Abdominal Vascular Surgery

1. Abdominal Vascular Surgery

2. 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

3. 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

4. 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

7. 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

9. PATHOLOGY

10. Aneurysms • Trueaneurysm=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

11. 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

12. 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)

13. 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%

14. 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

15. 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

16. 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

17. Preoperative Testing & Diagnostics • 1. CT Scan • diagnose an aneurysm • Extent • Location of thromboembolytic matter • Shows whether or not there is leakage • 2. Ultrasound • Detection

18. 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

19. Prep & Positioning • Arteriogram films should be displayed in the x-ray 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

20. 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

21. Drape Sequence • Groin towel, towels x 6 (at sides, across knees, across chest) • Drying towels • Ioban • Drape (universal sheets or laparotomy sheet)

22. 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

23. 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)

24. 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

25. 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

26. Basic Supplies, Instrumentation, And Equipment • Equipment • ESU/Bovie • Suction/Cell Saver • Headlight for the surgeon • Bair hugger for patient (upper body) • Doppler box

27. 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)

28. Procedures • Abdominal Aortic Aneurysm • Aorto-Bifemoral Bypass Graft • Aorto-Iliac Bypass Graft • Resection of Renal Artery Aneurysm

29. 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

30. 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

31. 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 re-implanted into the graft using smaller lumened Dacron grafts (renals, superior mesenteric, celiac)

33. 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

34. 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 non-pledgeted 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. Equipment • Warming blanket or Upper Body Bair Hugger • Cell saver • Extra suction • ECU • Headlamp • Warmer for irrigants

42. 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

43. 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

44. Draping • Groin towel • Towels x 6 • Drying towel • Ioban • Universal drapes

45. 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 self-retaining 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)

46. 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

47. 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)

48. Complications • Bleeding/hemorrhage • Impaired renal function • Infection

49. ENDOVASCULAR Repair Of Abdominal Aortic Aneurysm

50. 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