Perioperative management - PTA of the right common iliac artery and external iliac artery in PAOD stage IIb

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

TASC criteria of aortoiliac vascular occlusions

Video example: TASC B, high-grade stenosis of the A. iliaca externa and 50 % stenosis of the A. iliaca communis on the right, clinically PAOD stage IIb according to Fontaine → Indication for endovascular reconstruction

• ASA IV
• Infections in the groin (e.g. Erythrasma)

History

• Claudication
• Walking distance
• Risk factors -> Smoking, arterial hypertension, CAD, heart failure, diabetes mellitus, hyperlipidemia, manifest renal insufficiency with/without dialysis requirement, coagulopathies

Inspection

• Skin changes
• Muscular abnormalities
• Orthopedic malpositions
• Skin color
• Hair growth
• Trophic changes
• Swelling, edema, mycoses, phlegmons, leg ulcers etc.    

Bilateral comparative palpation

• Pulse status
• Skin temperature

Bilateral comparative 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 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.

Color-coded duplex sonography

• Carotid, abdominal aorta, extremity arteries
• Localization of stenoses and occlusions in almost all vascular regions except in the thoracic area
• Quantification of the degree of stenosis and assessment of plaque morphology possible
• Sensitivity and specificity approx. 90%   
• Well suited as a screening method

Contrast-enhanced MR angiography or alternatively CT angiography

• Validation of findings or for therapy planning

Cardiac check

• Resting ECG
• Exercise ECG
• Echocardiography

Chest X-ray

If necessary, spirometry

Laboratory

• CBC
• Electrolytes
• Coagulation
• Retention values
• Liver enzymes
• Blood lipids
• Blood type

• Mark the side, shaving
• Fasting 2 – 6 hours depending on clinic standard
• Cotton boot to avoid positioning-related pressure injuries
• Leave platelet aggregation inhibitors; in dual therapy, individual decision depending on cardiac risk profile

General Surgical Risks

• Severe bleeding, blood transfusions, transmission of hepatitis/HIV through donor blood products
• Allergy/intolerance
• Wound infection
• Thrombosis/embolism
• Skin, vessel, nerve damage e.g. due to positioning
• Keloids

Specific Surgical Risks

• Recurrent vascular occlusion, possibly further intervention, (partial) amputation
• Vascular dissection/tearing by balloon catheter, possibly stent or bypass
• Alternative procedure -> Bypass
• AV fistula, pseudoaneurysm
• Infections, sepsis, amputation
• Nerve injury with dysesthesia or pain, weakness or partial paralysis of the extremity
• Embolism upon withdrawal of the balloon catheter, e.g. gangrene in the foot area, amputation
• Lymphedema
• Impairment of renal function due to contrast agent during intraoperative angiography

• in cooperative patients local anesthesia, otherwise ITN

• Supine position
• ipsilateral arm abducted, contralateral adducted (due to C-arm)

• Surgeon on the side to be operated on
• Assistant opposite the surgeon
• OR specialist towards the feet next to the assistant
• intraoperative angiography: C-arm comes from the contralateral side, as does the monitor next to the patient's head end

• Instrumentation for intervention (dilation catheters of different sizes and lengths, guide wires, sheaths 5F to 7F)
• mobile DAS unit
• Heparin-saline solution

In reserve:

• special atraumatic vascular instrumentation with wound retractors
• 120° angle clamps
• Profunda clamp
• Pott's scissors
• Button cannulas of different sizes
• monofilament suture material size 5-0 to 6-0 with atraumatic needle

Follow the link here to PROSPECT (Procedures Specific Postoperative Pain Management) and to the current Guideline for the Treatment of Acute Perioperative and Posttraumatic Pain.

Medical Follow-up Care

• Close monitoring of cardiovascular and pulmonary systems
• Control of extremity pulses, duplex sonography
• Therapeutic heparinization weight-adapted; on the day of surgery only 10,000 IU from the 4th postoperative hour (risk of rebleeding), then increase heparin dose
• Antiplatelet agents as long-term medication, overlapping with heparin from the 3rd postoperative day

Mobilization

• from 1st postoperative day

Physiotherapy

• generally dispensable

Diet Build-up

• 3 hours postoperatively

Bowel Regulation

• generally dispensable

Inability to Work

• 2-3 weeks