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Complications - Retrograde iliofemoral TEA (ring stripper desobliteration) right with profunda patch plasty

vascular surgery
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Anatomy Perioperative management Technique Complications Evidence Total Video

  1. Intraoperative Complications

    Intimal tears and dissections, vessel perforation

    • Cause: usually too aggressive approach during the maneuver using ring stripper
    • Clinical presentation: persistent ischemia
    • mandatory: intraoperative angiography to check the flow path
    • Rupture of the pelvic flow path -> prosthetic replacement
    • Rupture of the patch in the groin with artery of too small caliber -> prosthetic interposition; profunda femoris artery unexpectedly not suitable for anastomosis -> femoro-popliteal bypass to PI, II or III
    • Prophylaxis: perform ring stripper maneuver carefully and with sensitivity

  2. Postoperative Complications

    Postoperative Bleeding, Hematoma

    • Causes: technical errors such as e.g. suture insufficiency, slipping of ligatures, insufficient hemostasis; also puncture channel bleedings, iatrogenic vascular lesions, surgery under platelet aggregation inhibition
    • emergency treatment of active and hemodynamically relevant bleedings
    • generous indication for hematoma evacuation as breeding ground for infection and possibly also compression of other structures (compartment syndrome)
    • Prophylaxis: careful preparation, subtle hemostasis

    Reocclusions

    • Cause: residual stenosis, intraoperative vascular lesion
    • Clinical presentation: persisting ischemia, renewed deterioration of perfusion
    • Diagnostics: angiographic evaluation
    • Therapy: surgical revision
    • Prophylaxis: intraoperative control angiography mandatory for detection of residual stenosis or vascular lesion during TEA maneuver

    In case of persisting or newly occurring limb ischemia, with initially still preserved residual perfusion, the limb findings can quickly deteriorate and, with increasing vascular thrombosis (apposition thrombi), progress rapidly with increasing vital threat to the limb!

    Wound Infection

    • Diagnosis: local findings, laboratory, fever
    • Therapy: if unavoidable, opening of the wound, swab, debridement, if necessary vacuum sealing (“VAC” therapy), antibiotic therapy according to resistogram
    • Prophylaxis: careful, atraumatic, anatomically correct surgical technique, subtle hemostasis, avoidance of lymphatic vessel lesions 

    Compartment Syndrome

    • Cause: Reperfusion after complete or incomplete ischemia leads to damage of the capillary membrane with increased permeability and edema formation in the soft tissues, resulting in pressure increase in the muscle compartments with tissue destruction
    • Clinical presentation: see Red Flags
    • Diagnostics: clinical, see Red Flags; objectification by intracompartmental pressure measurement (borderline range between 30 and 50 mm Hg over 6 hours is pathological as well as pressure values over 50 mm Hg)
    • Therapy: immediate dermatofasciotomy with complete longitudinal splitting of all muscle compartments; later dermatotraction over artificial skin or vacuum sealing, split-thickness skin graft

    Red Flags  - Clinical warning signs for the presence of a compartment syndrome

    Pathognomonic signs are:

    • painful soft tissue swelling of the muscle compartment with reduced elasticity (early symptom)
    • passive stretch pain of the affected muscle
    • intense, analgesic-resistant resting pain (ischemic pain)
    • sensory disturbances and motor deficits (foot drop weakness due to paralysis of the tibialis anterior muscle)

    Clinical P's of compartment syndrome:

    • Pressure (swelling and reduced elasticity)
    • Pain out of proportion (disproportionately intense pain)
    • Pain with passive stretch (passive stretch pain)
    • Paresthesia (affection of the nerves running through the compartments)
    • Paresis or Palsy (motor weakness)
    • Pulses present! Pulselessness is not considered a classic symptom!
    • Pink skin colour (shiny, marbled skin)

    Lymph Fistula, Lymphocele

    • Risk: access route over the inguinal region predisposed for lesion of lymphatic vessels
    • Diagnosis: clinical local findings
    • Therapy: lymphoceles conservatively considering the risk of infection; lymph fistulas should remain drained prolonged without suction, alternatively after exclusion of infection injection of fibrin glue or also revision with encircling ligation (methylene blue, magnifying glasses), very rarely plastic coverage
    • Prophylaxis: sparing of the lymphatic vessels during access, transpose lymphatic tissue ventro-medially

    persistent lymphedema

    • manual lymph drainage and with sufficient arterial perfusion (!) consistent compression treatment