1. Chapter 31
Peripheral Vascular
Surgery

2. Peripheral Vascular
Review terms and definitions listed at beginning of chapter
Use your medical dictionary if necessary
Familiarize yourself with the chapter terminology.
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3. Peripheral Vascular Encompasses procedures of arteries and veins
Excludes those involving heart, brain, and cranial vessels
Requires focused concentration and preparation for surgical emergency
Vascular surgeries are performed to treat arteriosclerosis, atherosclerosis, and thromboembolic disease.
Timing is extremely important to minimize the risk of ischemia.
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4. (From Thibodeau G, Patton K: Anatomy and physiology ed 6, Mosby 2007.)
Peripheral Vascular
The systematic and pulmonary systems.
Where does the pulmonary system begin?
Where does the systemic vascular system begin?
(From Thibodeau G, Patton K: Anatomy and physiology ed 6, Mosby 2007.)
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5. (From Thibodeau G, Patton K: Anatomy and physiology ed 6, Mosby 2007.)
Peripheral Vascular
Arteries
Major systemic arteries.
The arteries dilate and contract to accommodate the metabolic needs of the body.
Some tissues such as the liver and the spleen have a rich supply of capillary networks, causing them to bleed easily and profusely when injured.
(From Thibodeau G, Patton K: Anatomy and physiology ed 6, Mosby 2007.)
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6. (From Thibodeau G, Patton K: Anatomy and physiology ed 6, Mosby 2007.)
Peripheral Vascular
Veins
Major systemic veins.
Unlike arteries, veins contain one-way valves, which prevent blood from backing up.
What is the term for the smallest artery in the body?
What is the term for the smallest vein in the body?
(From Thibodeau G, Patton K: Anatomy and physiology ed 6, Mosby 2007.)
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7. (From Thibodeau G, Patton K: Anatomy and physiology ed 6, Mosby 2007.)
Peripheral Vascular
Microciculation in the capillary network.
Describe the organization of the vascular system, including the capillary beds.
What is the largest artery in the body?
What is the largest vein in the body?
(From Thibodeau G, Patton K: Anatomy and physiology ed 6, Mosby 2007.)
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8. Peripheral Vascular Structure of the vessels Tunica adventitia
Tunica media
Tunica intima
Name the three layers of blood vessels.
Vasodilating medications act on which layer of tissue?
(From Applegate E: The anatomy and physiology learning system, ed 2, St Louis, 2000, Saunders.)
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9. Peripheral Vascular Arteries
Carry oxygenated blood from lungs to rest of body
Are pressurized
Are much thicker than veins
Are more elastic than veins
Reference Figure 31-1, Structure of blood vessels, in the textbook.
Arteries have a thicker muscle layer and more elastic fibers than do veins.
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10. Peripheral Vascular Veins
Carry deoxygenated blood from body tissues back to heart
Have small valves
Blood within veins moves by pumping action of skeletal muscles
Venous blood pressure is lower than arterial pressure
Veins are more fragile than arteries. Venous bleeding can be difficult to control.
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11. Peripheral Vascular Blood pressure is affected by Sex Age Weight
Exercise
Diurnal fluctuation
What is blood pressure?
Blood pressure is influenced by physiological conditions such as body position, temperature, pain, and emotion.
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12. Peripheral Vascular Blood pressure’s physiological influences
Elasticity of the arterial walls
Total blood volume
Peripheral vascular resistance
Blood viscosity
What are some causes of hypertension?
What are some causes of hypotension?
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13. Peripheral Vascular Diagnostic procedures
Doppler duplex ultrasonography
Arterial plethysmograph
Doppler scanning
Arteriography
Intravascular ultrasound
Diagnosis of peripheral disease is based first on patient history, physical, and routine blood tests.
Interventional arteriography is performed in conjunction with insertion of stents and other devices.
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14. Peripheral Vascular Instruments
A, Top: Vein retractors and metal ruler; Left to right: Obturator for Rumel tourniquet; 2 Weitlaner retractors; 2 Army-Navy retractors; Poole suction tip; Poole suction guard; 2 Yankauer suctions. B, Top: Ribbon retractors; Left to right: 4 Richardson retractors; 3 Deaver retractors. C, Top: Knife handles; Left to right: 2 Adson forceps; 2 Martin forceps; 2 Ferris Smith vascular forceps; 2 DeBakey vascular forceps, medium; 2 DeBakey forceps, long; 2 Russian forceps.
(From Tighe S: Instrumentation for the operating room, ed 6, St Louis, 2003, Mosby.)
What are some factors that determine what instruments will be needed for the peripheral vascular case?
Vascular instrumentation is fragile. Great care must be taken when handling these instruments to avoid damaging their fine tips or causing accidental bending.
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15. Peripheral Vascular Instruments Left to right:
1 Mayo dissecting scissors, straight
1 Mayo dissecting scissors, curved
1 Metzenbaum scissors, 5-inch
1 Metzenbaum scissors, 7-inch
1 Lincoln Metzenbaum scissors
1 Potts-Smith cardiovascular scissors, 45-degree angle
1 Strully scissors, probe tip
(From Tighe S: Instrumentation for the operating room, ed 6, St Louis, 2003, Mosby.)
Reference Figure 31-8, Instruments used in vascular surgery, in the textbook.
Dissection requires sharp, delicate scissors. Blunt and sharp dissection are used to gain access to blood vessels.
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16. Peripheral Vascular Equipment and supplies Suture Materials and design
Nonabsorbable sutures
Sizes range from 3-0 to 8-0
Atraumatic, round, tapered, or beveled needles are used
Double-armed sutures are commonly used
Why are nonabsorbable sutures used on vessels?
Why are double-armed sutures used on blood vessels?
When double-armed sutures are used, the surgical technologist must keep track of both needles. The needles are small and fine and can be easily lost.
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17. Peripheral Vascular Suture (cont.)
Handling of suture material in the field
Should be removed from packet carefully and lightly stretched
GORE-TEX must not be stretched
Rubber shods may be used
Stretching GORE-TEX suture can cause a weakness in its continuity.
A rubber shod holds the unused needle of a double-armed suture, allowing it to apply traction to the suture line and preventing the needle from getting lost.
What purpose do the felt pledgets attached to vascular suture serve?
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18. Peripheral Vascular Vascular grafts Synthetic grafts Natural materials
Dacron
Polyester
GORE-TEX (Polytetrafluoroethylene or PTFE)
Natural materials
Banked human umbilical cord
Bovine grafts
Autograft
Vascular grafts can be made from what materials?
When would a bifurcated graft be used?
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19. Peripheral Vascular Vascular grafts Patch grafts
Vascular grafts are extremely expensive. They must not be opened until the surgeon is sure of the length and the size required.
All commercially prepared grafts include a set of instructions for use. These instructions must be strictly followed to ensure a successful graft.
A, Traction sutures placed at each end of the graft. B, Sutures applied at both sides of the graft.
(From Ouriel K, Rutherford R: Atlas of vascular surgery: Basic techniques and exposures, Philadelphia, 1993, Saunders.)
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20. Peripheral Vascular Vascular Grafts (cont.)
A patch graft is sewn into place using a moistened double-armed suture.
The surgeon will need irrigation squirted into his or her hand to tie the suture.
The suture can be difficult to work with when dry. Moistening the hands and the suture allows for easier manipulation of the suture.
C, The graft may be trimmed as needed (dotted line). D, Completed graft.
(From Ouriel K, Rutherford R: Atlas of vascular surgery: Basic techniques and exposures, Philadelphia, 1993, Saunders.)
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21. Peripheral Vascular Retraction of Vessels
Application of a Rumel tourniquet.
A, The two ends of the umbilical tape are hooked.
B, The tape is pulled through the rubber catheter.
C, The tourniquet is cinched down and secured with a hemostat.
Why would a blood vessel require retraction?
(From Ouriel K, Rutherford R: Atlas of vascular surgery: Basic techniques and exposures, Philadelphia, 1993, Saunders.)
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22. Peripheral Vascular Catheters Fogarty-type embolectomy catheter
Length varies
Size ranges 1- 6 Fr
Tuberculin syringe needed
The most common method of removing thrombi is with a Fogarty type of embolectomy catheter.
The balloon must be tested before use and never be overinflated.
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23. Peripheral Vascular Stents
Small metal implant designed to fit against the artery wall
Materials
Stainless steel
Titanium
Nitinol
Most stents are implanted permanently.
What are two commonly used types of stents?
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24. Peripheral Vascular Drugs Anticoagulation Coagulation
Heparinized saline
Coagulation
Collagen or fibrin products
Topical thrombin
Why is heparinized saline used as an irrigation solution in peripheral vascular cases?
Systemic heparin is given intravenously to the patient by the anesthesia provider. What medication is given to reverse the effects of heparin?
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25. Peripheral Vascular Vasospasm Spasm of an artery or vein
May occur because of handling
May be prevented by injection of
Lidocaine
Papaverine
What two medications can be administered to prevent vasospasm?
Medications and irrigation solutions must be clearly labeled on the sterile field.
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26. Peripheral Vascular Atherosclerosis
Obstructive arterial disease that causes stiffening and loss of elasticity of the artery wall
Plaque is a rubbery substance that adheres to the internal lining of a blood vessel.
Plaque that breaks free from the blood vessel and travels to a distant site is an embolism. Embolism formation is a risk when removing plaque.
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27. Peripheral Vascular Endarterectomy
During an endarterectomy, the plaque can be removed in one piece or in smaller bites.
A Freer or Penfield elevator is used to free the plaque from the vessel wall.
A, An arteriotomy is made. B, A plane is created between the vessel wall and the plaque. C, The plaque is divided over a right-angle clamp.
(From Ouriel K, Rutherford R: Atlas of vascular surgery: Basic techniques and exposures, Philadelphia, 1993, Saunders.)
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28. Peripheral Vascular Closure of the Vessel
A, Double-arm suture is placed at each end. B, Continuous sutures placed to provide a sealed closure.
Incisions are closed with a double-armed suture.
Reference Figures 31-13, 31-14, and in the textbook. They illustrate suturing technique, end-to-end anastomosis, and patch graft placement technique.
(From Ouriel K, Rutherford R: Atlas of vascular surgery: Basic techniques and exposures, Philadelphia, 1993, Saunders.)
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29. Peripheral Vascular Anastomosis
When performing a circumferential anastomosis, the two sutures are placed 180 degrees apart from each other. The sutures are then sewn toward each other.
The suture line will be drawn taut and checked for leaks before tied.
A, Two double-arm sutures placed in opposite locations. B, Continuous sutures placed circumferentially.
(From Ouriel K, Rutherford R: Atlas of vascular surgery: Basic techniques and exposures, Philadelphia, 1993, Saunders.)
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30. Peripheral Vascular Hemostasis
Maintaining a dry surgical site, which is critical in vascular surgery
Suction is used more than sponges in peripheral vascular surgery to maintain a dry surgical site.
Hemostasis can be maintained at vessel anastomosis sites by using which hemostatic agents?
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31. Peripheral Vascular Graft tunneling
Establishment of a tunnel through subcutaneous tissue for placement of a graft
Techniques
Use of surgeon’s fingers
Use of tunneler (long metal shaft or instrument)
The surgeon usually threads the graft through the subcutaneous tissue by inserting a long clamp such as a Péan into the tunnel and grasping the graft from the entry site.
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32. Peripheral Vascular Surgical procedure Intraoperative angiography
Preoperatively, injection of contrast media into selected artery and its branches
Used with angioplasty to determine exact location of strictures, occlusion, or malformation
Intraoperative angiography is performed with intravascular ultrasound and other imaging techniques. Why?
When angiography is planned, all personnel must wear a lead shield over their scrub attire.
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33. Peripheral Vascular Surgical procedure Angioplasty
Term describes methods of remodeling inner surface of artery narrowed because of stricture or atherosclerosis
Goal is to reestablish patency and circulation of arterial blood
Areas of plaque are most dense near arterial bifurcations.
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34. Peripheral Vascular Angioplasty (cont.) Stent placement
A, Stenosis of the artery. B, A guidewire is inserted. C, The balloon catheter is inserted over the guidewire. D, The balloon is inflated. E, A mesh stent is inserted over the guidewire. F, The stent is inflated and guidewire removed.
(From Garden O, Bradbury A, Forsythe J, Parks R: Principles and practice of surgery, ed 5, Edinburgh, 2007, Churchill Livingston Elsevier.)
What position is the patient placed in for implantation of a balloon stent?
Describe the Palmaz stent.
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35. Peripheral Vascular Angioplasty (cont.) Balloon angioplasty
Arterial stricture is expanded with balloon catheter
When inflated, balloon pushes plaque against vessel wall and releases stricture
Angioplasty balloons are available in graduated lengths and widths.
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36. Peripheral Vascular Surgical procedure Thrombectomy
A thrombectomy catheter is introduced through a femoral venotomy to extrude the thrombosis. The balloon is inflated and the catheter carefully withdrawn, pulling the thrombus with it.
(From Ouriel K, Rutherford R: Atlas of vascular surgery: Operative procedures, Philadelphia, 1998, Saunders.)
What is a thrombus? What are the symptoms of a thrombus?
Embolectomy catheters and balloons are available in a variety of sizes. The surgeon will choose one based on the size of the blood vessel requiring the embolectomy.
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37. Peripheral Vascular Surgical procedure
Vascular access for renal hemodialysis
A graft is implanted to form an anastomosis between the arterial and the venous circulation. In this technique, the brachiocephalic vein and the radial artery have been used. An alternative technique is direct anastomosis between the artery and the vein.
(From Wilson SE: Vascular access: Principles and practice, ed 3, St Louis, 1996, Mosby.)
What is hemodialysis?
What type of patient requires hemodialysis? Why does a hemodialysis patient need to have a vascular access graft?
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38. Peripheral Vascular Surgical procedure Insertion of vena cava filter
What are the indications for placement of a vena cava filter?
A vena cava filter can be placed by either a vascular surgeon or a specially trained interventional radiologist.
X-ray study showing position of caval filter.
(From Garden O, Bradbury A, Forsythe J, Parks R: Principles and practice of surgery, ed 5, Edinburgh, 2007, Churchill Livingston Elsevier).
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39. Peripheral Vascular Surgical procedure Carotid endarterectomy
Where do most carotid artery obstructions occur?
What instruments should have the scrub have ready before the actual endarterectomy?
The incision site for a carotid endarterectomy is made parallel to the anterior border of the sternocleidomastoid muscle, along its upper two thirds.
(From Ouriel K, Rutherford R: Atlas of vascular surgery: Operative procedures, Philadelphia, 1998, Saunders.)
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40. Peripheral Vascular Carotid endarterectomy (cont.)
The patient is placed supine on the table with arms tucked at the sides, the neck hyperextended, and the head tilted away from the operative site.
Retractors should have dull ends to prevent injury to surrounding tissue.
The internal jugular vein is laterally mobilized, and the common, internal, and external carotid vessels are exposed and controlled.
(From Ouriel K, Rutherford R: Atlas of vascular surgery: Operative procedures, Philadelphia, 1998, Saunders.)
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41. Peripheral Vascular Carotid endarterectomy (cont.)
Before the carotid is incised, the anesthesia provider will administer what medication?
There should be 1% lidocaine available in the surgical field. Why?
The endarterectomy is begun at the area of greatest plaque deposition, elevating the plaque off the outer medial and adventitial layers with longitudinal strokes of the endarterectomy spatula (inset).
(From Ouriel K, Rutherford R: Atlas of vascular surgery: Operative procedures, Philadelphia, 1998, Saunders.)
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42. Peripheral Vascular Carotid endarterectomy (cont.)
What is the function of an intraluminal shunt?
Which end of an intraluminal shunt is placed inside the vessel first—the proximal or distal end? Why?
The arteriotomy is closed primarily with a patch. Polyester carotid patch material may be precut or may be shaped at the ends to achieve an appropriate shape.
(From Ouriel K, Rutherford R: Atlas of vascular surgery: Operative procedures, Philadelphia, 1998, Saunders.)
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43. Peripheral Vascular Saphenous vein harvesting
The saphenous vein is commonly harvested to replace a diseased coronary artery and for other bypass procedures
Why is the greater saphenous vein the choice for grafting material?
What is a vein bath? Why is it important?
A, Line of incision exposed using external rotation of the hip. B, Exposure of the saphenous vein and artery and vein. Tributaries are clamped, tied, and divided C, The vein is preserved during surgery using saline solution (note Asepto syringe). D, The vein has been removed and is tested for leaks. These are clamped and ligated.
(From Ouriel K, Rutherford R: Atlas of vascular surgery: Operative procedures, Philadelphia, 1998, Saunders.)
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44. Peripheral Vascular Surgical procedure Axillofemoral bypass
Creates circulation between the femoral arteries and the axillary artery
What are the indications for performing an axillofemoral bypass?
What are the boundaries of the prep for an axillofemoral bypass?
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45. A, The suprapubic tunnel is created digitally.
Peripheral Vascular
Surgical procedure
Femoral bypass
A, The suprapubic tunnel is created digitally.
(From Ouriel K, Rutherford R: Atlas of vascular surgery: Operative procedures, Philadelphia, 1998, Saunders.)
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46. Peripheral Vascular Femoral bypass (cont.)
B, The midline fascia is pierced with a long clamp, grasping a Penrose drain or an umbilical tape to facilitate delivery of the graft without kinks or twists. C, Bilateral end-to-side anastomoses are constructed, each anastomosis being run onto the profunda femoris artery if the superficial femoral arteries are occluded.
(From Ouriel K, Rutherford R: Atlas of vascular surgery: Operative procedures, Philadelphia, 1998, Saunders.)
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47. Peripheral Vascular Surgical procedure
In situ saphenous femoropopliteal bypass
The surgical alternative to using a synthetic graft by using the existing saphenous vein, which is anastomosed to the popliteal artery
What vein is used in an in situ graft?
The valves of the grafted vein must be severed before being used as an arterial graft. Why?
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48. Peripheral Vascular Surgical procedure Femorofemoral bypass
The patient must have one good iliac artery to provide inflow for a femorofemoral graft to be successful.
Before closing, the pedal pulses will be checked by touch and with Doppler scanning to assess blood flow.
Bilateral end-to-side anastomoses are constructed, each anastomosis being run onto the profunda femoris artery if the superficial femoral arteries are occluded.
(From Ouriel K, Rutherford R: Atlas of vascular surgery: Operative procedures, Philadelphia, 1998, Saunders.)
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49. Peripheral Vascular Surgical procedure Varicose vein excision
A varicose vein excision involves removing dilated and tortuous veins and their tributaries from the lower extremities.
Before surgery, the surgeon will mark the veins with a skin marker while the patient is standing.
An elastic compression bandage is placed on the leg(s) postoperatively. Why?
(From Townsend CM: Sabiston textbook of surgery, ed 17, Philadelphia, 2001, Saunders.)
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50. Peripheral Vascular Surgical procedure
Abdominal aortic aneurysmectomy with graft insertion
Where do abdominal aortic aneurysms typically occur?
A blood-recovery system usually is used in emergency surgery.
A, The retroperitoneum is incised over the aneurysm. B, The left renal vein can be safely divided to gain additional exposure.
(From Ouriel K, Rutherford R: Atlas of vascular surgery: Operative procedures, Philadelphia, 1998, Saunders.)
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51. Peripheral Vascular
Abdominal aortic aneurysmectomy with graft insertion (cont.)
The plaque and aneurysm sac is sent to pathology as a specimen.
Angiograms and ultrasound are used to verify patency of the vessels.
C, Alternatively, a narrow retractor can be used provide exposure. D, The aorta is cross-clamped.
(From Ouriel K, Rutherford R: Atlas of vascular surgery: Operative procedures, Philadelphia, 1998, Saunders.)
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52. Peripheral Vascular Endovascular abdominal aneurysm repair
Approach is through the femoral artery
Bifurcated or straight stent can be placed
This procedure is under statistical review
Peripheral pulses are carefully monitored and chest x-ray study and electrocardiogram are routinely performed in the postoperative period.
Complications include hemorrhage, infection, renal failure, and bowel obstruction.
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53. Peripheral Vascular Aortofemoral bypass
Performed to treat aortoiliac occlusive disease
Graft is implanted between aorta and femoral arteries
Graft bypasses iliac arteries and produces free circulation
Describe the area to be prepped for an aortofemoral bypass.
The surgeon uses his or her fingers to perform blunt tissue dissection at the groin, creating a tunnel for the graft material.
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54. Peripheral Vascular Surgical procedure Above-knee amputation
Many surgeons prefer to place the gangrenous foot in a plastic bag to protect the wound site from contamination. The foot is excluded from the scrub prep.
After the lower limb has been removed, the sciatic nerve may be crushed with a Kocher clamp. Why?
Amputation levels with flap designs. Below, amputation with anterior flap.
(From Garden O, Bradbury A, Forsythe J, Parks R: Principles and practice of surgery ed 5, , Edinburgh, 2007,Churchill Livingston Elsevier.)
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