Perioperative management - Aortoiliac TEA in bilateral peripheral arterial occlusive disease stage IIb

According to the TASC criteria, therapeutic treatment options can be derived depending on the length of the local occlusion/stenosis. The length of the stenosis and the regions of its localisation determine the choice of therapy: endovascular or open vascular surgery.

TASC criteria for aortoiliac vascular occlusions

Film example:

High aortic occlusion with subtotal stenosis of the iliac bifurcation, occlusion of the right common iliac artery and thrombosis in the region of the left external iliac artery (clinically PAOD IIb bilateral)

-> TASC D, hence a recommendation for open reconstruction

Preoperative i.a. DSA

Classification of PAOD according to the Fontaine stages and Rutherford categories

• serious cardiopulmonary risks (e.g. NYHA IV, COPD Gold stage IV)
• Acute or chronic inflammatory abdominal processes (e.g. florid ulcerative colitis, recurrent sigmoid diverticulitis)
• History of multiple extensive abdominal procedures ("hostile abdomen")
• Liver cirrhosis
• Advanced malignancy
• Transmural calcification of the aorta and pelvic vessels (so-called "pretzel-stick vessels")*
• Abdominal aortic aneurysm*

* in such cases: Y-graft

History

• Claudication
• Walking distance
• Risk factors -> nicotine, arterial hypertension, coronary heart disease, heart failure, diabetes mellitus, manifest renal insufficiency with/without dialysis dependence, coagulopathies

Inspection

• Skin changes
• Muscular abnormalities
• Orthopaedic malalignments
• Skin colour
• Hair growth
• Trophic changes
• Swelling, oedema, mycoses, phlegmons, ulcera cruris, etc.

Side-comparing palpation

• Pulse status
• Skin temperature

Side-comparing auscultation of the extremity arteries

Ankle-brachial index (ABI)

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

• An ABI value of < 0.9 is considered proof of the presence of relevant PAD.
• Determination of the ankle-brachial index (ABI) by non-invasive measurement of the Doppler occlusion pressure is a suitable test for detecting PAD.
• For the diagnosis of PAD, the ABI value with the lowest ankle artery pressure is decisive.
• A pathological ankle-brachial index is an independent risk indicator for increased cardiovascular morbidity and mortality.

Colour-coded duplex sonography

• Carotid, abdominal aorta, extremity arteries
• 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 approximately 90%
• Well suited as a screening method

CT angiography

• Multislice computed tomography (MS-CT) using non-ionic contrast medium
• Broad spectrum of indications: traumatic vascular lesion (especially trunk), vascular dissection/rupture, aneurysm, arterial thrombosis/embolism, portal/mesenteric vein thrombosis, pulmonary artery embolism, PAD, vascular tumours
• Advantages: quickly performed, detection of relevant concomitant diseases, visualisation of peripheral arteries, sensitivity and specificity each approximately 90%
• Disadvantages: radiation and contrast medium exposure, allergies (approximately 3%), no functional assessment

Angiography (i.a. DSA)

• Usually as digital subtraction angiography (DSA)
• Contraindications: hyperthyroidism, manifest renal disease, creatinine elevation relative to the indication, metformin-containing antidiabetics (risk of lactic acidosis), prothrombin time (Quick) < 30%
• Advantages: highest level of detail recognition, superselective visualisation possible, immediate intervention possible, sensitivity 100%, specificity 100%
• Radiation exposure, contrast medium exposure, only the patent vascular lumen can be visualised, i.e. non-visualisation of thrombosed areas and extravascular processes, puncture and catheter complications
• Necessity of determining TSH and creatinine before DSA
• Caution in patients with multiple myeloma -> renal failure

Cardiac check

• Resting ECG
• Exercise ECG
• Echocardiography

Chest X-ray examination

If necessary, spirometry

Laboratory

• Full blood count
• Electrolytes
• Coagulation
• Retention values
• Liver enzymes
• Blood lipids
• Blood group

• Enema the evening before
• Clipping of hair in the operative field
• Order blood units to be available
• Indwelling bladder catheter
• Perioperative antibiotic prophylaxis 30 min before the start of surgery (see KRINKO recommendation, Robert Koch Institute)

General surgical risks

• Major bleeding, blood transfusions, transmission of hepatitis/HIV through allogeneic blood transfusions
• Allergy/intolerance
• Wound infection
• Thrombosis/embolism
• Skin, vascular and nerve damage, e.g. due to patient positioning
• Keloids
• Incisional hernia

Specific procedural risks

• Thrombosis, possibly leg ischaemia, amputation
• Infection with bleeding from suture lines; sepsis, leg ischaemia, amputation
• Damage to adjacent organs, e.g. ureter, bladder, spleen, liver; intestinal ischaemia -> resection, ostomy formation
• Paraplegia in the presence of a low origin of the artery of Adamkiewicz (arteria radicularis magna)
• Nerve lesions -> dysaesthesia, pain, paralysis of the abdominal wall and thigh muscles
• Peritoneal adhesions -> chronic pain, mechanical ileus
• Lymph fistula
• Secondary bleeding
• Impotence
• Compromise of renal function due to intraoperative angiography