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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.

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summary
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
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
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
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
aneurysms
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
true aneurysms
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
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 continued1
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
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
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
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
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
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
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
prep and positioning continued
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
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
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
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 continued1
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
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 equipment1
Basic Supplies, Instrumentation, And Equipment
  • Equipment
  • ESU/Bovie
  • Suction/Cell Saver
  • Headlight for the surgeon
  • Bair hugger for patient (upper body)
  • Doppler box
medications
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
Procedures
  • Abdominal Aortic Aneurysm
  • Aorto-Bifemoral Bypass Graft
  • Aorto-Iliac Bypass Graft
  • Resection of Renal Artery Aneurysm
abdominal aortic aneurysmectomy
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
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
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)
aaa continued1
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 continued2
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
aaa continued3
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 continued4
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
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
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
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
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
Equipment
  • Warming blanket or Upper Body Bair Hugger
  • Cell saver
  • Extra suction
  • ECU
  • Headlamp
  • Warmer for irrigants
instruments
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
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
Draping
  • Groin towel
  • Towels x 6
  • Drying towel
  • Ioban
  • Universal drapes
procedure
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)
procedure continued
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 continued1
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
Complications
  • Bleeding/hemorrhage
  • Impaired renal function
  • Infection
anatomy physiology of aaa
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
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 
presentation of aaa
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
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
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 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

Endovascular Repair
how does the stent graft work
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
slide60
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 options1
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 market

Graft options
diagnosis
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
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
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
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 sequence1
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
Basic supplies,instruments & equipment
  • Cell saver ( available )
  • Omni retractor or Bookwalter (surgeon preference) available
  • Fluid warmer available
  • C-arm ( fluoroscopy )
  • Lead aprons
supplies instruments
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
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
Medication (on sterile field)
  • Heparin / saline
  • Antibiotic / saline (Ancef, other)
  • Contrast
  • 0.25 % marcaine plain
procedures1
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
summary1
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