- Vessel wall after TEA too thin → Vessel interposition
- Injury to deep leg veins during preparation → central and peripheral compression and vessel suture
- peripheral embolization → embolectomy
- Nerve lesions can usually be avoided through careful anatomical preparation
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Intraoperative Complications
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Postoperative Complications
Postoperative bleeding, Hematoma
- Causes: technical errors such as suture insufficiency, slippage of ligatures, inadequate hemostasis; also stab wound 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
Early closure of arterial reconstruction due to thrombosis/embolism (≤ 4 weeks postoperatively)
- Causes: technical or indicative errors such as dissections
- Diagnosis: color-coded duplex sonography, if necessary angio-CT
- in case of "immediate closure" (within 24 hours postop.) proximal and distal exposure, careful Fogarty maneuver, error correction
- vascular surgical revision, if necessary thrombectomy/embolectomy, possibly also endovascular, if necessary new creation
- Check coagulation status
Wound infection
- Diagnosis: local findings, laboratory, fever
- Therapy: if unavoidable opening of the wound, swab, debridement, if necessary vacuum sealing ("VAC" therapy), antibiosis according to resistogram
- Caveat: in the presence of alloplastic material (as in the film example Dacron patch, stents) an infection of the foreign material can always be causative, conversely a wound infection can also spread to alloplastic material!
- 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 presentation, 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 dermotraction over artificial skin or vacuum sealing, split skin
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 rest pain (ischemic pain)
- sensory disturbances and motor deficits (foot drop 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 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 predisposes 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 an infection injection of fibrin glue or also revision with encircling ligation (methylene blue, magnifying glasses), very rarely plastic coverage
- Prophylaxis: Sparing of lymphatic vessels through lateral access, transpose lymphatic tissue ventro-medially
persistent lymphedema
- manual lymphatic drainage
- in sufficient arterial perfusion (Attention: CLI!) consistent compression treatment
Pseudoaneurysm
- Cause: Bleeding into the surrounding tissue with formation of an extravasal, pulsating hematoma after vascular puncture, in the area of anastomoses and patch plasties, also due to infections/suture rupture
- Diagnostics: color-coded duplex sonography (circulating blood flow paravasal, detection of an aneurysm neck with to-and-fro flow)
- Therapy: for small, asymptomatic aneurysms wait and see, otherwise endovascular or open exclusion
Late closure of arterial reconstruction due to stenosis (> 4 weeks postoperatively)
- see Early closure
Suture aneurysm
- Cause: Suture rupture, turbulent flow, thrombendarterectomy, infection
- Clinical presentation: depending on location e.g. pulsating tumor inguinal, also hemorrhagic shock in rupture
- Diagnostics: color-coded duplex sonography, angio-CT
- Therapy: vascular surgical revision, endovascular intervention