Perioperative management - Aortofemoral bifurcation bypass (bifurcated graft) for peripheral arterial occlusive disease stage IIb–III

Depending on the length of the local occlusion/stenosis, the TASC criteria allow therapeutic treatment options to be derived. The length of the stenosis and the regions where it is located determine the type of management: endovascular or open vascular surgery.

TASC criteria for aortoiliac arterial occlusions

Video example:

Clinically the patient is classified as Fontaine PAOD IIb–III and the preoperative angiogram demonstrates: occlusion of the right common iliac artery and external iliac artery, subtotal stenosis of the left external iliac artery including bilateral stenosis of the femoral bifurcation.

-> TASC D, thus recommendation for open revascularisation

PAOD classification according to Fontaine stages and Rutherford categories

• 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

Medical history

• Claudication
• Walking distance
• Risk factors -> nicotine; arterial hypertension; CHD; heart failure; diabetes mellitus; manifest renal failure with/without dialysis dependency; coagulation disorders

Inspection

• Skin changes
• Muscular abnormalities
• Orthopaedic deformities
• Skin colour
• Hair
• Trophic changes
• Swelling; oedema; mycosis; phlegmon; leg ulcers etc.

Palpation with contralateral comparison

• Arterial pulse examination
• Skin temperature

Arterial auscultation of the extremities with contralateral comparison

Ankle-Brachial Index (ABI)

• ABI = systolic BP of the posterior tibial artery / systolic BP of the brachial artery

• An ABI of < 0.9 is considered proof of the presence of significant PAOD.
• Noninvasive Doppler ultrasound measurement of the occlusion pressure to determine the Ankle-Brachial Index (ABI) is an adequate test for the presence of PAOD.
• For the diagnosis of PAOD, the ABI with the lowest ankle artery pressure is used.
• A pathological ankle-brachial index is an independent risk indicator for increased cardiovascular morbidity and mortality.

Colour-coded duplex sonography

• Carotid arteries, abdominal aorta, arteries of the extremities
• Localisation of stenoses and occlusions in almost all vascular regions except the thoracic region
• Quantification of the degree of stenosis and assessment of plaque morphology possible
• Sensitivity and specificity about 90%.
• Well suited as a screening method

CT angiography

• Multi-slice computed tomography (MS-CT) using 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 tumours
• Pros: quickly performed; detection of relevant 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

Spirometry if required

Clinical chemistry

• FBC
• Electrolytes
• Coagulation
• Renal function
• Liver function
• Blood lipids
• Blood group

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

General surgical risks

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

Specific surgical risks

• Thrombosis of the vascular graft and possibly adjacent vascular segments, possibly leg ischaemia, amputation
• Graft infection with bleeding from suture lines; sepsis; leg ischaemia; amputation
• Injury to adjacent organs such as ureter, bladder, spleen, liver; intestinal ischaemia -> resection, stoma formation
• Paraplegia in the case of a low-origin arteria radicularis magna
• Nerve lesions -> paraesthesia; 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 due to intraoperative angiography