Vascular Surgery

Vascular surgery is the specialized field of medicine that focuses on the surgical management of the pathologies of the peripheral circulation. The main goal of most vascular procedures is to restore circulatory function to the affected vessels by relieving occlusions or by redirecting blood flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure (e.g., bypass). Surgical intervention is either open or endovascular. Vascular interventions require a multidisciplinary approach, including vascular surgeons, interventional radiologists, anesthesiologists (or anesthetists), nurses, physiotherapists, and occupational therapists.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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Arteriovenous (AV) Fistulas

Definition

An AV fistula is a surgically created anastomosis between an artery and a vein. This procedure is commonly performed for individuals with end-stage renal disease who require permanent vascular access for hemodialysis, although it may also be congenital.

Indications

  • CKD CKD Chronic kidney disease (CKD) is kidney impairment that lasts for ≥ 3 months, implying that it is irreversible. Hypertension and diabetes are the most common causes; however, there are a multitude of other etiologies. In the early to moderate stages, CKD is usually asymptomatic and is primarily diagnosed by laboratory abnormalities. Chronic Kidney Disease stage 5: defined by a GFR < 30 mL/min
  • Imminent need for dialysis Dialysis Renal replacement therapy refers to dialysis and/or kidney transplantation. Dialysis is a procedure by which toxins and excess water are removed from the circulation. Hemodialysis and peritoneal dialysis (PD) are the two types of dialysis, and their primary difference is the location of the filtration process (external to the body in hemodialysis versus inside the body for PD). Overview and Types of Dialysis

Contraindications

  • Venous occlusion
  • Amputation Amputation An amputation is the separation of a portion of the limb or the entire limb from the body, along with the bone. Amputations are generally indicated for conditions that compromise the viability of the limb or promote the spread of a local process that could manifest systemically. Amputation
  • Advanced peripheral artery disease Peripheral artery disease Peripheral artery disease (PAD) is obstruction of the arterial lumen resulting in decreased blood flow to the distal limbs. The disease can be a result of atherosclerosis or thrombosis. Patients may be asymptomatic or have progressive claudication, skin discoloration, ischemic ulcers, or gangrene. Peripheral Artery Disease with necrosis on the side of AV fistula creation

Procedure

Preoperative care Preoperative Care Thorough preoperative care is important for patients scheduled to undergo surgery so that they can have the best possible outcomes after their surgical procedure. The preoperative process begins once the decision has been made to proceed with a surgical procedure. Preoperative Care

  • Previous fast (nil per os (NPO)) for 8 hours
  • Explain the procedure, benefits, risks, and alternatives to obtain informed consent.
  • Labs:
    • Platelet count > 50,000
    • PTT and PT within acceptable ranges
  • Required imaging: duplex ultrasonography
  • Anticoagulants Anticoagulants Anticoagulants are drugs that retard or interrupt the coagulation cascade. The primary classes of available anticoagulants include heparins, vitamin K-dependent antagonists (e.g., warfarin), direct thrombin inhibitors, and factor Xa inhibitors. Anticoagulants are held before the procedure.
  • Antibiotic prophylaxis before the procedure: 1st-generation cephalosporin (cefazolin)

In the OR:

  • The individual is placed in the supine position.
  • IV access is obtained.
  • Continuous monitoring:
    • HR
    • Blood pressure
    • Oxygen saturation (pulse oximetry)
    • ECG ECG An electrocardiogram (ECG) is a graphic representation of the electrical activity of the heart plotted against time. Adhesive electrodes are affixed to the skin surface allowing measurement of cardiac impulses from many angles. The ECG provides 3-dimensional information about the conduction system of the heart, the myocardium, and other cardiac structures. Normal Electrocardiogram (ECG) rhythm monitor

Operative care:

  • The most common AV fistula techniques include:
    • Radiocephalic fistula
    • Brachiocephalic fistula
    • Transposed brachiobasilic fistula
  • Recommended to perform this on the nondominant arm Arm The arm, or "upper arm" in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm 
  • Access placed as distally as possible

Radiocephalic fistula (Brescia-Cimino fistula):

  1. A transverse incision is made in the wrist. 
  2. The radial artery and cephalic vein are dissected.
  3. An anterolateral arteriotomy is made on the radial artery, and a corresponding venotomy is made on the cephalic vein.
  4. The 2 vessels are anastomosed using a nonabsorbable suture.

Brachiocephalic fistula (Kaufmann fistula):

  1. A transverse incision is made over the antecubital fossa.
  2. The brachial artery and cephalic vein are dissected.
  3. Arteriotomy and venotomy are performed on each vessel.
  4. The vessels are anastomosed using a nonabsorbable suture.

Transposed brachiobasilic fistula (2-stage approach):

  1. A transverse incision is made distal to the antecubital fossa.
  2. The brachial artery and basilic vein are dissected.
  3. An arteriotomy is made in the distal brachial artery.
  4. The distal basilic vein is ligated and divided, leaving a free end.
  5. An end of the basilic vein is anastomosed to the arteriotomy on the brachial artery using nonabsorbable suture.

Final steps:

  • Vascular Doppler imaging is used to confirm patency.
  • The skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin is closed by layers using nonabsorbable sutures and cleansed of any residue (e.g., blood, adipose tissue Adipose tissue Adipose tissue is a specialized type of connective tissue that has both structural and highly complex metabolic functions, including energy storage, glucose homeostasis, and a multitude of endocrine capabilities. There are three types of adipose tissue, white adipose tissue, brown adipose tissue, and beige or "brite" adipose tissue, which is a transitional form. Adipose Tissue).
  • Sterile gauze and a dressing are placed over the surgical wound. 
  • The following are documented:
    • Hour of initiation
    • Hour of completion
    • Steps followed
    • Complications encountered

Postoperative care Postoperative care After any procedure performed in the operating room, all patients must undergo close observation at least in the recovery room. After larger procedures and for patients who require hospitalization, observation must continue on the surgical ward. The primary intent of this practice is the early detection of postoperative complications. Postoperative Care:

Observation in the recovery room for 6 hours if necessary, or moved directly to the wards, according to each individual case.

Fistula maintenance:

  • Monitoring during dialysis Dialysis Renal replacement therapy refers to dialysis and/or kidney transplantation. Dialysis is a procedure by which toxins and excess water are removed from the circulation. Hemodialysis and peritoneal dialysis (PD) are the two types of dialysis, and their primary difference is the location of the filtration process (external to the body in hemodialysis versus inside the body for PD). Overview and Types of Dialysis sessions.
  • Individuals can be taught to examine the fistula for a thrill (indicates patency). The fistula should also be evaluated by a physician with routine appointments.
  • Ensure proper cleanliness and avoidance of clothing and jewelry over the access point to prevent flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure restriction.
  • Bathing and everyday activities can be resumed as tolerated.

Complications

  • Steal syndrome: 
    • Blood entering the limb moves through the fistula without entering capillaries Capillaries Capillaries are the primary structures in the circulatory system that allow the exchange of gas, nutrients, and other materials between the blood and the extracellular fluid (ECF). Capillaries are the smallest of the blood vessels. Because a capillary diameter is so small, only 1 RBC may pass through at a time. Capillaries
    • Clinical presentation: hand pain Hand Pain Hand and wrist pain is very common among the general population. Up to 30% of adults will have hand pain during their lives, and half of all cases progress to chronic pain. The causes of hand and wrist pain can be classified into mechanical (e.g., fractures, inflammation, ligament tear), neurologic (e.g., nerve entrapment), and systemic (e.g., autoimmune arthritis). Hand and Wrist Pain, coldness, sensory and/or motor dysfunction, cyanosis or pallor of the digits, and reduced or absent pulses,
    • Secondary to decreased blood flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure to the distal extremity
  • Thrombosis
  • Hematoma
  • Hemorrhage
  • Edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema
  • Aneurysm Aneurysm An aneurysm is a bulging, weakened area of a blood vessel that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel. Aneurysms occur more often in arteries than in veins and are at risk of dissection and rupture, which can be life-threatening. Extremity and Visceral Aneurysms/pseudoaneurysm: 
    • Common complication because of repetitive needle sticks during dialysis Dialysis Renal replacement therapy refers to dialysis and/or kidney transplantation. Dialysis is a procedure by which toxins and excess water are removed from the circulation. Hemodialysis and peritoneal dialysis (PD) are the two types of dialysis, and their primary difference is the location of the filtration process (external to the body in hemodialysis versus inside the body for PD). Overview and Types of Dialysis
    • To avoid this complication, the needle should be inserted at different points in a rotating pattern.
  • Fistula infection
  • Central venous stenosis
  • Failure to mature: Most commonly due to anastomotic stricture.

Thrombectomy/Embolectomy

Definition

Thrombectomy is an interventional procedure by which a blood clot or thrombus is surgically removed from a vessel via endovascular devices under imaging guidance.

Classification

  • Pullback thrombectomy with a balloon catheter
  • Aspiration (suction) thrombectomy
  • Fragmentation:
    • Recirculation thrombectomy: pulverizes the thrombus into microscopic fragments
    • Nonrecirculation thrombectomy: macerates the thrombus into macroscopic fragments
  • Energy-assisted thrombectomy: uses ultrasound, laser, or radiofrequency to lyse the thrombus

Indications

  • Stroke: injury undergone by brain tissue after interruption of blood flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure ( ischemic stroke Ischemic Stroke An ischemic stroke (also known as cerebrovascular accident) is an acute neurologic injury that occurs as a result of brain ischemia; this condition may be due to cerebral blood vessel occlusion by thrombosis or embolism, or rarely due to systemic hypoperfusion. Ischemic Stroke) or active hemorrhage (hemorrhagic stroke) that has characteristic neurologic deficits
  • MI MI MI is ischemia and death of an area of myocardial tissue due to insufficient blood flow and oxygenation, usually from thrombus formation on a ruptured atherosclerotic plaque in the epicardial arteries. Clinical presentation is most commonly with chest pain, but women and patients with diabetes may have atypical symptoms. Myocardial Infarction: injury to the myocardium due to ischemia, characterized by an increase in cardiac enzymes Enzymes Enzymes are complex protein biocatalysts that accelerate chemical reactions without being consumed by them. Due to the body's constant metabolic needs, the absence of enzymes would make life unsustainable, as reactions would occur too slowly without these molecules. Basics of Enzymes (especially troponin T), ECG ECG An electrocardiogram (ECG) is a graphic representation of the electrical activity of the heart plotted against time. Adhesive electrodes are affixed to the skin surface allowing measurement of cardiac impulses from many angles. The ECG provides 3-dimensional information about the conduction system of the heart, the myocardium, and other cardiac structures. Normal Electrocardiogram (ECG) changes suggestive of ischemia in 2 contiguous leads, and chest pain Chest Pain Chest pain is one of the most common and challenging complaints that may present in an inpatient and outpatient setting. The differential diagnosis of chest pain is large and includes cardiac, gastrointestinal, pulmonary, musculoskeletal, and psychiatric etiologies. Chest Pain
  • Pulmonary embolism Pulmonary Embolism Pulmonary embolism (PE) is a potentially fatal condition that occurs as a result of intraluminal obstruction of the main pulmonary artery or its branches. The causative factors include thrombi, air, amniotic fluid, and fat. In PE, gas exchange is impaired due to the decreased return of deoxygenated blood to the lungs. Pulmonary Embolism (PE): potentially fatal condition that occurs as a result of intraluminal obstruction of the main pulmonary artery or its branches by material (e.g., thrombus, air, amniotic fluid, or fat)

Contraindications

  • Intracranial hemorrhage
  • Large infarct core with minimal penumbra
  • Small-vessel occlusion
  • Coagulopathies
  • Uncontrolled hypertension Uncontrolled hypertension Although hypertension is defined as a blood pressure of > 130/80 mm Hg, individuals can present with comorbidities of severe asymptomatic or "uncontrolled" hypertension (≥ 180 mm Hg systolic and/or ≥ 120 mm Hg diastolic) that carries with it a significant risk of morbidity and mortality. Uncontrolled Hypertension

Procedure

Preoperative care Preoperative Care Thorough preoperative care is important for patients scheduled to undergo surgery so that they can have the best possible outcomes after their surgical procedure. The preoperative process begins once the decision has been made to proceed with a surgical procedure. Preoperative Care

  • Dietary fast (nil per os (NPO)) for 8 hours.
  • Explain the procedure, benefits, risks, and alternatives to obtain informed consent.
  • Labs:
    • Platelet count > 50,000
    • PTT and PT within acceptable ranges
    • Renal function: serum creatinine and blood urea nitrogen within normal ranges.
    • HbA1c
  • Diagnostic images: ultrasound, head CT scan
  • Anticoagulants Anticoagulants Anticoagulants are drugs that retard or interrupt the coagulation cascade. The primary classes of available anticoagulants include heparins, vitamin K-dependent antagonists (e.g., warfarin), direct thrombin inhibitors, and factor Xa inhibitors. Anticoagulants are withheld before the procedure.

In the OR:

  • The individual is placed in the supine position.
  • IV access is obtained.
  • Continuous monitoring:
    • HR
    • Blood pressure
    • O2 saturation (pulse oximetry)
    • ECG ECG An electrocardiogram (ECG) is a graphic representation of the electrical activity of the heart plotted against time. Adhesive electrodes are affixed to the skin surface allowing measurement of cardiac impulses from many angles. The ECG provides 3-dimensional information about the conduction system of the heart, the myocardium, and other cardiac structures. Normal Electrocardiogram (ECG) rhythm monitor

Operative care:

There are several thrombectomy techniques. The following uses a balloon catheter and stent for thrombus removal. 

  1. A balloon catheter is inserted through a groin puncture. 
  2. The catheter is advanced until it reaches the thrombus. 
  3. A guidewire is advanced through the thrombus.
  4. A microcatheter is passed over the guidewire and through the thrombus. 
  5. A stent is deployed, and once it reaches the thrombus, it is deployed within the vessel.
  6. The projections of the stent secure the thrombus to its surface. 
  7. Contrast is injected through the balloon catheter to ensure patency of the vessel. 
  8. The balloon is inflated to temporarily restrict flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure and allow removal of the stent with the thrombus and microcatheter.
  9. Angiography is performed to check if the thrombus was completely removed.
  10. The balloon catheter is removed. 

Final steps:

  • Sterile gauze and a dressing are placed over the puncture site.
  • The following are documented:
    • Name of procedure
    • Hour of initiation
    • Hour of completion
    • Steps followed
    • Complications encountered

Postoperative care Postoperative care After any procedure performed in the operating room, all patients must undergo close observation at least in the recovery room. After larger procedures and for patients who require hospitalization, observation must continue on the surgical ward. The primary intent of this practice is the early detection of postoperative complications. Postoperative Care:

  • Observation in the recovery room for 6 hours; later moved to the wards. Individuals with neurologic conditions may need to be admitted to the neurosurgery Neurosurgery Neurosurgery is a specialized field focused on the surgical management of pathologies of the brain, spine, spinal cord, and peripheral nerves. General neurosurgery includes cases of trauma and emergencies. There are a number of specialized neurosurgical practices, including oncologic neurosurgery, spinal neurosurgery, and pediatric neurosurgery. Neurosurgery ICU.
  • Close monitoring of:
    • Blood pressure ( hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension → reperfusion injury)
    • Temperature ( fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever)
    • Glycemia (hyperglycemia → worse clinical outcomes)
  • Serial neurologic examination 

Complications

  • Dislodging of embolic material
  • Stenosis at the thrombectomy site
  • Vessel perforation or dissection
  • Groin/retroperitoneal hematomas
  • Reocclusion (due to thrombocytosis or preexisting stenosis)
Extraction of thrombus

Extraction of thrombus

Image: “CCR-8-202_F2” by Dimitrios Alexopoulos* and Periklis A Davlouros. License: CC BY 2.5

Peripheral Artery Bypass (PAB)

Definition

A PAB (also known as a peripheral vascular bypass) is a surgical procedure that uses a graft to restore perfusion to a segment of the arterial circulation distal to an occlusion. This procedure can be performed in potentially any segment of circulation.

Indications

  • Peripheral artery disease (PAD): Obstruction of the arterial lumen, commonly secondary to atherosclerosis Atherosclerosis Atherosclerosis is a common form of arterial disease in which lipid deposition forms a plaque in the blood vessel walls. Atherosclerosis is an incurable disease, for which there are clearly defined risk factors that often can be reduced through a change in lifestyle and behavior of the patient. Atherosclerosis or thrombosis, that results in decreased blood flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure to visceral organs or the distal limbs. Individuals may initially be asymptomatic and later develop organ dysfunction, claudication, skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin discoloration, ischemic ulcers, or gangrene.
    • Narrowing in the heart is termed coronary artery disease.
    • Narrowing in the brain is termed cerebrovascular disease.
    • Narrowing in the kidneys Kidneys The kidneys are a pair of bean-shaped organs located retroperitoneally against the posterior wall of the abdomen on either side of the spine. As part of the urinary tract, the kidneys are responsible for blood filtration and excretion of water-soluble waste in the urine. Kidneys is termed renovascular disease.
    • Narrowing in the legs may cause leg Leg The lower leg, or just "leg" in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg pain with walking (intermittent claudication)
    • Smoking is the strongest risk factor for PAD
  • Traumatic arterial injuries
  • Aneurysms

Contraindications

  • History of cardiac surgery Cardiac surgery Cardiac surgery is the surgical management of cardiac abnormalities and of the great vessels of the thorax. In general terms, surgical intervention of the heart is performed to directly restore adequate pump function, correct inherent structural issues, and reestablish proper blood supply via the coronary circulation. Cardiac Surgery (e.g., stenting, angioplasty or coronary artery bypass) 
  • Respiratory disease (e.g., chronic obstructive pulmonary disease Chronic obstructive pulmonary disease Chronic obstructive pulmonary disease (COPD) is a lung disease characterized by progressive, largely irreversible airflow obstruction. The condition usually presents in middle-aged or elderly persons with a history of cigarette smoking. Signs and symptoms include prolonged expiration, wheezing, diminished breath sounds, progressive dyspnea, and chronic cough. Chronic Obstructive Pulmonary Disease (COPD))

Procedure

Preoperative care Preoperative Care Thorough preoperative care is important for patients scheduled to undergo surgery so that they can have the best possible outcomes after their surgical procedure. The preoperative process begins once the decision has been made to proceed with a surgical procedure. Preoperative Care:

  • Dietary fast (nil per os (NPO)) for 8 hours
  • Explain the procedure and obtain informed consent.
  • Labs:
    • Platelet count > 50,000
    • Adequate hemoglobin and hematocrit
    • PTT and PT within acceptable ranges
    • Blood type, cross, and match
    • Renal function: serum creatinine and BUN within normal ranges (unless performing renovascular intervention).
    • HbA1c
  • Required imaging: ultrasonography
  • These procedures may involve significant blood loss requiring transfusion. Blood products are made available for transfusion after blood type is obtained.
  • Anticoagulants Anticoagulants Anticoagulants are drugs that retard or interrupt the coagulation cascade. The primary classes of available anticoagulants include heparins, vitamin K-dependent antagonists (e.g., warfarin), direct thrombin inhibitors, and factor Xa inhibitors. Anticoagulants are withheld before the procedure.
  • Antibiotic prophylaxis within 1 hour before the procedure: 1st-generation cephalosporin (cefazolin) 

In the OR:

  • The individual is placed in the supine position.
  • IV access is obtained.
  • Continuous monitoring:
    • HR
    • Blood pressure
    • O2 saturation (pulse oximetry)
    • ECG ECG An electrocardiogram (ECG) is a graphic representation of the electrical activity of the heart plotted against time. Adhesive electrodes are affixed to the skin surface allowing measurement of cardiac impulses from many angles. The ECG provides 3-dimensional information about the conduction system of the heart, the myocardium, and other cardiac structures. Normal Electrocardiogram (ECG) rhythm monitor

Operative care:

The procedure itself will vary widely depending on the surgical anatomy and location of the obstruction. However, the underlying principle of PAB is establishing proximal and distal anastomoses in disease-free segments. Some examples of PAB include:

  1. Iliofemoral bypass: ipsilateral or contralateral iliac artery is communicated with the common femoral artery (CFA)
  2. Aortobifemoral bypass: the abdominal aorta is communicated with both CFAs
  3. Femoropopliteal bypass: the popliteal artery is communicated with a single femoral artery

Grafts are created with organic (e.g., harvested saphenous vein) or artificial (e.g., polytetrafluoroethylene) materials. 

Final steps:

  • The skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin is closed by layers using nonabsorbable sutures and cleansed of any residue (e.g., blood, adipose tissue Adipose tissue Adipose tissue is a specialized type of connective tissue that has both structural and highly complex metabolic functions, including energy storage, glucose homeostasis, and a multitude of endocrine capabilities. There are three types of adipose tissue, white adipose tissue, brown adipose tissue, and beige or "brite" adipose tissue, which is a transitional form. Adipose Tissue).
  • Sterile gauze and a dressing are placed over the surgical wound. 
  • The following are documented:
    • Name of procedure
    • Hour of initiation
    • Hour of completion
    • Steps followed
    • Complications encountered

Postoperative care Postoperative care After any procedure performed in the operating room, all patients must undergo close observation at least in the recovery room. After larger procedures and for patients who require hospitalization, observation must continue on the surgical ward. The primary intent of this practice is the early detection of postoperative complications. Postoperative Care:

  • Observation in recovery room for 6 hours; later moved to the wards
  • Physical examination:
    • Vascular: reduced pulses, prolonged capillary filling time, hematomas
    • Neurologic: paresthesias Paresthesias Subjective cutaneous sensations (e.g., cold, warmth, tingling, pressure, etc.) that are experienced spontaneously in the absence of stimulation. Respiratory Alkalosis, paralysis

Complications

  • Surgical site infection ( SSI SSI Surgical site infection (SSI) is a type of surgical infection that occurs at or near a surgical incision within 30 days of the procedure or within 90 days if prosthetic material is implanted. Surgical site infections are classified according to the depth of involvement as superficial, deep, or organ/space. Surgical Site Infections): A type of infection that occurs at or near a surgical incision within 30 days after the procedure or within 90 days if prosthetic material is implanted. An SSI SSI Surgical site infection (SSI) is a type of surgical infection that occurs at or near a surgical incision within 30 days of the procedure or within 90 days if prosthetic material is implanted. Surgical site infections are classified according to the depth of involvement as superficial, deep, or organ/space. Surgical Site Infections is classified according to the depth of compromise—superficial, deep, or organ/space.
  • Hemorrhage/hematoma
  • Aneurysm Aneurysm An aneurysm is a bulging, weakened area of a blood vessel that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel. Aneurysms occur more often in arteries than in veins and are at risk of dissection and rupture, which can be life-threatening. Extremity and Visceral Aneurysms/pseudoaneurysm
  • Failure of anastomoses
  • Pneumonia Pneumonia Pneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy. Pneumonia
  • Graft occlusion
  • Neighboring nerve injury
Example of a bypass graft

Example of a bypass graft

Image by Lecturio.

Carotid Endarterectomy (CEA)

Definition

A CEA is a surgical procedure in which atherosclerotic plaque is manually removed from the common and/or internal carotid artery. The therapeutic goals are to restore normal blood flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure and reduce the likelihood of embolization.

Indications

  • Carotid artery (> 50% stenosis) and symptoms
  • Asymptomatic individuals with carotid stenosis > 60%
  • History of ipsilateral stroke or transient ischemic attack Transient ischemic attack Transient ischemic attack (TIA) is a temporary episode of neurologic dysfunction caused by ischemia without infarction that resolves completely when blood supply is restored. Transient ischemic attack is a neurologic emergency that warrants urgent medical attention. Transient Ischemic Attack (TIA) ( TIA TIA Transient ischemic attack (TIA) is a temporary episode of neurologic dysfunction caused by ischemia without infarction that resolves completely when blood supply is restored. Transient ischemic attack is a neurologic emergency that warrants urgent medical attention. Transient Ischemic Attack (TIA))

Contraindications

  • Very ill and symptomatic individuals who are unable to undergo an open surgical procedure
  • History of radiation therapy to the neck
  • Individuals with high-likelihood of poor outcomes must be carefully selected.
    • Older age (> 70 years)
    • Severe heart disease
    • Severe pulmonary dysfunction
    • Renal insufficiency or failure
    • Stroke as the indication for endarterectomy

Procedure

Preoperative care Preoperative Care Thorough preoperative care is important for patients scheduled to undergo surgery so that they can have the best possible outcomes after their surgical procedure. The preoperative process begins once the decision has been made to proceed with a surgical procedure. Preoperative Care

  • Dietary fast (nil per os (NPO)) of 8 hours
  • Explain the procedure and obtain informed consent.
  • Labs:
    • Platelet count > 50,000
    • PTT and PT within acceptable ranges
    • Renal function: serum creatinine and blood urea nitrogen within normal ranges
    • HbA1c
  • Required images: carotid duplex ultrasonogram; head CT scan
  • Antiplatelet therapy with aspirin (81–325 mg/day) prior to the procedure 
  • Anticoagulants Anticoagulants Anticoagulants are drugs that retard or interrupt the coagulation cascade. The primary classes of available anticoagulants include heparins, vitamin K-dependent antagonists (e.g., warfarin), direct thrombin inhibitors, and factor Xa inhibitors. Anticoagulants are withheld if so indicated by the surgeon.
  • Antibiotic prophylaxis within 1 hour before the procedure: 1st-generation cephalosporin (cefazolin)

In the OR:

  • The individual is placed in the supine position.
  • IV access is obtained.
  • Continuous monitoring:
    • HR
    • Blood pressure
    • O2 saturation (pulse oximetry)
    • ECG ECG An electrocardiogram (ECG) is a graphic representation of the electrical activity of the heart plotted against time. Adhesive electrodes are affixed to the skin surface allowing measurement of cardiac impulses from many angles. The ECG provides 3-dimensional information about the conduction system of the heart, the myocardium, and other cardiac structures. Normal Electrocardiogram (ECG) rhythm monitor
  • The individual can be placed under general or local anesthesia Anesthesia Anesthesiology is the field of medicine that focuses on interventions that bring a state of anesthesia upon an individual. General anesthesia is characterized by a reversible loss of consciousness along with analgesia, amnesia, and muscle relaxation. Anesthesiology: History and Basic Concepts with sedation.

Operative care:

  1. An incision is made alongside the medial border of the sternocleidomastoid muscle.
  2. The platysma muscle and soft tissues are dissected until the carotid sheath is reached. 
  3. The carotid sheath is incised carefully and the carotid artery is exposed. 
  4. The compromised artery is clamped proximally and distally to the plaque. 
  5. An arteriotomy is performed on the vessel, and surgery progresses until both ends of the plaque are reached. 
  6. The plaque is removed from the vessel (the vessel wall may be everted around the plaque). 
  7. The arterial wall is repaired with a patch that will widen the vessel lumen. The patch can be of organic (e.g., vein, bovine patch) or synthetic (Dacron) material.

Final steps:

  • The skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin is closed by layers using nonabsorbable sutures and cleansed of any residue (e.g., blood, adipose tissue Adipose tissue Adipose tissue is a specialized type of connective tissue that has both structural and highly complex metabolic functions, including energy storage, glucose homeostasis, and a multitude of endocrine capabilities. There are three types of adipose tissue, white adipose tissue, brown adipose tissue, and beige or "brite" adipose tissue, which is a transitional form. Adipose Tissue).
  • Sterile gauze and a dressing are placed over the surgical wound. 
  • The following are documented:
    • Name of procedure
    • Hour of initiation
    • Hour of completion
    • Steps followed
    • Complications encountered

Postoperative care Postoperative care After any procedure performed in the operating room, all patients must undergo close observation at least in the recovery room. After larger procedures and for patients who require hospitalization, observation must continue on the surgical ward. The primary intent of this practice is the early detection of postoperative complications. Postoperative Care:

  • Observation in recovery room for 6 hours; later moved to the wards
  • Neurologic examination every hour.
  • Blood pressure control ( hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension → neck hematoma)

Complications

  • Hemorrhage
  • Neck hematoma
  • Surgical site infection
  • Dysphagia Dysphagia Dysphagia is the subjective sensation of difficulty swallowing. Symptoms can range from a complete inability to swallow, to the sensation of solids or liquids becoming "stuck." Dysphagia is classified as either oropharyngeal or esophageal, with esophageal dysphagia having 2 sub-types: functional and mechanical. Dysphagia
  • MI MI MI is ischemia and death of an area of myocardial tissue due to insufficient blood flow and oxygenation, usually from thrombus formation on a ruptured atherosclerotic plaque in the epicardial arteries. Clinical presentation is most commonly with chest pain, but women and patients with diabetes may have atypical symptoms. Myocardial Infarction
  • Cerebral hyperperfusion syndrome: A clinical presentation secondary to increased cerebral perfusion after carotid endarterectomy that is characterized by ipsilateral headache, hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension, seizures Seizures A seizure is abnormal electrical activity of the neurons in the cerebral cortex that can manifest in numerous ways depending on the region of the brain affected. Seizures consist of a sudden imbalance that occurs between the excitatory and inhibitory signals in cortical neurons, creating a net excitation. The 2 major classes of seizures are focal and generalized. Seizures, and focal neurological deficits. If not treated, cerebral hyperperfusion can result in severe cerebral edema or intracerebral or subarachnoid hemorrhage Subarachnoid Hemorrhage Subarachnoid hemorrhage (SAH) is a type of cerebrovascular accident (stroke) resulting from intracranial hemorrhage into the subarachnoid space between the arachnoid and the pia mater layers of the meninges surrounding the brain. Most SAHs originate from a saccular aneurysm in the circle of Willis but may also occur as a result of trauma, uncontrolled hypertension, vasculitis, anticoagulant use, or stimulant use. Subarachnoid Hemorrhage (SAH).
  • Greater auricular nerve injury
  • Cranial nerve injury (hypoglossal, vagus, glossopharyngeal, and facial)
  • Perioperative stroke and TIA TIA Transient ischemic attack (TIA) is a temporary episode of neurologic dysfunction caused by ischemia without infarction that resolves completely when blood supply is restored. Transient ischemic attack is a neurologic emergency that warrants urgent medical attention. Transient Ischemic Attack (TIA)

References

  1. Gonzalez, R., Cassaro, S. (2021). Percutaneous central catheter. StatPearls. Retrieved October 23, 2021, from http://www.ncbi.nlm.nih.gov/books/NBK459338/
  2. Mole, D. J. (2018). Practical procedures and patient investigation. In Garden, O. J., et al. (Eds.), Principles and Practice of Surgery, pp. 112–127. Retrieved October 19, 2021, from https://www.clinicalkey.es/#!/content/3-s2.0-B978070206859100008X
  3. Adams, G.A., et al. (2020). Intravascular access. In Adams, G.A. et al. (Eds.), On Call Surgery, pp. 265–308. Retrieved October 19, 2021, from https://www.clinicalkey.es/#!/content/3-s2.0-B9780323528894000193
  4. Flick, A. I., Winters, R. (2021). Vascular tunneled central catheter access. Retrieved October 23, 2021, from http://www.ncbi.nlm.nih.gov/books/NBK557614/
  5. Phillips, N., Hornacky, A. (2021). Berry & Kohn’s Operating Room Technique. Elsevier. 
  6. Delaney, C., Netter, F. (2021). Netter’s Surgical Anatomy and Approaches. Elsevier.
  7. Marsh, A. M., Genova, R., Buicko, J. L. (2021). Dialysis fistula. Retrieved October 24, 2021, from http://www.ncbi.nlm.nih.gov/books/NBK559085/
  8. Allon, M. (2021). Overview of hemodialysis arteriovenous fistula maintenance and thrombosis prevention. UpToDate. Retrieved November 2, 2021, from https://www.uptodate.com/contents/overview-of-hemodialysis-arteriovenous-fistula-maintenance-and-thrombosis-prevention
  9. Elias, N., Stapleton, S. (2020). Creation of a radial-cephalic arteriovenous fistula. Journal of Medical Insight. 2020(110). https://doi.org/10.24296/jomi/110 
  10. Mathews, S., De Jesus, O. (2021). Thrombectomy. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK562154/
  11. Alexopoulos, D., Davlouros, P. A. (2012). Thrombus extraction catheters vs. angiojet rheolytic thrombectomy in thrombotic lesions/SV grafts. Current Cardiology Reviews. 8, 202–208. https://doi.org/10.2174/157340312803217265 
  12. Moore, W., Lawrence, P., Oderich, G. (2019). Moore’s Vascular and Endovascular Surgery: A Comprehensive Review. Elsevier.
  13. Samaniego, E., Hasan, D. (2019). Acute stroke management in the era of thrombectomy. Cham: Springer.
  14. Schwartz, S., Robinson, M. (2019). Carotid endarterectomy (cadaver). Journal of Medical Insight. https://jomi.com/article/260.1/Carotid-Endarterectomy-(Cadaver)
  15. van Mook, W. N., et al. (2005). Cerebral hyperperfusion syndrome. Lancet Neurology. 4, 877–888. https://pubmed.ncbi.nlm.nih.gov/16297845/
  16. DaCosta, M., Tadi, P., Surowiec, S. M. (2021). Carotid endarterectomy. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK470582/
  17. Fairman, R. M., Jim, J. (2021). Carotid endarterectomy. UpToDate, Post, Kathryn A Collins, MD, PhD, FACS (Ed), UpToDate, Waltham, MA. https://www.uptodate.com/contents/carotid-endarterectomy

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