Perioperative management - Aortobifemoral bypass for peripheral arterial disease Fontaine stage IIb–III

  1. Indications

    Depending on the length of the local occlusion/stenosis, the TASC III criteria suggest the treatment options to be used. The length of the stenosis and the region where it is located determine the general type of management: Endovascular or open vascular surgery.

    TASC II classification in aortoiliac occlusion

    Lesion typeMorphologyRecommended treatment

    A

    Short (<3 cm) unilateral or bilateral stenosis of the CIA or EIA  Endovascular

    B

    Single or multiple stenosis totaling 3–10 cm involving the EIA, not extending into the CFA; and/or unilateral CIA occlusionEndovascular

    C

    Bilateral CIA occlusion;[MM3]  bilateral EIA stenoses 3–10 cm long not extending into the CFA; unilateral complete EIA occlusion Open reconstruction

    D

    Diffuse disease involving the aorta and both iliac arteries requiring treatment; unilateral occlusions of both CIA and EIA; bilateral occlusions of EIA  Open reconstruction

     

    Video example

    Präoperatives Angiogramm
    Preoperative angiogram

     

    Clinically the patient is classified as Fontaine PAOD IIb–III and the preoperative angiogram demonstrates: Occlusion of the right CIA and EIA, subtotal stenosis of the left EIA and bilateral stenosis of the femoral bifurcation

    -> TASC D, , thus recommendation for  open revascularization

    PAOD classification according to Fontaine and Rutherford

                                                                                                                   

    Fontaine stage

    Clinical symptoms                                    

    Rutherford

    Grade

    Clinical symptoms

    I

    Asymptomatic

    0

    0

    Asymptomatic

    IIa

    Distance > 200 m

    1

    I

    Mild claudication

    IIb

    Distance< 200 m

    2

    I

    Moderate claudication

     

     

    3

    I

    Severe claudication

    III

    Ischemic rest pain

    4

    II

    Ischemic rest pain

    IV

    Ulcers or gangrene

    5

    III

    Ischemic ulceration not exceeding ulcer of the digits of the foot
      

    6

    III

    Severe ischemic ulcers or frank gangrene
  2. Contraindications

    • Serious cardiopulmonary risks (e.g., NYHA IV, COPD GOLD stage IV)
    • Acute or chronic inflammatory abdominal disease (e.g., florid ulcerative colitis, recurrent sigmoid diverticulitis)
    • History of multiple extensive abdominal procedures ("hostile abdomen")
    • Cirrhosis
    • Advanced malignancy
  3. Preoperative diagnostic work-up

    Medical history

    • Claudication
    • Distance walking without complaints
    • Risk factors -> nicotine; arterial hypertension; CHD; heart failure; diabetes; manifest renal failure with/without dialysis; coagulation disorder

    Inspection

    • Skin changes
    • Muscular abnormalities
    • Orthopedic deformities
    • Skin color
    • Hair
    • Trophic changes
    • Swelling; edema; mycosis; phlegmon; leg ulcers etc.    

    Palpation with contralateral comparison

    • Arterial pulse examination
    • Skin temperature

    Arterial auscultation of the extremities with contralateral comparison

    Palpation-Auskultation
    Palpation–auscultation

     

    Ankle-Brachial Index (ABI)

    • ABI = systolic BP of posterior tibial artery / systolic BP of brachial artery
    ABISeverity of PAOD
    > 1.3false high values (suspected Mönckeberg arteriosclerosis, e.g. in diabetes)
    > 0.9Normal finding
    0.75 - 0.9Mild PAOD
    0.5 - 0.75Moderate PAOD
    < 0.5Severe PAOD
    • An ABI of < 0.9 demonstrates the presence of significant PAOD.
    • Noninvasive Doppler ultrasound measurement of the Ankle-Brachial Index (ABI) is an adequate test for the presence of PAOD.
    • For the diagnosis of PAOD, the ABI with the lowest posterior tibial artery pressure is used.
    • A pathologic ankle-arm index is an independent risk indicator for increased cardiovascular morbidity and mortality.

    Color coded duplex sonography

    • Carotid arteries, abdominal aorta, arteries of the extremities
    • Localization of stenoses and occlusions in almost all vascular regions except the chest
    • Quantifies the degree of stenosis and allows assessment of plaque morphology
    • Sensitivity and specificity about 90%.   
    • Well suited for screening purposes

    CT angiography

    • Multi-slice computed tomography (MS-CT) with non-ionic contrast medium
    • Broad range of indications: Traumatic vascular lesion (especially trunk); vascular dissection/rupture; aneurysm; arterial thrombosis/embolism; portal vein/mesenteric vein thrombosis; pulmonary artery embolism; PAOD; vascular tumors
    • Pros: Fast; detection of significant concomitant disease; imaging of peripheral arteries; sensitivity and specificity each about 90%.
    • Cons: Exposure to radiation and contrast media, allergies ( about 3%), no functional assessment

    Cardiac check-up

    • Resting ECG
    • Exercise ECG
    • Echocardiography

    Chest radiograph

    Possibly spirometry

    Clinical chemistry

    • RBC
    • Electrolytes
    • Coagulation
    • Renal function
    • Liver function
    • Blood lipids
    • Blood group
  4. Special preparation

    • Enema evening before surgery
    • Hair trimmed in surgical field
    • Packed RBCs ordered
    • Foley catheter
    • Perioperative prophylactic antibiotics 30 minutes before surgery (see German KRINKO and Robert-Koch-Institut recommendations)
  5. Informed consent

    General surgical risks

    • Major bleeding; blood transfusions; hepatitis/HIV transmission from allogeneic blood units.
    • Allergy/incompatibility
    • Wound infection
    • Thrombosis/embolism
    • Injury to skin, vessels, nerves, e.g. due to positioning.
    • Keloids
    • Incisional hernia

    Specific surgical risks

    • Thrombosis of grafts and possibly regions supplied by runoff vessels, possibly leg ischemia, amputation
    • Graft infection with suture bleeding; sepsis; leg ischemia; amputation
    • Injury to adjacent organs such as ureter, bladder, spleen, liver; intestinal ischemia -> resection, colo-/ileostomy
    • Paraplegia in artery of Adamkiewicz with low origin
    • Nerve lesions -> paresthesia; pain; paralysis of the abdominal wall and thigh muscles
    • Peritoneal adhesions -> chronic pain, mechanical ileus
    • Lymphatic fistula
    • Secondary bleeding
    • Impotence    
    • Anastomotic/graft aneurysm
    • Impaired renal function by intraoperative angiography
Anesthesia

General anesthesia ... - Operations in general, visceral and transplant surgery, vascular surgery a

Activate now and continue learning straight away.

Single Access

Activation of this course for 3 days.

€4.99 inclusive VAT

Most popular offer

webop - Savings Flex

Combine our learning modules flexibly and save up to 50%.

from €3.29 / module

€39.50 / yearly payment

price overview

vascular surgery

Unlock all courses in this module.

€7.42 / month

€89.00 / yearly payment