Perioperative management - Right femoropopliteal PTFE bypass (P3) – Vascular Surgery - vascular surgery
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Indications
The TASC II (Transatlantic Inter-Society Consensus for the Management of Peripheral Arterial Disease) consensus document addresses aspects of revascularization in PAOD.
The TASC II criteria recommend therapeutic treatment options depending on the length of the local occlusion/stenosis. The length of the stenosis and its regional location determine the treatment: endovascular or open vascular surgery.
TASC II classification of femoropopliteal lesions
Type
Morphology
Procedure
A
Unilateral or bilateral stenosis of CIA; unilateral or bilateral single short (<3 cm) stenosis of EIA
Endovascular
B
Short (≤3 cm) stenosis of infrarenal aorta; unilateral CIA occlusion; single or multiple stenosis totalling 3–10 cm involving the EIA, not extending into the CFA; unilateral EIA occlusion not involving the origins of IIA or CFA
Endovascular
C
Bilateral CIA occlusion; bilateral stenoses 3–10 cm long, not extending into CFA; unilateral EIA stenosis extending into the CFA; unilateral EIA occlusion involving the origins of IIA and/or CFA; heavily calcified unilateral EIA occlusion with/without involvement of origins of IIA and/or CFA
Open revascularization
D
Infrarenal aortoiliac occlusion; diffuse disease involving the aorta and both iliac arteries requiring treatment; diffuse multiple stenoses involving the unilateral CIA, EIA, and CFA; unilateral occlusions of both CIA and EIA; bilateral occlusions of EIA; iliac stenoses in patients with AAA requiring treatment and not amenable to endograft placement; or other lesions requiring open aortic or iliac surgery
Open revascularization
Video example: TASC D → open repair
Right leg PAOD Fontaine grade IV, left leg grade III with:
- High-grade arteriosclerosis of the terminal aorta and both iliac arteries
- Extended occlusion of both superficial femoral arteries
- Partial occlusion of the infrapopliteal arteries in bith legs
Preoprative DSA:
Contraindications
- Infection in region of planned repair
- ASA IV
- Previous inguinal radiotherapy (which would mandate extra-anatomical bypass)
Preoperative diagnostic work-up
Medical history
- Claudication
- Walking distance
- Risk factors -> nicotine abuse; arterial hypertension; coronary heart disease; cardiac failure; diabetes, manifest renal failure with/without dialysis; coagulopathy
Inspection
- Skin changes
- Muscular abnormalities
- Orthopedic malalignment
- Skin color
- Body hair
- Trophic changes
- Swelling; edema; mycosis; phlegmon; leg ulcers
Palpatory bilateral comparison
- Pulse status
- Skin temperature
Auscultatory bilateral comparison of the limb arteries
Ankle-Brachial Index (ABI)
- ABI = systolic BP of posterior tibial artery / systolic BP of brachial artery
ABI value PAD severity > 1,3 Falsely high values (suspected Mönckeberg medial sclerosis, e.g. in diabetes) > 0,9 Normal finding 0,75 - 0,9 Mild PAD 0,5 - 0,75) Moderate PAD < 0.5 schwere PAVK - ABI < 0.9 is considered evidence of significant PAD.
- Determining the ankle-brachial index (ABI) through non-invasive Doppler occlusion pressure measurement is a suitable test for confirming PAD.
- PAD diagnosis is determined by the ABI value with the lowest ankle artery pressure.
- A pathologic ankle-brachial index is an independent risk indicator for increased cardiovascular morbidity and mortality.
Color flow Doppler ultrasonography
- Carotid arteries, abdominal aorta, limb arteries
- Stenoses and occlusions in almost all vascular regions apart from chest
- Allows quantifying the degree of stenosis and assessing plaque morphology
- Sensitivity and specificity around 90%
- Well suited as screening modality
CT angiography
- Multislice computed tomography (MS-CT) with nonionic contrast agent
- Broad range of indications: traumatic vascular lesion (esp. trunk); vascular dissection/rupture; aneurysm; arterial thrombosis/embolism; portal vein/mesenteric vein thrombosis; pulmonary artery embolism; PAD; vascular tumors
- Benefits: rapid; detects relevant comorbidities; visualizes peripheral arteries; sensitivity and specificity each about 90%
- Drawbacks: Radiation and contrast agent exposure, allergies (about 3%), no functional assessment
Cardiac check
- Resting ECG
- Exercise ECG
- Echocardiography
Chest x-ray
Possibly spirometry
Laboratory panels
- Blood count
- Electrolytes
- Coagulation
- Kidney function parameters
- Liver function parameters
- Blood lipids
- Blood group
- In PAOD Fontaine grade IV → swab, antimicrobial susceptibility testing
Special preparation
- Hair cut in surgical field
- Order packed RBCs
- Protect the foot of the side to be operated on with a cotton shoe ( to avoid intraoperative pressure injury when clamping the vessels)
- Antibiotis according to AST (see diagnostic work-up) for 5 days postoperatively, depending on local findings
Informed consent
General surgical risks
- Major bleeding, blood transfusions, transmission of hepatitis/HIV through allogeneic blood transfusions
- Allergy/intolerance
- Wound infection
- Thrombosis/embolism
- Skin/vascular/nerve damage, e.g., due to patient positioning
- Keloid
Specific procedural risks
- Thrombosis with occlusion of the bypass and possibly adjacent vessels; reoperation, (partial) amputation
- Massive infection with severe bleeding from the bypass suture lines; bypass explantation, (partial) amputation, sepsis
- Sensory and motor nerve injury; dysesthesia , pain, temporary and even persistent (partial) palsy of the thigh muscles
- Lymph vessel injury; temporary or persistent lymphedema, lymphatic fistula
- Compartment syndrome; possibly requiring surgical pressure relief/fasciotomy, persistent palsy, limb loss
- Renal dysfunction with temporary or chronic dialysis due to Tourniquet syndrome and intraoperative angiography (contrast medium)
- Suture line aneurysm; surgical intervention depending on size/presentation
Anesthesia
Positioning
Operating room setup
Special instruments and fixation systems
Postoperative management
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