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

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 determine the therapy: endovascular or open vascular surgery.

TASC criteria of aortoiliac vascular occlusions

Video example: PAOD stage IIb right leg with subtotal stenosis of the external iliac artery, common femoral artery occlusion, profunda origin occlusion, long-segment occlusion of the superficial femoral artery, occlusion of the anterior tibial artery on both sides (right proximal, left peripheral) -> TASC D

• ASA IV
• severe COPD
• Prior radiation in the groin
• Infections in the area of reconstruction      

Medical 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
• Hairiness
• Trophic Changes
• Swelling, Edema, Mycoses, Phlegmons, Leg Ulcers etc.    

Side-Comparing Palpation

• Pulse Status
• Skin Temperature

Side-Comparing Auscultation of the Extremity Arteries

Ankle-Brachial Index (ABI)

• ABI = Syst. BP Posterior Tibial Artery/Syst. BP Brachial Artery

• An ABI Value of < 0,9 is Considered Proof of the Presence of Relevant PAD.
• The 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 Examination

If Necessary, Spirometry

Laboratory

• CBC
• Electrolytes
• Coagulation
• Retention Values
• Liver Enzymes
• Blood Lipids
• Blood Group

• Fast for 6 hrs. before the procedure
• Mark the surgical side on the patient
• Shave groin, lower abdomen and leg
• Pack foot in cotton boot (to avoid intraoperative pressure injuries when clamping the arteries)
• AVK Stage IV: antibiotic treatment according to antibiogram and continuation of therapy postoperatively for at least 5 days (depending on local findings)

General Surgical Risks

• Severe bleeding, blood transfusions, transmission of Hepatitis/HIV through blood products
• Allergy/Intolerance
• Wound infection
• Thrombosis/Embolism
• Skin, vessel, nerve damage e.g. due to positioning
• Keloids

Specific Surgical Risks

• renewed vessel occlusion, possibly further intervention, (partial) amputation
• persistent ischemia with risk of amputation
• vessel dissection/tearing by balloon catheter, possibly stent or interposition from vein or plastic
• massive infections with severe bleeding from suture sites, sepsis, amputation
• injury to nerves with dysesthesias or pain, weakness or partial paralysis of the extremity
• embolism when withdrawing the balloon catheter, e.g. gangrene in the foot area, amputation
• lymphedema, lymphocele, -fistula
• compartment syndrome
• restriction of kidney function due to contrast medium in the context of intraoperative angiography
• risk of ureter lesion if retroperitoneal preparation is necessary
• in case of failure of TEA, method change with prosthetic replacement (uni- or also bilateral e.g. Y-prosthesis)