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Complications - Right femoropopliteal PTFE bypass (P3) – Vascular Surgery

vascular surgery
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Anatomy Perioperative management Technique Complications Evidence Total Video

  1. Intraoperative complications

    Arterial dissection

    • Graft extension mandatory

    Venous bleeding

    Since the popliteal vein parallels the popliteal artery and, in addition, the epifascial veins and their side branches often encase the popliteal artery, injuries to the veins may result in troublesome bleeding.

    • Severe venous bleeding -> compression and targeted sutures
    • Prevention: careful dissection of the popliteal artery with transection of crossing veins and gentle mobilization of the large main veins; if necessary, encircle thems with vessel loops and retract them to the side

    Suture stenosis

    • Dilation, possibly revidion surgery

    Peripheral embolism

    • Embolectomy

     

  2. Postoperative complications

    Secondary bleeding, hematoma

    • Causes: technical errors such as suture line failure; slipped off ligatures; inadequate hemostasis; also needle track bleeding; iatrogenic vascular lesions; surgery under concomitant antiplatelets
    • Management: emergency surgery in active and hemodynamically significant bleeding
    • Liberal indication for evacuation of hematomas as a breeding ground for infection and also possible cause of compression of other structures (compartment
    • Prevention: careful dissection, subtle hemostasis

    Thrombosis/embolism of the revascularization with early occlusion (≤ 4 weeks following surgery)

    • Causes: technical errors such as dissections
    • Diagnosis: color- flow Doppler ultrasonography, possibly CT-angiography
    • In "immediate occlusions" (within 24 h post surgery) proximal and distal exposure, careful Fogarty maneuver, correcting errors
    • Revision surgery, (possibly endovascular) thrombectomy/embolectomy if needed, perhaps even new bypass
    • Check coagulation status

    Wound infection

    • Diagnosis: Local findings, lab panels, fever
    • Management: if unavoidable, reopen the wound; swab; debridement; possibly NPWT, AST-specific antibiotics
    • Caution: In the presence of alloplastic material (see video), graft infection could always be the root cause; conversely, wound infection could also spread to the alloplastic material!
    • Prevention: careful atraumatic, anatomically correct surgical technique, subtle hemostasis, avoidance of injury to the lymphatics

    Compartment syndrome

    • Cause: Reperfusion after complete or incomplete ischemia results in damage to the capillary membrane with increased permeability and soft tissue edema, increasing the pressure in muscle compartments with tissue death.
    • Clinical signs: see red flags
    • Diagnostic work-up: Clinical picture, see Red Flags; assess objectively by intracompartmental pressure measurement (borderline pressure between 30 and 50 mmHg over 6 hours, as well as pressure readings above 50 mmHg, are pathologic).
    • Management: immediate dermatofasciotomy with complete longitudinal fascia cleavage in all muscle compartments, followed later by dermatotraction via alloplastic skin graft or NPWT, split-thickness skin graft.

    Red flags - Clinical warning signs in compartment syndrome

    Pathognomonic signs:

    • Painful soft tissue swelling of the muscle compartment with reduced elasticity (early symptom)
    • Pain on passive stretching of the affected muscle
    • Intense, analgesic-refractory rest pain (ischemic pain)
    • Sensory impairment and motor deficits (paralysis of the tibialis anterior muscle with weakness of the extensor muscles of the lower leg)

    Clinical P‘s of compartment syndrome:

    • Pressure (swelling and impaired elasticity)
    • Pain out of proportion
    • Pain with passive stretching
    • Paresthesia (affection of the nerves passing through the compartments)
    • Paresis or palsy (motor weakness)
    • Pulses present! Pulselessness is not considered a classic symptom!
    • Pink skin color (shiny marbled skin)

    Lymphatic fistula, lymphocele

    • Risk: Access via the inguinal region predestined for injury to lymphatics
    • Diagnosis: clinical local findings
    • Treatment: nonsurgical management of lymphoceles, bearing in mind the risk of infection; lymphatic fistulas should be drained long-term without suction, or, after ruling out infection, by injection of fibrin glue or revision surgery with ligation (methylene blue, surgical loupes), very rarely by plastic surgery
    • Prevention: Protect the lymphatics by lateral approach, sweep lymphatic tissue anteromediad

    Persistent lymphedema

    • Manual lymph drainage
    • With adequate arterial perfusion (Caution: PAOD!) consistent compression treatment

    Pseudoaneurysm

    • Cause: bleeding into the surrounding tissue with formation of an extravascular, pulsating hematoma after vessel puncture, in the vicinity of anatosmoses and patch plasties, also due to infection/broken sutures
    • Diagnostics: color flow Doppler ultrasonography (circulating perivascular blood flow, evidence of aneurysm neck with "to and fro" blood flow pattern)
    • Management: watchful waiting in small, asymptomatic aneurysms, otherwise endovascular or open repair

    Thrombosis Stenosen embolism of the revascularization with late occlusion (> 4 weeks following surgery)

    • See early occlusion

    Suture line aneurysm

    • Cause: Suture line fracture; turbulent flow; thromboendarterectomy; infection; graft degeneration
    • Clinical signs: depending on location, e.g., pulsating inguinal tumor, also hemorrhagic shock in rupture
    • Diagnostics: color-flow Doppler ultrasonography, possibly CT-angiography
    • Management: revision surgery, endovascular intervention.