PHOTOGRAPHIC ATLAS OF RECONSTRUCTIVE ARTERIAL SURGERY

Transcription

1 PHOTOGRAPHIC ATLAS OF RECONSTRUCTIVE ARTERIAL SURGERY

2 PHOTO GRAPH I C ATLAS OF RECONSTRUCTIVE ARTERIAL SURGERY REINIER J. A. M. VAN DONGEN M.D. Head of the department of surgery Hospital 'De Goddelijke Voorzienigheid' Sittard, The Netherlands with a foreword by PRO F, J. eid DOS 5 A N TOS M. D. H.E.STENFERT KROESE N.V.jLEIDEN 1970

3 Copyright 1970 by H. E. Stenfert Kroese N.V., Pieterskerkhof 38, P.B. 33, Leiden, The Netherlands Softcover reprint of the hardcover 1 st edition 1970 Published simultaneously in the United States, its possessions, and Canada by Springer-Verlag New York Inc., 175 Fifth Avenue, New York/NY in Japan by Nankodo Company Limited, 42-6, Hongo 3-chome, Bunkyo, Tokyo, 113 Japan Library of Congress Catalog Card Number: ISBN-13: e-isbn-13: : / All rights reserved No part of this book may be reproduced by print, photoprint or any other means without written permission of the publisher

4 FOREWORD Direct surgery on arteries was born at the turn of the nineteenth and twentieth century. However, it was only during the last twenty-four years, that this new chapter of clinical surgery could be weil established, owing to diverse kinds of minds and hands. The result is that limbs, organs, functions, and lives have since then been saved in increasing numbers. We may now consider that the main impulse of this new phase is over. But the material of wh ich the chapter was built is still defective, incomplete, or inadequate, and therefore surgeons and many other men will still have to spend a lot of sagacity and vigour to give this chapter its proper arrangement. Principles evolve, methods are modified as a result of technical progress, surgeons' solid opinions on a particular matter give way to other distinct but equally solid opinions on the same matter. These are the reasons why the moment we are living in is a wonderful one. As always in Iife, the great flame burns more intensely when one finds himself at the verge of attaining so me proposed design. The first phase of dream and failure has given way to a more structured ground on wh ich the final battle must be fought. Such a battle is taking place right now. To find our way amidst this uncertainty, we need landmarks to help us chart our course, and these are best provided by an author's report on his direct experience. This is the kind of work we need the most - individual productions, offering to us ideas, principles, techniques, details, devices, impressions, proposals, and revisions. Books based on general information are useless or destined to lose most of their fugitive value before the ink used to print them has had a chance to dry. But personal books based on the personal experience of authors of integrity always remain valuable and will always be useful to the reader whether or not he puts their contents into practice. Personal books become an inexhaustible source of suggestions for the reader; they open doors or engender strong personal reactions against the author's opinions. The present volume is the achievement of an experienced man. There are many such men in the world, but Van Dongen's experience is sustained by one all too rare quality - clarity of mind. This clear mind enables him to explain and interpret the work of a minutious hand throughout many possible technical combinations. In their turn they are criticized in a simple and systematic way. And the reader may take as much time as he likes to consider this weil presented and invaluable material. An atlas is usually intended to be looked at, with a minimum of attention to the legends. It does not seem to me that this atlas should be treated in the usual way. Although the special technique used for the illustrations is highly effective and facilitates enormously a quick appreciation of the subject in question, the text is in no way inferior to the pictures and in its conciseness throws light on problems and doubts which are present at the moment. In his preface, Van Dongen speaks of providing general surgeons with a guide to reconstructive arterial operations. Although he himself qualifies the broad meaning of this purpose, I think it would not be too much for someone else to express his own feelings about so delicate a question. The many sectors into which surgery is divided may or may not be considered as specialities, but in their early phases they must be treated as such. And since they are in the process of being built up, standardization is per force still unattained. The architects of these sectors may quite weil be general surgeons (as it is the case with vascular surgery) but it seems to me that in matters concerning surgery of arteries only men who wish to dedicate a good part of their professional lives to this work should decide to enter this field in the present moment. Otherwise, it is likely that many common errors will result from inexperienced hands and still more from inexperienced minds. This would inevitably slow progress in the field. Later on, when its main aspects have been sufficiently defined, arterial surgery may be incorporated into general surgery. This is what has happened in the past with gastric surgery, biliary surgery, esophageal surgery, pulmonary surgery, and many others, even perhaps, urology. Although anyone of them may be selected as a 'speciality', they have all become part of general surgery. I weil know that views and opinions on this matter differ widely, and I hl;lve no wish to reopen the controversy here. I have no great fear about general surgeons taking over arterial surgery; because there are two important factors to keep them weil away V

5 from this uncertain and treacherous field, one being artenal surgery itself and the other the patients requiring this kind of treatment. As a general surgeon who has devoted a large part of his life to the vascular system, I am certain that the book for which I have been given the honour of writing the introduction will not only be extremely useful to vascular surgeons but will also become an exellent support for general surgeons, young and old, provided they are determined to carry on their activity in this new field, spending a lot of time to acquire quality, and feel themselves possessed of the inquisitive spirit needed to improve our actual and far too insufficient knowledge. Then, they may all become arterial surgeons besides being general surgeons. Lisbon, Casa da Rosa, July 1969 J. Cid dos Santos VI

6 PREFACE In the Netherlands, as in most other countries, vascular surgery is not yet aseparate specialty. Vascular surgery is usually performed by general surgeons who take a special interest in it. They have to find time for the lenghthy diagnostic and operative procedures in the vascular field, apart from their already busy general surgical work. Because this book is intended for those surgical colleagues who are forced to divide their time and attention between general surgery and vascular surgery, and for cardiologists, internists, radiologists and residents in surgery who wish to orientate themselves about the possibilities offered by reconstructive vascular surgery, the form of an atlas was chosen, with the accent on visual presentation and a bare minimum of text. This photographic atlas is arecord of experience gained by the author in the course of more than 2600 reconstructive vascular operations performed in aperiod of twelve years. During these years there have been frequent changes in the views on 'ideal' methods of reconstruction. Failures occurred and stimulated the search for better procedures, the soundness of which was tested experimentally. In addition, gratefully use was made of the experience of others, such as were known from the literature or through personal communication. In this way the material came to exhibit considerable range of variation - variation which had to be expressed in this photographic atlas because it is the author's conviction that, in vascular surgery, there exists no 'method of choice'. No fixed rules can be given for the reconstruction of arteries. Variation is the only rule. In each individual ca se, the method to be preferred must be selected on the basis of clinical and aortographic data, operative findings and the surgeon's personal experience. The most common patterns of arterial obstruction are depicted in this atlas. An attempt has been made to do justice to the various possibilities of reconstruction in so far as they could be applied in the author's surgical department, and to delimitate their indications. This photographic atlas is not an operative manual. The basic principles of vascular diagnosis and surgery are supposed to be known. Nevertheless, a description is presented of the surgical approaches which in certain reconstructive procedures merit preference. Moreover, a number of new personal techniques and procedures, and some improvements of conventional methods, so far not published elsewhere, yet used for many years with good results, are described in detail. The objects of this book - to provide the general surgeon and all those who have an interest in vascular surgery with a guide to the wide variety of reconstructive vascular operations - precluded in advance the depiction and description of the surgical treatment of aneurysms of the aortic arch, because abnormalities of this type can be treated only with the aid of extracorporeal circulation. All the operations described in this book can be and were performed without special devices, and in particular without extracorporeal circulation. Hypothermia was used in the treatment of some aneurysms of the abdominal aorta, but it is the author's conviction that these aneurysms can be treated equally weil without resorting to hypothermia. Acknowledgement is due to all who have helped directly or indirectly vithile this book was in preparation. Above all, the author would like to express his gratitude to Miss R. de Zwart for her high-class photographic work. Without her assistance and indispensable efforts it would have been impossible to accomplish this atlas in this form. In addition the author is indebted to his assistants for their interest and co-operation in the treatment of vascular patients. They gave much of their time in discussions, operations and post-operative care. Acknowledgement is due also to my friend Dr. E. Lokin for his support in reviewing the manuscript. It is to be hoped, that this book, which is the result of co-operation and the enthusiastic support of all colleagues of the Departments of Surgery and Roentgenology and many others of the hospital staft, might arouse interest in vascular surgery in a still wider circle and could serve as a supplement to the manuals already available in the field of vascular surgery, for the benefit of the reader and his patients. Sittard, December 1969 VII

7 CONTENTS THE SEGMENTAL NATURE OF PERIPHERAL OBLITERATIVE ARTERIAL DISEASE/1 CHAPTER 1- RECONSTRUCTIVE SURGERY IN CHRONIC OBLITERATIVE DISEASE OF THE SUPERFICIAL FEMORAL ARTERY /5 1. Extensive occlusion of the superficial femoral artery / Discarded femoral bypass procedures / Autogenous saphenous vein bypass graft / Composite saphenous vein graft. Combination of saphenous vein bypass graft and disobliteration with venous patch graft angioplasty / Composite saphenous vein bypass graft. Combination of ipsilateral and contra lateral saphenous vein / Thromboendarterectomy with venous patch graft angioplasty / Closed-Ioop endarterectomy / Segmental obstruction of the superficial femoral artery / Thromboendarterectomy and Iimited intimectomy with autogenous vein patch graft angioplasty / Autogenous vein graft. Bypass operation and exclusion arterioplasty with proximal end-to-end anastomosis / Reconstruction using a prosthesis / Autogenous vein bypass graft in combination with proximal endarterectomy / Treatment of stenosis at the origin of the superficial femoral or the profunda femoris artery / 40 CHAPTER II-RECONSTRUCTIVE SURGERY IN POPLITEAL OCCLUSIVE DISEASE/ Endarterectomy with vein patch graft angioplasty / Closed-Ioop endarterectomy / Autogenous saphenous vein bypass graft / Exclusion arterioplasty with autogenous vein graft / Resection and replacement by venous autograft / 54 CHAPTER 111- RECONSTRUCTIVE SURGERY IN EXTENSIVE OCCLUSION OF THE FEMORO POPLITEAL ARTERY / Autogenous saphenous vein bypass graft / Bilateral autogenous saphenous vein bypass graft / Composite saphenous vein bypass graft. Combination of ipsilateral and contralateral saphenous vein / Combination of proximal endarterectomy with venous patch graft angioplasty and distal saphenous vein bypass graft / 64 VIII

8 CHAPTER IV - R ECONSTRUCTIVE SU RG ERY I N CO M MON FEMORAL OCCLUSIVE DISEASE / Bilateral stenosis of the common femoral artery bifurcation treated by disobliteration and vein patch graft angioplasty / Bilateral obstruction of the common femoral artery treated by thromboendarterectomy and vein patch graft angioplasty / Occlusion of the common femoral artery and stenosis of the external iliac artery / Open and closed-ioop endarterectomy with synthetic patch graft angioplasty / Endarterectomy and vein patch graft angioplasty / Occlusion of the common femoral artery and its bifurcation; treatment by disobstruction and Y shaped vein patch graft angioplasty / Occlusion of the common femoral arteryand inoperable occlusive disease of the femoropopliteal artery; reconstruction of the inflow tract of the profunda femoris artery / 78 CHAPTER V-RECONSTRUCTIVE SURGERY IN EXTERNAL ILiAC OCCLUSIVE DISEASE/81 1. Stenosis of the external iliac artery / Endarterectomy and patch graft angioplasty / Side-to-side anastomosis between hypogastric artery and external iliac artery / Extensive occlusion of the external iliac (and common femoral) artery / Prosthetic bypass graft / Prosthetic bypass graft through the obturator foramen / Combination of proximal prosthetic bypass graft and distal endarterectomy with venous patch graft angioplasty / Endarterectomy with proximal synthetic and distal autogenous venous patch graft angioplasty / Autogenous saphenous vein graft / Closed-Ioop endarterectomy / 92 CHAPTER VI-RECONSTRUCTIVE SURGERY IN UNILATERAL COMMON ILIAC OCCLUSIVE DIS EAS E / Disobliteration and prosthetic patch graft angioplasty / Resection and replacement by prosthetic graft / Partial resection and exclusion arterioplasty with prosthesis / Bypass reconstruction / 102 CHAPTER VII-RECONSTRUCTIVE SURGERY IN EXTENSIVE THROMBOSIS OF THE COMMON AN 0 E X TE R N ALl LI A C ARTE R I ES / Prosthetic exclusion arterioplasty / Combination of proximal prosthetic substitution and distal endarterectomy with synthetic patch graft angioplasty / Combination of proximal prosthetic replacement and distal endarterectomy with venous patch graft angioplasty / Crossover bypass with prosthetic graft / Crossover bypass with venous autograft / 116 IX

9 CHAPTER VIII-RECONSTRUCTIVE SURGERY IN AORTOILIAC OCCLUSIVE DISEASE/ Stenosis of the aortic bifurcation treated by endarterectomy and patch graft angioplasty / Stenosis of aortoiliac arteries / Disobliteration and synthetic patch graft angioplasty on both sides / Disobliteration and synthetic patch graft angioplasty on both sides (continued) / Endarterectomy in combination with synthetic patch graft angioplasty on one side and venous patch graft angioplasty on the other side / Disobliteration and Y-shaped patch graft angioplasty / Disobliteration with patch graft angioplasty on one side and bypass graft on the other / Bypass reconstruction with bifurcated tube / Resection and replacement by prosthetic bifurcation / Occlusion of aortoiliac arteries / Resection and replacement by prosthetic bifurcation / Resection and prosthetic replacement with distal end-to-side anastomosis / Bypass operation / Coarctation of the aortic bifurcation treated by resection and replacement / 146 CHAPTER IX - R ECONSTRU CTIVE SU RG ERY I N I LI 0 FEM 0 RAL OCCLUSIVE D ISEAS E / Elective revascularizing procedures of the profunda femoris artery / Prosthetic aortoprofunda bypass graft / Combination of proximal prosthetic replacement and distal endarterectomy with venous patch graft angioplasty / Endarterectomy with proximal synthetic and distal venous patch graft angioplasty / Autogenous saphenous vein graft / Crossover bypass with venous autograft / Closed-Ioop endarterectomy / (Aorto-) iliopopliteal bypass procedure / Resection and replacement of the aortic bifurcation; bypass of the iliofemoral artery and endarterectomy of the common femoral artery / liiopopliteal composite saphenous vein bypass graft / 166 CHAPTER X-RECONSTRUCTIVE SURGERY FOR ASCENDING THROMBOSIS OF AORTOILIAC ARTE R I ES / Ascending thrombosis of the aortoiliac arteries with partial patency of the subrenal aortic segment (Types A and B) / Resection and replacement of the obstructed aortic bifurcation; endarterectomy of the infrarenal part of the aorta combined with patch graft angioplasty / Resection and replacement of the obstructed aortoiliac arteries; endarterectomy of the infrarenal aortic segment and left common femoral artery combined with patch graft angioplasty / Aortoiliac bypass operation; treatment of the common femoral arteries by endarterectomy and vein patch graft angioplasty / 178 X

10 2. Ascending occlusion of the aortoiliac arteries to immediately below the level of the renal arteries (Type C); treatment by resection and prosthetic replacement using an infrarenal aortic anastomosis/ Ascending occlusion of the aortoiliac arteries with associated stenosis of one renal artery (Type D) / Resection and prosthetic replacement of the aortoiliac arteries; left-sided nephrectomy / Resection and prosthetic replacement of the aortoiliac arteries; revascularization of the left kidney by means of splenorenal anastomosis / Resection and prosthetic replacement of the infrarenal aorta and aortic bifurcation; re-implantation of the post-stenotic renal artery into the prosthesis with interposition of a synthetic graft / Resection and prosthetic replacement of the infrarenal aorta and aortic bifurcation; re-implantation of the post-stenotic renal artery into the prosthesis with interposition of a splenic artery segment! Resection and prosthetic replacement of the aortoiliac arteries; autogenous vein bypass graft between endarterectomized subrenal part of the aorta and post-stenotic renal artery / Resection and prosthetic replacement of the aortoiliac arteries; re-implantation of the post-stenotic renal artery into the endarterectomized subrenal part of the aorta with interposition of an autogenous vein graft / Ascending occlusion of the aortoiliac arteries with associated stenosis of both renal arteries (Type E) / Aortoiliac bypass operation using parts of the autogenous splenic artery as renal branches / Resection and prosthetic replacement of the aortoiliac arteries; insertion of two autogenous vein bypass grafts between endarterectomized subrenal part of the aorta and post-stenotic renal arteries/ 200 CHAPTER XI-RECONSTRUCTIVE SURGERY OF ARTERIAL ANEURYSMS/ Aneurysm of the femoropopliteal artery / Aneurysm of the common femoral artery / Aneurysm of the infrarenal aorta / Resection and replacement by prosthetic bifurcation / Resection and replacement by prosthetic bifurcation with suprarenal aortic clamping / Multiple aortic aneurysms with kinking of the pre-aneurysmal portion of the aorta / Ruptured aneurysm of the infrarenal aorta / Aneurysm of the infrarenal aorta and aortic bifurcation / Aneurysm of the aortic bifurcation / Aneurysm of the infrarenal aorta with associated stenosis of one renal artery / Resection of the aneurysm and prosthetic replacement; transaortic endarterectomy of the stenotic renal artery / Resection of the aneurysm and prosthetic replacement; insertion of autogenous vein bypass graft between subrenal part of aorta and post-stenotic renal artery / 224 XI

11 9. Aneurysm of the midportion of the abdominal aorta with associated occlusion of one renal artery / Aneurysm of the thoracoabdominal aorta / Resection of the aneurysm and prosthetic replacement, using a temporary external bypass shunt / Resection of the aneurysm and prosthetic replacement, using a temporary internal bypass shunt / Aortic aneurysm combined with iliac occlusive disease / Stenosis of the aortic bifurcation and aneurysm of the abdominal aorta. Resection and prosthetic replacement / Aneurysm of the abdominal aorta combinedwith iliac occlusive disease. Treatment by resection and prosthetic replacement / 234 CHAPTER XII - RECONSTRUCTIVE SURGERY IN RENAL ARTERY STENOSIS AND o C C L U S ION / Unilateral renal artery stenosis / Excision of the stenotic part of the renal artery with end-to-end anastomosis / Straight end-to-end anastomosis / Oblique end-to-end anastomosis / Endarterectomy with patch graft angioplasty / Endarterectomy with autogenous venous patch graft angioplasty / Disobliteration with autogenous venous patch graft angioplasty / Endarterectomy with aortorenal synthetic patch graft angioplasty / Endarterectomy and aortorenal autogenous arterial patch graft angioplasty / Splenorenal anastomosis / Resection of the stenotic part of the renal artery; end-to-end splenorenal anastomosis / End-to-side splenorenal anastomosis / End-to-end anastomosis between the splenie artery and the right renal artery / Resection and replacement by autogenous vein graft / Aortorenal bypass reconstruction / Aortorenal prosthetic bypass graft / Aortorenal bypass with autogenous splenie artery graft / Aortorenal bypass with autogenous vein graft / Aortorenal bypass with autogenous vein graft (continued) / Re-implantation with graft interposition / Re-implantation with interposition of splenie artery graft / Re-implantation with interposition of venous graft / Re-implantation with interposition of prosthetic graft / lliac-renal reconstructive procedures / liiac-renal prosthetic bypass / Re-implantation of the renal artery into the common iliac artery with interposition of venous graft / Unilateral renal artery occlusion / Re-implantation with interposition of venous graft / End-to-end splenorenal anastomosis / Bilateral renal artery stenosis / 280 XII

12 3.1. Endarterectomy and bilateral aortorenal patch graft angioplasty / Endarterectomy with aortorenal patch graft angioplasty on the rightside; splenorenal anastomosis on the left side / Bilateral aortorenal bypass with splenic artery grafts / Bilateral re-implantation with interposition of one continuous venous graft / 286 CHAPTER XIII-RECONSTRUCTIVE SURGERY IN CELIAC AND SUPERIOR MESENTERIC ARTERY OCCLUSIVE DISEASE / Stenosis of the superior mesenteric artery / 292 Endarterectomy with synthetic patch graft angioplasty / 292 Aortomesenteric bypass procedure / 294 Aortomesenteric prosthetic bypass graft / 294 Aortomesenteric venous bypass graft / 296 Re-implantation of the superior mesenteric artery into the aorta / Compression and stenosis of the celiac trunk / 300 CHAPTER XIV- RECONSTRUCTIVE SURGERY IN OCCLUSIVE DISEASE OF THE BRANCHES OF T H E A 0 R T I C AR C H / Stenosis of the carotid bifurcation / Endarterectomy with synthetic patch graft angioplasty / Endarterectomy with venous patch graft angioplasty / Extensive stenosis of the internal carotid artery, treated by endarterectomy and venous patch graft angioplasty / Kinking of the internal carotid artery treated by transection and re-implantation of the internal carotid artery into the common carotid artery / Obstruction of the proximal part of the left common carotid artery / Endarterectomy with synthetic patch graft angioplasty / Re-implantation into the aortic arch with interposition of prosthetic graft / Stenosis of the proximal part of the vertebral artery, treated by disobliteration and venous patch graft angioplasty / Total occlusion of the left subclavian artery, treated by endarterectomy and venous patch graft angioplasty / Stenosis of the proximal part and occlusion of the distal half of the left subclavian artery; stenosis of the proximal vertebral artery. Reconstruction by disobliteration and patch graft angioplasties / Subclavian steal syndrome in left subclavian artery obstruction / Resection and prosthetic replacement / Prosthetic bypass graft / 326 XIII

13 8.3. Endarterectomy and synthetic patch graft angioplasty / Subclavian steal syndrome in right subclavian artery occlusion, treated by disobliteration and synthetic patch graft angioplasty / Subclavian steal carotid recovery phenomenon in innominate artery occlusion. Reconstruction of the innominate artery by endarterectomy and synthetic patch graft angioplasty / Occlusive lesions of the innominate and right subclavian and common carotid arteries, treated with bifurcated bypass graft / 334 CHAPTER XV-RECONSTRUCTIVE SURGERY IN TRAUMATIC AND IATROGENIC ARTERIAL L E S ION S / Traumatic arterial lesions of the upper and lower extremities / Acute traumatic lesion of the brachial artery; resection and replacement by an autogenous venous graft / Acute traumatic lesion and thrombosis of the superficial femoral artery; resection and venous graft replacement / Traumatic occlusion of the femoropopliteal artery; treatment with synthetic bypass graft / Traumatic arterial lesions of the shoulder and inguinal region / Traumatic occlusion of the left subclavian artery, treated by resection and venous graft replacement / Acute traumatic lesion and thrombosis of the common femoral artery bifurcation; treatment by resection and venous graft replacement / Traumatic arterial lesions of the trunk / Traumatic rupture of the descending aorta; treatment by resection of an aortic segment and prosthetic graft replacement / Acute traumatic lesion of the left iliac artery; treatment by crossover prosthetic bypass graft through the obturator foramen / latrogenic aneurysms and arteriovenous fistulas / Traumatic false aneurysm and arteriovenous fistula of the popliteal artery, treated by resection and replacement by an autogenous vein / False aneurysm due to disruption of a femoral bypass anastomosis, treated by resection and replacement / False aneurysm of the superficial femoral artery due to disruption of the suture of a synthetic patch; resection and replacement by an autogenous vein graft / 356 XIV

14 APPROACH ES Approach to the superficial femoral artery / 6 Medial approaches to the popliteal artery / 44 a. approach to the proximal portion of the popliteal artery b. approach to the midportion of the popliteal artery c. approach to the distal portion of the popliteal artery d. medial approach to the entire popliteal artery Posterior approach to the popliteal artery / 47 Approach to the femoropopliteal artery / 59 Approach to the common femoral artery /69 Extraperitoneal approach to the external and common iliac arteries / 83 Approach to the common iliac artery / 97 Approach to the aortoiliac arteries / 122 Approach to the upper part of the abdominal aorta and renal arteries / 173 Approach to aneurysms of the abdominal aorta / 205 Approach to the renal arteries / 240 approach to the left renal artery approach to the right renal artery approach to both renal arteries Approach to the celiac and superior mesenteric arteries / 291 Approaches to the arteries of the head and arms / 305 approach to the extracranial portion of the carotid artery approach to the vertebral artery approach to the left subclavian artery approach to the innominate, right subclavian, and common carotid arteries xv