy begins with #11 or #12 blades and continues with Potts scissors
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AAA (ITEMS NEEDED)

  • Equipment & Supplies: Cell savor, hypothermia unit, Doppler, ESU, suction, major vascular set, major laparotomy set, Balfour retractor
  • Anesthesia and Positioning: general; supine
  • Prep and Drape: Pred from mid-chest to mid-thigh and bilateral to table; modified laparotomy drape
  • Post-op Complications: SSI, hemorrhage, failure of graft, secondary complications
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AAA Operative Procedure:

  • Incision from xiphoid to pubis and aorta exposed
  • Inferior mesenteric artery isolated; peritoneal incision extended over the common iliac arteries
  • Aorta mobilized proximal to the aneurysm to the level of renal arteries
  • Blood drawn from vena cava for pre-clotting of graft
  • Intravenous heparin administered and vascular clamps applied to common iliac arteries
  • Aortic vascular clap applied above the aneurysm
  • Aneurysm opened longitudinally; thrombus material removed from the interior aorta; lumbar vessels within the aneurysm sac are oversewn
  • T-shaped extension cut into the proximal border of the aneurysm; the aneurysm wall is irrigated with heparinized saline
  • Proximal anastomosis begins; Fogarty clamp placed across the graft immediately distal to anastomosis; aortic clamp released and anastomosis completed
  • Right limb of graft is cut to the length down to the common iliac bifurcation
  • Arteriotomy performed on common iliac vessels and graft anastomosed
  • Anterior wall of aneurysm sac sutured over the proximal aortic graft; abdominal wound closed in layers
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Aortofemoral Bypass (ITEMS NEEDED)

  • Equipment and supplies: Cell savor, Hypothermia unit, Doppler, ESU, Suction, Major vascular set, Major laparotomy set, Balfour retractor, Tunneler
  • Anesthesia and Positioning: General; Supine
  • Prep and Drape: Prep from the mid-chest to toes, bilateral as far as possible and entire leg; abdomen and inguinal areas squared-off, plastic incise drape and laparotomy drape
  • Post-op Complications: SSI. failure/rejection of graft
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Femoropopliteal Bypass (ITEMS NEEDED)

  • Equipment and supplies: ESU, Suction, Doppler, Major vascular set, Minor set, Valvulotome, Tunneler
  • Anesthesia and positioning: General; supine with affected leg externally rotated and abducted
  • Prep and drape: Mid-abdomen to toes and leg circumferentially; flat sheet under the leg, stockinette over foot, femoral area squared-off and split sheet or fenestrated sheet around the leg
  • Post-op Complications: SSI, Failure/rejection of graft
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Femorofemeral Bypass Procedure

  • Subcutaneous graft placed between the two femoral arteries
  • One iliac artery must be free of plaque/obstruction for a bypass to be successful
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Axillofemoral Bypass Procedure

  • Used is abdominal surgery contraindicated for aorta-iliac reconstruction
  • Subcutaneous passage of graft prosthesis from the axillary artery to the femoral artery
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Arteriovenous Fistula and Shunt

  • Established for vascular access for patients who require long-term renal dialysis
  • Creatinine clearance regularly monitored in patients with renal disease
    • Abnormal levels require fistula and shunt procedure in preparation for dialysis
  • Cimino procedure provides shunt between the radial artery and cephalic vein in the forearm
34

IVC Filter Placement

  • Prevents pulmonary embolism (PE) due to deep vein thrombosis (DVT)
    • Deep veins most commonly affected are the iliac and femoral veins
  • Placement is performed when medical therapy does not resolve the disorder
  • Approach typically VIA jugular vein
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Vein Stripping/ Ligation

  • Varicose veins are veins that have become elongated, dilated, and tortuous
    • Characteristic of disorder that is progressive and has no cure
  • Veins characterized as primary and secondary
    • primary: Dilated, visible protrusions of superficial veins
    • Secondary: Results of deep venous disorders
  • Legs most often affected (saphenous veins and tributaries)