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Abdominal Vascular Surgery Summary Abdominal Vascular Surgery A&P Pathology Diagnostics/Preoperative Testing Prep & Positioning Basic Supplies, Equipment, & Instrumentation Abdominal Aortic Aneurysmectomy Aorto-Bifemoral Bypass Graft Resection of Renal Artery Aneurysm Anatomy & Physiology Abdominal aorta begins below the diaphragm Multiple arteries between the diaphragm and the bifurcation all of which supply oxygen rich blood to the abdominal wall and the abdominal organs or viscera Abdominal Aorta & It’s Arteries See Overhead Celiac Superior mesenteric Renal Inferior mesenteric Lumbar Bifurcation >iliacs>internal & external External >femoral>popliteal>anterior & posterior tibial Peroneal is off the posterior tibial Venous System See Overhead Abdominal & thoracic walls drained by brachiocephalic and azygos veins>SVC Hepatic Portal Vein (Hepatic Portal System) > IVC Lower Extremities>Superficial and deep groups Deep have same names as the arteries around them Greater Saphenous Vein is the longest vein in the body PATHOLOGY Aneurysms True aneurysm=dilation of all layers of the arterial wall May find atherosclerosis along with true aneurysm, but it is not the cause of the aneurysm False Aneurysm (pseudoaneurysm)=not an aneurysm, but a tear that allows blood between the layers of the artery Results from trauma, infection or post-arterial surgery where suture has been disrupted True Aneurysms Most often found in the aorta Can be in the iliacs, femoral and popliteal arteries Men get more than women Generally found in the elderly 18% have family history Aneurysms Continued Generally occur below the renal arteries Are fusiform or tapered at the ends Involves weakening of the tunica media (elastic layer) and intimal layer damage (atherosclerosis) Patients generally asymptomatic and these are found during routine physicals Low mortality (3%) with elective surgical intervention (AAA Repair) Aneurysms Continued May extend to the bifurcation of the aorta or involve the common iliacs as well as the external and internal iliacs Aneurysm rupture patients present with severe back and abdominal pain Usually rupture is contained in the retroperitoneal space but can rupture into the peritoneal space causing certain death from the hemorrhage Rupture requires immediate intervention as mortality goes to 80% Treatment Abdominal aortic aneurysm resection or repair If the iliacs are involved a Y or bifurcated graft is used If the iliacs are not involved a straight or tube graft is used Graft material can be Knitted polyester dacron, Knitted velour polyester dacron,Woven polyester dacron, or PTFE (Gortex) Knitted polyester requires preclotting, the others do not Graft Options DACRON (Meadox/Boston Scientific) 1.“Knitted” polyester dacron Must be pre-clotted 2.“Woven” polyester and Knitted velour polyester Do not need to be pre-clotted *Both come in a spiral design that is designed for bends such as in the iliacs or knee joint Graft Options Continued 3. PTFE: polytetrafluoroethylene (Gortex or Impra) Specifically designed for knee joint bends or popliteal bend Not desirable for aortic aneurysm repair May be doctor preference Come with rigid rings or without Rings add support Come thin walled or standard walled Preoperative Testing & Diagnostics 1. CT Scan diagnose an aneurysm Extent Location of thromboembolytic matter Shows whether or not there is leakage 2. Ultrasound Detection Preoperative Testing & Diagnosis 3. Angiography Follows detection or diagnosis of aneurysm Provides clear picture of aneurysm so that surgery can be planned Will show all of the vessel(s) that are involved Displays areas that are not getting blood flow as evidenced by the fact that contrast dye does not reach those areas Prep & Positioning Arteriogram films should be displayed in the xray box before the surgeon comes into the room Blood should be available in the room prior to incision A foley catheter is placed upon induction of anesthesia Patient is supine with arms tucked or on padded armboards Pillow under head or headrest Foam or gel pads may be used on the heels Foam or gel pad for the OR bed Prep and Positioning Continued Patient should be shaved nipples to knees in pre-op unless is emergent and must be shaved in the room Prep is nipples to knees Prep starts at the abdomen where the incision will be and works outward to the groins and the pubis is prepped last Separate prep sticks should be used for the legs working outward to the bed and prepping the groins and pubis last Drape Sequence Groin towel, towels x 6 (at sides, across knees, across chest) Drying towels Ioban Drape (universal sheets or laparotomy sheet) Basic Supplies, Instruments, and Equipment Supplies 1” penrose, long polyester tapes, silicone vessel loops, cotton umbilical tapes (*Surgeon preference) for isolating the aorta and iliacs 2-0, 3-0, 4-0 SH or MH Prolene suture for sewing the proximal portion of the aortic graft 5-0 or 4-0 RB-1 or C-1 Prolene for the iliacs 2-0, 3-0, 0 Silk or Nurolon for oversewing the lumbars Supplies Continued Silk ties or reels 0, 2-0, 3-0, 4-0 Laparotomy or universal pack #20,#10, #11, #15 blades Major Basin Pack Custom CV Tray (contains kittners, rubber shods, umbilical tapes, cytal, kidney basin, bowl, blades, foley catheter, towels) Ioban Drains (JP, Blake, or Snyder) Supplies Continued Clips (small, medium, or large) Dacron graft straight or bifurcated Syringes (30cc) Doppler probe Fish or Viscera Retainer Closing Suture (varies by surgeon) #1 or 0 PDS, Prolene, Novafil for fascia/0, 2-0, 3-0 CTX Vicryl for subcutaneous (may do two layers), Stapler or 4-0 Monocryl or Vicryl for skin or subcuticular Binder (with obese patient) Dressing sponges (xeroflo or telfa, 4x4s, ABD post final count Basic Supplies, Instrumentation, and Equipment Instruments CV Tray complete with variety of aortic clamps and vascular clamps Extra-long instruments should be available (debakey forceps, long metz, long NHs, long tonsils, kellys, and right angles) Hand-held abdominal retractor tray (richardsons deavers, & Harrington/Sweetheart) Self-retaining retractor tray (balfours x 2, omni-tract, or bookwalter) *Surgeon preference Micro instuments (Vascular NH, scissors, forceps) Standard and Long Clip Appliers (small, med & large) Tunneler Basic Supplies, Instrumentation, And Equipment Equipment ESU/Bovie Suction/Cell Saver Headlight for the surgeon Bair hugger for patient (upper body) Doppler box Medications Saline irrigation with antibiotic of surgeon choice (should be in a warmer) Heparin saline (1,000ut/250ml NS) can keep warm in warmer Contrast available Topical hemostatics available (Gelfoam, Thrombin, Surgicel, Avitene) Procedures Abdominal Aortic Aneurysm Aorto-Bifemoral Bypass Graft Aorto-Iliac Bypass Graft Resection of Renal Artery Aneurysm Abdominal Aortic Aneurysmectomy Repair of the portion of the aorta between the renal arteries and the bifurcation of the iliac arteries Aneurysm will be 6cm or greater in diameter AAA Procedure Incision starts with a #10m blade, incision is made below the xiphoid process and to the left and ends at the umbilicus Provide hand cautery, debakey forceps Will proceed through various layers, provide hand-held retractors; may use/set up the omni, bookwalter, or balfour retactor (provide moist laps to go under blades be they hand-held or self-retaining Offer metz as needed with bovie as go deeper be prepared to change the cautery for a longer tip, longer debakeys, and longer metz Isolate bowel and place in an intestinal bag/wrap in a moist sponge AAA Continued Isolate aorta (may go around aorta with a vessel loop and clamp with a rommel tourniquet or long polyester or cotton tape passed from a ligature passer) Surgeon will ask CRNA to heparinize patient Provide the aortic clamp of the surgeons choice Iliacs will be clamped with straight or angled vascular clamps such as peripheral debakeys or patent ductus clamps Aorta will be incised with a knife (long handle) or scissors Plaque will be removed if present Other involved arteries with backup arteries to oxygenate their respective organs (inferior mesenteric and lumbers), are clipped, tied, or sewn off with non-absorbable suture Involved arteries without back-up circulation are reimplanted into the graft using smaller lumened Dacron grafts (renals, superior mesenteric, celiac) AAA Continued Prepare graft Graft sizers prn (may pass on a long tonsil or kelly Irrigate inside aorta before grafting with heparinized saline Start with proximal anastamosis (have long vascular NH, loaded with 3-0 SH double ended, long debakey forceps, long suture scissors, rubber shod) Usually sew ½ way around tag and begin with the other needle coming the other way Surgeon may want his hands wet with saline when he ties to keep suture from sticking to his hands AAA Continued Graft will be measured to its distal end and cut with either a knife or scissors Distal anastamosis will follow the same sequence as the proximal Surgeon will slowly remove the aortic clamp, observing for leaks Leaks will be repaired with pledgeted or nonpledgeted 3-0 or 4-0 prolene suture Topical hemostatic agents may be applied Distal clamps will be removed, leaks will be repaired using the same type of suture Topical hemostatics may be applied AAA Continued Abdomen will be irrigated with antibiotic saline Aneurysm sac will be sewn to prevent the intestine from adhering to the graft usually with a 0 Vicryl on a CT-1 needle with a long NH Remove all laps do first count Return bowel to their normal position and pull greater omentum back over the bowel Place a fish or viscera retainer over the abdominal organs and close the peritoneum, fascia, and muscles with a heavy 0 or #1 PDS, Novafil, Ethibond (Ticron) or Prolene (usually done as one layer) Do second count Close subcutaneuos layer with 0, 2-0, or 3-0 vicryl on CTX or CT-1 tapered needle Close subcuticular with 4-0 vicryl on PS-1, Monocryl or staplers AAA Continued Dress with xeroflo or telfa, 4x4s, ABD pad and tape May need an abdominal binder with the obese patient Pedal pulses should be checked at the end of the procedure by the surgeon Keep table sterile until patient safely out of the room Clean up per policy Aorto-Bi-Iliac Bypass Graft Procedure is the same as an Abdominal Aortic Aneurysmectomy with following changes: Aorto-Iliac Bypass Graft Will need: a bifurcated graft May require a heavier vascular clamp such as a straight or angled patent ductus clamp (surgeon preference) Will need smaller prolene suture for the iliac anastamoses such as 5-0 or 4-0 on a smaller needle (still need rubber shods) May cut down the groin areas using weitlanders for retractors or gelpis depending on patient anatomy Will use standard length instuments when working in the groin Will isolate the iliacs with tapes or vessel loops Will need two layers of closing suture for groins when done Will need dressings for the groins post surgery Aorto-Bi-Femoral Bypass Graft Same as Aorto-Bi-Iliac with following differences: Definitely will cut down groins Will need: a bifurcated graft, short tunneler (may use long kelly or aortic clamp) Will isolate femoral artery with cotton tapes or vessel loops (using right angle and debakey forceps/may use rommel tourniquet) Will use peripheral debakey clamps to clamp femoral arteries Resection of Renal Artery Aneurysm Renal artery aneurysm repair Function of renal artery is to supply kidneys with oxygenated blood Renal artery arises from the abdominal aorta This is an arteriosclerotic aneurysm and classified as a “true aneurysm” Resection indicated for: symptomatic, renal artery stenosis, pregnant women or those women considering pregnancy Renal Artery Aneurysm Resection Patient Preparation and Prep Shaved nipples to top of thighs Prep soap betadine nipples to knees and betadine paint nipples to knees (use drip towels) Supine with arms tucked or on armboards and padding to prevent ulner and brachial nerve damage (pay attention to areas where post for abdominal retractor will be placed Pillow under head and knees Equipment Warming blanket or Upper Body Bair Hugger Cell saver Extra suction ECU Headlamp Warmer for irrigants Instruments Major tray with cardiovascular clamps (aortic clamps) Cardiovascular tray Major vascular tray Extra Long Instruments Surgeon’s specialty instruments Abdominal retractor (Bookwalter, Omni-Tract, or Balfour retractors x 2) Medium and large long clip appliers Heparin needle Supplies Foley and urimeter Medium and large clip cartridges Rumels #16 or #18 red rubber catheter for rumel tourniquet Fogarty inserts if using fogarty aortic clamp Vessel loops, long umbilical tapes, or dacron polyester tapes Peanuts or Kittners Rubber shods Sponge on a stick x 2 available Draping Groin towel Towels x 6 Drying towel Ioban Universal drapes Procedure #10 blade on #3 knife handle for vertical midline incision (base of xiphoid to around umbilicus to the pubis) Cautery/metz dissect through subcutaneous, fascia, muscle, and peritoneal layer Moist laps available for placement under hand-held or selfretaining retractors to protect abdominal organs Long metz, long kittner, clips, ties available to dissect through the omentum Isolate renal artery and renal vein May use rumel tourniquet or vessel loop or umbilical tapes around renal artery, vein and vena cava May need to retract pancreas and duodenum for optimal exposure Heparinize patient (CRNA) Procedure Continued Cooley clamps or peripheral debakey clamps available to clamp renal artery and any other arteries in close proximity to renal artery Excise aneurysm Repair with short piece of Hemashield graft material or just do simple closure of arterial defect with prolene suture Remove clamps allowing release of blood to dispel air Reversal of anticoagulated state with Protamine Sulfate by CRNA Hemostasis achieved Irrigate with antibiotic saline Procedure Continued Close retroperitoneum with 0 Vicryl on CT-1 tapered needle Return bowel to anatomical position remove all packs, retractors Initiate first count Close peritoneum, fascia, and muscles as single or individual layer (surgeon choice) using nonabsorbable or absorbable suture Perform final count Close skin with subcuticular stitch or staples Cleanse prep solution from skin Dress per surgeon preference (telfa, 4x4s, ABD pads, tape) Complications Bleeding/hemorrhage Impaired renal function Infection ENDOVASCULAR Repair Of Abdominal Aortic Aneurysm Anatomy & Physiology of AAA An aneurysm refers to a bulge or balloon that forms in the wall of a blood vessel If an aneurysm forms in the part of the aorta that extends past the diaphragm, it is called an abdominal aortic aneurysm (AAA) Result of true or false aneurysm Over time, the vessel wall loses elasticity and the force of normal blood pressure in the aneurysm can lead to bursting or rupture of the vessel The abdominal aorta is the most common site for an aneurysm development The exact cause (AAA) is unknown Risks associated with AAA include: atherosclerosis (accumulation of fatty deposits on the vessel wall), hypertension, smoking, trauma to the arterial wall, infection, peripheral vascular disease, arteriosclerosis, and congenital defects of the artery wall Most AAA occur below the level of the renal artery and involve the bifurcation of the aorta as well as the proximal ends of the iliac arteries Stasis of blood can lead to thrombus formation along arterial wall Peripheral emboli can develop causing arterial insufficiency Once an aneurysm forms it often increases in size and consequently the chances of rupture also increase Aneurysm rupture can lead to hemorrhage and death Presentation of AAA Most patients present without a symptomatic pulsatile abdominal mass The aortic bifurcation is located just above the umbilicus An overlying mass (pancreas or stomach) may be mistaken for an AAA An abdominal bruit is nonspecific for a nonruptured aneurysm Patients with popliteal artery aneurysms have a high incidence of AAAs (25-50%). Presentation of Ruptured AAA Ruptured may present in many ways Most typical presentation is abdominal or back pain with a pulsatile abdominal mass Symptoms may be vague and therefore overlooked Symptoms may include groin pain, syncope, paralysis, or flank mass The diagnosis may be confused with renal calculus, diverticulitis, incarcerated hernia, or lumbar spine disease What is an Endovascular Stent Graft? A woven polyester tube externally supported by a tubular metal web that expands to a preestablished diameter when placed intraluminally in the artery Endovascular Repair Advantages: Significantly lower number of complications Fewer deaths Shorter hospital stay Disadvantages: Increase in health care costs Is manufacturer competitiveness currently that is slowly decreasing costs How Does the Stent Graft Work The stent graft excludes the aneurysm from the circulation and thus prevents continued pressurization and possible rupture of the aneurysm The stent graft is placed inside the aneurysm using a delivery catheter Endovascular repair appears to have augmented treatment options rather than replaced open surgical repair for patients with AAA Patients who previously were not candidates for repair because of medical co-morbidity may now be safely treated with endovascular repair Graft options Manufacturers: Surgeon preference WL Gore (Gore-tex) Some companies are trying “Excluder” Medtronic “Aneuryx” Cook “Zenith” Allows for AAA that goes up beyond the renal arteries, but does not include aneurysmal renal artery involvement to modify their product to be used in ever increasing situations These changes take years of FDA trials to receive approval to come on the market Diagnosis During a routine physical exam a doctor may feel a throbbing mass in the middle or lower part of your abdomen However, most aneurysms are identified when diagnostic imaging ( X-ray, CT, MRI, arteriogram) is performed for other reasons Indications for Use Adequate iliac / femoral access Infra-renal , non-aneurysmal neck length greater than 1 cm at the proximal & distal ends of the aneurysm & an inner diameter 10-20% smaller than the labeled device diameter (Exception currently “Zenith”) Morphology suitable for endovascular repair Aneurysm diameter > 5 cm Aneurysm diameter of 4-5 cm which has also increased in size by 0.5 cm in the last 6 months or which is twice the diameter off the normal infra-renal aorta Pre-op testing CBC (complete blood count) BMP (basal metabolic panel) PT, & PTT /c INR ( clotting factor) Type & cross for blood EKG Chest x-ray Prep and positioning Patient warm with silver hat, warm blankets, or ideally bair hugger Position patient supine, arms tucked at sides, legs slightly apart, head on headrest, upper body bair hugger (nipples up) Foley catheter Scrub & paint betadine nipples to knees, lateral to sides bedsheet to bedsheet Drape sequence Drying towels Groin towel, square off using entire area nipples to knees Ioban drape/may need two if larger or longer patient Universal drapes Basic supplies,instruments & equipment Cell saver ( available ) Omni retractor or Bookwalter (surgeon preference) available Fluid warmer available C-arm ( fluoroscopy ) Lead aprons Supplies & Instruments Major vascular tray Dr’s special instruments Universal drape pack Major basin pack Cardiovascular Pack Sutures (surgeon preference card) Deployment device per manufacturer Anesthesia General anesthesia primarily Spinal anesthetic along with MAC in case of increased risk of complications (COPD) Local anesthetic and MAC Medication (on sterile field) Heparin / saline Antibiotic / saline (Ancef, other) Contrast 0.25 % marcaine plain Procedures Abdominal aortic aneurysm stent grafting Aorto bi-iliac Aorto uni-iliac Aorto bi femoral Aorto uni-femoral FDA has approved trial of stent grafts for thoracic aneurysms Summary Abdominal Vascular Surgery A&P Pathology Diagnostics/Preoperative Testing Prep & Positioning Basic Supplies, Equipment, & Instrumentation Abdominal Aortic Aneurysmectomy Aorto-Bifemoral Bypass Graft Resection of Renal Artery Aneurysm Endovascular AAA Repair
