Right retrograde iliofemoral TEA (ring stripper desobliteration) with profunda patch plasty

Skin incision and dissection of the subcutis approx. 1 cm lateral to the palpable femoral artery. Medial to the M. sartorius, the incision of the thigh fascia is performed, then the superficial femoral artery can be exposed and looped. Below the inguinal ligament, the crossing lymphatic collectors are divided between clamps and secured with transfixion ligatures.

Tips:

1. The access approx. 1 cm lateral to the artery spares the lymphatic collectors and allows a later curtain-like wound closure with the goal of better wound healing.

2. The early exposed or looped superficial femoral artery serves as a guide during central preparation.

3. Transfixion ligatures of the lymphatic collectors help to largely avoid later lymphocysts or lymph fistulas. Lymph accumulations in the groin often pave the way, especially in stage IV of PAD, for a deep wound infection that endangers the extremity and even the life of the patient.

Preparation and looping of the common femoral artery. In doing so, lymph and fatty tissue are dissected from lateral to medial. Exposure of smaller side branches and the deep femoral artery. Control of the medial and lateral circumflex femoral arteries.

Tips:

1. The deep femoral artery must be prepared at least up to the third bifurcation for a profundaplasty, because otherwise - experimentally proven – an improved inflow cannot be achieved.

3. Transversely running, crossing veins should be managed with penetrating ligatures, as simple ligatures easily slip off.

4. Small arterial branches can be managed with thread tourniquets. The use of numerous bulldog clamps restricts freedom of movement in the site, and during vessel sutures, the threads often get caught in the clamps.

Since the right external iliac artery is occluded, only the peripheral branches and the collaterals need to be clamped during clamping. Incision of the common femoral artery into the deep femoral artery (note the stenosing cylinder). Instillation of approx. 2000 IU heparin-saline solution into the deep femoral artery.

Tip:

Even with a still open but stenosed pelvic arterial pathway, it is better to achieve central bleeding control merely with a tourniquet, as the intima cylinder can easily break when using a vascular clamp. This then leads to difficulties in finding a suitable dissection plane with the ring stripper.

Seeking an appropriate dissection layer in the area of the common femoral artery and performing the TEA using a vascular spatula. The intima is smoothly detached in the periphery of the deep femoral artery if the cylinder does not run out.

Tips:

1. Depending on the severity of the atherosclerosis, there are two different dissection planes for eversion. One is - as in the present case – close to the intima, that is, at the internal elastic membrane, which represents the best layer for ring stripper TEA. The other dissection plane is close to the adventitia, thus in the area of the external elastic membrane. This plane is also suitable for ring stripper TEA, but less favorable, as perforations can occur much more easily during the eversion maneuver.

2. Only in rare cases are intima fixation sutures necessary. Usually, it is possible to sufficiently fix the intima, if necessary, with the anastomosis suture.