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Distended vein
25
Anastomosis
353
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INCISION AND EXPOSURE e gra is brought through the
previously made tunnel, with great care being taken to avoid kinking or
twisting of the gra . e leg must be straightened to ensure that the length
of the gra is adequate and the tension appropriate (figure 26). e common femoral, super cial femoral, and profunda femoris arteries and any
additional tributaries are now cross-clamped, and a common femoral arteriotomy is performed in the usual manner (figure 27). Identi able disease
at the origin of the profunda femoris artery suggested by arteriography or
by direct inspection may require femoroprofunda endarterectomy or patch
angioplasty with the performance of this anastomosis. e proximal anastomosis is then performed in a similar fashion (figure 28). Upon completion of the heel of the anastomosis, a No. coronary dilator is passed distally
to ensure that no stenosis has occurred at this location (figure 29). If the
dilator cannot be passed, the anastomosis must be redone or a prosthetic
gra procedure must be undertaken. e anastomosis then is continued
as previously described with careful ushing maneuvers performed immediately before completion (figure 30). e completed femoropopliteal
reconstruction lies comfortably within its tunnel with no tension, twisting,
or kinking (figure 31).
Careful palpation for pulsation of the vein gra distally and the artery
distal to the popliteal anastomosis is performed to con rm patency. Completion arteriography should be performed via an angiocatheter introduced
through a side branch of the saphenous vein with injection of to mL
of contrast over seconds. Routine arteriography con rms a technically
perfect reconstruction and provides accurate assessment of the gra runo .
F R
Any defects must be corrected if a successful outcome is to be expected.
Intraoperative pulse volume recording may be used to assess the immediate
hemodynamic improvement.
CLOSURE Meticulous hemostasis must be attained. Anticoagulation may
be reversed with protamine sulfate if required by continued oozing. e
incisions are then closed in layers in the usual fashion. Dry sterile dressings
are employed.
POSTOPERATIVE CARE e cardiopulmonary status must be observed
carefully and o en in an intensive care setting. Distal pulses should be palpated hourly for the rst hours and subsequently at regular intervals.
Many surgeons use low-molecular-weight Dextran infusions of about mL
per hour for the rst hours, especially if a low popliteal or tibial vessel
anastomosis was performed. e patients begin ambulation on the day a er
surgery and many can be discharged home within days. Aspirin is given for
its platelet e ects. Noninvasive vascular laboratory testing in the postoperative period is valuable to assess hemodynamic improvement and the success
of the bypass procedure. Special attention is given to the care of the feet. All
e orts should be directed to controlling risk factors, such as smoking, and
careful postoperative follow-up is imperative to enhance long-term bene t.
Early or late occlusion is the most frequent complication. Gra occlusion
is manifest by loss of pulses, pallor, pain, paresthesias, and loss of function.
Noninvasive vascular laboratory studies may be helpful, whereas repeat arteriograms will verify the occlusion. If the occlusion occurs in the early period
a er surgery, immediate exploration without arteriography is warranted. ■
354
26
Penrose drain
Vein graft
Anastomosis
27
Common
femoral artery
29
Coronary dilator No. 4
Incision
Profunda femoris arerty
Supercial
femoral artery
Graft
30
28
Initial suture
Cobra-head
tailoring
Flushing
Vein graft
31
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INDICATIONS Infrainguinal arterial bypass procedures may be indicated
in patients with ischemic nocturnal rest pain, with impending tissue loss
such as occurs with gangrene of the toes or ulceration of the foot or ankle,
or with progressive, severe claudication. Compared to bypass procedures
using either a synthetic gra or a reversed autogenous saphenous vein, the
use of the in situ saphenous vein technique is preferred by some surgeons.
Currently, there are no signi cant di erences in patency rates between
in situ and reversed vein gra s. Hence, the choice is largely a matter of surgeon preference. Additionally, this technique extends the level of the distal
anastomosis especially into the tibial and peroneal arteries. is is possible
because the vein size tapers in the correct direction in contrast to reversed
vein gra s. e taper results in an easier anastomosis as the sizes are comparable and in improved hemodynamic ow. It is believed that all these factors contribute to the improved results in a biologically living bypass gra
whose natural lining is not thrombogenic.
PREOPERATIVE PREPARATION e majority of the patients are older and
have generalized arteriosclerotic cardiovascular disease. A general medical
assessment is necessary, with special attention being given to associated risk
factors like diabetes and smoking. Cardiopulmonary function should be
assessed with a chest x-ray, electrocardiography, and additional studies as
indicated while the patient’s overall condition is optimized.
Segmental Doppler pressures and waveforms are useful in evaluating the
extent of the arterial disease and serve as baseline for postoperative studies
that document improvement. However, most surgeons believe that the best
evaluation is obtained with detailed biplane contrast angiograms. ese
may require visualization from the aorta to the foot so as to evaluate any
possible obstruction of in ow, the levels of occlusion, and the suitability
for use of the arteries in the lower leg, ankle, or foot. Venous mapping with
duplex ultrasound studies is the preferred method for assessment of the
saphenous vein. It demonstrates the patency and anatomy of the saphenous vein, as it is prone to variation, double systems, or unexpectedly large
perforating connectors.
Immediately prior to operation, systemic antibiotics are given. Catheters
are placed to monitor the urinary output, arterial pressure and blood gases,
and central venous pressure. A Swan-Ganz pulmonary artery catheter for
measurement of the pulmonary artery wedge pressure and cardiac output
may be indicated in high-risk patients. Finally, the course of the saphenous
vein is marked with an indelible pen on the overlying skin using a Doppler
instrument.
ANESTHESIA General or continuous epidural anesthesia may be used
while hemodynamic parameters are monitored carefully.
POSITION e patient is placed supine on the operating table.
OPERATIVE PREPARATION e lower abdomen and entire leg are pre-
pared with the usual antiseptic solutions. e sterile drapes are applied so
as to allow access to the entire leg. Gangrenous toes or a foot ulcer should
be enclosed in a sterile, impervious plastic wrap or bag.
DETAILS OF PROCEDURE Most surgeons prefer a long, continuous inci-
sion beginning at the level of the inguinal ligament. It is placed just medial
or posterior to the marked course of the saphenous vein, and it continues
beyond the anticipated level for the distal anastomosis (figure 1). Alternatively, several isolated incisions with intervening skin bridges may be created, but this makes isolation of the saphenous branches and disruption of
the venous valves more di cult. A two-team approach may be used to prepare both ends of the incision simultaneously, but a single-team procedure
will be presented. Several intraluminal valve cutters are now commercially
available. ey allow the use of small distal incisions and have been associated with fewer incisional site problems. Direct visualization with intraluminal endoscopy may soon improve upon this technique.
e entire course of the saphenous vein is exposed with the dissection
approaching the anterior medial aspect of the vein (figure 2). A special
e ort is made to expose only this surface of the saphenous vein such that
S V S A B
its delicate blood supply is maintained over the greatest possible area for
the entire length of the vein. All venous branches are searched for diligently
and then doubly looped with silk ligatures that are not tied. is technique allows any of these side branches to be used as an entrance site for the
retrograde valvulotome.
e proximal incision is deepened to expose the common femoral, super cial femoral, and profunda femoris arteries. e region for proximal arterial
takeo of the gra is chosen, and elastic loops are placed about each artery
(figure 3). e proximal saphenous vein is exposed, and silk ligatures
are tied about each branch, including the fairly large and constant super cial epigastric, super cial external pudendal, medial and lateral super cial
circum ex iliac, and the medial super cial femoral cutaneous veins (see
Plate , figure 2). e super cial or Scarpa’s fascia of the fossa ovalis is
incised to allow complete exposure of the saphenofemoral venous junction.
is junction is usually just at the level of the profunda artery. Additional
venous length may be needed if the anastomosis is to be proximal on the
common femoral artery. is length can be obtained by excising a portion
of the anterior common femoral vein in continuity with the saphenous bulb.
is technique can also be used to create a larger in ow anastomosis. e
common femoral vein is then repaired with a mono lament - vascular
continuous suture. Ordinarily, however, the Satinsky curved vascular clamp
is applied to the saphenous side of the junction. A small cu of saphenous vein is le above the clamp for closure with a running - mono lament vascular suture such that there will be no constriction of the common
femoral vein when the vascular clamp is removed (figure 4).
e proximal to cm of the saphenous vein is mobilized as its major
tributaries are ligated and divided. Using Potts scissors, the rst valve, about
cm into the saphenous bulb, is excised in the translucent central portion of
each valve under direct vision (figure 5). e second valve is typically to
cm farther distal. e remainder of the saphenous vein valves are cut and
rendered incompetent using either the in situ valve cutter instrument for
large thigh valves only or the retrograde valvulotome for all of the valves.
VALVE CUTTER METHOD If a good single saphenous vein of mm or
greater in diameter is present, some surgeons prefer to use a valve cutting
instrument (see Plate , figure 10). A guide catheter is introduced into
the cut end of the saphenous vein at the ankle. It is passed cephalad and
through the open proximal saphenous bulb. e system is attached to a
heparinized saline solution delivery system and an elastic loop is snugged
about the saphenous bulb. Infusion of the heparinized solution in ates
the proximal vein and delineates the next valve assuming all side branches
have been occluded with the simple silk loops. e valve cutter should oat
freely within the larger vein. It is rotated such that the cutting edges are at
degrees to the plane of the valve lea ets. at is to say, the blades should
be perpendicular to the skin as the lea ets lie parallel to it. e cutter catheter assembly is slowly pulled distally. Resistance is felt as the cutter engages
each valve. A “popping” sensation is noted or felt as the lea ets are cut and
the vein immediately distends downward to the level of the next valve.
Alternatively, some surgeons prefer to make several small incisions for
division of the saphenous branches rather than the long continuous incision illustrated. In these cases, an on-the-table venogram beginning at
the ankle site will show the major side branches. Individual incisions are
made a er the branches are located precisely with a Doppler. e branches
are then ligated or clipped. e same Doppler search is performed again
a er the arterial anastomoses are completed. Any missed branches are
found with the Doppler and ligated.
RETROGRADE VALVULOTOME METHOD Alternatively, the valves may
be divided using a retrograde valvulotome. In this technique the proximal
saphenous vein may be in ated with heparinized saline via the cut open bulb
(proximal) end. However, the usual method is to in ate the saphenous vein
with the patient’s own heparinized blood. e patient is given systemic heparin, and several minutes later the proximal arterial in ow site is isolated and
opened at about the level of the profunda branch (figure 6). is allows
inspection of the profunda stoma and possible endarterectomy.
CONTINUES
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RETROGRADE VALVULOTOME METHOD e open proxi-
mal end of the saphenous vein is tailored to match the arteriotomy. e
edges of the tip may be removed to create a more oval taper and the vein
may be opened in a longitudinal direction posteriorly to create a larger
opening if needed. e anastomosis is performed with a - mono lament
polypropylene suture that is double-ended with a needle at each end. As
shown in figure 7A, the course of each stitch in this running suture begins
by entering the vein from the outside to lumen and proceeds from lumen
to outside on the artery. is avoids raising an intimal ap in the artery,
since the point of the needle is always pressing the intima onto rather than
o the arterial wall. e suture line is begun with a mattress-type suture at
the “heel” end of the vein (figure 7). e lateral or far side is run rst and
brought around the tip or “toe” end to join the medial or near-side suture
in the midportion (figure 8). e anastomosis is ushed with heparinized
saline, and the sutures are tied.
e arterial vessel loops are released, and the proximal saphenous vein
will dilate with a pulsatile arterial in ow that stops at the next venous valve
about to cm downstream. A retrograde valvulotome is introduced into
the saphenous vein via a venotomy in a small side branch (figure 9). e
blunt-tip valvulotome is positioned above (proximal to) each competent
valve in the in ated proximal section and then rotated and withdrawn separately through each anterior and posterior valve. It is important that the
valve be in ated and that the retrograde valvulotome be positioned to cut
perpendicularly to the plane of the skin as the valve lea et lies parallel to the
skin surface (figure 10). Several passes are o en needed. When the valve is
successfully cut, the proximal in ation will proceed distally to the next valve.
e distal vein is marked longitudinally with ink to ensure against rotation.
When all the valves have been successfully cut, the valvulotome is
removed via the side branch, which is doubly ligated and divided between
silk sutures. is technique is repeated sequentially down the saphenous vein to the level chosen for the distal anastomosis. A strong pulsatile
arterial ow should eject from this distal end of the in situ saphenous vein.
Care must be taken not to hook the valvulotome into a posterior branch
ori ce as a disastrous tear may result.
e choice of site for the distal bypass anastomosis is determined according to the preoperative studies. It is important that the vein have a clear
path without angulation. Also, the vein must be of su cient length for it
to reach the anastomotic site without tension when the leg is straightened.
An anastomosis to the posterior tibial artery is shown. e peroneal artery
may be approached in a similar manner, whereas the anterior tibial artery is
approached by tunneling through the interosseous membrane in its upper
two-thirds or by tunneling around the anterior tibia in its lower one-third.
e appropriate arterial segment has been previously dissected over a to -cm zone and isolated with Bulldog vascular clamps (figure 11). An
advantage of the in situ vein bypass technique is now apparent as the sizes
of the two vessels (distal artery and bypass vein) are nearly the same. Most
surgeons use magnifying loops or glasses for the end-of-vein-to-side-of-
S V S A B
artery anastomosis, which is performed in a manner similar to the proximal
anastomosis.
e vein may be incised longitudinally and tapered to create a larger
stoma. All vessels are occluded with the elastic loops or small Bulldog vascular clamps. e artery is opened longitudinally (figure 12). A double-
ended - or - mono lament vascular suture is placed through the vein
and artery in a mattress-suture manner at the proximal angle with the knots
and free ends on the outside. A continuous, running suture is placed such
that it enters through the vein and exits through the artery. is prevents
the raising of an intimal ap as the needle point is pressed from the lumen
outward on the artery. e posterior suture line is run rst and usually carried around the distal angle to the midportion of the anterior line. is
allows better visualization in the placement of the completed anterior line
suture. e artery and vein are ushed with heparinized solutions and the
loops and clamps are transiently released to ush all segments clear of clot
or air (figure 13). e two suture ends are tied.
Pulsations within the in situ vein and artery are palpated or veri ed with
a Doppler instrument. An intraoperative on-the-table angiogram should
be performed. e leg is exed and straightened to be certain that the vein
does not kink. A careful search is made along the entire vein to reveal any
arteriovenous stulas in the venous branches that were not recognized and
ligated. ese stulas may be visualized or may be palpated as a hum or
thrill, which can be localized with a Doppler instrument. Simple division
between silk ligatures is su cient.
e super cial fascia is approximated with interrupted absorbable
sutures, and the skin is closed in the routine manner.
POSTOPERATIVE CARE e hemodynamic status of the patient is moni-
tored carefully in the recovery or intensive care setting. Cardiac output and
tissue perfusion are maximized, while pulmonary function is monitored with
arterial blood gases. A record of distal pulses obtained by palpation or Doppler
is made hourly for the rst day and at sequentially regular intervals therea er.
e patient is usually not anticoagulated but is kept well hydrated.
Many surgeons use low-molecular-weight Dextran infusions of about
mL per hour for the rst hours, especially if a low anastomosis was
performed. e patients begin ambulation on the day a er surgery. Many
can be discharged home within days. Aspirin is given for its platelet e ects.
Distal lesions such as gangrenous toes or ischemic ulcers will need continued local care. Patients may experience dependent edema in the treated leg
for several months. Patients are studied with duplex ultrasound scans at
weeks, months, and months to detect areas of stenosis, which predict
gra failure. Early bypass occlusion usually results from a mechanical or
technical defect in either anastomosis. is event may be signaled by loss of
pulses or a cool, pale extremity with pain, paresthesia, or loss of motor function. Doppler studies followed by angiography are useful in preparation for
urgent reoperation. Late occlusions occur less frequently when compared
with synthetic gra s or reversed saphenous vein bypass gra s. ■
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169
H L S
S V
INDICATIONS Stripping of the greater saphenous trunk and its varicose
tributaries is indicated in symptomatic patients who have valvular incompetence, incompetent communicating veins, or resulting complications. e
lesser saphenous system is unilaterally or bilaterally involved in percent
of these patients and, if a ected, should also be stripped. Otherwise, this frequently causes recurrence. Before consideration of stripping, these patients
must have a complete peripheral vascular examination to determine whether
the varicosities are primary or secondary, to evaluate the status of the deep
venous system, and to ascertain the adequacy of arterial circulation. Stigmata, history, suspicion, or other evidence of deep venous involvement suggesting that the varicosities may be secondary mandates the performance of
impedance venous plethysmography or venography for objective evidence.
CONTRAINDICATIONS Incompetence or obstruction of the deep venous
system to such an extent that the super cial venous system is necessary
for return ow contraindicates complete saphenous system stripping. However, in selected cases in which the varicosities are a major contributor to
disabling complications, stripping up to knee level may be safe a er careful
assessment and critical judgment by the surgeon.
Stasis dermatitis, cutaneous infections, or varicose ulcers result in a high
incidence of postoperative wound infections. Pregnancy, advanced age, and
systemic diseases constituting signi cant operative risks are relative contraindications, except in unusual circumstances.
PREOPERATIVE PREPARATION Healing of varicose ulcers and elimina-
tion of stasis eczema can almost always be achieved by use of local treatment, compression dressings, and elevation when at rest. If such lesions
are healed at least weeks before operation, the incidence of postoperative
infections will be minimized and wound healing will be normal.
e patient is instructed to take two cleansing hexachlorophene showers within hours before operation. A er the groin and extremity have
been shaved, the involved saphenous trunks, major varicose tributaries,
and location of suspected incompetent communicating veins—which can
be detected by walking with a tourniquet applied at various levels or, better, yet with a Doppler—are then marked with indelible skin dye (Bonnie’s
blue or brilliant cresyl green). It is imperative that the surgeon understand
that incompetent communicating veins o en connect with major varicose
tributaries, which must also be stripped to ensure a good result and to minimize necessary postoperative injections with sclerosing solutions.
ANESTHESIA General anesthesia is usually preferred, although epidural
or spinal anesthesia is acceptable.
POSITION e patient is supine with the thigh and knee in slight exter-
nal rotation and exion. A er the high ligation, division of the primary
tributaries below the medial malleolus, and passage of the stripper through
the entire length of the greater saphenous vein, moderate Trendelenburg
position is used during segmental resection of the varicose tributaries and
before the stripping. is lowers venous pressure and decreases bleeding
during and a er the procedure.
OPERATIVE PREPARATION e skin of the foot, lower extremity, and
groin is prepared in the usual manner. e forefoot is covered by a rubber
glove, and usual draping is used (figure 1). Specially designed holders may
be used to suspend the leg at to degrees to facilitate skin preparation.
e holder is adjustable and, as an alternative, may be used for positioning
throughout the procedure.
DETAILS OF PROCEDURE A -cm oblique incision is made in the femo-
ral skin crease with its lateral end over the femoral pulse (figure 1). A er
the super cial fascia is incised, the proximal part of the saphenous trunk,
one or more of its tributaries, and occasionally an accessory saphenous vein
will be exposed at the center of the incision.
e adventitial sheath of the proximal saphenous trunk is incised longitudinally, and circumferentially separated from the vein. High early
transection of the trunk greatly facilitates dissection proximally to the
saphenofemoral junction as well as exposure of various tributaries.
During this dissection the medial and lateral super cial circum ex iliac
(figure 2, a and b), the super cial epigastric (c), the super cial external
pudendal (d), the medial super cial femoral cutaneous (e), and occasional deep muscular venous branches (f) must be meticulously divided
and ligated to avoid later development of collaterals that would result in
recurrences of the varices. e medial circum ex iliac artery lies at the
lower margin of the fossa ovalis and consequently is a reliable anatomic
reference to the saphenofemoral junction just above it (figure 3). e
proximal stump of the saphenous trunk is doubly ligated with a proximal free tie and then a trans xed nonabsorbable suture (figure 3). e
other end of the saphenous trunk is dissected distally until a large medial
tributary, the medial super cial femoral cutaneous, is exposed, divided,
and ligated (figure 4). is avoids postoperative hematomas and excessive extravasation and ecchymosis of the medial thigh.
A -cm transverse incision, placed one fingerbreadth below and just
anterior to the tip of the medial malleolus, and downward retraction will
expose the trifurcated origin of the saphenous vein (figure 5). Each of
the three primary tributaries is divided and ligated. The saphenous vein
is then dissected proximally above the malleolus for cm. Sizable anterior and posterior tributaries are usually exposed, divided, and ligated
(figure 6). The edges of the transected lower end of the saphenous
trunk are grasped between two mosquito hemostats and slit cm to
enhance the insertion of the probe end of the stripper (figure 7). The
instrument is then passed gently proximally with guidance by palpating, advancing fingers. The stripper can usually be passed through the
entire length of the vein but may be arrested by large varices, tributaries,
communicating veins, or by stenosis resulting from previous phlebitis.
At these points an additional small transverse incision may be made to
expose the vein and the tip of the stripper. The tip may then be manually guided proximally, or the vein may be transected to allow introduction of an additional stripper through the proximal end. Alternatively,
a second stripper may be inserted into the proximal end of the divided
saphenous trunk through the femoral incision and passed distally till it
contacts the instrument inserted from the ankle. The end of the saphenous trunk is then securely tied to the stripper with two encircling ligatures of silk, about cm apart, to prevent inversion of the vein over
the stripper (figure 8).
At this point the surgeon may choose to strip the lesser saphenous vein
if indicated. Approximately percent of patients with varicose veins have
involvement of one or both lesser saphenous systems, which should also
be stripped. Adequate positioning can be achieved by exing the knee
degrees, placing the sole of the foot at on the operating table, and slightly
internally rotating the hip (figure 9). e primary tributaries converging
on the lateral side of the ankle to form the lesser saphenous trunk can be
exposed through a -cm transverse incision between the posterior tip of the
lateral malleolus and the lateral edge of the Achilles tendon. Careful attention is given to identify and avoid damage to the sural nerve (figure 9).
e branches are divided and ligated, and a short stripper is inserted and
passed proximally in the lesser saphenous trunk up to the popliteal skin
crease (figure 10). A small transverse incision is made over the palpable
stripper probe, and the vein is isolated and divided, and the proximal end
is ligated. Major varicose tributaries identi ed and marked before operation are segmentally stripped, as described below for the greater saphenous stripping. A large varicose tributary connecting the greater and lesser
saphenous trunks is o en present at the level of the upper medial bulge of
the calf and requires similar resection.
CONTINUES
360
1
Incision
Greater
saphenous vein
3
Greater
saphenous vein
a
2
c
Femoral
vein
Incision
d
b
f
e
Sphenous vein
4
Medial supercial
femoral cutaneous
tributary
5
7
Lateral leg position
Medial
malleolus
6
8
Stripper
Lesser
9
saphenous
vein
Stripper
Sural nerve
10
Lesser
saphenous vein
361
PLATE
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170
H L S
S V—V C I
DETAILS OF PROCEDURE With the greater and perhaps the
lesser saphenous trunks traversed by strippers, attention is then turned to the
varicose tributaries and suspected sites of incompetent communicating veins of
the greater saphenous system (
to the saphenous trunk, at the junction of the middle third with the lower and
upper thirds of the leg below the knee. Small and medium-sized major varicose
tributaries that were marked preoperatively are removed with the stab avulsion technique. A No. scalpel makes a - to -mm stab in the skin. Using
blunt dissection with a hemostat, the venous tributary is isolated, clamped, and
removed by avulsion. Larger tributaries are dissected free, ligated, and divided
between ligatures. e veins are exposed, doubly clamped, and divided between
hemostats. Subcutaneous dissection with tonsil hemostats in the plane between
the vein and skin will mobilize and permit segmental stripping of these
tributaries (
be encountered, divided, and ligated. Other suspected sites of incompetent
communicating veins located by a preoperative walking tourniquet test or
venogram should be explored to allow appropriate ligation.
e distal end of the stripper is pulled upward about cm to a subcutaneous position, and all the distal incisions are closed carefully and accurately
with vertical mattress sutures of nonabsorbable suture (
greater saphenous trunk then is removed by pulling the stripper from distally
out through the femoral incision. Very slow stripping of the saphenous trunks
extending over to minutes while the surgical assistants apply advancing,
rm pressure behind the instrument will minimize intraoperative bleeding and
postoperative ecchymosis. e lesser saphenous vein may be similarly stripped.
Stripping proximally is more e ective in avulsing longer segments of undivided tributaries and is less likely to result in tearing the saphenous trunk and
inverting it over the stripper. Free blood then is milked and extruded from the
saphenous channel. e femoral incision is approximated in two layers with
interrupted absorbable sutures in the super cial fascia and a continuous
subcuticular stitch. All other incisions are closed with a single layer of similar
subcuticular suture. e operated extremities are snugly wrapped with a layer
of elastic cotton gauze and compression elastic bandages from the base of the
toes to the groin.
POSTOPERATIVE CARE e extremities are elevated to degrees until
the patient becomes ambulatory, which should be as early as possible. Once
ambulatory, the patient should not stand still for long periods or sit in a chair
without elevating the legs. A er hours the original dressings are removed,
and hospital elastic stockings are applied up to the knee. e patient may begin
showering. Except at night, the stockings are worn for two or three weeks until
all discoloration, edema, and tenderness have disappeared. e patient should
be reexamined at -month intervals, at which time any residual or recurrent
varicosities can be obliterated by injection with sodium tetradecyl sulfate.
figure 12). During this dissection, communicating veins may
VENA CAVAL INTERRUPTION
INDICATIONS Life-threatening pulmonary embolism is a frequent complica-
tion of many medical illnesses and surgical procedures when antecedent venous
thrombosis is associated with low- ow states, venous injuries, obesity, prolonged
immobilization, hypercoagulability, and the poorly understood e ects of certain
malignant tumors.
Heparin is generally accepted as the primary therapy for thromboembolic
disease. Venous interruption, proximal to the site of venous thrombosis, is usually reserved for patients who have recurrent, documented pulmonary emboli
despite well-controlled, adequate heparinization who have a large, life-threatening
embolus such that an additional one might be fatal; who cannot be anticoagulated
because of potential bleeding problems; or who are developing progressive pulmonary hypertension from repeated emboli.
Super cial femoral ligation has been largely abandoned because of the inability
to precisely localize the proximal extent of the process and the likelihood of undetected thrombus in the opposite extremity or deep pelvic veins. Inferior vena caval
ligation avoids these uncertainties and is indicated primarily for recurrent small
septic emboli usually associated with pelvic infections.
Caval lters (e.g., Green eld) placed via the jugular vein are the most commonly used today for prophylaxis against recurrent emboli. If these devices are
not available, then caval partitioning using a serrated external clip should be
considered. Vena caval interruption by partially occlusive serrated clips has the
advantage of maintaining caval ow with a minimal increase in downstream
venous pressure, arresting all but the smallest thrombi, and minimizing the
resultant edema of the lower extremities. e vena cava remains intact, the new
channels are uniform in size, and there are no intraluminal sutures for potential thrombosis as in the sieve technique. Alternatively, the use of a Green- eld
lter may be considered.
figure 11). e latter most o en occur adjacent
figure 13). e
PREOPERATIVE PREPARATION Most patients are heparinized when the deci-
sion for vena caval interruption is made. Since heparin is usually administered
intravenously and its duration of anticoagulation e ect is limited, there should
be little delay beyond hours a er the last injection. Protamine sulfate should
be available during the procedure for heparin reversal, but this is rarely needed.
ese patients may have impaired cardiac function and abnormal ventilation/
perfusion of the lung, requiring vigorous cardiac and pulmonary support.
ANESTHESIA Epidural or general anesthesia is favored. Airway maintenance
for increased oxygenation must be anticipated, and a secure intravenous catheter for medications or transfusions is essential.
POSITION e patient is supine with the right ank slightly elevated with a
pillow or pads under the opposite ank. e operative site should be at the
break level of the operating table, as hyperextension may improve the operative exposure. If the patient has been receiving heparin, coagulation parameters
should be obtained immediately before operation to ensure that clotting is normal. Both lower extremities should be wrapped rmly with elastic bandages
from ankles to groins, and electrodes should be placed to allow electrocardiographic monitoring. e operative site is widely prepped and draped as usual.
INCISION AND EXPOSURE e transperitoneal approach is used when con-
current ligation of the gonadal veins is indicated, as in pelvic thrombophlebitis;
otherwise, the extraperitoneal method is preferred. is approach is tolerated
better and is performed more easily. A transverse incision is made just above
the level of the umbilicus (
right rectus muscle to midway between the costal margin and the iliac crest at
the level of the midaxillary line. e incision must not be placed too low, as
proper exposure of the infrarenal vena cava is di cult.
DETAILS OF PROCEDURE e incision is extended down to the external
oblique aponeurosis, which is incised lateral to the border of the rectus muscle.
If necessary, the incision is extended laterally to expose more internal oblique.
If the tenth and eleventh intercostal nerves are encountered, they are retracted
to avoid injury. e internal oblique and transversus muscles are split down
to the peritoneum. e ureter is identi ed and is retracted medially with the
peritoneum. e peritoneum is freed posteriorly and medially with blunt dissection to expose the vena cava. Care must be taken not to dissect beneath the
psoas muscle, which is in a somewhat anterior position at the depth of the dissection. If di culty in exposure because of obesity or if ascites is anticipated,
the muscles should be incised and the incision extended. e right renal vein
and upper right lumbar veins are exposed (
bifurcation is a useful point of reference.
Circumferential dissection of the vena cava immediately below the renal
vein but above a major lumbar vein allows passage of the ligature and the lower
half of the Adams–DeWeese clip around the vessel (
should be palpated gently to determine whether there is proximal extension
of the thrombus to this level. If a thrombus is found, the patient is placed in a
reverse Trendelenburg position. e vena cava is temporarily occluded above
the clot, and the vein is opened through a purse-string suture. e thrombus
may then be removed before completion of the interruption. A er its placement, the clip is closed and its ligature is securely tied (
should be exercised to avoid tearing or avulsion of the lumbar veins and to
apply the clip just below the renal vein; these ensure good collaterals should the
lower vena cava become occluded.
Patients who have had multiple small emboli resulting in pulmonary hypertension should have ligature of the vena cava with heavy nonabsorbable sutures
instead of partial occlusion with a clip.
CLOSURE A er hemostasis is ensured, the patient is returned to an un exed
position, and the incision is closed in layers as usual.
POSTOPERATIVE CARE In the event of intraoperative arrhythmia or other
overt evidence of a new pulmonary embolus, heparin should be administered
soon and continued. Otherwise, heparinization is reinstituted hours a er operation. is is indicated to control and limit extension of the distal thrombus as well
as to prevent thrombosis at the site of the clip or ligation and to improve collateral
ow. Anticoagulation should continue until all pain and tenderness and most of
the edema have disappeared in the lower extremities. In general, the patient will
receive to days of in-hospital heparinization followed by several months of
oral anticoagulant therapy. In the meantime, the legs should be encased in elastic
bandages or elastic stockings, which may be necessary for several months.
Any necessary respiratory support and general postoperative care are maintained as a er other major operations. Cardiac disease or complications that
o en accompany thromboembolic phenomena may require special attention
and management.
figure 1). It is carried from the lateral border of the
figure 2). Palpation of the aortic
figure 3). e vena cava
figure 4). Great care
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