Perioperative management - Right femoropopliteal PTFE bypass (P3) – Vascular Surgery

The TASC II (Transatlantic Inter-Society Consensus for the Management of Peripheral Arterial Disease) consensus document addresses aspects of revascularization in PAOD.

The TASC II criteria recommend therapeutic treatment options depending on the length of the local occlusion/stenosis. The length of the stenosis and its regional location determine the treatment: endovascular or open vascular surgery.

TASC II classification of femoropopliteal lesions

Type	Morphology	Procedure
A	Unilateral or bilateral stenosis of CIA; unilateral or bilateral single short (<3 cm) stenosis of EIA	Endovascular
B	Short (≤3 cm) stenosis of infrarenal aorta; unilateral CIA occlusion; single or multiple stenosis totalling 3–10 cm involving the EIA, not extending into the CFA; unilateral EIA occlusion not involving the origins of IIA or CFA	Endovascular
C	Bilateral CIA occlusion; bilateral stenoses 3–10 cm long, not extending into CFA; unilateral EIA stenosis extending into the CFA; unilateral EIA occlusion involving the origins of IIA and/or CFA; heavily calcified unilateral EIA occlusion with/without involvement of origins of IIA and/or CFA	Open revascularization
D	Infrarenal aortoiliac occlusion; diffuse disease involving the aorta and both iliac arteries requiring treatment; diffuse multiple stenoses involving the unilateral CIA, EIA, and CFA; unilateral occlusions of both CIA and EIA; bilateral occlusions of EIA; iliac stenoses in patients with AAA requiring treatment and not amenable to endograft placement; or other lesions requiring open aortic or iliac surgery	Open revascularization

Video example:  TASC D → open repair

Right leg PAOD Fontaine grade IV, left leg grade III with:

• High-grade arteriosclerosis of the terminal aorta and both iliac arteries
• Extended occlusion of both superficial femoral arteries
• Partial occlusion of the infrapopliteal arteries in bith legs

Preoprative DSA:

 

 

 

 

 

 

 

• Infection in region of planned repair
• ASA IV
• Previous inguinal radiotherapy (which would mandate extra-anatomical bypass)

Medical history

• Claudication
• Walking distance
• Risk factors -> nicotine abuse; arterial hypertension; coronary heart disease; cardiac failure; diabetes, manifest renal failure with/without dialysis; coagulopathy

Inspection

• Skin changes
• Muscular abnormalities
• Orthopedic malalignment
• Skin color
• Body hair
• Trophic changes
• Swelling; edema; mycosis; phlegmon; leg ulcers    

Palpatory bilateral comparison

• Pulse status
• Skin temperature

Auscultatory bilateral comparison of the limb arteries

Ankle-Brachial Index (ABI)

• ABI = systolic BP of posterior tibial artery / systolic BP of brachial artery

ABI value	PAD severity
> 1,3	Falsely high values (suspected Mönckeberg medial sclerosis, e.g. in diabetes)
> 0,9	Normal finding
0,75 - 0,9	Mild PAD
0,5 - 0,75)	Moderate PAD
< 0.5	schwere PAVK

• ABI < 0.9 is considered evidence of significant PAD.
• Determining the ankle-brachial index (ABI) through non-invasive Doppler occlusion pressure measurement is a suitable test for confirming PAD.
• PAD diagnosis is determined by the ABI value with the lowest ankle artery pressure.
• A pathologic ankle-brachial index is an independent risk indicator for increased cardiovascular morbidity and mortality.

Color flow Doppler ultrasonography

• Carotid arteries, abdominal aorta, limb arteries
• Stenoses and occlusions in almost all vascular regions apart from chest
• Allows quantifying the degree of stenosis and assessing plaque morphology
• Sensitivity and specificity around 90%   
• Well suited as screening modality

CT angiography

• Multislice computed tomography (MS-CT) with nonionic contrast agent
• Broad range of indications: traumatic vascular lesion (esp. trunk); vascular dissection/rupture; aneurysm; arterial thrombosis/embolism; portal vein/mesenteric vein thrombosis; pulmonary artery embolism; PAD; vascular tumors
• Benefits: rapid; detects relevant comorbidities; visualizes peripheral arteries; sensitivity and specificity each about 90%
• Drawbacks: Radiation and contrast agent exposure, allergies (about 3%), no functional assessment

Cardiac check

• Resting ECG
• Exercise ECG
• Echocardiography

Chest x-ray

Possibly spirometry

Laboratory panels

• Blood count
• Electrolytes
• Coagulation
• Kidney function parameters
• Liver function parameters
• Blood lipids
• Blood group
• In PAOD Fontaine grade IV → swab, antimicrobial susceptibility testing

• Hair cut in surgical field
• Order packed RBCs
• Protect the foot of the side to be operated on with a cotton shoe ( to avoid intraoperative pressure injury when clamping the vessels)
• Antibiotis according to AST (see diagnostic work-up) for 5 days postoperatively, depending on local findings

General surgical risks

• Major bleeding, blood transfusions, transmission of hepatitis/HIV through allogeneic blood transfusions
• Allergy/intolerance
• Wound infection
• Thrombosis/embolism
• Skin/vascular/nerve damage, e.g., due to patient positioning
• Keloid

Specific procedural risks

• Thrombosis with occlusion of the bypass and possibly adjacent vessels; reoperation, (partial) amputation
• Massive infection with severe bleeding from the bypass suture lines; bypass explantation, (partial) amputation, sepsis
• Sensory and motor nerve injury; dysesthesia , pain, temporary and even persistent (partial) palsy of the thigh muscles
• Lymph vessel injury; temporary or persistent lymphedema, lymphatic fistula
• Compartment syndrome; possibly requiring surgical pressure relief/fasciotomy, persistent palsy, limb loss
• Renal dysfunction with temporary or chronic dialysis due to Tourniquet syndrome and intraoperative angiography (contrast medium)
• Suture line aneurysm; surgical intervention depending on size/presentation

• General anesthesia
• Lumbar epidural anesthesia (Caution: Pat. may not notice new-onset ischemia in early postoperative occlusion of the repair!)

• Supine
• Arm on side of surgeon adducted (in the video example, on the right), contralateral arm abducted
• The slightly flexed knee of the leg to be operated on is temporarily rested on rolled up drapes in a sterile cover

• The surgeon stands on side be operated on (in video on the right), with the assistant facing him/her
• Scrub nurse adjacent to assistant toward patient's feet

Tray with atraumatic instruments and

• various retractors
• Infragenual van Dongen retractor
• 120° angle clamps, Gregory profunda clamp
• Pott scissors
• Button cannulas, various sizes
• Damp abdominal towels for wound edge protection
• Monofilament sutures 5/0 and 6/0, atraumatic
• Possibly instruments for intervention (balloon catheters of different sizes, guide wires)
• Microvascular instruments

Also:

• e-PTFE or collagen graft if no autologous vein can be harvested
• Damp abdominal towels for wound edge protection
• Mobile DAS unit

Postoperative analgesia:

Follow this link to PROSPECT (Procedures Specific Postoperative Pain Management) and to the current German guideline Behandlung akuter perioperativer and posttraumatischer Schmerzen [Treatment of acute perioperative and posttraumatic pain].

Postoperative care

• 24-hour monitoring on ICU or possibly intermediate care unit
• Check pulse in legs and capillary perfusion in feet

Heparin

• Low molecular weight-adapted, intravenously, at least 10,000 IU over 24 hrs.
• Starting 4 hours after surgery
• After 4-5 days switch to antiplatelet medication
• If necessary, modify in case of concurrent CHD (after cardiology consultation)

Ambulation

• On postoperative day 2-3 with assistance to the edge of bed
• Walking exercises after 5 days the earliest
• Beware of impaired mobility:  The graft may rip out of the anastomosis, if the patient falls!

Physical therapy

• Isometric muscle training
• Walking exercises after 5 days the earliest!

Diet

• 4-6 hours after surgery

Bowel movement

• Enema from postoperative day 3, if needed

Work disability

• With PAOD Fontaine grade IV mostly unable to work