Perioperative management - Interventional management of type Ia endoleak after endoluminal repair of bilateral internal iliac artery aneurysms - Vascular Surgery

Endoleak classification

Type I and type III endoleaks are associated with a higher risk of aneurysm rupture-> prompt intervention recommended

• ASA IV

Thorough vascular surgery examination:

• Pulse status
• Doppler study of both legs
• Possibly walk test in case of concomitant PAOD and poor foot pulses on palpation
• Abdominal ultrasonography
• Carotid color doppler study
• Echocardiography
• Exercise ECG
• Laboratory panels (electroytes, coagulation, renal function, blood count, blood lipids)
• Chest X-ray
• Spiral CT -> exact dimensioning of the endografts required for the endoleak repair

• Identify blood group, provide for packed RBCs, if needed
• Remove the hair in the surgical field
• Possibly, place urinary catheter
• Prophylactic antibiotics are usually administered as recommended by the German Society for Vascular Surgery (single-shot cefuroxime 30 minutes before skin incision), but the benefit is currently subject to debate because of issues around antibiotic resistance (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
• Keloids (in open surgery)

Specific procedural risks

• Vascular injuries, e.g., during graft delivery: surgical hemostasis, blood transfusions, in case of massive bleeding or arterial rupture, immediate conversion to open surgery
• Pseudoaneurysm of the punctured vessels, arteriovenous fistula, seroma
• Inadequate graft fixation or leakage: corrective procedures, possibly open surgery
• Graft infection: possible after days, months, or even years; endocarditis, sepsis, leg ischemia, amputation; surgical removal of vascular graft
• Nerve lesions -> dysesthesia; pain; paralysis of abdominal wall / thigh muscles
• Lymph fistula
• Temporary or permanent lymphedema of the legs; compression stockings, lymphatic drainage
• Secondary bleeding
• Impotence    
• Deterioration of renal function induced by intraoperative angiography, chronic dialysis

Risks due to impaired perfusion

• Thrombosis/embolism: pulmonary embolism, apoplexy, myocardial infarction; prophylaxis: heparin → HIT II risk
• Legs: thrombosis of the graft and possibly adjacent vascular segments, possibly leg ischemia, amputation (e.g., toes)
• Gluteal muscles: due to overstenting of the iliac arteries, in particular bilaterally; claudication during walking, possibly gluteal necrosis

• General anesthesia
• In suitable patients (compliance) also local anesthesia

Supine; left arm (side to be operated on in video example) abducted, right arm adducted (C-arm for intraoperative angiography wheeling in from the right)

The surgeon stands on the side to be operated on, with the assistant facing him/her. The scrub nurse stands to the right of the assistant. The C-arm for intraoperative angiography approaches from the right side, with the monitor positioned to the right of the patient's head and clearly visible to the surgeon.

• Smal vascular instrument tray
• Adequate guide wires (Terumo®, Lunderquist®, Amplatz®)
• Guiding catheters (e.g. Hockey Stick®, Renal Double Curve®, Sidewinder®, etc.)
• Angioplasty balloons in different sizes (6-9 mm)
• Long and short pigtail catheters, pigtail with gradations
• DSA unit, high pressure injector for contrast media
• Suitable endoluminal graft customized to preoperative measurements
• Have instruments ready for conversion to emergent open surgery

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 from postoperative day 1 if possible
• 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
• for patients on phenprocoumon, switch from heparin to phenprocoumon on postoperative day 5

Ambulation

• To edge of bed from postoperative day 1-2

Physical therapy

• Usually not needed

Diet

• 4– 6 hours after surgery

Bowel movement

• Usually not needed

Work disability

• Around 3 weeks