Vascular Surgical Techniques

Greenhalgh

Basic principles

Operation planning

Roger M. Greenhalgh, MA, MD, MChir, FRCS,     Professor of Surgery, Charing Cross Hospital Medical School, London, UK

Publisher Summary

This chapter describes the careful planning of operative procedures that is important for arterial reconstructive surgery. Noninvasive tests are equally valuable in assessing the arteries supplying the lower limbs. The simplest test involves the use of a Doppler probe with a blood pressure cuff. This enables the ultrasonic systolic pressure to be recorded at a particular segment. If the cuff is placed around the ankle, calf, and upper thigh, segmental pressures can be measured on both legs and this can give vital information to be considered alongside an arteriogram. It is found that where all pulses are present and the Doppler systolic pressure in the ankle is normal compared to that in the arm, it is important to perform an exercise test to ensure that pressure is maintained after exercise. The waveforms of the velocity profiles on different points along the leg can also give vital information on the site and severity of disease. It is necessary to work closely with the hematology department. Adequate whole blood needs to be cross-matched before the operation and if excessive blood loss is anticipated, albumin and fresh frozen plasma should be at hand.

Introduction

All operative procedures require careful planning and this is especially important for arterial reconstructive surgery. The desired result cannot be achieved if patient selection is poor. Learning how to choose the right procedure for the right patient takes at least as much experience as learning how to do the vascular surgical techniques and both should form an integral part of training for vascular surgeons. The indications for the individual procedures are mentioned at the beginning of the later chapters but are only given in outline, as this really is a separate subject.

Preoperative assessment, non-invasive testing and angiography are essential stages in accurate patient selection for a procedure and these are outlined here. This is followed by a note on anaesthetic aspects and monitoring during the operative procedure, followed by some haematological considerations.

Preoperative assessment

A very careful history of the patient must initially be taken. It is vital to relate the patient’s complaint to age, occupation and way of life before deciding what is the best treatment.

Almost all patients with severe arterial disease have been heavy smokers for many years. Patients at risk of stroke or suffering from ischaemic rest pain or imminent gangrene should be offered any possible operative procedure immediately. If the situation is not so urgent, the surgeon must decide whether to ask the patient to stop smoking before the operation is carried out.

The cardiac status needs to be thoroughly assessed. Approximately one-third of patients presenting with the symptoms of peripheral arterial disease have already had a myocardial infarction in the past as demonstrated by resting electrocardiographic abnormality and a greater proportion have exercise ECG changes. Those centres with the facility should always perform ventricular injection fractions on their patients to assess the cardiac status before embarking upon arterial reconstruction in the extremities. Centres without this facility can still rely to a great extent on careful history taking and examination of cardiac function to establish which patients are at high risk of cardiac failure. Often, such as for impending gangrene or stroke, there is no alternative but to perform a reconstruction.

Approximately 10% of patients with peripheral arterial disease are diabetic and just as it is important to work closely with a cardiologist for cardiac problems, it is equally important to work hand in hand with an endocrine physician when dealing with diabetic patients. Each endocrine specialist has his own way of managing the problem. There is increasing use of a constant infusion of insulin over the perioperative period. It is claimed that this facilitates easier moment-to-moment control of diabetes mellitus. Of course, the most important rule is that the blood glucose level should never be allowed to fall; a slight rise is preferable but the expert will aim at perfect control of the blood glucose level over the whole perioperative period.

If patients are taking warfarin or similar oral anticoagulant drug this should be stopped and the prothrombin time should become normal before surgery. If it is thought that a prosthetic graft is going to be used in a low flow situation, an antithrombotic regimen may be instituted 48 h before surgery. Aspirin 300 mg daily with dipyridamole 75 mg three times daily is found to be an acceptable dosage in most centres.

A complete physical examination should be undertaken for all patients. The chest must, of course, be examined most carefully in those patients who are to undergo general anaesthesia. All of the pulses are felt and a careful examination is made for aneurysmal disease over the aorta, femoral and popliteal regions. It is important to listen for bruit over diseased arteries, particularly in the neck.

Two of the most important special investigations that are performed are for detection of diabetes mellitus and renal disease. Examination of urine and measurement of blood sugar and plasma creatinine levels is essential and any abnormalities discovered required further investigation.

Non-invasive testing

Until recently it was felt that a thorough clinical examination and an angiogram were all that were required for correct patient selection. Increasingly, the place of non-invasive tests has become established. These now have a firm place in the investigation of carotid artery disease and disease of the arteries supplying the lower limbs. Ideally, the carotid vessel should be investigated whenever the arterial tree is to be operated upon at another site. It is mandatory to evaluate the carotids in patients who have a carotid bruit. Oculoplethysmography and carotid phonan-giography have been used to assess the carotid vessels by an indirect method. The Kartschner and McRae oculoplethysmography system (OPG) compares the transit time to the eyeballs and the transit times to the ears. The Gee OPG works on a completely different principle and measures pressure in the orbit.

The indirect methods are now being superceded by imaging methods. The Mobile Arterial and Venous Imaging System (MAVIS) is a pulsed gated Doppler imaging system which enables an image to be built up using Doppler ultrasound based on the moving blood in the vessels. The duplex scanner combines B-mode ultrasound with Doppler velocity profile. This scanner has been shown to have a 98% correlation with conventional angiography. Digital subtraction angiography also provides valuable additional anatomical information about the carotid vessels but this is strictly invasive because the contrast material is injected into a vein. This technique also has approximately 98% correlation with conventional angiography, and when combined with duplex scanning, a 99% correlation. The main concern about conventional angiography is that it carries a small but definite morbidity risk. This suggests that its use is only justified in patients with symptomatic carotid arterial disease, whereas the non-invasive tests mentioned here have no morbidity and provide an extremely convenient method of assessment of the carotid vessels before arterial reconstruction at another site is undertaken.

Non-invasive tests are equally valuable in assessing the arteries supplying the lower limbs. The simplest test involves the use of a Doppler probe with a blood pressure cuff. This enables the ultrasonic systolic pressure to be recorded at a particular segment. If the cuff is placed around the ankle, calf and upper thigh, segmental pressures can be measured on both legs and this can give vital information to be considered alongside an arteriogram. Where all pulses are present, and the Doppler systolic pressure in the ankle is normal compared to that in the arm, it is important to perform an exercise test to ensure that pressure is maintained after exercise (Laing and Greenhalgh, 1980). The waveforms of the velocity profiles on different points along the leg can also give vital information on the site and severity of disease.

An example of where these tests are of a special value is before performance of a femorofemoral cross-over graft. For this procedure it is not enough just to look at the arteriogram; it is absolutely essential to know that the donor iliac segment is normal and that it is a suitable source of blood supply for the opposite limb. A combination of waveform analysis, segmental pressure measurement and exercise testing can be most helpful here.

Angiography

The perfemoral Seldinger technique is the most commonly used method of arteriography today. With this approach it is possible to pass catheters to almost all parts of the arterial tree, provided that there are no arterial occlusions or very tight stenoses. If the iliac system above or the aorta is occluded it may be necessary to approach the arterial tree from another route. The transaxillary approach gives the same degree of flexibility as the femoral approach but this requires proper training to avoid damage to the nearby brachial plexus. The advantage of this approach is the ability to perform selective arterial catheterization, e.g. of the carotid subclavian, vertebral, renal or visceral vessels. These techniques do not require general anaesthesia but the patient is frequently slightly sedated.

Translumbar aortography requires general anaesthesia but can be performed as an outpatient procedure. It is difficult though to take films in more than one plane and this is essential for satisfactory assessment of the arteries, particularly, at, for example, the origin of the profunda femoris artery which arises from behind the main vessel.

Anaesthetic options and monitoring

Most of the contributors to this book draw attention to the great value of the expertise of the anaesthetist who has experience with vascular surgical patients. Either a general anaesthetic or a light anaesthetic with continuous epidural can be used. It is essential to assess pulmonary function properly before embarking upon a procedure and to decide on the most appropriate form of anaesthesia. In some circumstances it is possible to provide a local block or even local infiltration to perform simple procedures as, for example, in the groins. The monitoring system which is used for continuous assessment of the patient during the operative procedure is designed for the benefit of the anaesthetist and the surgeon. A radial intra-arterial catheter should be passed so that continuous monitoring of the systolic and diastolic pressures is possible throughout the procedure. A central venous pressure line and ECG monitor are essential for every arterial operation. A number of venous lines is required – up to four if rapid transfusion is envisaged as, for example, when operating upon thoracoabdominal aneurysms. The insertion of a Swan-Ganz catheter is more controversial, but this is being used increasingly. Ideally the catheter is inserted a day or so before the operation so that the optimal capillary wedge pressure for maximal cardiac output can be determined and the knowledge is used during surgery.

During the operation it is vital to estimate blood gases at least every 30 min so an anaesthetic is chosen that does not depress the myocardium. For muscle relaxation, muscle relaxant drugs are used. A urinary catheter is passed so that the the hourly urine output can be monitored. When the surgeon clamps a major blood vessel he should work with the anaesthetist, observing the monitoring system and, if necessary, performing the clamping and unclamping very slowly. The use of heparin is very controversial. Most surgeons performing arterial bypass use approximately 5000 i.u. of heparin intravenously before cross-clamping. A wait of approximately 3 min before applying the clamps is generally recommended to allow the heparin to circulate. For emergency abdominal aneurysms and for all thoracoabdominal aneurysm replacements the use of heparin is not advisable.

Haematological considerations

It is necessary to work closely with the haematology department. Adequate whole blood needs to be cross-matched before the operation, and if excessive blood loss is anticipated, albumin and fresh frozen plasma should be at hand. For major procedures such as thoracoabdominal aneurysms 10–16 u of platelets should be available so that these can be infused the moment the blood flow is restored to the graft. For major transfusions it is wise to alternate 1 u of frozen plasma to every 2 u of whole blood.

The planning of venous procedures is just as important as the planning of arterial ones. Varicose veins are assessed and marked following clinical examination and the use of the Doppler probe can be valuable to determine whether there is any incompetence at a particular site. When considering surgery of the deep venous system, it is important to perform ascending and descending venograms.

Reference

Laing, S.P., Greenhalgh, R.M. Standard exercise test to assess peripheral arterial disease. British Medical Journal. 1980; 280:13.

Techniques of anastomosis

Roger M. Greenhalgh, MA, MD, MChir, FRCS,     Professor of Surgery, Charing Cross Hospital, Medical School, London, UK

Publisher Summary

This chapter discusses the techniques of anastomosis. The various techniques of anastomosis, or joining of blood vessels, fall into two main types that include end-to-end anastomosis and end-to-side anastomosis. Various graft materials are preferred for bypass in different parts of the body. Essentially Dacron prostheses are of two main types that include woven and knitted. The woven variety has the advantages that it does not require any preclotting of the Dacron and it does not leak blood. Its disadvantage is that it is rather stiff and when cut, it frays. The great advantage of knitted Dacron is that it can be shaped exactly as required but must be preclotted. Preclotting can be achieved by taking approximately 100 ml of blood from a nearby vein such as the vena cava and syringing it down through the graft so that the blood pours through the holes. After the graft is pulled down, the suturing is continued to the mid-point, the polypropylene sutures being pulled tight in opposite directions as suturing proceeds to avoid slippage. Slippage will lead to leakage around the back of the anastomosis, which is difficult to correct subsequently.

Introduction

The various techniques of anastomosis, or joining of blood vessels, fall into two main types: end-to-end anastomosis and end-to-side anastomosis. Various graft materials are preferred for bypass in different parts of the body and these are described in detail in subsequent chapters. For replacement of large vessels such as the aorta, Dacron has become the material of choice. Essentially Dacron prostheses are of two main types, woven and knitted. The woven variety has the advantages that it does not require any preclotting of the Dacron and it does not leak blood. Its disadvantage is that it is rather stiff and when cut it frays. It is advisable to cut woven Dacron with an electric diathermy needle so that the ends are sealed, but this can be quite a tricky procedure compared with the precise cutting of a knitted Dacron graft which can be performed with scissors. The great advantage of knitted Dacron is that it can be shaped exactly as required but must be preclotted. Preclotting can be achieved by taking approximately 100 ml of blood from a nearby vein such as the vena cava and syringing it down through the graft so that the blood pours through the holes. The blood is then caught in a dish and syringed through the graft again and again with some pressure until the interstices become blocked by the clotting blood. The blood is then squeezed out of the Dacron which should be leak proof and it is ready for anastomosis. To dispense with or minimize preclotting, there has been a recent introduction of collagen coating of Dacron. An externally supported Dacron graft has gained much favour and may prove ideal in sites where it is important that the graft should not be squashed, such as for axillofemoral bypass.

Dacron is perhaps the material of choice for the replacement or bypass of arteries ranging in size from the aorta to the common femoral artery. Expanded polytetrafluoroethylene (PTFE) is mainly used in long straight tubes for the replacement of smaller arteries than is ideal for Dacron. However, a bifurcated graft of PTFE is now available to replace or bypass the aortic bifurcation; it does not require preclotting and is easy to work. Patients who are expected to have a PTFE graft should begin aspirin and dipyridomole 48 h before surgery to minimize postoperative graft thrombosis. It is an excellent graft material for femorofemoral crossover, axillobifemoral bypass and bypass of the femoral artery in the