1. Abdominal Vascular Surgery

2. Summary Abdominal Vascular Surgery A & P Pathology
Diagnostics/Preoperative Testing
Prep & Positioning
Basic Supplies, Equipment, & Instrumentation
Abdominal Aortic Aneurysmectomy
Aorto-Bifemoral Bypass Graft
Resection of Renal Artery Aneurysm

3. Anatomy & Physiology Abdominal aorta begins below the diaphragm
Multiple arteries between the diaphragm and the bifurcation all of which supply oxygen rich blood to the abdominal wall and the abdominal organs or viscera

4. Abdominal Aorta & It’s Arteries
See Overhead
Celiac
Superior mesenteric
Renal
Inferior mesenteric
Lumbar
Bifurcation >iliacs>internal & external
External >femoral>popliteal>anterior & posterior tibial
Peroneal is off the posterior tibial

7. Venous System See Overhead
Abdominal & thoracic walls drained by brachiocephalic and azygos veins>SVC
Hepatic Portal Vein (Hepatic Portal System) > IVC
Lower Extremities>Superficial and deep groups
Deep have same names as the arteries around them
Greater Saphenous Vein is the longest vein in the body

9. PATHOLOGY

10. Aneurysms True aneurysm=dilation of all layers of the arterial wall
May find atherosclerosis along with true aneurysm, but it is not the cause of the aneurysm
False Aneurysm (pseudoaneurysm)=not an aneurysm, but a tear that allows blood between the layers of the artery
Results from trauma, infection or post-arterial surgery where suture has been disrupted

11. True Aneurysms Most often found in the aorta
Can be in the iliacs, femoral and popliteal arteries
Men get more than women
Generally found in the elderly
18% have family history

12. Aneurysms Continued Generally occur below the renal arteries
Are fusiform or tapered at the ends
Involves weakening of the tunica media (elastic layer) and intimal layer damage (atherosclerosis)
Patients generally asymptomatic and these are found during routine physicals
Low mortality (3%) with elective surgical intervention (AAA Repair)

13. Aneurysms Continued
May extend to the bifurcation of the aorta or involve the common iliacs as well as the external and internal iliacs
Aneurysm rupture patients present with severe back and abdominal pain
Usually rupture is contained in the retroperitoneal space but can rupture into the peritoneal space causing certain death from the hemorrhage
Rupture requires immediate intervention as mortality goes to 80%

14. Treatment Abdominal aortic aneurysm resection or repair
If the iliacs are involved a Y or bifurcated graft is used
If the iliacs are not involved a straight or tube graft is used
Graft material can be Knitted polyester dacron, Knitted velour polyester dacron,Woven polyester dacron, or PTFE (Gortex)
Knitted polyester requires preclotting, the others do not

15. Graft Options DACRON (Meadox/Boston Scientific)
1.“Knitted” polyester dacron
Must be pre-clotted
2.“Woven” polyester and Knitted velour
polyester
Do not need to be pre-clotted
*Both come in a spiral design that is designed for bends such as in the iliacs or knee joint

16. Graft Options Continued
3. PTFE: polytetrafluoroethylene (Gortex or Impra)
Specifically designed for knee joint bends or popliteal bend
Not desirable for aortic aneurysm repair
May be doctor preference
Come with rigid rings or without
Rings add support
Come thin walled or standard walled

17. Preoperative Testing & Diagnostics
1. CT Scan
diagnose an aneurysm
Extent
Location of thromboembolytic matter
Shows whether or not there is leakage
2. Ultrasound
Detection

18. Preoperative Testing & Diagnosis
3. Angiography
Follows detection or diagnosis of aneurysm
Provides clear picture of aneurysm so that surgery can be planned
Will show all of the vessel(s) that are involved
Displays areas that are not getting blood flow as evidenced by the fact that contrast dye does not reach those areas

19. Prep & Positioning
Arteriogram films should be displayed in the x-ray box before the surgeon comes into the room
Blood should be available in the room prior to incision
A foley catheter is placed upon induction of anesthesia
Patient is supine with arms tucked or on padded armboards
Pillow under head or headrest
Foam or gel pads may be used on the heels
Foam or gel pad for the OR bed

20. Prep and Positioning Continued
Patient should be shaved nipples to knees in pre-op unless is emergent and must be shaved in the room
Prep is nipples to knees
Prep starts at the abdomen where the incision will be and works outward to the groins and the pubis is prepped last
Separate prep sticks should be used for the legs working outward to the bed and prepping the groins and pubis last

21. Drape Sequence
Groin towel, towels x 6 (at sides, across knees, across chest)
Drying towels
Ioban
Drape (universal sheets or laparotomy sheet)

22. Basic Supplies, Instruments, and Equipment
1” penrose, long polyester tapes, silicone vessel loops, cotton umbilical tapes (*Surgeon preference) for isolating the aorta and iliacs
2-0, 3-0, 4-0 SH or MH Prolene suture for sewing the proximal portion of the aortic graft
5-0 or 4-0 RB-1 or C-1 Prolene for the iliacs
2-0, 3-0, 0 Silk or Nurolon for oversewing the lumbars

23. Supplies Continued Silk ties or reels 0, 2-0, 3-0, 4-0
Laparotomy or universal pack
#20,#10, #11, #15 blades
Major Basin Pack
Custom CV Tray (contains kittners, rubber shods, umbilical tapes, cytal, kidney basin, bowl, blades, foley catheter, towels)
Ioban
Drains (JP, Blake, or Snyder)

24. Supplies Continued Clips (small, medium, or large)
Dacron graft straight or bifurcated
Syringes (30cc)
Doppler probe
Fish or Viscera Retainer
Closing Suture (varies by surgeon) #1 or 0 PDS, Prolene, Novafil for fascia/0, 2-0, 3-0 CTX Vicryl for subcutaneous (may do two layers), Stapler or 4-0 Monocryl or Vicryl for skin or subcuticular
Binder (with obese patient)
Dressing sponges (xeroflo or telfa, 4x4s, ABD post final count
May want a 0 vicryl to oversew the leftover shell of aorta over the new graft for extra protection

25. Basic Supplies, Instrumentation, and Equipment
Instruments
CV Tray complete with variety of aortic clamps and vascular clamps
Extra-long instruments should be available
(debakey forceps, long metz, long NHs, long tonsils, kellys, and right angles)
Hand-held abdominal retractor tray (richardsons deavers, & Harrington/Sweetheart)
Self-retaining retractor tray (balfours x 2, omni-tract, or bookwalter) *Surgeon preference
Micro instuments (Vascular NH, scissors, forceps)
Standard and Long Clip Appliers (small, med & large)
Tunneler

26. Basic Supplies, Instrumentation, And Equipment
ESU/Bovie
Suction/Cell Saver
Headlight for the surgeon
Bair hugger for patient (upper body)
Doppler box

27. Medications
Saline irrigation with antibiotic of surgeon choice (should be in a warmer)
Heparin saline (1,000ut/250ml NS) can keep warm in warmer
Contrast available
Topical hemostatics available (Gelfoam, Thrombin, Surgicel, Avitene)

28. Procedures Abdominal Aortic Aneurysm Aorto-Bifemoral Bypass Graft
Aorto-Iliac Bypass Graft
Resection of Renal Artery Aneurysm

29. Abdominal Aortic Aneurysmectomy
Repair of the portion of the aorta between the renal arteries and the bifurcation of the iliac arteries
Aneurysm will be 6cm or greater in diameter

30. AAA Procedure
Incision starts with a #10m blade, incision is made below the xiphoid process and to the left and ends at the umbilicus
Provide hand cautery, debakey forceps
Will proceed through various layers, provide hand-held retractors; may use/set up the omni, bookwalter, or balfour retactor (provide moist laps to go under blades be they hand-held or self-retaining
Offer metz as needed with bovie as go deeper be prepared to change the cautery for a longer tip, longer debakeys, and longer metz
Isolate bowel and place in an intestinal bag/wrap in a moist sponge

31. AAA Continued
Isolate aorta (may go around aorta with a vessel loop and clamp with a rommel tourniquet or long polyester or cotton tape passed from a ligature passer)
Surgeon will ask CRNA to heparinize patient
Provide the aortic clamp of the surgeons choice
Iliacs will be clamped with straight or angled vascular clamps such as peripheral debakeys or patent ductus clamps
Aorta will be incised with a knife (long handle) or scissors
Plaque will be removed if present
Other involved arteries with backup arteries to oxygenate their respective organs (inferior mesenteric and lumbers), are clipped, tied, or sewn off with non-absorbable suture
Involved arteries without back-up circulation are re-implanted into the graft using smaller lumened Dacron grafts (renals, superior mesenteric, celiac)

33. AAA Continued Prepare graft
Graft sizers prn (may pass on a long tonsil or kelly
Irrigate inside aorta before grafting with heparinized saline
Start with proximal anastamosis (have long vascular NH, loaded with 3-0 SH double ended, long debakey forceps, long suture scissors, rubber shod)
Usually sew ½ way around tag and begin with the other needle coming the other way
Surgeon may want his hands wet with saline when he ties to keep suture from sticking to his hands

34. AAA Continued
Graft will be measured to its distal end and cut with either a knife or scissors
Distal anastamosis will follow the same sequence as the proximal
Surgeon will slowly remove the aortic clamp, observing for leaks
Leaks will be repaired with pledgeted or non-pledgeted 3-0 or 4-0 prolene suture
Topical hemostatic agents may be applied
Distal clamps will be removed, leaks will be repaired using the same type of suture
Topical hemostatics may be applied

35. AAA Continued Abdomen will be irrigated with antibiotic saline
Aneurysm sac will be sewn to prevent the intestine from adhering to the graft usually with a 0 Vicryl on a CT-1 needle with a long NH
Remove all laps do first count
Return bowel to their normal position and pull greater omentum back over the bowel
Place a fish or viscera retainer over the abdominal organs and close the peritoneum, fascia, and muscles with a heavy 0 or #1 PDS, Novafil, Ethibond (Ticron) or Prolene (usually done as one layer)
Do second count
Close subcutaneuos layer with 0, 2-0, or 3-0 vicryl on CTX or CT-1 tapered needle
Close subcuticular with 4-0 vicryl on PS-1, Monocryl or staplers

36. AAA Continued Dress with xeroflo or telfa, 4x4s, ABD pad and tape
May need an abdominal binder with the obese patient
Pedal pulses should be checked at the end of the procedure by the surgeon
Keep table sterile until patient safely out of the room
Clean up per policy

37. Aorto-Bi-Iliac Bypass Graft
Procedure is the same as an Abdominal Aortic Aneurysmectomy with following changes:
Aorto-Iliac Bypass Graft
Will need: a bifurcated graft
May require a heavier vascular clamp such as a straight or angled patent ductus clamp (surgeon preference)
Will need smaller prolene suture for the iliac anastamoses such as 5-0 or 4-0 on a smaller needle (still need rubber shods)
May cut down the groin areas using weitlanders for retractors or gelpis depending on patient anatomy
Will use standard length instuments when working in the groin
Will isolate the iliacs with tapes or vessel loops
Will need two layers of closing suture for groins when done
Will need dressings for the groins post surgery

38. Aorto-Bi-Femoral Bypass Graft
Same as Aorto-Bi-Iliac with following differences:
Definitely will cut down groins
Will need: a bifurcated graft, short tunneler (may use long kelly or aortic clamp)
Will isolate femoral artery with cotton tapes or vessel loops (using right angle and debakey forceps/may use rommel tourniquet)
Will use peripheral debakey clamps to clamp femoral arteries

39. Resection of Renal Artery Aneurysm
Renal artery aneurysm repair
Function of renal artery is to supply kidneys with oxygenated blood
Renal artery arises from the abdominal aorta
This is an arteriosclerotic aneurysm and classified as a “true aneurysm”
Resection indicated for: symptomatic, renal artery stenosis, pregnant women or those women considering pregnancy

40. Renal Artery Aneurysm Resection Patient Preparation and Prep
Shaved nipples to top of thighs
Prep soap betadine nipples to knees and betadine paint nipples to knees (use drip towels)
Supine with arms tucked or on armboards and padding to prevent ulner and brachial nerve damage (pay attention to areas where post for abdominal retractor will be placed
Pillow under head and knees

41. Equipment Warming blanket or Upper Body Bair Hugger Cell saver
Extra suction
ECU
Headlamp
Warmer for irrigants

42. Instruments Major tray with cardiovascular clamps (aortic clamps)
Cardiovascular tray
Major vascular tray
Extra Long Instruments
Surgeon’s specialty instruments
Abdominal retractor (Bookwalter, Omni-Tract, or Balfour retractors x 2)
Medium and large long clip appliers
Heparin needle

43. Supplies Foley and urimeter Medium and large clip cartridges Rumels
#16 or #18 red rubber catheter for rumel tourniquet
Fogarty inserts if using fogarty aortic clamp
Vessel loops, long umbilical tapes, or dacron polyester tapes
Peanuts or Kittners
Rubber shods
Sponge on a stick x 2 available

44. Draping
Groin towel
Towels x 6
Drying towel
Ioban
Universal drapes

45. Procedure
#10 blade on #3 knife handle for vertical midline incision (base of xiphoid to around umbilicus to the pubis)
Cautery/metz dissect through subcutaneous, fascia, muscle, and peritoneal layer
Moist laps available for placement under hand-held or self-retaining retractors to protect abdominal organs
Long metz, long kittner, clips, ties available to dissect through the omentum
Isolate renal artery and renal vein
May use rumel tourniquet or vessel loop or umbilical tapes around renal artery, vein and vena cava
May need to retract pancreas and duodenum for optimal exposure
Heparinize patient (CRNA)

46. Procedure Continued
Cooley clamps or peripheral debakey clamps available to clamp renal artery and any other arteries in close proximity to renal artery
Excise aneurysm
Repair with short piece of Hemashield graft material or just do simple closure of arterial defect with prolene suture
Remove clamps allowing release of blood to dispel air
Reversal of anticoagulated state with Protamine Sulfate by CRNA
Hemostasis achieved
Irrigate with antibiotic saline

47. Procedure Continued
Close retroperitoneum with 0 Vicryl on CT-1 tapered needle
Return bowel to anatomical position remove all packs, retractors
Initiate first count
Close peritoneum, fascia, and muscles as single or individual layer (surgeon choice) using nonabsorbable or absorbable suture
Perform final count
Close skin with subcuticular stitch or staples
Cleanse prep solution from skin
Dress per surgeon preference (telfa, 4x4s, ABD pads, tape)

48. Complications
Bleeding/hemorrhage
Impaired renal function
Infection

49. ENDOVASCULAR Repair Of Abdominal Aortic Aneurysm

50. Anatomy & Physiology of AAA
An aneurysm refers to a bulge or balloon that forms in the wall of a blood vessel
If an aneurysm forms in the part of the aorta that extends past the diaphragm, it is called an abdominal aortic aneurysm (AAA)
Result of true or false aneurysm
Over time, the vessel wall loses elasticity and the force of normal blood pressure in the aneurysm can lead to bursting or rupture of the vessel

52. The abdominal aorta is the most common site for an aneurysm development
The exact cause (AAA) is unknown
Risks associated with AAA include: atherosclerosis (accumulation of fatty deposits on the vessel wall), hypertension, smoking, trauma to the arterial wall, infection, peripheral vascular disease, arteriosclerosis, and congenital defects of the artery wall  

53. Most AAA occur below the level of the renal artery and involve the bifurcation of the aorta as well as the proximal ends of the iliac arteries
Stasis of blood can lead to thrombus formation along arterial wall
Peripheral emboli can develop causing arterial insufficiency
Once an aneurysm forms it often increases in size and consequently the chances of rupture also increase
Aneurysm rupture can lead to hemorrhage and death 

55. Presentation of AAA
Most patients present without a symptomatic pulsatile abdominal mass
The aortic bifurcation is located just above the umbilicus
An overlying mass (pancreas or stomach) may be mistaken for an AAA
An abdominal bruit is nonspecific for a nonruptured aneurysm
Patients with popliteal artery aneurysms have a high incidence of AAAs (25-50%).

56. Presentation of Ruptured AAA
Ruptured may present in many ways
Most typical presentation is abdominal or back pain with a pulsatile abdominal mass
Symptoms may be vague and therefore overlooked
Symptoms may include groin pain, syncope, paralysis, or flank mass
The diagnosis may be confused with renal calculus, diverticulitis, incarcerated hernia, or lumbar spine disease

57. What is an Endovascular Stent Graft?
A woven polyester tube externally supported by a tubular metal web that expands to a pre-established diameter when placed intra-luminally in the artery

58. Endovascular Repair Disadvantages: Increase in health care costs
Significantly lower number of complications
Fewer deaths
Shorter hospital stay
Disadvantages:
Increase in health care costs
Is manufacturer competitiveness currently that is slowly decreasing costs

59. How Does the Stent Graft Work
The stent graft excludes the aneurysm from the circulation and thus prevents continued pressurization and possible rupture of the aneurysm
The stent graft is placed inside the aneurysm using a delivery catheter

60. Endovascular repair appears to have augmented treatment options rather than replaced open surgical repair for patients with AAA
Patients who previously were not candidates for repair because of medical co-morbidity may now be safely treated with endovascular repair

61. Graft options Manufacturers: WL Gore (Gore-tex) “Excluder”
Medtronic “Aneuryx”
Cook “Zenith” Allows for AAA that goes up beyond the renal arteries, but does not include aneurysmal renal artery involvement
Surgeon preference
Some companies are trying to modify their product to be used in ever increasing situations
These changes take years of FDA trials to receive approval to come on the market

62. Diagnosis
During a routine physical exam a doctor may feel a throbbing mass in the middle or lower part of your abdomen
However, most aneurysms are identified when diagnostic imaging ( X-ray, CT, MRI, arteriogram) is performed for other reasons

63. Indications for Use Adequate iliac / femoral access
Infra-renal , non-aneurysmal neck length greater than 1 cm at the proximal & distal ends of the aneurysm & an inner diameter 10-20% smaller than the labeled device diameter (Exception currently “Zenith”)
Morphology suitable for endovascular repair
Aneurysm diameter > 5 cm
Aneurysm diameter of 4-5 cm which has also increased in size by 0.5 cm in the last 6 months or which is twice the diameter off the normal infra-renal aorta

64. Pre-op testing CBC (complete blood count) BMP (basal metabolic panel)
PT, & PTT /c INR ( clotting factor)
Type & cross for blood
EKG
Chest x-ray

65. Prep and positioning
Patient warm with silver hat, warm blankets, or ideally bair hugger
Position patient supine, arms tucked at sides, legs slightly apart, head on headrest, upper body bair hugger (nipples up)
Foley catheter
Scrub & paint betadine nipples to knees, lateral to sides bedsheet to bedsheet

66. Drape sequence Drying towels
Groin towel, square off using entire area nipples to knees
Ioban drape/may need two if larger or longer patient
Universal drapes

67. Basic supplies,instruments & equipment
Cell saver ( available )
Omni retractor or Bookwalter (surgeon preference) available
Fluid warmer available
C-arm ( fluoroscopy )
Lead aprons

68. Supplies & Instruments
Major vascular tray
Dr’s special instruments
Universal drape pack
Major basin pack
Cardiovascular Pack
Sutures (surgeon preference card)
Deployment device per manufacturer

69. Anesthesia General anesthesia primarily
Spinal anesthetic along with MAC in case of increased risk of complications (COPD)
Local anesthetic and MAC

70. Medication (on sterile field)
Heparin / saline
Antibiotic / saline (Ancef, other)
Contrast
0.25 % marcaine plain

71. Procedures Abdominal aortic aneurysm stent grafting Aorto bi-iliac
Aorto uni-iliac
Aorto bi femoral
Aorto uni-femoral
FDA has approved trial of stent grafts for thoracic aneurysms

72. Summary Abdominal Vascular Surgery A & P Pathology
Diagnostics/Preoperative Testing
Prep & Positioning
Basic Supplies, Equipment, & Instrumentation
Abdominal Aortic Aneurysmectomy
Aorto-Bifemoral Bypass Graft
Resection of Renal Artery Aneurysm
Endovascular AAA Repair