Appendix. Vascular Anastomosis Workshop PURPOSE DESCRIPTION WORKSHOP TOOLS

Transcription

1 Appendix Vascular Anastomosis Workshop PURPOSE The purpose of this workshop is to expose the participant to commonly used basic vascular reconstructions. The participant is expected to learn new skills during the workshop and be able to review and practice what was learned at a later convenient date. It is hoped that this workshop will improve the surgical residents performance in the operating room when rotating on the vascular surgery service. DESCRIPTION The workshop will have a structured format with flexible applications. The participant will be asked to perform a series of technical exercises of increasing complexity. Participants can skip the exercises that may be too simple for their level of training. At the completion of the workshop, the participant should be familiar with 1. Primary closure of an arteriotomy using an interrupted or continuous suture technique 2. Patch angioplasty closure of an arteriotomy using an anchor or parachute technique 3. End-to-side anastomosis using an anchor or parachute technique 4. End-to-end anastomosis in a straight or beveled fashion 5. End-to-end anastomosis between two grafts of different diameters WORKSHOP TOOLS Each participant will be provided with 1 suture board 1 needle holder 1 forceps 1 scissors (2) 8-mm grafts (2) 6-mm grafts Vascular sutures Workshop manual (Part II) 383

2 384 Appendix. Vascular Anastomosis Workshop Part II will provide guidance through detailed illustrations on the various techniques used to perform the required exercises. The workshop supervisor can add his suggestions and recommendations to the instructions provided in Part II. Even with minimal supervision, the participant should be able to benefit from the workshop and identify any shortcomings in understanding the technical aspects of the reconstruction. A workshop video demonstrating the exercises to be performed can also be supplemented for review before or after the workshop.

3 Appendix. Vascular Anastomosis Workshop 385 EXERCISES TO BE PERFORMED IN THE WORKSHOP For the purpose of this workshop, assume that the 8-mm graft is an artery. The 6-mm graft will serve as a conduit to be used for creating a bypass. Create a transverse arteriotomy. Close the arteriotomy with interrupted sutures. Create a longitudinal arteriotomy. Close the arteriotomy with a running suture. Create a longitudinal arteriotomy. Transect a 2-cm segment of the distal part of the 6-mm graft. Create a patch from that segment. Use that patch to close the arteriotomy. Create a 1-cm longitudinal arteriotomy in the 8-mm graft near the left end. Construct an end- to-side anastomosis with one end of the 6-mm graft using an anchor technique.

4 386 Appendix. Vascular Anastomosis Workshop EXERCISES TO BE PERFORMED IN THE WORKSHOP Create a 1-cm longitudinal arteriotomy in the 8-mm graft close to its right end. Construct an end-to-side anastomosis with the free end of the 6-mm graft using a parachute technique. Transect the 6-mm graft and suture it back together in a straight fashion. Excise a 4-cm segment of the 6-mm graft and suture the ends back together in a beveled fashion. Construct an end-to-end anastomosis between the 6- mm graft segment and the 8-mm graft.

5 Index A Abdominal aorta and its branches anatomy of, exposure of, retroperitoneal exposure of, transperitoneal exposure of, Abdominal aortic graft, coverage of, Anastomosis distal, of an infrainguinal prosthetic bypass, end-to-end, end-to-side, in aortoiliac aneurysmal disease, proximal in replacement of an infrarenal abdominal aortic aneurysm, in replacement of a thoracoabdominal aortic aneurysm, of infrainguinal bypass, side-to-side, Anchor technique end-to-end anastomosis large vessel, transection perpendicular to the longitudinal axis, small vessel, beveled transection, end-to-side anastomosis, 183 anchoring suture between apex and heel, horizontal mattress sutures, 191 simple anchoring sutures, stapling, infrarenal abdominal aortic aneurysm replacement, patch closure of a longitudinal arteriotomy, side-to-side anastomosis, Aneurysm clips, Yasargil, 15 for blood vessel control, 118 Aneurysm wall wrap, around an implanted graft, 377, 380 Angiography, intraoperative, for evaluating vascular reconstruction, 134 Angioscopy, for guiding valvulotomy, 6 Anterior tibial artery anatomy, 77 exposure of, Anticoagulation in thrombectomy-embolectomy, 149 in vascular reconstruction, 117 Antiplatelet therapy, in carotid surgery or infrainguinal reconstruction, 117 Aorta See abdominal aorta Aortic allografts, 20 Aortic aneurysm general principles for replacement of, infrarenal abdominal, replacement of, managing the inferior mesenteric artery during replacement of, thoracoabdominal, replacement of, Aortic clamps, Aortic grafts, abdominal, coverage of, Aortic patch, reimplantation of the celiac, superior mesenteric and right renal arteries on, 328 Aortic reconstruction, pelvic revascularization during, Aortobifemoral bypass, 348 tunnel for, 110 Aortoiliac aneurysmal disease, distal anastomosis reimplanting the external iliac artery, with bypass, to the aortic bifurcation, to the common iliac artery, 361 to the external iliac artery, to the external iliac artery, with bypass to the internal iliac artery, 368 to the iliac bifurcation, 362 to the internal iliac artery, reimplanting the external iliac artery,

6 388 Index with a bypass to the internal iliac artery, 368 Aortoiliac occlusive disease, 348 end-to-end aortobifemoral bypass, 350, 353 end-to-side aortobifemoral bypass, Arterial substitutes, 17 Arteries abdominal aorta and its branches, lower extremity, neck and upper extremity, See also Abdominal aorta; Axillary artery; Anterior tibial artery; Brachial artery; Carotid artery; Celiac artery; Common femoral artery; Common iliac artery; Hepatic artery; Iliac arteries; Individual artery; Inferior mesenteric artery; Innominate arteries; Peroneal artery; Popliteal artery; Posterior tibial artery; Plantar arteries; Profunda femoris artery; Radial artery; Renal arteries; Subclavian arteries; Superficial femoral artery; Superior mesenteric artery; Suprageniculate popliteal artery; Ulnar artery; Vertebral artery Arteriotomy, closure of, Arteriovenous fistulae primary for hemodialysis, 113 prosthetic for hemodialysis, to reduce infrainguinal prosthetic bypass failure, end-to-side, side-to-side, Arteriovenous grafts loop upper arm, straight upper arm, Aspirin, for anticoagulation in vascular reconstruction, 117 Autogenous conduits, Autogenous patches, 22 Axillary artery, anatomy and exposure of, Axillofemoral bypass, tunnel for, 110 B Balloon catheters, for vascular control, 122 in infrainguinal bypass, Basilic veins anatomy of, 100 for bypasses, 19 exposure of, 101 Biodegradable material, silk sutures, Bite size, in suture line construction, Bleeding/blood loss from needle holes, controlling, 137 in thrombectomy-embolectomy, 150, Blood supply, to the pelvis, Blood vessels (for specific vessels refer to individual artery/vein) anatomy and exposure of arteries, list, 108 control of, in vascular reconstruction, exposure and dissection of, Boazul Roll-On Cuff, 123 Brachial artery anatomy of, exposure of, 38 Brachiobasilic fistulae, 114 Brachiocephalic fistulae, 113 Bush retrograde valvulotome, 6 Bypass in aortoiliac aneurysmal disease to the external iliac artery, to the internal iliac artery, 368 in aortoiliac occlusive disease, 348 axillofemoral, tunnel for, 110 basilic or cephalic veins for, 19 composite vein, end-to-end anastomosis between vessels of unequal diameter, 253 end-to-end aortobifemoral, in aortoiliac occlusive disease, 350, 353 end-to-side aortobifemoral, in aortoiliac occlusive disease, failure caused by neointimal hyperplasia, 276 infrainguinal, infrainguinal prosthetic distal anastomosis, end-to-side arteriovenous fistula, side-to-side arteriovenous fistula, preparation of, prosthetic, arteriovenous fistula for improving success rate in, saphenous vein aortorenal, 19 vein, to the infrapopliteal artery, 19, C Calcified plaque, endarterectomy of, 139 in pelvic revascularization during aortic reconstruction, 349 Carotid artery anatomy of, exposure of, external, internal anatomy of, high exposure of, Carotid shunts, 7, 16 inlying and outlying, 10 Carotid surgery, antiplatelet therapy in, 117 Carrell patch, mesenteric artery reimplantation, 371 Catheter, for thrombectomy-embolectomy avoiding trauma from, placing in a tibial artery, 156 Celiac artery anatomy of, 48-49

7 Index 389 reimplantation on an aortic patch, 328, transperitoneal exposure of, 63 Cephalic veins anatomy of, 100 arteriovenous fistulae to, 113 for bypasses, 19 exposure of, 101 Circle of Willis, Clamps aortic,12-14 bulldog, 14 hypogastric, 13 pediatric, 14 peripheral vascular, 13 soft-jaw, for thrombectomy-embolectomy, 150 subclavian, 14 vascular, 5 straight jaw and curved jaw, 8 Common femoral artery anatomy of, 74 exposure of, 78 lateral exposure of, 79 Common iliac artery, anatomy of, 51 Composite bypass, veins for, 19 Composite vein graft, for joining vessels of unequal diameter, 220 Cryopreserved veins, from cadaveric donors, 20 D Dextran, as an antiplatelet agent, 117 E Elevator, Freer, for separating plaque from an artery, Embolectomy, 149 Endarterectomy, of calcified plaque, 139 in pelvic revascularization during aortic reconstruction, 349 carotid, risk of rupture of autogenous patches in, 22 for creating a patch, 125 open, , See also Eversion endarterectomy End-to-end anastomosis in large vessels of comparable diameter, in small vessels beveled transection, anchor technique, of comparable diameter, 219 transection perpendicular to the longitudinal axis anchor technique, anterior patch angioplasty, parachute technique, triangulation technique, between vessels of unequal caliber, beveled transection, combined techniques, composite vein bypass, 253 end-to-side; functional end-to-end, End-to-side anastomosis anchor technique, 183 construction of the apex with interrupted sutures, simple anchoring sutures, stapling, suture between apex and heel, parachute technique, start a few bites from center of the heel, start at center of the heel, start at the center of the apex, Evaluation intraoperative, of vascular reconstruction, of a thrombectomy-embolectomy, 152 Eversion endarterectomy, 158, 164 of the inferior mesenteric artery, 370 F Femorofemoral bypass, tunnel for, 110 Femoropopliteal bypass, above-knee and below-knee, tunnel for, Fluoroscopy, for following a balloon catheter, in thrombectomyembolectomy, 151 Fogarty valvulotome, 6 Forceps, figures, 11 Freer double-ended elevator, 15 specification and common use, 5 G Geometry, of an end-to-side anastomosis, Gore Eze-Sit valvulotome, 6 Grafts bovine, complications in use of, 20 homologous, 20 textile, 21 Greater saphenous vein (GSV) anatomy of, for a bypass, 18 exposure of, 103 H Hall Valve Stripper, 6 Hemodialysis, creating an arteriovenous fistula for, 113 Hemostasis, securing, in vascular reconstruction, 134 topical agents for, list, 137

8 390 Index Hemostatic forceps, specification and common use, 3 Heparin systemic anticoagulation with, 117 tunneling before systemic anticoagulation with, 110 Hepatic artery common, anatomy of, 49 transabdominal exposure of, 64 Instruments, vascular, 3-16 Internal occluders, 15 for blood vessel control, 122 specification and common use, 5 Interrupted mattress suture, infrarenal abdominal aortic aneurysm replacement anchor technique, transected posterior wall, I Iliac arteries internal, as a conduit in young patients, 19 retroperitoneal exposure of, 70, 73 transperitoneal exposure of, 72 Inahara Pruit shunt, 7, 16 Incision blood vessel, creating, 124 types of, for thrombectomy-embolectomy, 149 Inferior mesenteric artery (IMA) anatomy of, 50 pelvic blood supply contribution by, protection of, in infrarenal abdominal aortic aneurysm replacement, 304 reimplantation of, suture ligation of, Infrageniculate popliteal artery lateral exposure of, 87 medial exposure of, Infrainguinal bypass proximal anastomosis of, tunnel for, 110 Infrainguinal reconstruction, antiplatelet therapy in, 117 Infrainguinal revascularization, superficial femoral-popliteal vein for, Infrapopliteal bypass composite vein bypass for, 19 tunnel for, Infrarenal abdominal aortic aneurysm, replacement of, proximal anastomosis for, posterior wall intact, anchor technique for suturing, continuous sutures, interrupted mattress anchor technique for suturing, parachute technique for suturing, posterior wall transected, 302 anchor technique for suturing, 325 interrupted mattress technique for suturing, parachute technique for suturing, 325 Injury, to autogenous conduits during harvesting, Innominate arteries exposure of, median sternotomy for exposing, J Javid shunt, 7, 16 L Lateral exposure of the infrageniculate popliteal artery, 87 of the suprageniculate popliteal artery, 82 LeMaitre valvulotome, 6 Lesser saphenous vein (LSV) anatomy of, 102 as a bypass, 18 exposure of, 104 Linton's patch, 276 Longitudinal arteriotomy, patch closure of, 168, Longitudinal tears, repair of, to achieve hemostasis, 137, Loop forearm grafts, arteriovenous, Lower extremity arteries of, thrombectomy-embolectomy of, veins of, anatomy of, Lumbar vessels, bleeding control with a figure-of-8 suture, 139 M Mattress sutures closure of a large transected artery, end-to-side anastomosis, anchor technique, 191 infrarenal abdominal aortic aneurysm replacement posterior wall intact, posterior wall transected, Medial visceral rotation, to expose the suprarenal abdominal aorta and its branches, Median sternotomy, to expose the innominate and subclavian arteries, Miller's cuff, Mills retrograde valvulotomes, 9 N Needle holders, specification and common use, 4

9 Index 391 Needle size, for vascular reconstructions, 25 Neointimal hyperplasia, bypass failure caused by, 276 Nerve damage, in carotid artery exposure, risk of, 45 O Obturator, inner, in tunneling, 109 Occluders, internal, 15 for blood vessel control, 122 specification and common use, 5 Olympus retrograde valvulotome, 6 Omental flaps, for covering an aortic prosthesis, , P Parachute technique end-to-end anastomosis, large vessels, transection perpendicular to the longitudinal axis, end-to-side anastomosis, , infrarenal abdominal aortic aneurysm replacement, 325 posterior wall intact, posterior wall transected, 325 patch closure of a longitudinal arteriotomy, side-to-side anastomosis, Patch aortic, for replantation of the celiac, superior mesenteric and right renal arteries, 328 autogenous, 22 Linton's, 276 prosthetic, polyester or polytetrafluoroethylene, 23 Taylor's, 277 vascular, vein, preparation of, See also Vein patches and cuffs Patch angioplasty bypass hood, in infrainguinal bypass, 268, 273 inflow vessel, in infrainguinal bypass, 268, 272 Patch closure, of a longitudinal arteriotomy, 168 parachute technique, Pelvic revascularization, during aortic reconstruction, Peroneal artery anatomy of, 77 lateral exposure of, medial exposure of, Plantar arteries, exposure of, at the ankle, 92 Polybutester sutures, 24 Polyester grafts, knitted and velour, 21 Polyester sutures, braided, 24 Polypropylene sutures, 24 Polytetrafluoroethylene (PTFE) expanded, nontextile grafts of, for grafts, needle-hole bleeding from, 137 for sutures, Popliteal artery anatomy of, 76 infrageniculate popliteal artery lateral exposure of, 87 medial exposure of, posterior exposure of, 88 proximal exposure of, 88 suprageniculate popliteal artery lateral exposure of, 82 medial exposure of, Portocaval shunt, side-to-side anastomosis to create, Posterior tibial artery anatomy of, 77 exposure of, Profunda femoris artery anatomy of, 75 lateral exposure of, 79 medial exposure of, 78 Profundaplasty in aortoiliac occlusive disease bypass surgery, 348 incorporation of, infrainguinal bypass, 268, 274 Prosthetic grafts, thrombectomy-embolectomy of, difficulties in, 152, 155 Prosthetic patches, polyester or polytetrafluoroethylene, 23 Protamine, for reversing heparin activity, Proximal anastomosis, of an infrainguinal bypass, Pseudointima, of prosthetic grafts, 20 R Radial artery, anatomy and exposure of, 39 Radiobasilic fistulae, Radiocephalic fistulae, 113 Renal arteries anatomy of, 50 left, transabdominal exposure of, 58 right reimplantation on an aortic patch, 328, transabdominal exposure of, Retractors, 15 handheld, specification and common use, 5 self-retaining, specification and common use, 5 Retrograde valvulotomes, Mills, 6, 9 Retroperitoneal exposure of the abdominal aorta and its branches, of the iliac arteries, 73

10 392 Index left, of the abdominal aorta, of the suprarenal aorta and its branches, 70 Rummel tourniquet for stabilizing a carotid shunt, 7 for vascular control in medium-sized arteries, 118 S Saphenofemoral junction, with femoral vein cuff, , 270 Sartorius muscle flap, for covering an infrainguinal bypass anastomosis, 269, 275 Scalpel blades, specification and common use, 3 Scissors, 11 specification and common use, 3 Side effects, of protamine, 137 Side-to-side anastomosis anchor technique, parachute technique, Silastic vessel loops, for blood vessel control, Silk sutures, biodegradable nature of, Slip knot for tying in vascular reconstruction, 133 Square knot, for tying in vascular reconstruction, 133 Subclavian arteries anatomy of, exposure of, median sternotomy for exposing, supraclavicular exposure of, Substitutes, arterial, 17 Sundt shunt, 7, 16 Superficial femoral artery anatomy of, 76 medial exposure of, 79 Superficial femoral-popliteal vein, as a conduit for infrainguinal revascularization, Superficial femoral vein anatomy of, 102 exposure of, 104 Superior mesenteric artery anatomy of, 50 reimplantation on an aortic patch, 328, transperitoneal exposure of, Supraceliac aorta, transperitoneal blind dissection of, Supraclavicular exposure, of the subclavian artery, Suprageniculate popliteal artery lateral exposure of, 82 medial exposure of, Suprarenal abdominal aorta, medial visceral rotation to expose, Suprarenal aorta, retroperitoneal exposure of, 70 Suture ligation, for hemostasis, 136 Suture line braided polyester, 24 construction of, in vascular reconstruction, loose, repair of, , polybutester, 24 polypropylene, 24 Sutures for open endarterectomy, permanent vascular, silk, See also Anchor technique; Continuous sutures; Mattress sutures; Parachute technique T Taylor's patch, 277 Tension, on a suture line, 132 Thoracic aorta, thoracoabdominal exposure of, 71 Thoracoabdominal aortic aneurysm replacement, proximal anastomosis for, Thoracoabdominal exposure, of the thoracic and upper abdominal aorta, 71 Thoracotomy left anterior, trapdoor, 30 Thrombectomy-embolectomy, Thrombosis determining the cause of, after thrombectomy-embolectomy, 152 Tibial artery anterior anatomy of, 77 exposure of, exposure of, in the lower leg, 99 bypass to, posterior, exposure of, at the ankle, 91 exposure of, in the upper leg, Tibioperoneal trunk, anatomy of, 77 Tissue forceps, 11 specification and common use, 3 T-junction, in infrainguinal bypass, 268, 271 Tourniquet, external pneumatic, for blood vessel control, 123 Transabdominal exposure of the common hepatic artery, 64 of the infrarenal aorta, 52 of the juxtarenal aorta and renal arteries, of the left renal artery, Transperitoneal exposure of the abdominal aorta and its branches, of the aorta and its branches, at the diaphragm, 62-65

11 Index 393 of the iliac arteries, 72 of the juxtarenal aorta and renal arteries, of the superior mesenteric artery, of the supraceliac aorta, 63 blind dissection, Transverse arteriotomy, primary closure of, 167 continuous sutures, interrupted sutures, 172 Trapdoor thoracotomy, 30 Trauma, avoiding in thrombectomyembolectomy, Tunneling, Tying guidelines, for vascular reconstruction, 133 U Ulnar artery, anatomy and exposure of, 39 Ultrasonography, for intraoperative evaluation of vascular reconstruction, 134 Umbilical vein grafts (UVG), 20 Upper abdominal aorta, thoracoabdominal exposure of, 71 Upper extremity, veins of, exposure of, 101 V Valve cutting procedure, using valvulotomes, 6 Valvulotomes, 6, 16 Bush, 6 Fogarty, 6 Gore Eze-Sit, 6 Hall, 6 LeMaitre, 6 Mills retrograde, 9 Vascular clamps for blood vessel control, partially occluding, specifications and common use, 4 self-compressing, specifications and common use, 5 totally occluding, specifications and common use, 4 Vasculare reconstruction, basic steps in, Vascular grafts, Vascular patches, Vascular sutures, permanent, Vein patches and cuffs distal anastomosis of an infrainguinal prosthetic bypass, Linton patch, Miller cuff, Miller cuff modification, St. Mary's boot, Taylor patch, in distal anastomosis of an infrainguinal prosthetic bypass, Veins cryopreserved, 20 superficial femoral-popliteal, of the upper and lower extremities, See also Basilic veins; Cephalic veins; Greater saphenous vein; Lesser saphenous vein; Superficial femoral vein Vertebral artery anatomy of, exposure of, W Workshop, vascular anastomosis,