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Aorta
11
Dacron
graft
Aortic stump
Left common
iliac artery
12
Wall of
aneurysm
Graft
13
Anastomosis
14
Clamp
released
15
Graft
Wall of
aneurysm
Occluding
clamp
Common
iliac artery
Blood ow
333
Blood
clot
PLATE
156
DETAILS OF PROCEDURE e clamp is closed and the suture
line completed and tied. e completed limb is occluded by nger control,
and the aortic clamp is removed slowly. Blood ow is gradually reestablished to the limb to prevent hypotension (figure 16). Close coordination
between surgeon and anesthesiologist is required at this point so that the
rate of opening the gra is compensated by uids and blood administration
with maintenance of stable blood pressure.
e other iliac anastomosis is carried out in similar fashion (figure 17).
e aneurysm sac, if adequate, is closed over the gra with a running suture
(figure 18). If at all possible, closure of the proximal aneurysmal sac should
cover the aortic anastomosis so as to provide tissue between it and the duodenum. Alternatively, some surgeons tuck a segment of omentum in this
region. e posterior peritoneum is reapproximated, with care taken not to
injure the ureters.
In the presence of occlusive disease of the common iliac in addition
to the aneurysm, the common iliac may be divided and oversewn with
a continuous suture (figure 19) on both sides following removal of the
aneurysm. e gra is tailored to permit anastomosis of the aorta above
the aneurysm with end-to-side anastomosis to the external iliacs beyond
the points of stenosis (figure 20). is bypass procedure makes extensive endarterectomy unnecessary and prevents sacri ce of the hypogastric
arteries, which are important in maintaining colonic viability.
CLOSURE e small intestine is returned to the peritoneal cavity from the
plastic bag, and the peritoneal cavity is cleared of blood clots and sponges.
Before closure, particular attention is given to the adequacy of the blood
supply to the sigmoid. Ordinarily, the blood supply is adequate a er ligation of the inferior mesenteric artery. Evidence of bleeding from the prosthesis or at the site of anastomosis is thoroughly searched for before the
R A A A
closure is nally completed. e femoral vessels should be palpated from
time to time to ensure that thrombosis has not occurred and that a good
ow of blood is going through to the lower extremities. In case of doubt it
may be necessary to reexplore one or both sides and remove any blood clots
that are found. Routine abdominal closure is done.
POSTOPERATIVE CARE Postoperative care usually is provided in an
intensive care unit for the rst to hours. In the postoperative period
it is particularly important to ensure that there is a good blood supply to
the lower extremities and a good hourly output of urine. Blood should be
given until all major blood loss has been replaced, and the blood pressure is satisfactory. e use of a cell saver system during surgery should
lessen this need for blood replacement. Intravenous uids are administered
slowly during the rst hours to ensure a steady output of urine from the
indwelling catheter. e presence or absence of pulsation in the dorsalis
pedis arteries should be recorded. Con rmation may be di cult at rst,
but the pulsations usually become more apparent later in the postoperative
period. If pulsations are absent and there is a cold extremity, thrombosis
may have occurred, and reexploration and removal of the blood clot should
be considered.
An electrocardiogram is taken in the early postoperative period. Laboratory studies to evaluate the blood volume and kidney function are performed daily until the convalescence becomes uneventful. A tendency to
paralytic ileus should be combatted by gastric suction until there is evidence
that peristalsis has returned. Renal failure should be suspected if there has
been preoperative evidence of impaired renal function or if there has been
a prolonged period of hypotension.
If adequate hourly output of urine is not maintained despite an adequate
intake, anuria should be suspected and appropriate therapy instituted. ■
334
16
17
Clamp
released
Occluding
clamp
Partial
occlusion
Ureter
Aneurysmal sac
reconstructed
18
Ureter
Occluding
clamp
Ureter
20
Right ureter
Blood ow
Occluding
clamp
Ureter
Ureter
Graft
19
Left ureter
Ureter
Closure of
iliac stump
End - to - side
anastomosis
335
PLATE
157
INDICATIONS Only patients with severe and debilitating occlusive dis-
ease of the aortoiliac segment should be considered for surgery. In general, these patients will have claudication that is progressing or disabling.
Patients with rest pain, ulceration, or gangrene who fall in the limb salvage group may require surgery to preserve limb function. ese patients
are generally elderly and have associated generalized arteriosclerosis with
a high incidence of coronary disease and hypertension. In addition, the
majority are long-time smokers, and it is not unusual for limitation of
pulmonary function to be present. e risks associated with these factors
must be carefully weighed against the bene ts expected from a successful surgical procedure. e careful selection of patients is of the utmost
importance.
PREOPERATIVE PREPARATION See Plate .
ANESTHESIA See Plate .
POSITION See Plate .
OPERATIVE PREPARATION See Plate .
INCISION AND EXPOSURE A midline incision is made from the xiphoid
to the pubis to a ord maximum exposure (figure 1). e abdomen is
explored for the presence of other pathology, and the intra-abdominal
arterial tree is carefully assessed. figure 2 demonstrates typical aortoiliac
occlusive disease. e aorta is freed by entering the retroperitoneal space.
e posterior peritoneum is divided, and the duodenum is mobilized
until the renal vein is identi ed. Sharp and blunt dissection then is used to
clear the aorta on its anterior, lateral, and medial surfaces (figure 3). It is
usually not necessary to encircle the aorta or to free it completely; this o en
A B
leads to troublesome bleeding from lumbar arteries and veins. Additionally,
if the le renal vein is not visualized, it may lie beneath the aorta and be
injured by such a dissection. Heparin is injected intra-arterially to protect
the distal extremities from thrombosis, as outlined for resection of abdominal aortic aneurysm (Plate ).
DETAILS OF PROCEDURE An aortic clamp is then used to clamp the aorta
proximally just below the renal arteries (figure 4). A second aortic clamp
is placed horizontally to occlude the iliac vessels and the lumbar arteries,
as depicted in figures 4 and 5. A small vascular clamp should be applied
to the inferior mesenteric artery. It is important to have the distal aorta
freed su ciently that this clamp can be placed far posteriorly to avoid interference with the arteriotomy and the anastomosis. A linear arteriotomy is
made in the aorta to a point just above the inferior mesentery artery takeo
(figure 5). An attempt is made to preserve that vessel if at all possible. e
gra is beveled (figure 6a), and an end-to-side anastomosis is then cre-
ated (figures 6b, 7, 8, and 9) with a running vascular suture, begin-
ning at the inferior margin of the arteriotomy with a mattress suture, much
as described in Plate . e running suture then is carried up each side of
the arteriotomy, and nally the anastomosis is completed in the middle of
the arteriotomy on the operator’s side.
ALTERNATIVE TECHNIQUE Many vascular surgeons prefer a direct end-
of-aorta to end-of-gra anastomosis. In this technique, the aorta is dissected free circumferentially at the same level below the renal arteries and
between lumbar vessels. Care must be taken to identify the caval and lumbar vessels during this dissection. A pair of vascular clamps are applied and
the aorta is transected, leaving an adequate cu for anastomosis proximally
while oversewing the distal cu with a vascular suture.
CONTINUES
336
1
3
2
Renal vein
Inferior
vena cava
Abdominal
incision
Groin incision
Aorta
External
iliac artery
Inferior
mesenteric artery
Aorta
Arteriosclerotic
plaque
Profunda artery
4
Incision
in aorta
5
Incision
in aorta
Ureter
6b
6a
Inferior
mesenteric
artery
Graft
Renal
artery
7
Renal
vein
Lumbar arteries
8
Common
iliac artery
9
337
PLATE
158
ALTERNATIVE TECHNIQUE A linear incision is made in the
groin over the femoral artery (figure 10), and the common femoral, the
profunda femoris, and the super cial femoral artery are carefully isolated.
It is important to dissect at least several centimeters of the profunda femoris to evaluate the presence of disease in this vessel. If it is signi cantly
involved, profunda endarterectomy or a profundoplasty should be considered, because this procedure appears to increase the longevity of gra
function. A retroperitoneal tunnel is then made overlying the iliac artery
and extending into the femoral incision (figure 10) by blunt nger dissection from above as well as from below the inguinal ligament. It is important to make this tunnel on the artery so that the ureter does not become
entrapped. Care should be given to anterior displacement of the ureter
so that a er the procedure it will overlie the prosthetic gra . Finally, it is
important to remember that all of the dissections, aortic and femoral, and
the tunnel should be completed before the patient is heparinized.
e gra is pulled into the groin incision (figure 11) and the end beveled
(figure 12). Vascular clamps have been placed on the common femoral, the
profunda femoris, and the super cial femoral arteries (figure 13), and the
linear arterotomy is made. It is not necessary to excise a button of artery wall.
A B
e anastomosis is carried out in the same manner as the upper endto-side anastomosis of the gra to the aorta (figures 14 and 15). Just
before completion of the femoral anastomosis, a clamp is placed on the
opposite iliac limb of the gra and across the right common iliac beyond
the bifurcation. e aortic clamp is opened momentarily to allow any
potentially clotted material to be ushed out from the gra (figure 16).
e clamp is replaced and the anastomosis is completed. en the aortic
clamp is removed, with secure digital compression of the gra in order
to ensure a gradually increased ow to the limb (figure 17). e limb
slowly is allowed to ll so that hypotension does not occur, much as was
outlined in the aortic aneurysm procedure. A similar procedure is followed in completing the anastomosis of the gra to the le common
femoral artery.
CLOSURE e incisions are closed in the routine manner. A running (
or ) mono lament suture with large wide bites is used for the midline
incision, whereas the groin incisions are closed in layers with absorbable
sutures. See Chapter .
POSTOPERATIVE CARE See Plate . ■
338
Finger in
inguinal canal
10
11
Graft
Inguinal
ligament
Femoral
artery
14
13
15
12
Graft
Femoral vein
16
Occluding
clamp open
17
339
PLATE
159
INDICATIONS e role of carotid endarterectomy is the prevention of
strokes in patients with systemic disease of the vascular system. e indications for the procedure are varied, but the chief indication is transient ischemia. When the symptoms of cerebral ischemia are transient, intermittent,
and self-resolving, the results of surgical correction of the area of carotid
stenosis are excellent. e operation may be considered in some patients
who have recovered from old strokes who develop new symptoms. Mild
intracranial disease with severe proximal disease is another indication for
carotid endarterectomy. e two principal indications are asymptomatic
high-grade stenosis and transient ischemia.
Duplex ultrasound blood- ow imaging studies with or without magnetic
resonance angiography (MRA) or contrast angiography are used to visualize
the arch carotids and vertebral vessels. is allows accurate documentation
of any areas of stenosis as well as the extent of the collateral blood supply.
Surgical improvement is minimal in patients with complete occlusion of
the internal carotid artery, and operation is not usually recommended for
patients with established long-standing occlusion. e risks of increasing
cerebral damage or of the patient su ering hemiplegia are ever present, and
the patient and family should be thoroughly informed of the risks.
A thorough medical evaluation of the cardiovascular system with special attention to the coronary arteries is indicated. Other medical problems,
including diabetes, must be under complete control. e incidence of stroke
is greater in patients with contralateral carotid occlusion, and one-stage
bilateral carotid endarterectomy is inadvisable because of the increased
incidence of complications. At least a week or more should separate two
procedures. e operation may be delayed in patients with acute strokes,
allowing them to stabilize for to weeks. At that time, angiographic studies and operation can be considered.
POSITION e patient is placed in a supine position with the head slightly
extended and turned toward the contralateral side.
OPERATIVE PREPARATION A er routine skin preparation, the operative eld
is draped to expose the mastoid process superiorly, the angle of the mandible
anteriorly, the manubrium and clavicle inferiorly, to the trapezius posteriorly.
INCISION AND EXPOSURE e incision is made along the anterior
border of the sternocleidomastoid muscle from the mastoid process to a
point two-thirds of the distance to the sternoclavicular joint (figure 1).
e incision is carried through the platysma muscle exposing the anterior
border of the sternocleidomastoid muscle, which is then retracted laterally to expose the carotid sheath. Care must be taken to avoid making the
upper end of the incision too far anteriorly, where the marginal mandibular branch of the facial nerve may be injured in its course just inferior to
the horizontal ramus of the mandible. Such an injury results in paralysis of
the lower lip. In the cephalad portion of the incision, the greater auricular
nerve and sensory branches of the cervical plexus o en can be identi ed
and preserved if exposure is not compromised. Injury to these nerves will
result in a sensory de cit involving the earlobe or the angle of the mandible.
Gentle self-retaining retractors may be positioned at this time to provide
maximal exposure. e omohyoid muscle may be retracted inferiorly or
divided to permit exposure of the common carotid artery, depending upon
the required extent of the procedure.
C E
DETAILS OF PROCEDURE e anatomy of the neck must be understood
clearly so that inadvertent injury to nearby cranial nerves can be avoided
(figure 2). e vagus nerve lies within the carotid sheath generally in a
posterolateral position; injury will result in vocal cord paralysis. e hypoglossal nerve passes super cial to the carotid arteries to cm cephalad
to the carotid bifurcation; injury will result in deviation of the tongue and
dysphagia. e ansa hypoglossi branches from the hypoglossal nerve as it
crosses the internal carotid artery and passes inferiorly to innervate the
strap muscles. is may be sacri ced without signi cant consequence to
facilitate exposure of the more distal internal carotid artery, allowing the
hypoglossal nerve to be gently retracted superiorly. e carotid body is in
the crotch of the carotid bifurcation. Dissection in this area may result in
hypotension and bradycardia, cardiovascular e ects that can be blocked
e ectively by injecting the carotid body with lidocaine. e facial nerve
is at the most cephalad extent of the incision and should be well out of the
eld anteriorly (figure 2).
A er the described exposure has been obtained, the facial vein is
divided, exposing the carotid bifurcation (figure 3). e carotid sheath is
entered and opened superiorly and inferiorly. A vessel loop is passed about
the common carotid artery proximally and distally. A vessel loop is passed
around the external carotid artery to facilitate later placement of a vascular clamp. A vessel loop or a silk ligature then is passed doubly around
the superior thyroid artery as a Potts tie to provide vascular control. e
internal carotid artery is then dissected circumferentially at a point cm
distal to palpable disease and encircled with a vessel loop. Great gentleness is required and care is taken during this dissection to prevent plaque
embolization.
If selective shunting is to be used, appropriate monitoring equipment
(a transducer, extension tubing, and a -gauge needle) must be readied
and carefully ushed with saline to free it of bubbles or particulate debris.
Clamps are placed across the external carotid artery and common carotid
artery, a er which the needle is placed within the carotid artery to measure
the carotid stump pressure (figure 4). Stump pressures greater than to
mmHg document signi cant collateral blood ow and are associated with
a lower incidence of cerebrovascular accident. Care must be taken in the
presence of extensive or ulcerated plaques to avoid plaque embolization with
this maneuver. Some rely upon continuous electroencephalographic monitoring to gauge the adequacy of collateral blood ow and the requirement for
intraluminal shunting; others choose to shunt all patients routinely; and still
others may choose not to shunt patients at all but attain acceptable results.
Heparin is now given intravenously by the anesthesiologist at the surgeon’s discretion. Bulldog clamps are placed across the internal carotid
artery, external carotid artery, and common carotid artery in sequence. An
incision then is made on the anterolateral surface of the common carotid
artery just inferior to the bifurcation. Potts scissors then are used to elongate the incision proximally and distally across the area selected for endarterectomy (figure 5). Care must be taken to extend the arteriotomy distally
to a point beyond the end of the atheromatous plaque so that the endarterectomy can be performed entirely under direct vision. e incision is
carried through the thickened intima into the lumen. e line of cleavage
is within the media, leaving the adventitia and media externa for closure as
indicated by the arrows (figure 6).
CONTINUES
340
1
Internal
carotid artery
Facial vein
Internal
jugular vein
2
External
carotid
artery
Omohyoid muscle
Facial nerve
Common
carotid artery
Incision
Hypoglossal nerve
3
Vagus nerve
Sternocleidomastoid
muscle
Internal
jugular vein
Common
carotid artery
Vessel
loop
Ansa hypoglossal nerve
Vagus nerve
Facial vein
Superior
thyroid artery
External carotid artery
Carotid body
Superior
thyroid artery
Common
carotid artery
Incision
6
Endarterectomy plane
Thickened intima
Restricted lumen
4
5
Incision
Potts’
scissors
Carotid stump pressure
20
341
PLATE
160
DETAILS OF PROCEDURE If intraluminal shunting is
elected with a Pruitt-Inahara shunt it needs to be ushed and prepped
ahead of time. Heparinized saline is ushed through the irrigating port
and hemostats are placed on the proximal and distal limbs of the shunt
directly adjacent to the irrigating port. e distal end is inserted rst and
the balloon is gently in ated to seal o back bleeding around the shunt
(figure 7). e distal hemostat is opened and the distal limb aspirated back
through the irrigating limb to remove all air. e hemostat is reapplied. e
proximal end of the shunt is then inserted into the common carotid artery
and the balloon gently in ated to prevent any antegrade ow around the
shunt (figures 8 and 9). Overin ation is to be avoided to prevent tear-
ing of the intima or prolapsing of the balloon over the end of the shunt
and occluding ow. e proximal hemostat is removed and the limb aspirated through the irrigating port to remove any air or debris. e aspirating
process should be repeated one more time and the hemostats removed to
establish ow through the shunt. e shunt is checked with the Doppler
probe to check for ow and the endarterectomy is them commenced. With
experience and planning placement of such a shunt should consume no
more than to seconds.
Endarterectomy then is begun in the distal common carotid artery,
using a Freer elevator, blunt spatula, or a mosquito hemostat. e appro-
C E
priate endarterectomy plane usually is identi ed easily in the mid to outer
media, leaving a smooth, glistening reddish-brown arterial wall behind
(figure 10).
is dissection is continued quite carefully in an attempt to elevate
the plaque circumferentially. A blunt-tipped right-angle clamp is o en
valuable (figure 11). e plaque then is divided proximally with the
Potts scissors to facilitate exposure. e endarterectomy then proceeds
distally in a meticulous fashion, care being taken to maintain a single
endarterectomy plane. e most important aspect of the procedure is the
delicate feathering of the endarterectomy at the distal boundary of the
atheromatous plaque. No ap or shelf can be tolerated, since a technical fault will result in dissection a er restoration of prograde ow with
subsequent thrombosis and probable neurologic catastrophe. Plaque is
removed similarly from the external carotid ori ce allowing removal of
the specimen (figure 12). All residual debris then is removed carefully
with forceps in a circumferential direction. A Kitner sponge also may be
helpful in clearing the eld of debris. Heparinized saline is used to irrigate the eld, allowing free removal of clot. Forceful irrigation distally
may reveal elevation of a distal ap that may require attention or tacking
sutures (figure 13).
CONTINUES
342
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