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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3749_Библиотеки_им_академика_М_И_Перельмана
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Contributors
Yunus Ahmed Department of Cardiac Surgery, University of Michigan Medical
School, Ann Arbor, MI, USA
Mark F. Conrad Vascular and Endovascular Surgery, St. Elizabeth’s Hospital,
Brighton, MA, USA
KaitlynDobesh Henry Ford Hospital, Detroit, MI, USA
SachinderSinghHans Vascular and Endovascular Services, Henry Ford Macomb
Hospital, Clinton Twp, MI, USA
LoayKabbani Department of Surgery, Henry Ford Hospital, Detroit, MI, USA
Wayne State University, Detroit, MI, USA
Michigan State University, Detroit, MI, USA
Henry Ford Hospital, Heart and Vascular Institute, Detroit, MI, USA
AliceLee Henry Ford Hospital, Detroit, MI, USA
Srihari K. Lella Vascular and Endovascular Surgery Resident, Massachusetts
General Hospital, Harvard Medical School, Boston, MA, USA
Khalil Masabni Division of Vascular Surgery, University of Arizona,
Tucson, AZ, USA
FarahHanifAliMohammad Henry Ford Hospital, Detroit, MI, USA
Abdul Kader Natour Division of Vascular Surgery, Henry Ford Hospital,
Detroit, MI, USA
Henry Ford Hospital, Detroit, MI, USA
Timothy J. Nypaver Division of Vascular Surgery, Wayne State School of
Medicine, Henry Ford Hospital, Detroit, MI, USA
Himanshu J. Patel Department of Cardiac Surgery, University of Michigan
Medical School, Ann Arbor, MI, USA
xiii
xiv
Contributors
AndiPeshkepija Henry Ford Hospital, Detroit, MI, USA
Wayne State University, Detroit, MI, USA
IraklisI.Pipinos Department of Surgery, University of Nebraska Medical Center,
Omaha, NE, USA
ChinmayeePotti Henry Ford Hospital, Detroit, MI, USA
Alexander D. Shepard Division of Vascular Surgery, Henry Ford Hospital,
Detroit, MI, USA
Wayne State University School of Medicine, Detroit, MI, USA
PieterA. J. van Bakel Department of Cardiac Surgery, University of Michigan
Medical School, Ann Arbor, MI, USA
MitchellR.Weaver Henry Ford Hospital, Detroit, MI, USA
Wayne State University School of Medicine, Detroit, MI, USA
Chapter 1
Basic Arterial Techniques
SachinderSinghHans
Arterial Dissection andMobilization
Anatomically, most arteries and veins often run parallel to each other and are often
surrounded by fascial sheath in the extremities. Arterial exposure and mobilization
are usually performed by using sharp dissection. After incising the sheath anteriorly
over the artery, the artery should be dissected on each side, staying close to the periadventitial plane (skeletonizing the artery). The lateral dissection should be extended
to involve 50% (one half) of posterior surface of the artery so that there should be
either no or very minimal tissue posterior to the artery before a right-angled vascular
clamp is passed. Failure to perform satisfactory dissection along the posterior wall
of the artery and passing the right-angled clamp blindly can damage the posterior
branches resulting in signicant bleeding during mobilization of abdominal aorta
and iliac arteries. Only anterior and lateral dissection is necessary, as these large
vessels can be safely clamped from each side, thus avoiding injury to the surrounding veins (Fig.1.1). During application of vascular clamps, care should be taken to
dene the exact location and extent of plaque. The plaque is usually posterior; therefore, the clamp should be applied with the anterior wall approximating the posterior
wall (Figs.1.2 and 1.3). A vascular clamp like a Satinsky or Glover clamp may be
selected for arteries with posterior plaque. In patients with circumferential or heavily calcied plaques, a double-looped silastic loop may be applied. In patients with
very hard calcied plaques (as in patients with end-stage renal artery disease), either
a manual pressure with ngers or with a Kittner (“peanut”) dissector is applied
proximally and distally. Arterial control is often obtained with the help of application of atraumatic vascular clamps or with the help of endoluminal balloon catheter
or Garrett arterial dilators (Fig. 1.4) resulting in signicant bleeding during
S. S. Hans (*)
Vascular and Endovascular Services, Henry Ford Macomb Hospital,
Clinton Twp, MI, USA
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
S. S. Hans et al. (eds.), Primary and Repeat Arterial Reconstructions,
https://doi.org/10.1007/978-3-031-13897-3_1
1
2
Fig. 1.1 Dissection
around each side of an
artery using atraumatic
forceps (DeBakey or
Gerald) and scissors.
Silastic vessel loop
retraction can aid in
mobilization of an artery
S. S. Hans
Fig. 1.2 Application of vascular clamp with vessel compressed anteroposteriorly
Fig. 1.3 Vessel
compressed with a vascular
clamp side to side because
of plaque location in the
lateral wall
1 Basic Arterial Techniques
Fig. 1.4 Distal control of
the artery obtained by an
arterial dilator
3
mobilization of arteries (Teleex Inc., Wayne, PA). A longitudinally arteriotomy is
performed and calcied plaque is removed with the help of arterial dissector before
vascular clamps are applied. Clamps should be applied in such a way that the wall
of the blood vessel be approximated to control the bleeding but should not be
clamped excessively so as to result in clamp injury or fracture of the plaque. Once a
proximal graft to artery anastomosis has been completed, the clamp is removed and
a clamp is then applied to the graft just distal to the proximal anastomosis.
Vascular Clamps
Prior to application of vascular clamps, silastic vessel loops doubled on itself are
passed proximally and distally in most arteries except around the aorta and iliac
arteries as this may cause signicant bleeding from the surrounding veins.
Vascular clamps have longitudinal rows of interdigitating or opposing serrations.
Clamps despite being atraumatic can cause intimal injury and fracture of the plaque.
For small-diameter arteries, clamps like Yasergil, Edward bulldog clamp, or Micro
bulldog may be helpful. Endoluminal occlusion can also be useful for calcied
4
Fig. 1.5 Sharp dissection
with a 15-blade scalpel
(belly of the cutting edge)
separating the adventitia of
the artery from the
surrounding vein
S. S. Hans
arteries or in patients with excessive scarring from previous arterial reconstructions.
Endoluminal control can be obtained by Fogarty balloon catheter or an angioplasty
catheter. In medium- and small-sized arteries, arterial dilators (Garrett), which are
available in various sizes (1–10 mm), can help provide hemostatic control especially in patients with arterial trauma. In patients with repeat arterial reconstructions, there is often obliteration of the tissue planes. Once the anterior wall of the
artery is exposed, the lateral wall of the artery is dissected from the surrounding
veins with the aid of a 15-blade scalpel kept at an angle (not vertical) from the surrounding veins using a sharp dissection with the belly of the scalpel (Fig.1.5).
Systemic Heparinization
Arterial reconstructions require administration of systemic heparin. In patients with
ruptured aneurysm with hypovolemic shock, heparin should not be administered,
until proximal anastomosis is completed, and the coagulation prole should be
obtained prior to administration of heparin in order to avoid coagulopathy. In most
1 Basic Arterial Techniques
instances, a dose of 100IU/kg body weight should be administered 5–10min prior
to arterial clamping. Adequate anticoagulation is achieved by keeping the activated
clotting time between 250 and 300s. In most cases, heparin should be reversed with
protamine sulfate after the completion of anastomosis and distal ow is conrmed.
Arterial Incision andClosure
In most arterial reconstructions, longitudinal incision is made by an 11-blade or a
15-blade scalpel (Fig.1.6). In patients undergoing arterial embolectomy (normal
arteries), transverse incision is preferred. The arteriotomy opening is extended with
the help of angled Potts scissors, keeping the lower blade of the scissors against the
anterior wall of the artery in order to avoid damage to the intima of the posterior
wall of the artery (Fig.1.7).
5
Fig. 1.6 (a) Arteriotomy
with a 15-blade or an
11-blade scalpel. (b) Potts
scissors through the
arteriotomy and butting the
anterior wall extending the
arteriotomy
a
b
6
Fig. 1.7 Suturing done
from intima with a needle
coming out of the
adventitia
S. S. Hans
Arterial Suturing Techniques andSuture Materials
Most often, continuous suturing (over and over) technique is preferred, making certain that intima is taken in the suture line. Interrupted suture is preferred in smallsized arteries like brachial artery closure. In children where subsequent growth is
anticipated, interrupted sutures should be performed. Sutures are usually placed
1mm apart and 1mm from the edge of the arteriotomy, and the suture loop should
lay 1mm from the previous suture loop and from one end of the arteriotomy and
continued till 60–70% of its length has been completed and a second suture has
started from the opposite end and the knots are tied about two-thirds/one-third distance from each end. A monolament vascular suture is preferred, and most vascular surgeons use polypropylene swedged into a half of a circle or three-eight of a
circle, round-bodied needles. In suturing graft to the host artery, the suturing is
started from the outer wall of the graft to its inner wall, and the needle is subsequently passed into the intima and then to the adventitial layer of the artery. Suturing
in deep body cavities or where accuracy is necessary, a parachute technique is preferred. Three or four loops of sutures are placed loosely with sutures parallel to each
other as a parachute and tightened by pulling on each side. One must be certain that
sutures are not crossing or caught in the previously placed suture as tightening of an
1 Basic Arterial Techniques
Fig. 1.8 Suturing from
adventitia to intima may
lift the plaque with the
potential of dissection
7
improperly placed suture may result in laceration of the wall of the artery. The
direction of the suturing should be from the intima (arterial lumen) outward so the
plaque is not lifted during the application of the suture (Figs. 1.7 and 1.8). The
needle and the suture should be brought and be pulled in the direction it was placed.
In most cases, a 3-0 cardiovascular polypropylene suture is used for the aorta and a
4-0 cardiovascular polypropylene suture for iliac arteries, a 5-0 or 6-0 for femoral
arteries, and a 7-0 for infrapopliteal arteries. Optical magnication (vessel loops) is
useful so that arteriotomy and artery-to-graft anastomosis are sutured in a meticulous fashion. Before completion of an anastomosis, suture line is inspected. Any
additional reinforcement sutures should be placed before releasing the clamp on
large arteries like aorta/iliac arteries once the clamps are released; Gelfoam (Pzer)
soaked in thrombin should be applied using gentle pressure with a gauze. In patients
receiving antiplatelet medications, Floseal (Baxter, Deereld, IL) followed by
Gelfoam soaked in thrombin with gentle pressure by dry gauze helps in achieving
satisfactory hemostasis. In patients with friable aortic anastomosis, application of
BioGlue (CryoLife, Kennesaw, GA) followed by Gelfoam soaked in thrombin and
pressure and a laparotomy pad is helpful. These adjuncts are used mainly for patients
with diffuse oozing. In situations where there is active pulsatile bleeding between
the suture line, vascular clamp should be reapplied, and additional sutures in the
form of horizontal mattress using pledgets help in achieving hemostasis. Control of
bleeding without application of clamps may result in the increase in the size of
needle hole with excessive bleeding due to strong arterial pulsation (Figs.1.9, 1.10,
and 1.11). The pledgets are used to control of bleeding from the suture line can be
either synthetic or autogenous by removing a small portion of nearby fascia.
Synthetic pledgets are preferred for reinforcement of an aortic suture line and fascial pledgets for arteries like subclavian and femoral arteries.
8
Fig. 1.9 Suture line with a
hole in the aorta during
anastomosis of the Dacron
graft to the aorta
Fig. 1.10 Control of
bleeding (the site of leak)
as proximal and distal
vascular clamps are
applied. Horizontal
mattress of a 4-0
cardiovascular
polypropylene using a
Dacron pledget for
satisfactory hemostasis
S. S. Hans
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