Perioperative management - Aortoiliac TEA (thromboendarterectomy) in bilateral stage IIb peripheral arterial (occlusive) disease (PAD) - Vascular surgery

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 aortoiliac lesions

Video example:

High aortic occlusion with subtotal stenosis of the iliac bifurcation, occlusion of the right CIA and thrombosis at the left EIA (bilateral clinical Fontaine stage IIb).

-> TASC II D, hence recommendation for open revascularization

Preoperative intra-arterial DSA

Classification of PAD according to Fontaine stage and Rutherford category                                                                                                        

• 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 axis*
• Abdominal aortic aneurysm*

in such cases: Y-graft

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 < 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.

Angiography (intra-arterial DSA)

• Most often performed as digital subtraction angiography (DSA)
• Contraindication: hyperthyroidism; manifest renal disease; creatinine elevation relative to indication; metformin-containing antidiabetics (risk of lactic acidosis); PT < 30%.
• Benefits: visualization in highest detail; superselective imaging possible; immediate intervention possible; sensitivity 100%, specificity 100%. 
• Drawbacks: Radiation exposure; contrast medium exposure; only patent vessels can be visualized while thrombosed regions and extravascular processes remain hidden; puncture and catheter complications. 
• TSH and creatinine levels must be determined prior to DSA
• Caution in patients with multiple myeloma -> renal failure

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

• Enema the evening before
• Hair cut in surgical field
• Order packed RBCs
• Foley catheter
• Administer prophylactic perioperative antibiotics 30 min. before beginning surgery (see KRINKO recommendation, Robert Koch Institute)
• Enema the evening before
• Hair cut in surgical field
• Order packed RBCs
• Foley catheter
• Administer prophylactic perioperative antibiotics 30 min. before beginning 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/nerve damage, e.g. due to patient positioning
• Keloid
• Incisional hernia

Specific procedural risks

• Thrombosis, possibly leg ischemia, amputation
• Infection with secondary suture bleeding; sepsis; leg ischemia; amputation
• Damage to adjacent organs, e.g., ureter; bladder; spleen; liver; intestinal ischemia -> resection, ostomy
• Paraplegia in the presence of deep origin of artery of Adamkiewicz
• Nerve lesions -> dysesthesia; pain; paralysis of abdominal wall / thigh muscles
• Peritoneal adhesions -> chronic pain, mechanical ileus
• Lymph fistula
• Secondary bleeding
• Impotence    
• Deterioration of renal function induced by intraoperative angiography