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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_630_Библиотеки_им_академика_М_И_Перельмана
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DETAILS OF PROCEDURE Rarely, tacking sutures will be
required to prevent subintimal dissection (figure 14). ese horizontal
mattress sutures of / polypropylene are placed at intervals circumferentially, using double-ended sutures passed from inside out and tied externally (figure 14).
Occasionally a very large artery with a short length of arteriotomy can
be closed, starting from both ends with / polypropylene sutures in a running manner using double ended vascular sutures. Care must be taken not
to narrow the vessels during closure, especially the internal carotid artery
distally. When approximately cm of arteriotomy remains to be closed, the
inlying shunt is doubly cross-clamped with straight mosquito hemostats
and divided. e two ends of the shunt are then removed, rst distally, then
proximally, and bulldog clamps are reapplied (figure 15). e remainder
of the arteriotomy then is closed rapidly, great care being taken to ush the
system of particulate debris and air (figure 16). Following completion of
closure, the clamps are removed in a speci c order: external carotid artery,
common carotid artery, and nally internal carotid artery. is order minimizes the possibility of cerebral embolization, permitting potential emboli
to be ushed into the external carotid system preferentially. e completed
endarterectomy must have thorough hemostasis and no residual stenosis.
Patch angioplasty with prosthetic material or autologous vein is preferred
especially when dealing with small vessels (in women) or following technical misadventure where there is fragmentation or damage to the arterial wall.
Mattress sutures of double ended / polypropylene are placed at either end
Both needles of each end suture pass through the patch from outside to in
and then pass from lumen to the outside of the carotid artery where the knots
are tied (figure 17). is provides a broad based loop that anchors the gra .
e inferior or proximal suture B’ is run superiorly in a continuous manner
on the medial side of the gra and tied to A’ (figure 18). Sutures A and B are
the run towards the midpoint on the lateral side of the arteriotomy. When
approximately cm of arteriotomy remains to be closed in the mid portion
of the incision, the balloons are de ated and the shunt is cross-clamped with
a straight mosquito hemostat. A brisk in ow and back ow are allowed so as
to ush the area as the two ends of the shunt are removed, rst distally, then
proximally (figure 19). e bulldog clamps are reapplied or the vessel loops
cinched down so as to secure active bleeding. e remainder of the arteriotomy then is closed rapidly, with great care being taken to ush the region
C E
of particulate debris and air (figure 20). Following completion of closure,
the clamps are removed in a speci c order: external carotid artery, common
carotid artery, and nally internal carotid artery. is sequence minimizes the
possibility of cerebral embolization, permitting potential emboli to be ushed
into the external carotid system preferentially. e completed endarterectomy
must have thorough hemostasis and no residual stenosis (figure 21).
Upon completion, a Doppler or duplex ultrasound study is performed to
verify an unobstructed blood ow. Any suspicion of recurrent thrombosis is
an urgent indication to reopen the arteriotomy and remove the thrombus.
Finally, many surgeons keep the patient in the operating room until they
awaken without a neurologic de cit. If any neurologic changes are present, the
operative site is reexplored immediately.
CLOSURE Meticulous hemostasis must be obtained to prevent cervical
hematoma and possible respiratory embarrassment from tracheal compression. If heparinization has been used, protamine sulfate may be given to
reverse anticoagulation. e wound is closed in layers, approximating the
sternocleidomastoid muscle and cervical fascia, the platysma, and the skin.
A small closed-suction Silastic drain may be brought out the inferior margin of the incision at the surgeon’s discretion.
POSTOPERATIVE CARE Bleeding into the wound may occur from exces-
sive anticoagulation, improper hemostasis, seeping from the suture line, or
postoperative hypertension. Tracheal obstruction may occur and requires
endotracheal intubation. Reexploration of the wound may be indicated for
hematoma evacuation.
e e ects of injury to sensory as well as motor nerves can range from
minor losses in skin sensation to drooping of the corner of the mouth
resulting from injury to the marginal branch of the facial nerve.
e patient should remain in the intensive care unit for physiologic
monitoring. Postoperative hypotension must be avoided by adequate blood
and uid replacement. Overmedication and cardiovascular complications
must be considered. Likewise, hypertension is to be avoided because of the
danger of an acute stroke or disruption of the arterial closure.
Major neurologic de cits do occur occasionally. Cerebral edema is treated
with steroids, diuretics, and hypertonic parenteral solutions. Self-limiting headaches may occur following the repair of very stenotic lesions. Hyponatremia
and hypernatremia may result in water intoxication with cerebral edema. ■
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INDICATIONS Surgical bypass of the femoropopliteal segment is reserved
for patients with severe claudication and impending limb loss manifested
by ischemic rest pain or tissue necrosis. Typically, such patients have generalized atherosclerosis and a high incidence of signi cant coronary artery
or extracranial carotid artery occlusive disease. Multiple risk factors—
including cigarette smoking, hypertension, diabetes mellitus, and hyperlipoproteinemia—can be identi ed in the majority. Careful selection of
candidates for operation is of utmost importance, weighing the expected
bene t against the potential risk.
PREOPERATIVE PREPARATION Aortography with full evaluation of the
distal runo is mandatory to identify and exclude more proximal occlusive
disease and to ensure adequate gra runo . Noninvasive vascular laboratory
studies—including duplex ultrasound scanning, segmental limb pressures
and segmental limb plethysmography—aid accurate physiologic assessment and serve as a baseline for estimation of the response to therapy.
Careful assessment of cardiopulmonary function is most important. An
electrocardiogram and chest x-ray are obtained and further investigations
may be prompted by the history or physical examination. Cardiac evaluation with an ultrasonic echo or radionuclide imaging stress test may be
prudent, as may be pulmonary function studies. Further investigation
may be prompted by history, physical examination, or these initial studies.
Immediately preceding operation, catheters are placed for monitoring the
central venous pressure, arterial pressure, and urinary output. Prophylactic antibiotic therapy is begun before operation and continued for to
hours. e entire abdomen and both lower extremities are shaved from
the nipples to toes bilaterally early on the day of operation.
ANESTHESIA General anesthesia or occasionally spinal anesthesia is
employed with careful attention given to maintaining satisfactory hemodynamic parameters.
POSITION e patient is placed supine on the operating table.
OPERATIVE PREPARATION e lower abdomen and appropriate limb are
prepared in the usual manner to allow full mobility and exposure of the
extremity. e foot is placed in a clear plastic Lahey bag, a er which a clear
plastic drape may be applied to the skin with special care anteromedially
F R
over the areas of planned incision. If the contralateral greater saphenous
vein is to be used as the gra , the opposite extremity must be prepared in a
similar fashion. If there is any question concerning the adequacy of in ow
from the aortoiliac segment, the entire abdomen must be prepared for possible aortofemoral bypass gra ing unless in ow has been secured with an
iliac stent.
INCISION AND EXPOSURE e initial incision, which follows the course
of the greater saphenous vein (figure 1), is made vertically across the ingui-
nal crease, and early identi cation is made of the greater saphenous vein at
the fossa ovalis. Dissection is continued distally in a progressive fashion to
expose the entire length of vein required for the bypass. Alternatively, multiple incisions with intervening skin bridges may be elected. e creation of
large skin aps must be avoided to prevent skin necrosis and serious wound
problems. A er exposure of a suitable length of saphenous vein (figure 2),
the venous tributaries are doubly ligated proximally and distally with
silk suture, or proximally with silk suture and distally with a medium
silver clip, and divided (figure 3). Flow is maintained with both ends intact
as tributaries are ligated. Precautions are taken not to gather venous adventitia by ligating these tributaries excessively close to the vein wall, which will
result in stenosis of the bypass gra (figure 4). e vein should be kept in
situ with ow maintained until just before the bypass gra is t o be p erform ed.
A er the saphenous vein is removed, a ball-tipped needle is inserted into the
distal lumen (figure 5) to permit ushing and distention during gra preparation (figure 6). e proximal vein is then clamped gently with a bulldog
clamp, and the vein is distended gently with cold autologous heparinized
blood. is maneuver reveals leaks resulting from division of unidenti ed
tributaries and stenotic areas that may require attention. Overdistention by
forceful irrigation is avoided, as this may irreversibly damage the vein gra .
At the completion of vein distention, an ink line is drawn down the gra to
help avoid twisting the segment as it is brought through the tunnel later in
the procedure (figure 7). e femoral arterial exposure is performed as for
aortofemoral bypass gra ing with tapes passed around the common femoral
artery proximally, the profunda femoris artery, and the super cial femoral
artery (figure 8). Care is taken to ligate the overlying lymphatic tissue to
prevent formation of a lymphocele or lymph stula.
CONTINUES
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1
Incision
Saphenous vein
Plastic Lahey bag
2
5
6
3
4
Avoid constriction
Ink marker
7
Ink line
Saphenous vein stump
Profunda femoris artery
8
Common femoral artery
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INCISION AND EXPOSURE e distal popliteal artery is
exposed immediately posterior to the tibia by opening the fascial compartment and retracting the gastrocnemius and soleus muscles posteriorly and
the adductor muscles anteriorly. Insertion of a self-retaining retractor greatly
facilitates the exposure as does a Richardson retractor proximally (figure 9).
e popliteal artery is identi ed medial to the posterior tibial nerve and the
popliteal vein. O en, the popliteal vein must be mobilized in order to get to
the more lateral artery. It is carefully dissected free over a distance of to cm
F R
(figure 10), controlling any small tributaries with double loops of silk (Potts
ties). Vessel loops are then passed around the vessel proximally and distally to
elevate the vessel and improve exposure (figure 11). e proximal popliteal
space then is entered by incising the fascia anterior to the sartorius muscle, and
the proposed gra tunnel is developed by blunt nger dissection (figure 12) or
a tunneling instrument. is instrument is particularly useful if the saphenous
vein is harvested through multiple incisions rather than the long continuous
one illustrated in the preceding Plate .
CONTINUES
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10
9
Sartorius muscle
Gastrocnemius
muscle
Popliteal
artery
Popliteal vein
Popliteal
artery
Posterior
tibial nerve
11
12
Posterior
tibial nerve
Retractor
Popliteal vein
Sartorius
Adductor muscles
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Gastrocnemius muscle
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INCISION AND EXPOSURE e tendinous portion of the
medial head of the gastrocnemius muscle may be incised sharply, if necessary, to prevent compression of the gra at that point (figure 13). A tunnel is
fashioned from the femoral triangle through to the proximal popliteal space
by similar blunt dissection in the subsartorius muscle plane. ese tunnels are
marked with Penrose drains (figure 13).
The patient is systemically anticoagulated with heparin. The popliteal
artery at the site chosen for anastomosis is occluded proximally and distally. The arteriotomy site is carefully chosen distally to a point beyond
significant disease to ensure adequate runoff. The artery is incised with
a small-bladed knife and the arteriotomy completed with Potts scissors
F R
(figure 14). A Fogarty catheter (size or ) may be passed distally to
ensure distal artery patency. The proximal larger end of the saphenous vein graft is then tailored to match the popliteal arteriotomy. The
vein is incised longitudinally (figure 15), and the edges of the tips are
removed to create a “cobra-head” tip (figure 16). The distal anastomosis is started with a mattress suture of double-ended - polypropylene
at the heel of the graft (figures 17 and 18). The anastomosis is then
begun by running one end of the suture toward the midpoint of the
anastomosis, using a running continuous technique proceeding from
outside-in on the vein and inside-out on the artery to avoid elevating an
intimal flap (figures 19 and 20).
CONTINUES
350
13
Sartorius muscle
Soleus muscle
14
17
Incision
Penrose drain
Retractor
Potts scissors
Gastrocnemius muscle
15
Excised
16
18
19
Cobra-head vein
20
Vein
Needle
Artery
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INCISION AND EXPOSURE e other suture end is then run
up the opposite side to the arteriotomy midpoint (figure 21). e toe of
the gra is sutured down to the tip of the arteriotomy with a horizontal
mattress suture (figure 22). e anastomosis is completed by carefully
running one suture all the way around to meet the other end at its midpoint
position (figures 23 and 24).
F R
e anastomosis is completed on the near side. Immediately prior to
completion, a coronary dilator of suitable size may be passed downward
through the anastomosis to con rm patency. When the anastomosis is
completed, the gra is ushed with cold autologous blood to con rm patency and to identify any suture line leaks, which can be repaired at this time
(figure 25).
CONTINUES
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