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

General anesthesia

Supine position, right arm adducted, left arm abducted. The upper body should be slightly retroflexed at the level of the thoracoabdominal transition between the pubic bone and xyphoid to increase the distance between the iliac crest and costal arch.

The surgeon stands to the right of the patient and the 1st assistant opposite the surgeon. The 2nd assistant stands to the left of the surgeon. Scrub nurse adjacent to first  assistant toward patient's feet.

• Abdominal wall retractor
• Aortic clamps, bulldog clamps
• Monofilament, non-absorbable vascular sutures (3/0 to 6/0)
• Cell-Saver

Postoperative analgesia:

Follow this link to PROSPECT (Procedures Specific Postoperative Pain Management) and to the current German guideline Behandlung akuter perioperativer and posttraumatischer Schmerzen [Treatment of acute perioperative and posttraumatic pain].

Postoperative care

• 24-hour monitoring on ICU or possibly intermediate care unit
• Regular ward possible from postoperative day 1 to 3
• Close cardiovascular and pulmonary monitoring
• Check pulse in legs and capillary perfusion in feet

Deep venous thrombosis prophylaxis

• Weight-adjusted low-molecular weight heparin; in multifocal arteriosclerosis ASA 100 mg/day when oral nutrition is restarted

Ambulation

• On postoperative day 2, edge of bed (Caution! Inguinal anastomosis: avulsion possible if ambulation is forced)

Physical therapy

• Isometric and breathing exercises    

Diet

• Following first bowel movement, gradually increase oral nutrition      

Bowel movement

• On day 3 enema if no spontaneous bowel movement
• If unsuccessful, administer amidotrizoic acid (Gastrografin®)
• Administer neostigmine if everything else fails

Work disability

• Around 3 months