Abdominal Vascular Surgery - PowerPoint Presentation

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Abdominal Vascular SurgerySlide2

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 AneurysmSlide3

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 visceraSlide4

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 tibialSlide5
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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 bodySlide8
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PATHOLOGYSlide10

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 disruptedSlide11

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 historySlide12

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)Slide13

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%Slide14

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 Slide15

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 jointSlide16

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 walledSlide17

Preoperative Testing & Diagnostics

1. CT Scan

diagnose an aneurysm

Extent

Location of thromboembolytic matter

Shows whether or not there is leakage

2. Ultrasound

DetectionSlide18

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 areasSlide19

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 bedSlide20

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 lastSlide21

Drape Sequence

Groin towel, towels x 6 (at sides, across knees, across chest)

Drying towels

Ioban

Drape (universal sheets or laparotomy sheet)Slide22

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 Slide23

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)Slide24

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 countSlide25

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)

TunnelerSlide26

Basic Supplies, Instrumentation, And Equipment

Equipment

ESU/Bovie

Suction/Cell Saver

Headlight for the surgeon

Bair hugger for patient (upper body)

Doppler boxSlide27

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)Slide28

Procedures

Abdominal Aortic Aneurysm

Aorto-Bifemoral Bypass Graft

Aorto-Iliac Bypass Graft

Resection of Renal Artery AneurysmSlide29

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 diameterSlide30

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 spongeSlide31

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)Slide32
Slide33

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 handsSlide34

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 appliedSlide35

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 staplersSlide36

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 policySlide37

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 surgerySlide38

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 Slide39

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 pregnancySlide40

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 kneesSlide41

Equipment

Warming blanket or Upper Body Bair Hugger

Cell saver

Extra suction

ECU

Headlamp

Warmer for irrigantsSlide42

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 needleSlide43

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 availableSlide44

Draping

Groin towel

Towels x 6

Drying towel

Ioban

Universal drapesSlide45

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) Slide46

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 salineSlide47

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)Slide48

Complications

Bleeding/hemorrhage

Impaired renal function

Infection Slide49

ENDOVASCULAR Repair Of Abdominal Aortic AneurysmSlide50

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 vesselSlide51

Slide52

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   Slide53

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 Slide54
Slide55

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%). Slide56

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 Slide57

What is an Endovascular Stent Graft?

A woven polyester tube externally supported by a tubular metal web that expands to a pre-established diameter when placed intra-luminally in the arterySlide58

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 costsSlide59

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 catheterSlide60

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 repairSlide61

Graft options

Manufacturers:

WL Gore (Gore-tex) “Excluder”

Medtronic “Aneuryx”

Cook “Zenith” Allows for AAA that goes up beyond the renal arteries, but does not include aneurysmal renal artery involvement

Surgeon preference

Some companies are trying 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 marketSlide62

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 reasonsSlide63

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 aortaSlide64

Pre-op testing

CBC (complete blood count)

BMP (basal metabolic panel)

PT, & PTT /c INR ( clotting factor)

Type & cross for blood

EKG

Chest x-raySlide65

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 bedsheetSlide66

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 drapesSlide67

Basic supplies,instruments & equipment

Cell saver ( available )

Omni retractor or Bookwalter (surgeon preference) available

Fluid warmer available

C-arm ( fluoroscopy )

Lead apronsSlide68

Supplies & Instruments

Major vascular tray

Dr’s special instruments

Universal drape pack

Major basin pack

Cardiovascular Pack

Sutures (surgeon preference card)

Deployment device per manufacturerSlide69

Anesthesia

General anesthesia primarily

Spinal anesthetic along with MAC in case of increased risk of complications (COPD)

Local anesthetic and MACSlide70

Medication (on sterile field)

Heparin / saline

Antibiotic / saline (Ancef, other)

Contrast

0.25 % marcaine plainSlide71

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 aneurysmsSlide72

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