EVAR – Endovascular repair of abdominal aortic aneurysm (Y-graft) – Vascular Surgery - vascular surgery

Approximately 1 cm lateral to the palpated femoral artery make a longitudinal skin incision on the proximal thigh distal to the inguinal aspect. After transecting the subcutaneous tissue, divide the femoral fascia longitudinally medial to the sartorius muscle. Open the fascia of the adductor canal at the distal edge of the incision, expose the superficial femoral artery, and encircle it with a vessel loop. Divide and suture ligate between Overholt forceps the lymph collectors crossing posterior to the inguinal ligament. Encircle the common and deep femoral arteries with vessel loops.

Repeat these steps to expose the femoral bifurcation in the left groin.

Tips:

1. Access lateral to the femoral artery spares the lymph collectors and permits subsequent offset layered closure to promote effective wound healing.

2. The superficial femoral artery serves as a landmark for proximad dissection lateral to it. This helps to easily locate the deep and common femoral arteries and also avoids the risk of injury to the veins running medially.

3. Suture ligation of the lymph collectors helps, to a large extent, to prevent subsequent lymphatic cysts and fistulae. Postoperative lymph collection in the groin often paves the way for deep wound infection with fatal consequences.

4. Lateral and medial circumflex femoral arteries: at times, these arteries are hidden and can bleed profusely if not clamped.

Puncture the left common femoral artery with an 18G needle and insert a 6F sheath in Seldinger technique. Administer 5000 IU heparin saline locally into the vessel. Under fluoroscopy, insert a guidewire with hydrophilic coating (here: Terumo®) into the descending aorta.

Tip:

In case of marked coiling, this may require steering with a curved guiding catheter.

Repeat surgical step 2 for the right groin.

Now introduce a graduated pigtail catheter via the indwelling guidewire on the left. Perform angiography with a high pressure injector to identify the renal artery level, which is marked extracorporeally with a needle for rough orientation.

After repeat injection of contrast medium, mark the origins of both internal iliac arteries extracorporeally with a needle each.

Tip:

By marking extracorporeally the renal artery level and the origins of both internal iliac arteries, respectively, it is possible to decrease the dose of contrast medium applied. However, do not rely blindly on the markings, as the abdominal aorta may elongate after introduction of the stiff graft delivery system, resulting in displacement of the anatomical landmarks