Perioperative management - Retrograde iliofemoral TEA (ring stripper disobliteration) on the 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 arteria iliaca externa, arteria femoralis communis occlusion, profunda origin occlusion, long-segment occlusion of the arteria femoralis superficialis, occlusion of the arteria tibialis anterior on both sides (right proximal, left peripheral) -> TASC D

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

Medical history

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

Inspection

• Skin changes
• Muscular abnormalities
• Orthopaedic malpositions
• Skin colour
• Hair growth
• Trophic changes
• Swelling, oedema, mycoses, phlegmons, ulcera cruris, etc.

Side-comparing palpation

• Pulse status
• Skin temperature

Side-comparing auscultation of the extremity arteries

Ankle-brachial index (ABI)

• ABI = syst. BP A. tibialis posterior/syst. BP A. brachialis

• 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.

Colour-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

• Keep patient fasted for 6 hrs before the procedure
• Mark the surgical side on the patient
• Shave groin, lower abdomen and leg
• Pack the foot in a cotton boot (to avoid intraoperative pressure injuries when clamping the arteries)
• PAOD 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 banked donor blood
• Allergy/intolerance
• Wound infection
• Thrombosis/embolism
• Skin, vessel and nerve damage, e.g. due to positioning
• Keloids

Specific Surgical Risks

• recurrent vessel occlusion, possibly further intervention, (partial) amputation
• persistent ischaemia with risk of amputation
• vessel dissection/rupture caused by the balloon catheter, possibly stent or interposition graft from vein or synthetic material
• massive infections with severe bleeding from the suture sites, sepsis, amputation
• injury to nerves with dysaesthesias or pain, weakness or partial paralysis of the extremity
• embolism when withdrawing the balloon catheter, e.g. gangrene in the foot area, amputation
• lymphoedema, lymphocele, lymph fistula
• compartment syndrome
• impairment of renal function due to contrast medium in the context of intraoperative angiography
• risk of ureteric injury if retroperitoneal dissection is required
• in the event of failure of TEA, change of method with prosthetic replacement (unilateral or also bilateral, e.g. Y-prosthesis)