1. Basic Skills in Vascular Surgery Tim Brandys MD FRCSC

2. Objectives: Learn Basic Operative Skills involved with management of unexpected vascular injuries: 1.Proximal and Distal Control 2.Primary Vessel Repair 3.Patch Angioplasty 4.Primary Anastomosis 5.Decision making (Interposition Graft) 6.Vessel Ligation

3. Unexpected Bleeding Do Not Panic Communicate Early with anesthesia that you will have ongoing bleeding

4. ASK FOR WHAT YOU NEED Group and cross match 6 units FFP,CRYO,PLTs Get appropriate sutures,clamps,retractors

5. Call for Help Ask for help early rather than too late

6. Think FIRST AID Apply direct pressure to the source of bleeding until you are ready to deal with it More diffuse bleeding pack off the area with LAP pads

7. Change your Mind Set Switch from elective procedure to Trauma protocols. Extend incisions to get greater exposure. Consider packing the patient and carrying out temporary closure if profound coagulopathy ensues.

8. Exposure,Exposure,Exposure ! Do I need to extend the incision ?

9. Arterial Injury Basic Principles: 1.Proximal /Distal Control 2.Avoid direct entry into hematoma 3.Heparin:Systemic,Local, or None 4.Active Bleeding apply Direct pressure 5.Debride damaged arterial wall 6.Arterial defect > 1/3 circumference,Do not do primary repair(Patch,Resect Reanastomose,Interposition Graft) 7.Arterial Defect >2cm long,Do not do primary anastomosis (Interposition Graft)

10. Arterial Injury Continued: 7.Remember possibility of through and through injury. 8.Suture Choice: Non absorb. Monofilament 9.Interposition graft:avoid prosthetic in contaminated field,consider extra anatomic bypass 10.Some arteries can be ligated (ext. carotid,int. iliac)

11. Dissection:

13. Prox./Distal Control:

14. Proximal and Distal Control

15. Primary Repair:

16. Primary Anastomosis:

17. End to End Repair

18. Primary Anastomosis Pediatrics:

19. Patch Repair:

20. Patch Angioplasty Repair

21. Fish Mouth:

22. Modified Fish Mouth:

23. Triangulated:

24. Interposition Graft Repair

25. Venous Injury: 1.Avoid any repair that will narrow lumen by 50% or more 2.Interposition grafts have poorer long term results. 3.Vigorous dissection around veins and attempts to clamp can sometimes do more harm than good 4.Proximal and Distal control of Cava try sponge sticks 5.Some veins can be ligated without limb or life threatening consequences 6. Prep. Leg for vein harvest

26. Cava Repair

27. Today Patch Angioplasty End to end Fish mouth Anastomosis