O p e rat i ve Te c h n i q u e s i n

6 Va sc u l a r S u rg e ry

A rc h a n d G re a t Ve s s e l R e c o n s t r u ct i o n w i t h
D e b ra n c h i n g Te c h n i q u e s 1 804
W. A n th o ny L e e a n d A lexa n de r Ku lik

Extrat h o ra c i c Reva s c u l a r i zat i o n

(Ca rot i d-Ca rot i d, Ca rot i d-S u b c l av i a n
B y p a s s a n d Tra n s p o s i t i o n ) 1810
Edwa rd Y. Wo o a n d Sco tt M. D a m ra u e r

Ca rot i d S u rg e ry :
I n t e r p o s i t i o n/E n d a rt e re cto m y
( I n c l u d i n g E v e rs i o n ) /L i g a t i o n 1818
Vin it N. Va ru a n d We i Zh o u

Ca rot i d S u rg e ry : B i f u rcat i o n Ste n t i n g w i t h

D i sta l P rotect i o n 1 82 1
Zh e n S . H u a n g a n d D a rren B . Sch n e ider

. .

Ca rot i d S u rg e ry : D i sta l E x p o s u re a n d
C o n t ro l Te c h n i q u e s a n d Co m p l i ca t i o n
M a n a g e m e nt 1 83 7
Ch e o n g J. L e e

Ve rt e b r a l Tra n s p o s i t i o n Te c h n i q u e s
a n d Ste n t i n g 1 843
Ma rk D . M o rasch

N e u ro g e n i c T h o ra c i c O u t l et S yn d ro m e
E x po s u re a n d D e co m p re s s i o n :
S u p ra c l a v i c u l a r 1 84 8
R o b e rt W. Th o mp s o n a n d Ch a n du Ve m u ri
N e u ro g e n i c T h o ra c i c O u t l et S y n d ro m e
E x po s u re a n d D e c o m p re s s i o n :
Tra n s a x i l l a ry 7 8 62
G e o rg e J. A rn a o u ta kis, Th o m a s R e ifsnyde r, a n d Julie A n n Fre ischlag

Ve n o u s a n d Arte r i a l T h o ra c i c O u t l et
S y n d ro m e 7 8 69
Ja s o n T. L e e

P rox i m a l to t h e Wr i st : U p p e r Extre m i ty
Reco n s t r u ct i o n/Revas c u l a r i za t i o n 7 877
M o h a m e d A . Zaye d a n d R o n a ld L . D a l m a n

U p p e r Extre m i ty A rte r i a l R e c o n st r u ct i o n
a n d Reva s c u l a r i za t i o n D i sta l
to t h e W r i st 7 894
Mich a e l G . Ga lvez a n d Ja m es Ch a n g

E x po s u re a n d O p e n S u rg i ca l
Reco n st r u ct i o n i n t h e C h e s t :
T h e T h o ra c o a b d o m i n a l A o rta 7 9 02
G e rm a n o M e lissa n o, Efrem Civilin i, En rico R i n a ldi,

a n d R o b e rto Chiesa

T h o ra c i c A o rt i c S t e n t - G raft R e p a i r fo r
A n e u ry s m . D i s s e ct i o n , a n d Tra u m a t i c
Tra n s e ct i o n 797o
B ra n t W. Ullery a n d Ja s o n T. L e e

E x po s u re a n d O p e n S u rg i ca l M a n a g e m e n t
at t h e D i a p h ra g m 7 92 7
Peter H. U. L e e a n d R a m in E. B eyg u i

R e t ro p e r i t o n e a l A o rt i c E x p o s u re 7 92 6
Ma tth e w M e l /

H y b r i d R e v a sc u l a r i za t i o n S t r a t e g i e s fo r
V i sce ra l/Re n a l A rte r i e s 7 93 1
B e nja m in W. S ta rn es
Snorkel/Chimney and Periscope Visceral
Revascularization During Complex
Endovascular Aneurysm Repair 1939
Jason T. Lee and Ronald L. Dalman

Branched and Fenestrated Endovascular

Stent Graft Techniques 1948
Gustavo 5. Oderich and Karina 5. Kanamori

Stenting, Endografting, and Embolization

Techniques: Celiac, Mesenteric, Splenic,
Hepatic, and Renal Artery Disease
Management 7959
Mohamed A. Zayed and Ronald L. Dalman

Visceral Reconstruction to Facilitate

Cancer Management: Celiac, Mesenteric,
Splenic, Hepatic and Renal Artery Disease
Management 1972
Mohamed A. Zayed and E. John Harris, Jr.

Hepatic- and Splenic-Based Renal

Revascularization 1986
Fred Weaver, Sung Wan Ham, and Grace Huang

. .

Advanced Aneurysm Management

Techniques: Open Surgical Anatomy
and Repair 7995
Elizabeth Blazick and Mark F. Conrad

Advanced Aortic Aneurysm Management:

Endovascular Aneurysm Repair-Standard
and Emergency Management 2006
Vinit N. Varu and Ronald L. Dalman

Advanced Aneurysm Management

Techniques: Management of Internal Iliac
Aneurysm Disease 2015
W. Anthony Lee
Occlusive Disease Management: Isolated
Femoral Reconstruction, Aortofemoral
Open Reconstruction, and Aortoiliac
Reconstruction with Femoral Crossover for
Limb Salvage 2024
Nathan /toga and E. John Harris, Jr.

Occlusive Disease Management:

Iliac Angioplasty and Femoral
Endarterectomy 2034
Venita Chandra

Management of the Infected

Femoral Graft 2044
Matthew Mel/

Surgical Exposure of the

Lower Extremity Arteries 2050
Luke X. Zhan and Joseph L. Mills, Sr.

Percutaneous Femoral-Popliteal
Reconstruction Techniques:
Reentry Devices 2061
Daniel/e E. Cafasso and Peter A. Schneider

Percutaneous Femoral-Popliteal
Reconstruction Techniques: Antegrade
Approaches 2068
F. Gallardo Pedrajas and Peter A. Schneider

Maximizing Vein Conduit for

Autogenous Bypass 2082
Gregory J. Landry

T ibial Interventions: Tibial-Specific

Angioplasty Considerations and
Retrograde Approaches 2092
Georges E. AI Khoury and Rabih A. Chaer
Perimalleolar Bypass and Hybrid
Techniques 2105
Geetha Jeyabalan and Rabih A. Chaer

Acute Iliofemoral Deep Vein Thrombosis

and May-Thurner Syndrome: Surgical and
lnterventional Management 2116
Sharon C. Kiang And Brian G. DeRubertis
 -

Arch and Great Vessel

Chapter 1 Reconstruction with
I
Debranching Techniques
- ----------------------------------- � ----------------------------------------------------- �

W Anthony Lee Alexander Kulik

DEFINITION IMAGING AND OTHER DIAGNOSTIC

• An aortic arch aneurysm is defined as dilation of the aortic
arch to greater than 5 em in diameter. Rarely occurring in
isolation, aneurysms of the aortic arch are often extensions
of aneurysms present in the ascending or descending aorta.
Causes of aortic arch aneurysms included atherosclerotic
degeneration, cystic medial degeneration, aortic dissection,
congenital aortopathy (i.e., bicuspid aortic valve), penetrat­
ing aortic ulcer, previous traumatic transection (chronic
pseudoaneurysm) , and previously repaired aortic coarcta­
tion (postsurgical pseudoaneurysm) . Aortic arch aneurysms
have traditionally been repaired with graft replacement of
the aorta, with or without an elephant trunk, using car­
diopulmonary bypass and deep hypothermic circulatory
arrest. With the advent of thoracic endovascular aortic re­
pair (TEVAR), debranching of the brachiocephalic vessels
is a recently developed technique that takes advantage of
the reduced surgical trauma associated with stent grafting. 1
Debranching functionally extends the proximal landing
zone by repositioning the inflow of the brachiocephalic ar­
teries toward the proximal ascending aorta. This facilitates
endovascular stent graft repair of the aortic aneurysm by
allowing stent coverage across the ostia of the arch vessels,
producing a stable and fixed proximal landing zone in the
ascending aorta.
STUDIES
• Although a routine chest x-ray may be the first imaging test to
note an aortic arch abnormality, further imaging is necessary,
including a CT scan of the aorta ( FIG 1 ) and an echocardiogram.
• An arterial phase CT angiogram should evaluate the entire
length of the aorta, from the level of the skull base proxi­
mally to the femoral heads distally, to ensure visualization of
the vertebral and iliofemoral arteries, respectively. The CT
images are then processed using 3D imaging software for
case planning and device selection. A magnetic resonance
imaging (MRI) or a noncontrast CT scan will not suffice.
• A transthoracic (2D) echocardiogram should be performed
to assess left and right ventricular function and to exclude
the presence of significant valvular heart disease.
• Strong consideration should be given to evaluating the
anatomy of the coronary arteries in the preoperative period.
A CT coronary angiogram may be an option for younger
patients or those with complex proximal aortic dissection.
However, if there is a strong suspicion of coronary disease,
then a preoperative conventional coronary angiogram
should be performed, including those patients older than
40 years of age and those with a history of smoking.
SURGICAL MANAGEMENT

PATIENT HISTORY AND PHYSICAL Preoperative Planning

FINDINGS • Indications for repair of an aortic arch aneurysm include

large aneurysmal size ( > 5.5 em), rapid growth ( > 0.5 em per
• Aortic arch aneurysms are usually diagnosed as incidental
year), the presence of chest pain or back pain unexplained
findings noted on imaging studies, such as a chest x-ray or
by other causes, and compression of adjacent organs (esoph­
computed tomography ( CT) scan, to evaluate other concur­
agus, trachea, or left main bronchus).2
rent medical conditions.
• More aggressive size criteria may be applied for patients
• Most patients have no symptoms from their aneurysms.
with Marfan's syndrome (repair at 4.5 to 5 em) . However,
Symptoms, if they exist, may include chest or back pain from
stent graft outcomes appear less favorable in patients with
aneurysmal growth or those associated with compression of
adj acent structures (i.e., trachea, esophagus ) . Hoarseness
may develop from stretching of the left recurrent laryngeal
nerve (Ortner's syndrome) . Acute chest or back pain, with
or without signs of shock, should raise the suspicion of im­
pending aortic rupture and/or acute aortic dissection. Ad­
ditional details regarding a patient's past medical history
should be gathered, including a history of previous coronary
intervention, previous cardiac surgery, known valvular heart
disease, previous aneurysm surgery, or a family history of
aortopathy.
• The physical examination is often unremarkable. However,
attention should be directed to the presence of aortic valve
insufficiency ( diastolic murmur, widened pulse pressure) ,
previous surgical incisions, a n d the presence of concomitant FIG 1 • Preope rative c omputed tom ography (CT) a n g iogram of
peripheral vascular disease. an a o rtic a rch a n e u rysm .

1804
 C h a p t e r 1 ARCH A N D G REAT V E S S E L R E C O N STRUCTI O N WITH D E B RA N C H I N G TEC H N I Q U E S
connective tissue disease, and therefore, alternative surgical
techniques ( such as conventional aortic replacement sur­
gery) should be considered.2
• The presence of significant concurrent cardiac disease may
alter the surgical approach. Should significant coronary ar­
tery or valvular heart disease be identified in the preoperative
period, consideration may be given to performing concomi­
tant coronary artery bypass grafting ( CABG) or valve re­
placement at the time of the aortic de branching procedure.
• During the second stage of the arch repair, stem graft deploy­
ment in the distal ascending aorta may require the placement
of a guidewire across the aortic valve into the left ventricular
cavity. The presence of a mechanical aortic prosthetic valve,
through which a guidewire and the delivery system cannot safely
be placed, may require a single-stage approach with deployment
of the stent graft at the time of debranching (see endovascular
second stage) . A bioprosthetic valve in the aortic position may
allow for careful transvalvular introduction of devices, with
preference to bovine pericardia! valves over porcine valves.
• Selection of the ideal treatment strategy for repair of an aor­
tic arch aneurysm remains controversial and is dictated by
surgical experience and local area expertise. Aortic arch deb­
ranching and stent graft completion is an appealing repair
option that avoids a thoracotomy incision and may avert
the use of cardiopulmonary bypass and circulatory arrest.
These types of hybrid procedures may be performed either as
single- or two-stage repairs. However, conventional open re­
placement of the entire aortic arch/·4 or replacement of the
ascending aorta and proximal arch with the creation of an
elephant trunk followed by stent graft completion/·5 should
be considered as clinically indicated.
• Debranching of the aortic arch off the ascending aorta may
not be applicable for a patient with an aortic arch aneurysm
who has previously undergone cardiac surgery and who is
too high-risk for consideration of redo sternotomy. In this
case, an alternative option would include extra-anatomic
debranching of the aortic arch (carotid-carotid, carotid­
subclavian) followed by stent graft repair of the arch, with
or without innominate artery chimney (snorkel) stenting.6
• The preoperative CT scan requires careful review before
undertaking an aortic arch debranching operation. Arch
branch anatomy and appropriate landing zones need to be
identified proximal and distal to the arch aneurysm, with
criteria similar to those that apply for stent graft repair of a
descending thoracic aortic aneurysm. Anatomic variations
of the aortic arch anatomy may require modification of the
debranching procedure. These include a bovine aortic arch
(common trunk of the innominate and left common carotid),
AORTIC ARCH DE B RANCH I N G
• Alth o u g h some a dvocate the use of a r i g ht tho racotomy
i n c i s i o n o r u p p e r h e m i sternotomy, we p refer to expose
the asce n d i n g a o rta through a convent i o n a l ste rnotomy
i n c i s i o n . This provides opti m a l visu a l ization and contro l .
T h e pericard i u m is i n c ised a n d retracted .
• T h e asce n d i n g a o rta is ca refu l l y m o b i l ized to fac i l itate
l ater p l a ce m e n t of a proxi m a l l y posit i o n e d s i d e - b i t i n g
1805
arch origin o f left vertebral artery, a n d a n aberrant right sub­
cia vi an artery.
• The ascending aorta is typically 6 to 7 em in length from the
sinotubular j unction to the innominate artery. Placement of
the proximal inflow anastomosis as low as possible on the
ascending aorta (j ust distal to the sinotubular j unction) will
result in an optimal 3- to 4-cm proximal landing zone for
the stent graft repair. The largest currently available thoracic
stent grafts are 42 to 46 mm in diameter. To provide a safe
and durable proximal landing zone and avoid a proximal
type I endoleak, we recommend replacement of an ascend­
ing aorta that is extremely short or if its diameter is 36 mm
or larger. Open replacement of the ascending aorta would
be performed at the time of the arch debranching procedure,
with implantation of an aortic graft 34 mm or smaller.
• The size of the iliofemoral arteries is worth noting on the pre­
operative CT study. The external iliac arteries need to be larger
than 7 mm in diameter to provide adequate vascular access
to deliver the stent graft devices during the second stage. An
iliac artery conduit may be needed if the iliofemoral arteries
are extremely small or in the presence of severe calcification
and occlusive disease. Alternatively, a single-stage antegrade
introduction of the stent graft from the ascending aorta may
be performed (see endovascular second stage) to avoid access
problems from a retrograde iliofemoral approach.
• The diameters of the brachiocephalic arteries are measured
on the preoperative CT scan to determine the interposition
graft sizes for the debranching procedure. Most frequently,
the size of the graft chosen for the innominate artery branch
is 10 to 1 4 mm, with 6- to 8-mm grafts usually used for the
left carotid and left subclavian arteries.
• Cerebral oximetry monitoring may be helpful for the aortic
debranching procedure to monitor brain perfusion before
and after clamping of the brachiocephalic arteries. For the
second-stage endovascular procedure, cerebrospinal fluid
( CSF) drains are placed preoperatively to reduce the risk of
spinal cord ischemia if a significant length of the descending
thoracic aorta is to be covered.
Positioning
• For the arch debranching procedure, patients are positioned
supine j ust as they are during standard cardiac surgical op­
erations. Prepping is performed from the neck to the knees,
with draping higher than usual to strategically provide ac­
cess to the lower neck. The head may be turned slightly to
the right to facilitate extension of the sternotomy incision
proximally along the left sternocleidomastoid muscle.
c l a m p . The space b etwe e n the l eft s i d e of the a o rta
and t h e p u l m o n a ry a rtery i s d i ssected, with s m a l l ves­
sels cauterized o r c l i p p e d and d i v i d e d . The a sce n d ­
i n g a o rta i s m o b i l ized p roxi m a l l y d o w n to t h e l evel
of t h e a o rt i c root (si n otu b u l a r j u n ct i o n ) to e n a b l e
i d e ntificat i o n (a n d avo i d i n j u ry) to t h e r i g h t c o ro n a ry
a rte ry.
• The brach ioce p h a l i c a rteries a re c i rcu mferentia l ly ex­
pose d . The i n n o m i nate ve i n is m o b i l ized a n d retracted
1806 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

with an u m b i l ica l tape to fac i l itate expos u re of the 8mm

a rch vessels (FIG 2) . U n common ly, the i n no m i nate
ve i n req u i res l i g ation and d ivision to aid i n a rch expo­
sure. The l eft s u bclavian a rtery i s often more poste rior
than expected, and exposu re of this a rtery may be d if­
ficult. In th ese circumstances, the ste rnotomy i n c ision
may be exte nded su periorly and l eftwa rd a long the
ste rnoc l e i domastoi d m u sc l e . Alternatively, i n no m i nate
and l eft caroti d d e b ra n c h i n g may be com b i ned with a
l eft carotid-s u bclavian bypa ss/transposition p roce d u re,
t h ro u g h a sta n d a rd s u p raclavicu l a r a p p roach, obviat i n g
the n e e d t o expose the l eft s u b c l a v i a n a rtery t h ro u g h t h e
ste rnotomy.
• Altho u g h a p reformed bifu rcated or m u lti l i m b g raft may
be used, th ese occ u py a l a rge footprint and reduce the
l e n gth ava i l a b l e for the asce n d i n g aortic l a n d i n g zone.
I nstead, we p refer to construct a Y-g raft by sew i n g a bev­
eled s m a l l e r Dacron g raft e n d -to-s ide to l a rger Dacron
g raft (FIG 3) . The g raft sizes a re sel ected based on the
measu red d i a m eters from the p reoperative CT sca n . Typ i ­
cal ly, a 1 0- or 1 2- m m g raft is u s e d f o r the i n nom i n ate a r­
tery, a n d a 6- or 8-mm g raft is used for the l eft caroti d
a rte ry.
• H e p a r i n is a d m i n i stered to a c h i eve a n a ctivated c l ot­
t i n g t i m e (ACT) of 200 secon d s . The b lood press u re FIG 3 • A Y-g raft i s constructed by sew i n g a beveled s m a l l e r
is lowe red to 90 m m H g systo l i c, a n d a n aort i c s i d e ­ Dacron graft (6 t o 8 m m ) e n d -to-s i d e t o l a rg e r Dacron g raft
b i t i n g c l a m p i s p l aced o n t h e r i g ht a ntero l atera l s i d e ( 1 0 to 1 2 m m ) .
(convexity) o f t h e asce n d i n g aorta, a s l o w as poss i b l e,
with care not to com p ro m i se t h e r i g h t coro n a ry a rte ry.

A ret raction s u t u r e i n t h e r i g h t atr i a l a p p e n d a g e m a y

• The p roxi m a l e n d of the l a rg e r (1 0 or 1 2 m m ) g raft is cut
• The i n nom i n ate a rte ry is tra nsected, a n d the p rox i m a l
FIG 2 • After ste rnotomy, the pericard i u m is i n cised
a n d retracte d . The asce n d i n g aorta is mob i l ized, a n d the
• N ext, t h e l eft com mon ca rot i d a rtery is transected, a n d
brach ioce p h a l i c a rteries a re ci rcumferentia l ly exposed. The
i n no m i nate ve i n is mobil ized a n d retracted with a n u m b i l i ca l
tape to fac i l itate expos u re of the a rch vesse l s .
be n e e d e d t o fa c i l itate p roxi m a l aort i c expos u re . C o n ­
s i d e ration m a y be g iven t o p e rfo rm i n g t h i s a n d s u b ­
seq u e nt ste ps i n t h e o p e r a t i o n with c a r d i op u l m o n a ry
bypass to p rov i d e opti m a l h e modyn a m i c control d u r­
i n g c l a m p a p p l ication a n d remova l a n d to i m p rove
b ra i n p rotect ion with syste m i c coo l i n g in the ra n g e of
32°C to 34°C.
to the a p prop r i ate l e n gth so the Y-g raft easily reaches
the a rc h vesse l s . The g raft is beve led and sewn e n d -to­
s i d e to the asce n d i n g aorta with a r u n n i n g 3-0 or 4-0
polypropy l e n e sutu re (FIG 4) . B ioG i u e may be a p p l ied
to f u rt h e r s u p port the a n a stomos is. The aort i c clamp i s
g e ntly released . A l a rg e c l i p may be p l aced a c ross the
h e e l of the a n a stomosis. T h i s wi l l help visu a l ize the ori­
gin of t h e d e b r a n c h i n g g ra ft from the asce n d i n g aorta
a n d precisely d efi n e the p roxi m a l l a n d i n g zone without
the need for contrast d u r i n g the seco n d -sta g e e n d ovas­
c u l a r p roced u re .
e n d is ove rsewn w i t h two l ayers o f 4-0 polypropy l e n e .
The d i sta l l a rg e e n d o f the Y-g raft is then t u n neled u n ­
derneath the i n no m i n ate ve i n a n d sewn end-to-e n d to
the i n nom i n ate a rtery with ru n n i n g 5-0 polypropylene
(FIG 5) .
the p rox i m a l e n d o f the ca rot i d a rtery is oversewn with
4-0 polypropy l e n e . The d i sta l s m a l l e r e n d of the Y-g raft
is t u n n e l e d u n d e rneath the i n nom i n ate ve i n a n d sewn
 C h a p t e r 1 ARCH A N D G REAT V E S S E L R E C O N STRUCTI O N WITH D E B RA N C H I N G TEC H N I Q U E S
FIG 4 • An aortic side-biti n g c l a m p is p l aced on the right
a nterol ate ral s i d e (convexity) of the ascen d i n g aorta, as low
as poss i b l e . The p roxi m a l end of the l a rg e r ( 1 0 or 1 2 mm) g raft
is beve led a n d sewn e n d -to-si d e to the asce n d i n g aorta with a
r u n n i n g 3-0 or 4-0 polypropylene suture.
Innom inate vein
Innominate artery
FIG 5 • The i n nom i nate a rte ry is tra nsected, a n d the p roxi m a l
e n d i s ove rsewn 4-0 polypropylene. T h e d ista l l a rg e e n d o f the
Y-g raft is then t u n neled u n d e rneath the i n no m i nate ve i n and
sewn end-to-e n d to the i n no m i nate a rtery with r u n n i n g 5-0
polypropy l e n e .
1807
FIG 6 • T h e l eft com mo n c a rot i d a rtery is tra n sected,
and t h e p rox i m a l end of the c a rot i d a rtery i s ove rsewn
with 4-0 polypropy l e n e . T h e d i st a l s m a l l e r end of the
Y-g ra ft i s t u n n e l e d u n d e rn eath t h e i n nom i nate ve i n a n d
sewn e n d -to- e n d t o t h e ca rot i d a rtery w i t h r u n n i n g 5-0
polypropy l e n e .
e n d -to-e n d to t h e c a rot i d a rtery with r u n n i n g 5-0 poly­
p ropy l e n e (FIG 6) .
• A t t h i s poi nt, a decision needs t o be made reg a rd i n g
t h e d e b ra n c h i n g strategy for t h e l eft subclavian a rte ry.
I n d ications for l eft subclavian revasc u l a ri zation a re
controve rsia l . Rout i n e versus sel ective strate g i es may
be adopte d .' If the l eft subclavian a rte ry needs to be
revasc u l a rized but can not safe ly be exposed, a ca rotid­
subclavian bypass can be performed as p reviously men­
tioned . If the subclavian a rtery can be exposed, the d i sta l
a n a stomosis is created fi rst u s i n g a 6- or 8-m m Dacron
g raft a n a stomosed either e n d -to-en d to the tra n sected
a rtery or end-to-s ide (fu n ction a l end-to-e nd) fol lowed by
l i g ation of the p roxi m a l a rtery in cont i n u ity. A side-biti n g
c l a m p is t h e n p l a ced a long the carotid g raft, a n d the s u b­
clavian g raft is sutu red e n d -to-side to the carot i d g raft
with 5-0 polypropy l e n e suture (FIG 7) .
• Prota m i n e is a d m i n istered t o reverse the h e p a r i n , a n d
hemostasis is e n s u re d . The g rafts shou l d l i e tension free
with i n the m e d i asti n u m . The perica rd i u m may be p a r­
tia l ly c losed ove r the g rafts, with care to avoid com p res­
sion of the g raft branches. Ch est tu bes a re positioned,
and the ste r n u m is c losed rout i n e ly. After the stern u m is
c losed, the blood p ressure shou l d be assessed i n each a r m
a n d cerebra l oxi m etry mon itored t o confi rm a d e q u ate
perfusion t h ro u g h the g raft branches a n d the a bsence of
g raft com pression.
1808 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

FIG 7 • If the subclavian a rtery can be exposed, the d i sta l

a n a stomosis is created fi rst u s i n g a 6- or 8-mm Dacron g raft
a n a stomosed e n d -to-end to the tra n sected a rte ry. The
s u bclavian g raft is then sutu red e n d -to-s i d e to the caroti d
g raft w i t h 5 - 0 polypropylene suture.

E N D OVASCULAR SECO N D STAG E
• The e n dovascu l a r second sta g e of the a rch repa i r is con -
d u cted i n a fairly s i m i l a r m a n n e r to that of stent g raft
repa i r of a descen d i n g thoracic aortic a n e u rysm, as de­
scribed i n Part 6, C h a pter 13 (Thora cic E n dog rafti n g ) .
• The t i m i n g of the e n dovascu l a r repa i r as a s i n g l e versus
sta ged a p p roach rem a i n s controversia l . We p refer to
delay the second sta g e d e pe n d i n g on the c l i n ical see-
n a rio. It can range from a few d ays (sa me hosp ita l i za­
tion) to several weeks (sepa rate a d m ission) to a l low the
patient to recover from the fi rst p roced u re . T h i s red uces
the overa l l physiolog ic stress on the patient.
• Althou g h we favor d e l ivery of the stent g raft in a retro­
grade m a n n e r from the i l iofemoral a rteries, in cases of
a mech a n ical aortic va lve or severe i l iofemora l occ l usive
disease, s i n g le-stage a ntegrade deployment sho u l d be
considered . The tech nical variations for these l ess com mon
situations a re beyond the scope of the present cha pter.
• The site of i n se rtion of the e n dovascu l a r g raft d e l ivery
system is decided based on the size a n d q u a l ity of the ac­
cess vessels. In g e n e ra l , the g rafts a re d e l ivered t h ro u g h
the com mon femora l a rte ry, whereas a n i l iac con d u it
may be req u i red for very s m a l l or d iseased i l iofe mora l
a rteries.
• The d e l ivery g u idewire is p l aced i n the l eft ventri cle d u r­
i n g the e n dovascu l a r p roced u re to p rovide suffi cient
p rox i m a l ra i l s u p port for the e n dovascu l a r g raft.
• The p rox i m a l ste nt g raft is deployed in the asce n d i n g
aorta j u st d ista l t o the orig i n o f the debranch i n g g raft.
D u ri n g d e p loyme nt, it is usefu l to lower the blood p res­
s u re u s i n g one of a va riety of p h a rmacolog i c, ventri c u l a r
paci n g or atri a l i n flow occ l u s ion tech n i q ues"

PEARLS AND PITFALLS

I n d ications • The p reoperative CT a n g iog ram shou l d be reviewed in d eta i l to e n s u re the patient is a s u ita b l e
ca n d i d ate for aortic a rch repa i r w i t h d e b ra n c h i n g a n d ste nt g raft i n g , i n c l u d i n g a p p ropriate l a n d i n g
zones p roxi m a l ly a n d d i sta l l y a n d a d e q u ate vascu l a r access.
Proxi m a l type I endoleak • To optim ize the length of the p rox i m a l l a n d i n g zone and p revent a type I endoleak, the debra n c h i n g
g raft sho u l d be p l a ced as low as poss i b l e on the asce n d i n g aorta . Preem ptive replacement o f t h e
asce n d i n g aorta shou ld be performed if it is extremely short or i t s d i a m eter is > 34 m m .
Mech a n i ca l aortic • After aortic d e b ra n c h i ng, the e ndovasc u l a r g raft d e l ivery system may h a v e t o cross the aortic valve.
p rosthesis Althou g h transva lvu l a r p l acement of a l a rge sheath is relatively safe for n ative and bioprosthetic
va lves, it is contra i n d i cated for a m ec h a n ical aortic valve. Anteg rade ste nt g raft d e p loyment at the
time of debranch i n g shou l d be con s i d e red i n the p resence of a mech a n i c a l p rosthesis.
I nj u ry to r i g ht coro n a ry • Care shou l d be taken when a p p ly i n g the side-b iti n g clamp low on the asce n d i n g aorta to avoid
a rte ry occl usion or i nj u ry to the right coro n a ry a rte ry.
 C h a p t e r 1 ARCH A N D G REAT V E S S E L R E C O N STRUCTI O N WITH D E B RA N C H I N G TEC H N I Q U E S 1809

Asce n d i n g aortic
d i ssection
Left subclavian a rtery
Com p ression and k i n k i n g
o f d e b ra n c h i n g g rafts
• The systo l i c blood p ress u re shou l d be lowe red to <90 m m H g when a p p l y i n g the side-biti n g c l a m p
on the asce n d i n g aorta t o p revent i n j u ry a n d d issection o f a n a l ready fra g i l e a n d d i seased aorta .
• If the l eft subclavian a rtery is not easily access i b l e via the ste rnotomy i n cision ( l a rg e rotated
aortic a rch a n e u rysm), then debranch i n g of t h i s a rtery can be performed via ca rotid-subclavian
bypass.
• I d e a l ly, the m a i n debranch i n g g raft shou l d l i e a long the r i g ht s i d e of the ascen d i n g aorta to avoid
com p ression by the ste r n u m after chest closure. The g raft branches shou l d lie tension free, with care
taken to avoid kinking at the t i m e of perica rdia I a n d chest wa l l clos u re .

POSTOPERATIVE CARE
• Following the de branching procedure, patients are monitored
in a cardiovascular surgical intensive care unit for 4 8 hours,
with a focus on neurologic status, applying standard post­
operative cardiac surgery protocols.
• Chest tubes are typically removed 2 days after the debranch­
ing operation.
• If a patient is recovering well after debranching without com­
plication and has stable renal function, then the stent graft
completion can be performed 3 to 5 days postoperatively. In
the event of a major complication requiring extended recovery,
the patient may be discharged to a rehabilitation center. The
stent graft procedure can be delayed for a few weeks. However,
up to 25% of patients may not return for their second stage.
• Following the second-stage stent graft procedure, the blood
pressure is augmented with fluid and vasopressor support to
achieve a target systolic blood pressure of 140 to 1 6 0 mmHg
for 48 hours to optimize spinal cord perfusion.
• CSF drains are left open for 24 hours following stent graft­
ing. Drainage is limited to less than 15 mL per hour or less
than 350 mL per day to avoid the potential risk of subdural
hemorrhage. In the absence of spinal cord injury, CSF drains
are then clamped for 12 hours and subsequently removed.
• Follow-up CT angiograms of the aorta are performed at
1 and 6 months after the stent graft procedure, and then
yearly thereafter.
OUTCOMES
• In the authors' experience of 37 aortic arch debranching
procedures/ rates of spinal cord inj ury, stroke, and 3 0-day
mortality were 0 % , 1 0 . 8 % , and 1 6 . 2 %, respectively. The
incidence of proximal type I endoleak was 3. 7% at 1 and
1 2 months. Survival at 1 and 1 2 months was 8 6 . 5::+::5 . 6 %
and 7 1 . 6::+:: 8 . 5 % , respectively. Freedom from undergoing
any secondary surgical procedure after stent graft comple­
tion at 1 and 12 months was 7 1 . 0::+::7 . 8 % and 5 2 . 8::+:: 1 0 % ,
respectively.
• A recent systematic review of aortic arch debranching sum­
marized the clinical outcomes of 27 published studies in­
cluding a total of 642 patients.9 Reporting results similar
to those of the authors' experience1; the review noted rates
of spinal cord inj ury, stroke, and 3 0-day mortality of 4 . 3 % ,
7.3 % , and 1 1 .9 % , respectively. I n this review, a trend ex­
isted between higher surgical volume and lower neurologic
complications, with stroke rates of 9 . 6 % and 6 . 5 % in low­
volume and high-volume case series, respectively.9
• In anomer review article that included 1 8 studies and data from
195 patients, the technical success rate following aortic arch
debranching and stent graft repair was reported at 8 6 % . The
most common reason for technical failure was endoleak ( 9 % ) .1 0
COMPLICATIONS
• Reopening for bleeding
• Stroke or transient ischemic attack (TIA)
• Spinal cord ischemic inj ury
• Ascending aortic dissection
• Endoleak
• Iliofemoral artery injury
• Mortality
REFERENCES
1. Lee CW, Beaver TM, Klodell CT Jr, et al. Arch debranching versus
elephant trunk procedures for hybrid repair of thoracic aortic patholo­
gies. Ann Thorac Surg. 2011;91(2):465-471.
2. Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHNAATS/
ACRIASNSCNSCAIISIRISTS/SVM guidelines for the diagnosis and
management of patients with Thoracic Aortic Disease: a report of the
American College of Cardiology Foundation/American Heart Asso­
ciation Task Force on Practice Guidelines, American Association for
Thoracic Surgery, American College of Radiology, American Stroke
Association, Society of Cardiovascular Anesthesiologists, Society for
Cardiovascular Angiography and Interventions, Society of Interven­
tional Radiology, Society of Thoracic Surgeons, and Society for Vascu­
lar Medicine. Circulation. 2010;121(13):e266-e369.
3. Kulik A, Castner CF, Kouchoukos NT. Outcomes after total aortic
arch replacement with right axillary artery cannulation and a presewn
multibranched graft. Ann Thorac Surg. 2011;92(3):889-897.
4. Sundt TM 3rd, Orszulak TA, Cook DJ, et al. Improving results of
open arch replacement. Ann Thorac Surg. 2008;86(3):787-796; dis­
cussion 787-796.
5. Milewski RK, Szeto WY, Pochetrino A, er al. Have hybrid proce­
dures replaced open aortic arch reconstruction in high-risk patients?
A comparative study of elective open arch debranching with endo­
vascular stent graft placement and conventional elective open total
and distal aortic arch reconstruction. J Thorac Cardiovasc Surg.
2010;140(3):590-597.
6. Yang J, Xiong J, Liu X, et al. Endovascular chimney technique
of aortic arch pathologies: a systematic review. Ann Vase Surg.
2012;26(7):1014-1021.
7. Matsumura JS, Lee WA, Mitchell RS, et al. The Society for Vascu­
lar Surgery Practice Guidelines: management of the left subcla­
vian artery with thoracic endovascular aortic repair. J Vase Surg.
2009;50(5):1155-1158.
8. Lee WA, Martin TD, Gravenstein N. Partial right atrial inflow occlu­
sion for controlled systemic hypotension during thoracic endovascular
aortic repair. J Vase Surg. 2008;48(2):494-498.
9. Cao P, De Rango P, Czerny M, et al. Systematic review of clinical outcomes
in hybrid procedures for aortic arch dissections and other arch diseases. ]
Thorac Gzrdiovasc Surg. 2012;144(6):1286-1300, 1300.e1-1300.e2.
10. Antoniou GA, El Sakka K, Hamady M, et al. Hybrid treatment of com­
plex aortic arch disease with supra-aortic debranching and endovascu­
lar stent graft repair. Eur ] Vase Endovasc Surg. 2010;39(6):683-690.

Chapter 2 Extrathoracic Revascularization
{Carotid-Carotid, Carotid­
Subclavian Bypass and
Transposition)
I
------------------------------------ -i -----------------------------------------------------
Edward Y. Woo
DEFINITION
• Extrathoracic revascularization, including carotid-subclavian
and carotid---<:arotid bypass, involves the bypass of the proxi­
mal great vessels outside of the chest. Initially described for
treatment of cerebrovascular and upper extremity occlusive
disease, these procedures are commonly now employed to cre­
ate a proximal seal zone for endovascular treatment of tho­
racic aortic disease by " debranching" the aortic arch.
• Carotid-subclavian bypass is accomplished by inserting a
graft conduit between the mid-common carotid artery to the
ipsilateral subclavian artery.
• Subclavian artery transposition is a potential alternative to
carotid-subclavian bypass requiring division of the subclavian
artery proximal to the vertebral artery and transposing it to the
ipsilateral common carotid artery. It is an efficient way to revascu­
larize the subclavian artery without the use of prosthetic conduit. 1
• Carotid---<:arotid bypass provides flow from one common
carotid artery to the contralateral common carotid artery.
• When carotid---<:arotid bypass is performed in a right-to-left
manner and in conjunction with carotid-subclavian bypass, the
blood flow to the left brain can be preserved while allowing for
extension of the proximal thoracic endovascular aortic repair
(TEVAR) seal zone to cover the left common carotid artery.
PATIENT HISTORY AND PHYSICAL FINDINGS
• The history should focus on neurologic symptoms that may
indicate the presence of symptomatic cerebrovascular dis­
ease. Previous head and neck or carotid surgery should be
noted, as well as a history of head, neck, or upper chest re­
gion external beam radiation therapy, as these may signifi­
cantly increase the complexity of the procedure.
• The directed physical exam should be focused on detection
of underlying vascular disease that may complicate planned
intervention. Bilateral upper extremity blood pressures
should be obtained; a difference of greater than 10 mmHg
indicates the potential presence of preexisting occlusive dis­
ease. Likewise, the presence of carotid bruits, delayed ca­
rotid upstrokes, or abnormal upper extremity pulses suggests
arterial occlusive disease that should be delineated prior to
extrathoracic reconstruction or bypass of the great vessels.
• Special attention should be directed toward the cranial nerves
and voice, especially in patients with prior cervical surgical
procedures. Indirect laryngoscopy should be performed preop­
eratively in patients with hoarseness or in whom a preexisting
vocal cord or cranial nerve deficit has been noted.
• Neck mobility and the presence of cervical spinal disease
should be assessed, as neck extension and rotation is essen­
tial for adequate operative exposure. Patients with relative
neck immobility may be poorly suited for these procedures.
1810
-
....
Scott M. Damrauer
IMAGING AND OTHER DIAGNOSTIC STUDIES
• Carotid duplex scanning should be used to identify patients with
carotid artery stenosis prior to planned bypass procedures. Fail­
ure to identify and address stenoses at the carotid bifurcation
may lead to postoperative steal phenomenon and neurologic se­
quelae. Manipulation of the diseased carotid artery may also in­
crease the risk of periprocedural stroke. In these circumstances,
concomitant or staged carotid intervention may be warranted.
• Computed tomographic (CT) angiography of the aortic arch and
proximal carotid arteries provides the anatomic detail necessary
to safely perform carotid-subclavian bypass, subclavian artery
transposition, or carotid---<:arotid bypass. This study is comple­
mentary to duplex scanning, as it provides anatomic rather than
hemodynamic assessment and images vessels equally well inside
and outside the chest. CT scanning also visualizes the course of
the subclavian artery in relationship to the clavicle, as its course
may also be distorted by a large arch aneurysm.
SURGICAL MANAGEMENT
Preoperative Planning
• Neuromonitoring is a useful adjunct to ensure adequacy of
cerebral perfusion from the contralateral cerebral circulation
when the ipsilateral common carotid artery is clamped. Nu­
merous modalities exist for neuromonitoring, including elec­
troencephalography (EEG), transcranial Doppler, near-infrared
spectroscopy, and stump pressure measurement. An indwelling
carotid shunt may be placed to improve ipsilateral blood flow
when monitoring indicates cerebral perfusion is inadequate.
This problem occurs infrequently, as only the common carotid
is occluded, but preparations should be made for shunting pro­
cedures when indicated. Alternatively, as with carotid endarter­
ectomy (CEA), in the absence of neuromonitoring, shunts may
be placed prophylactically to preserve carotid flow in all cases.
• Invasive continuous arterial pressure monitoring is routinely
employed, with line placement dictated by the laterality of the
procedure. Keeping in mind the potential need to occlude the
subclavian artery for the reconstruction, the arterial line should
be placed in the contralateral limb or in a femoral artery.
Positioning
• The patient is positioned supine with the head rotated away
from the operative side. A pneumatic pillow is placed under
the shoulders to allow for neck extension. Careful attention
must be paid to achieve maximum neck extension while still
supporting the occiput. The bed is placed in a semi-Fowler's
position to reduce venous pressure and minimize bleeding.
• For carotid---<:arotid bypass, the head is positioned midline to
facilitate bilateral dissection.
 C h a p t e r 2 EXTRATHORACIC REVASC U LARIZAT I O N 181 1

CAROTI D-S U BCLAVIAN BYPASS

Exposure of the Subclavian Artery

• The i n cision is exte nded from the latera l aspect of the

c l avicu l a r head of the ste rnoc l e i domastoid (SCM) m u scle
l atera l ly across the s u p ra c l avicu l a r fossa. T h i s is f u rther
developed t h ro u g h the su bcuta neous tissue a n d pla­
tys ma with e l ectroca utery. If the exte r n a l j u g u l a r ve i n i s
encou ntered, it sho u l d be l i g ated a n d d ivided.
• Suffi cient clavicu l a r head of the SCM is d ivided to
a l low for a d e q u ate m ed i a l expos u re . U p to one- h a l f of
the ste r n a l head of the SCM can a l so be d ivided if a lso
needed, but t h i s is rarely n ecessa ry. The sca l e n e fat pad i s
then visua l i zed a n d d ivided . It is prefera b l e t o d ivide t h i s
near i t s i nferior borde r s o t h a t most o f the f a t pad can
be preserved a n d reclosed to cover the reconstruction.
Ca re m ust be taken to i d e ntify a n d p rese rve the phrenic
nerve as it cou rses ove r the a nterior sca lene m uscle deep
to the fat p a d . The thoracic d u ct is easily identified . If it i s
i n j u red or i n the way, it sho u l d be l i g ated t o p reve nt sig­
n ificant morb i d ity from a postoperative lym p h atic leak.
• Once the fat pad has been mob i l ized, the a nterior sca lene FIG 2 • The s u bclavian a rte ry a n d its branches a re
m uscle is d ivided to reveal the u nderlying subclavian artery circumferent i a l l y d i ssected a n d controlled with vessel loops.
(FIG 1 ). It is best to d ivide the m uscle slowly a n d in layers to
prevent i nj u ry to the u nderlying vessel . The subclavian a r­
Exposure of Carotid Artery
tery is dissected circu mferentia l ly a n d control led with vessel
loops. Care m ust be taken when m a n i p u lating this vessel, as • I n the m ed i a l aspect of the wou nd, the l atera l bord er
the subclavian a rtery is sign ificantly more fra g i l e a n d prone of the i ntern a l j u g u l a r ve i n is i d e ntified a n d sharply de­
to i nj u ry than lower extrem ity a rteries of com parable d ia m­ fined. The vein is retracted poste riorly and the ca rot i d
eter (e.g., femora l or pop l itea l). Depe n d i n g on the method sheath is entered from the latera l poste rior m a rg i n . Ca re
of reconstruction and location of the p l a n ned anastomosis, m u st be taken to ide ntify the va g u s n e rve early, as its
the thyrocervical tru n k, i nferior m a m m a ry, and vertebral u s u a l posterior position p l aces it i m med iately in the fi eld
a rteries may need to be controlled sepa rately (FIG 2). of d i ssection as the shea th is opened from t h i s a p p roac h .

Sternal head
sternocleidomastoid

Phrenic nerve

Anterior scalene

FIG 1 • The skin i n cision is p l aced

in the supraclavicu l a r fossa over the
Cut edge clavicular head clavicu l a r head of the SCM m uscle.
sternocleidomastoid The subclavian a rtery l i es d i rectly
beneath the a nterior sca lene m uscle.
Care m ust be taken to ide ntify and
preserve the phrenic nerve when
d i vi d i n g the a nterior sca lene m uscle.
1812 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY
FIG 3 • The carotid a rtery is d issected ci rcumferentia l ly after
ente r i n g the ca rotid sh eath from its poster i o r latera l m a rg i n .
T h e i ntern a l j u g u l a r vein c a n b e seen retracted o u t o f t h e way.
The va g u s n e rve is r u n n i n g p a ra l l e l to the a rtery between it
a n d the n e rve.
• The c o m m o n ca rotid a rte ry is d issected ci rcu mferent i a l ly
(FIG 3) . O n ly 5 em of a rtery needs to be isolated i n order
to o bta i n control a n d perform the a n asto mosis. The d is­
sect i o n s h o u l d stay proxi m a l to the ca rotid b u l b, which
m i n i m izes risk of cere b ra l e m b o l ization a n d i n j u ry to
m o re proxi m a l n e rves.
Bypass
• Either Dacron or polytetrafl uo roethylene (PTFE) ca n be
used as con d u its for extrathoracic bypass with no d i ffer­
ence in o utco mes.2 Autogenous vei n g rafts shou l d be
Subclavian
art e ry
avoided, however, as their l o ng-term patency is i nferior to
p rosthetic in this location.3 We favor Dacron g iven the size
ra nges ava i l a b l e and the rel ative resista nce of the g raft to
k i n k i n g ove r the short d ista nce of the reco nstruct i o n .
• Prior to a rte r i a l c l a m p i ng, syste m i c a nticoag u l ation is
a c h i eved with i ntravenous heparin a d m i n istration. The
a ctivated clott i n g t i m e (ACT) should be m o n itored and
a d d i ti o n a l heparin a d m i n istered throughout the p roce­
d u re to m a i nta i n a d e q u ate anticoa g u lation.
• The subclavian a n a stomosis is perfo rmed fi rst. Arte r i a l
control (vesse l l o o p s o r c l a m ps) i s o bta i n e d a n d the vessel
is opened with a l o n g itud i n a l a rteriotomy. The a n asto­
mosis s h o u l d be fash ioned in the position m ost favora b l e
to the p l a n ned g raft. The g raft is beve l ed a n d t r i m m e d
so t h a t the g raft l i es at a n a p p roxi m ately GO-d eg ree
a n g l e to the a rtery. A r u n n i n g Pro l e n e suture is used to
perform the a n asto mosis with comp l et i o n of the back
wa l l fi rst. O n ce the a n asto mosis is co m p l ete, the g raft is
c l a m ped a n d f l ow restored to the a r m by u n c l a m p i n g the
subclavian a rte ry. It is usefu l to flush through the g raft
to remove a n y d e b ris pri or to open i n g to the a r m . The
g raft should a l so be flushed with h e p a r i n ized sa l i n e a n d
c l a m ped n e a r the a n asto mosis t o avo i d a n y throm bosis
of the sta g n a nt b l ood co l u m n with i n the g raft. If repa i rs
a re needed, control is restored a n d pledgeted sutu res a re
used to avo i d i nj u ry to the fra g i l e a rte ry.
• The g raft is ta i l o red to the a p p ropri ate l e n gth to p revent
red u n d a n cy and k i n k i n g , and beve led so that the heel of
the a n asto mosis w i l l l i e prox i m a l ly o n the carotid a rte ry.
As the c o m m o n ca rotid a rtery is c l a m ped, speci a l atten­
t i o n m u st be d i rected to n e u ro m o n ito r i n g ; s i g n ificantly
d i m i n ished cerebral perfusion, a lt h o u g h very u n com­
m o n , m a n d ates s h u nt p l acement at t h i s sta g e of the p ro­
ced u re . A l o n g itu d i n a l a rteriotomy is perfo rmed and the
prox i m a l a n asto m osis co m p l eted with r u n n i n g Pro l e n e
sutu re, a g a i n sta rti n g w i t h the back wa l l (FIGS 4 and S).
FIG 4 • After completing the d i sta l
a n a stomosis, the g raft a n d the subclavian
a rtery a re all contro l led a n d the prox i m a l
a n astomosis is performed i n a r u n n i n g
fash i o n . T h e g raft can be t u n neled superfi c i a l
o r deep t o the i nternal j u g u l a r ve i n depe n d i n g
o n patient a n atomy a n d s u rgeon p reference.
 C h a p t e r 2 EXTRATHORACIC REVASC U LARIZAT I O N
FIG 5 • T h e co m p l eted bypass g raft can cou rse anterior o r
poste rior to the i nte r n a l j u g u l a r ve i n . The p h r e n i c n e rve is
seen i n the l ower f i e l d .
• The f i n a l seq uence of c l a m p rem ova l is i m po rtant to p re­
vent e m b o l i s m to the b ra i n . Proxi m a l subclavian a rtery
control i s a g a i n o bta i n ed, and the c l a m p is rem oved from
the g raft. The prox i m a l ca rotid c l a m p is then removed to
a l l ow "flush i n g " d own the a rm rath e r t h a n to the b ra i n .
SUBCLAVIAN ARTERY TRANSPOS ITION
Exposure
• The subclavian a rte ry is exposed, as described i n the p re­
vious section, for ca rotid-s u bclavian bypass. The d issec­
tion m u st be carried p rox i m a l to the vertebral a rtery a n d
e n o u g h a rte ry m ust be exposed p roxi m a l ly t o a l low suf­
ficient length for the a n astomosis as we l l as control the
p roxi m a l stu m p . This can often be d iffi cult as a n a o rtic
a n e u rysm can occu py a s i g n ificant portion of the m e d i a s­
t i n u m l i m it i n g vessel m a n i p u lati o n .
• The carotid a rtery is exposed i n the same m a n n e r as
described i n the p revi ous sect i o n .
Division o f the Subclavian Artery
• Syste m i c h e p a r i n is a d m i n i stered, a n d maxi m u m a rte­
r i a l l en gth is o bta i n e d by adva n c i n g a Coo ley c l a m p as
deeply as possi b l e i nto the m e d i asti n u m a l o n g the sub­
clavian a rte ry. A d ista l atra u m atic c l a m p is then a p p l ied,
typ i ca l ly i n the m i dsubclavian a rte ry, with the m o re p rox­
i m a l branches i n d ivi d u a l ly contro l led with vessel loops.
There m ust be adeq u ate d i stance betwee n the p roxi m a l
c l a m p a n d t h e verte bral a rte ry t o a l low f o r p roxi m a l con-
tro l , transposition, a n d a n asto mosis. Prior to transection,
pledgeted 5-0 Pro l e n e stay sutu res a re p l a ced on each
side of the p roxi m a l a rtery to e n s u re that if c l a m p control
1813
After a few ca rdiac cyc l es, the d i sta l ca rotid c l a m p is a l so
remove d . The prox i m a l subclavian a rtery is then released
as we l l .
• When performed i n a ntici pat i o n of thoracic a o rtic stent
g raft i n g , the subclavian a rtery m ust be l i g ated p roxi m a l
t o t h e o r i g i n o f t h e verte bra l a rte ry. T h i s c a n i nvolve
d i ssection deep i nto the m e d i asti n u m and ca rries an i n ­
h e rent r i s k of catastro p h i c b l eed i n g . Alternative ly, t h e
p roxi m a l subclavian a rtery can be contro l l ed b y p l ace­
ment of an i ntra a rte r i a l occ l u s i o n device (e . g . , A m p­
l atzer), either d u r i n g the ca rotid-s u bclavian bypass or at
the t i m e of su bsequent ste nt g raft p l acement via a l eft
b rach i a l a p p roach 4
Closure
• If a p n e u m atic p i l l ow was used to p rovide exposu re, it is
d efl ated p r i o r to wo u n d closure i n order to red uce neck
extension and assist i n a l l ow i n g the wo u n d to be cl osed
without tensi o n .
• A c l osed suct i o n d r a i n is left i n the deep wound a n d
brought out t h r o u g h a sepa rate sta b i n c i s i o n .
• I n order to provide coverage for the g raft, the sca l e n e fat
pad is retu rned to its a n ato m i c l ocation a n d sutu red i n
p l a ce . T h e S C M is rea p p rox i m ated with r u n n i n g a bsorb­
able sutu res.
• The p l atysma a n d su bcuta neous tissues a re cl osed i n
sepa rate l ayers i n a r u n n i n g fash i o n a n d t h e s k i n is reap-
p roxi m ated with a r u n n i n g d e r m a l suture.
is l ost for a n y reason, the open a rte ry d oes not retract
i nto the m e d i asti n u m (FIG 6).
• The p roxi m a l subclavian a rtery is oversewn by exte n d i n g
the stay sutu res across t h e stu m p . Hemostasis is confirmed
by slowly releasing clamp contro l while m a i nta i n i n g trac­
tion o n the stay sutu res. Only once hem ostasis is rigorously
ensured a re the sutu res d ivided and the p roxi m a l subcla­
vian a rtery a l lowed to retract i nto the mediasti n u m .
Carotid-Subclavian Anastomosis
• The subclavian a rte ry, having been freed ci rcu mferen­
t i a l ly, i s then m o b i l ized toward the carotid a rte ry. It may
be t u n neled a nte rior o r poste rior to the i ntern a l j u g u l a r
ve i n d e pe n d i n g o n t h e l e n gth o f t h e a rtery a n d patie nt­
specific a n atomy. The ca rotid a rtery is then c l a m ped
p roxi m a l ly and d i sta l ly and the a n asto mosis pe rfo rmed
in the sta n d a rd r u n n i n g fash i o n . Prior control of the sub­
clavian a rtery is m a i ntained (FIG 7) . As the a n a stomosis
i s com p l eted, the u n c l a m p i n g seq uence s h o u l d be re­
peated as described i n the p reced i n g sect i o n to p revent
i n a dvertent a i r o r p a rticu l ate e m b o l i zation to the b ra i n .
Closure
• As descri bed in the section on ca rotid-subclavian bypass,
the wou n d is cl osed i n m u lti ple layers over a closed suction
d ra i n p l aced through a sepa rate sta b incision.
1814 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

F I G 6 • The s u bclavian a rtery a n d i t s branches

a re contro l l ed i n d ivid u a l ly with vesse l loops a n d
c l a m ps. A Cooley c l a m p is used prox i ma l ly o n
the s u bclavian a rte ry. Stay sutu res of 5 - 0 Pro l e n e
a re p l aced i n both ends of the s u bclavian a rtery
prox i m a l to the transection l i n e .

F I G 7 • T h e subclavian a rte ry i s m o b i l i zed so t h a t i t

may reach t o the carotid a rtery a n d the e n d-to-side
a n astomosis is performed i n the sta n d a rd r u n n i n g
fash ion, sta rt i n g a l o n g t h e b a c k wa l l . T h e thyrocervical
tru n k may be d ivided if necessary to fac i l itate
m o b i l izat i o n .

CAROTI D-CAROTI D BYPASS • The S C M is m o b i l ized latera l ly by c a r ry i n g t h e d i s­

sect i o n down towa rd the i nter n a l j u g u l a r ve i n ; t h i s
Exposure of the Bilateral Carotid Arteries exposes t h e c a r o t i d s h e a t h . Any b r i d g i n g ve i n s e n ­
• B i l atera l i ncisions a re m a d e ove r the a nterior border of cou ntered c a n be d iv i d ed; h oweve r, t h e e n t i re d i ssec­
the SCM at the base of the neck. The su bcuta neous tis­ t i o n s h o u l d be b e l ow t h e l evel of t h e faci a l v e i n , a s
sues and p l atysm a a re d ivided and the a nterior border of t h i s m a rks t h e c a r o t i d b i f u rcat i o n . F o r t h i s proce d u re,
the SCM is i d e ntifi e d . t h e re i s no need to risk i nj u ry to a d j a cent st r u ct u res by
 C h a p t e r 2 EXTRATHORACIC REVASC U LARIZAT I O N
expos i n g t h e carotid b i f u rcat i o n . T o o bta i n s u ffi c i e n t
p roxi m a l exposu re, t h e o m o h y o i d m u s c l e m a y n e e d t o
b e d i v i d e d b i l atera l l y.
• The ca rotid sheath is e ntered sharply on its a nte rior
su rface. The va g u s n e rve m ust be i d e ntified with i n the
ca rotid sheath a n d p rotected as the common carot i d
a rtery is exposed a n d contro l l e d .
Graft Tunneling and Anastomosis
• O n ce the b i l atera l c o m m o n ca rotid a rteries a re suffi­
ciently exposed and contro l l ed, the a p p ro p riate g raft
t u n n e l ca n be create d . Tu n n e l i n g is a c h i eved via b l u nt f i n ­
g e r d i ssection f r o m both s i d es of the n e c k . The g raft m a y
be t u n neled e i t h e r between the trachea a n d eso p h a g u s
o r b e h i n d the eso phag us, d e pe n d i n g o n patient h a b itus
a n d s u rgeon p refe rence (FIG 8). Care m u st obviously
be taken to avo i d i n j u ries to th ese critica l struct u res.
P l a cement of an orogastric or nasogastric tube p rio r to
creati o n of the d i ssection p l a n e can be h e l pf u l for identi­
fyi n g the eso p h a g u s .
• O n ce the t u n n e l has been deve l o ped, the g raft is passed
and patient syste m i ca l ly a nticoa g u lated with i ntrave-
n o u s h e p a r i n a d m i n istrat i o n .
• T h e a nastomoses a re performed i n t h e sta ndard r u n n i n g
fashion; either one m a y b e performed fi rst. Careful attention
Common
I nternal
jugular
vein
1815
must be p a i d t o neuromonitoring a s t h e carotid a rtery i s
clamped.
• O n ce the fi rst a n asto m osis is co m p l ete, the g raft is
c l a m ped a n d ca rotid a rtery f l ow restored o n that si de.
Prior to removi n g the d ista l ca rot i d a rtery c l a m p, the
d i sta l a rtery can be back-bled a n d the proxi m a l a rtery
f l u shed out the open g raft. As with the subclavian a rte ry,
the g raft s h o u l d be flushed with h e p a r i n ized sa l i n e a n d
c l a m ped c l ose t o t h e a n asto mosis t o avo i d a l o n g stag ­
nant col u m n of blood with i n the p rosthetic g raft.
• The contra l atera l a n astomosis is then performed in the
same fash i o n (FIG 9) . The g raft should be flushed with
h e p a r i n ized sa l i n e a n d the g raft, p roxi m a l ca rotid a rte ry,
a n d d ista l carotid a rtery shou l d be vi gorously flushed
pri or to completion.
Closure
• H e m osta s i s is obta i n e d . The neck wo u n d s a re c l osed
in l aye rs, fi rst ta k i n g ca re to rea p p roxi m ate t h e SCM
in its a n ato m i c posit i o n with i nterru pted a b s o r b a b l e
sutu res .
• A cl osed suct i o n d r a i n is l eft i n each wo u n d .
• The p l atysma a n d su bcuta neous tissues a re cl osed with
r u n n i n g a bsorba b l e sutu res and the skin rea p p roxi m ated
with a r u n n i n g deep d e r m a l suture.
FIG 8 • After iso l ati n g both com m o n ca rot i d a rteri es, a
retro p h a ryngeal t u n n e l is fash ioned u s i n g b l u nt f i n g e r
d i ssect i o n . The p l acement of a nasog astric o r orogastric t u b e
a l l ows for easy i d e ntification a n d p rotection of the eso p h a g u s .
1816 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

Internal

vein

Common
carotid
artery

FIG 9 • The d istal a nastomosis is performed in the

standard ru nning fash ion starti ng with the back wa l l . Prior
to completing the anastomosis, the carotid a rteries and graft
should be back-bled and fl ushed with heparin ized sa l i ne.

PEARLS AND PITFALLS

Positi o n i n g
Thoracic d u ct
S u bclavian a rtery control
S u bclavian a rtery
a n asto mosis
Position i n g vis-a-vis the
i ntern a l j u g u l a r ve i n
Proxi m a l subclavian con­
trol d u r i n g transposition
Common ca rot i d a rtery
expos u re
Closure
• When i nflating the p n e u m atic p i l l ow, care m u st be taken to e n s u re that the occ i put is adeq uately
s u p po rted. Fa i l u re to a d e q u ately s u p p o rt the head may result i n cervical spine and n e u ro l o g i c
i n j u ries.
• G reat care m ust be taken to avo i d i n j u r i n g the thoracic d uct when expos i n g the subclavian a rte ry.
A l l lymphatic tissue encou ntered s h o u l d be l i g ated before b e i n g d ivided as the ensu i n g lymphatic
leak ca n be q u ite tro u b lesome for the patient a n d the surgeon.
• The s u b c l a v i a n a rtery c a n be contro l l e d e i t h e r with vesse l l o o p s o r with atra u m at i c vascu l a r
c l a m ps, d e p e n d i n g o n w h i c h h e l ps t o better d e l iver t h e a rte ry i nto t h e wo u n d w i t h o u t u n d u e
tensi o n .
• T h e subclavian a rte ry is exceed i n g l y fri a b l e a n d s h o u l d be h a n d led ca refu l ly. G iven t h e exposu re, it
may be easier to parach ute the a n asto mosis rath e r than fix the suture l i n e at the heel of the
a n asto mosis.
• Depe n d i n g o n the h a b itus of the i n d ivid u a l patie nt, the g raft may lie better t u n neled either a bove
o r below the i nte r n a l j u g u l a r ve i n . It i s p r u d e nt to explore both options pri or to creat i n g a n d com­
p l et i n g the ca rot i d a n a stomosis.
• The use of stay sutu res o n the proxi m a l s u bclavian a rtery i n subclavian a rte ry transposition is cru­
cia l . Once the stay sutu re o n the prox i m a l e n d of the a rtery is released, the a rtery retracts deep
i nto the m e d i asti n u m a n d is not retrieva b l e . U n contro l led b l eed i n g may be d i sastro us a n d lead to
fata l co m p l i cations. As such, the proxi m a l oversewed subclavian a rtery m ust be hem ostatic prior
to rel ease of the stay sutu res. Stay suture safety i s ensu red by p l acement of pledgeted sutu res at
either end of the subclavian closure .
• It is n ot n ecessa ry a n d n ot advisa b l e to expose o r m a n i p u late the ca rotid b u l b o r b i f u rcation i n per­
form i n g a ny of these reco nstructions u n l ess a concomitant CEA is n ecessa ry or the bifurcati o n is situ­
ated l ow i n the neck. These p roced u res a re performed o n the common ca rotid a rtery, and expos i n g
the b i f u rcati o n o n l y i n c reases the r i s k of cra n i a l n e rve i n j u ry a n d stro ke.
• The pneu matic p i l l ow should be deflated prior to closure to assist i n bri n g i n g the tissue together
without tension.
 C h a p t e r 2 EXTRATHORACIC REVASC U LARIZAT I O N
POSTOPERATIVE CARE
• Careful attention should be paid to both systolic and mean
arterial blood pressure in the postoperative period. Invasive
arterial monitoring is usually maintained for the first
24 hours. When carotid-subclavian bypass or subclavian
artery transposition is performed, blood pressure should be
monitored in the contralateral arm.
• Neurologic status and distal pulses should be followed
closely in the postoperative period. Any pulse changes need
to be rigorously investigated as they may indicate the pres­
ence of either graft occlusion or distal embolization.
• When carotid-subclavian bypass, where the proximal sub­
clavian artery is not ligated, is performed as a debranching
procedure prior to thoracic aortic stent grafting, the timing
of the endovascular procedure is important. In these patients
who tend not to have concomitant occlusive disease, there is
competitive flow via the native circulation, putting the newly
placed graft at risk of thrombosis. In the absence of compli­
cations or other mitigating circumstances, the endovascular
aortic procedure should be performed within 3 to 5 days of
the debranching bypass.
• Patients should be placed on aspirin therapy and followed at
regular intervals with duplex ultrasonography.
OUTCOMES
• Recent review of the American College of Surgeons National
Surgical Quality Improvement Program (ACS-NSQIP) data­
base from 2005 to 2 0 1 0 demonstrates that extrathoracic
revascularization carries a 3 . 5 % risk of stroke and 3 . 3 %
risk o f death i n the immediate perioperative period.5 Over
this time period, 9 1 8 procedures were performed, with 1 0 %
o f them a s part o f a staged approach t o thoracic aortic stent
grafting.
• Carotid-subclavian bypass has excellent durability. In a
series of 284 consecutive patients, Takach and colleagues2
reported 5-, 1 0-, and 1 5 -year primary patency rates of
9 4 % , 8 8 % , and 8 6 % , respectively. These results have sub­
sequently been replicated by other large, multiple-decade
series.6 Subclavian artery transposition has similarly out­
standing long-term patency, with rates as high as 9 9 % re­
ported at 5 years.6•7
• Symptom-free survival following revascularization is like­
wise excellent, with long-term results approaching 8 8 % to
9 9 % at 5 years.6•7
COMPLICATIONS
• The thoracic duct lies at the medial aspect of the field of
dissection when dissecting in the supraclavicular fossa. This
can be easily inj ured and remain undetected during the
course of the operation. Continued or milky drainage is a
clear sign of duct injury. The oral administration of cream
can be used to promote chyle flow, and if a leak is pres­
ent, will promptly increase drain output. When this occurs,
the closed suction drain should be left in place, the patient
kept fasting, and parenteral nutrition instituted. With con­
servative management, some of these inj uries may close
without further intervention. The complete management of
1817
this complication is beyond the scope of this text; however,
it should be mentioned that reexploration of the wound in
the early period is relatively straightforward and may repre­
sent the best way to resolve the problem. Late reexploration
can be fraught with difficulty finding the leak as the tissue
becomes fixed. A muscle flap may then be needed to close
the space. The main concern with a persistent leak is the
potential for graft infection. Unfortunately, early wound re­
exploration significantly increases the risk of prosthetic graft
infection as well.
• The vagus, phrenic, and recurrent laryngeal nerves, as well
as the brachial plexus, can all be injured as a result of carotid
and subclavian artery exposure. Most injuries are due to
traction rather than transection, and conservative therapy
will generally resolve symptoms over the course of months
to a year. In the case of a staged bilateral subclavian revascu­
larization, it is important to ensure that any vagus or phrenic
nerve injury has resolved prior to contralateral intervention,
as bilateral inj uries can lead to tracheal obstruction and
acute respiratory failure.
• Although uncommon, significant bleeding from the wound
should mandate reexploration. More commonly, minor
wound hematomas may develop that can be observed.
Judgment regarding the need for reexploration of a neck
hematoma is similar to that required during any other neck
procedure.
• Infection of the wound can be devastating if prosthetic is
involved. Local cellulitis should be treated aggressively with
early institution of antibiotics in order to prevent deeper
infection. Upon removal of the drain, it is important that
the drain site does not continue to leak, as continued leak­
age may act as an entry point for bacterial contamination.
Simple suture closure should resolve this. Prosthetic graft
infection necessitates graft removal, which is extremely dif­
ficult and beyond the scope of this chapter.
• Although uncommon, stroke is a complication of any carotid
procedure. Taking the precautions outlined previously in
this chapter should minimize these risks.
REFERENCES
1. Morasch MD. Technique for subclavian to carotid transposition, tips,
and tricks. J Vase Surg. 2009;49(1):251-254.
2. Takach TJ, Duncan JM, Livesay JJ, et al. Contemporary relevancy
of carotid-subclavian bypass defined by an experience spanning
five decades. Ann Vase Surg. 20 1 1;25(7):895-901.
3. Ziomek S, Quinones-Baldrich WJ, Busuttil RW, et al. The superiority
of synthetic arterial grafts over autologous veins in carotid-subclavian
bypass. J Vase Surg. 1986;3(1 ):140-145.
4. Woo EY, Bavaria JE, Pochettino A, et al. Techniques for preserving
vertebral artery perfusion during thoracic aortic stent grafting requir­
ing aortic arch landing. Vase Endovaseular Surg. 2006;40(5):367-373.
5. Madenci AL, Ozaki CK, Belkin M, et al. Carotid-subclavian bypass
and subclavian-carotid transposition in the thoracic endovascular aor­
tic repair era. } Vase Surg. 20 1 3;57(5):1275-1282.
6. Cina CS, Safar HA, Lagana A, et al. Subclavian carotid transposition
and bypass grafting: consecutive cohort study and systematic review.
J Vase Surg. 2002;35(3):422-429.
7. Berguer R, Morasch MD, Kline RA, et al. Cervical reconstruc­
tion of the supra-aortic trunks: a 16-year experience. J Vase Surg.
1 999;29(2):239-246; discussion 246-248.

Chapter 3 Carotid Surgery:
Interposition/Endarterectomy
{Including Eversion)/Ligation
I
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - · - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Vinit N. Varu
DEFINITION
• Stroke is the leading cause of disability in the United States
and Western Europe and the third leading cause of death
behind coronary artery disease and cancer.
• Pivotal studies have shown the efficacy of carotid endarter­
ectomy ( CEA) in stroke prevention in both symptomatic and
asymptomatic patients with internal carotid artery (ICA)
stenosis versus medical therapy alone. 1•2
• CEA is defined as the surgical excision of atherosclerotic
lesions of the intima and tunica media of the carotid artery.
• Occasionally, ICA ligation and/or interposition bypass may
be indicated for stroke prevention.
PATIENT HISTORY AND PHYSICAL
FINDINGS
• Patients may be entirely asymptomatic and still benefit from
carotid intervention to prevent long-term stroke. In the
United States, most CEA procedures are performed on
asymptomatic patients. Symptoms of cerebroembolic dis­
ease originating from the carotid bifurcation, when present,
may include dysarthria, dysphasia, aphasia, hemiparesis,
or hemisensory deficit or amaurosis fugax. Symptoms that
resolve within 24 hours are defined as transient ischemic
attacks (TIAs) regardless of severity; symptoms that persist
past the first day constitute a stroke.
• For patients at risk for cerebroembolic disease, a thorough
vascular history is obtained including modifiable risk factors
such as smoking, hyperlipidemia, hypertension, and diabe­
tes management. Prior to surgery, single-agent antiplatelet
therapy is initiated and continued indefinitely following
intervention. Blood pressure control at or below 140 mmHg
systolic and 90 mmHg diastolic is the single most impor­
tant medical intervention to reduce stroke risk. 3 Sufficient
13-blockade to stabilize resting heart rate at 60 bpm is also
instituted prior to surgery to limit perioperative myocardial
oxygen demand unless contraindicated.4
• Cervical auscultation is performed in both the supraclavicu­
lar and mandibular regions. Bruits appreciated at the man­
dibular angle usually indicate ICA or bifurcation disease.
More proximal bruits may indicate common carotid artery
( CCA) disease or radiating heart sounds.
• A full neurologic assessment including mental status, speech,
facial symmetry, and extremity strength must be obtained
and documented prior to surgery.
IMAGING AND OTHER DIAGNOSTIC
STUDIES
• All patients exhibiting symptoms of carotid territory isch­
emia need appropriate vascular imaging studies. Screening
1818
-
·
Wei Zhou
is not recommended to detect asymptomatic disease in the
general population; patients with appropriate risk factors,
or those with a bruit on physical exam should be evaluated
when clinical circumstances warrant.
• Carotid duplex ultrasound provides a reliable and accu­
rate noninvasive tool to identify predicted stenosis and is
the initial diagnostic study of choice. Peak systolic veloc­
ity (PSV) higher than 125 em per second predicts angio­
graphic stenosis more than 5 0 % and higher than 230 em
per second predicts more than 70% stenosis. However, a
combination of PSV, end diastolic velocity, and the PSV
ratio of ICA to CCA is more accurate in estimating sig­
nificant carotid stenosis. In general, end diastolic veloc­
ity higher than 1 0 0 em per second correlates to more than
8 0 % carotid stenosis.
• When duplex imaging is not definitive, as is the case in the
setting of extensive carotid bifurcation calcification, addi­
tional cross-sectional imaging (computed tomography angi­
ography [CTA] or magnetic resonance angiography [MRA] )
may be necessary to quantify the degree of stenosis. When
accurate velocity information is obtainable, duplex imaging
provides the most accurate and physiologically relevant esti­
mates of percent diameter reduction.
SURGICAL MANAGEMENT
Indications
Endarterectomy
• The Society for Vascular Surgery recommends that neu­
rologically symptomatic patients with greater than 5 0 %
stenosis o r asymptomatic patients with greater than 6 0 %
stenosis should be offered CEA t o reduce risk of recurrent
or initial stroke, respectively. Endarterectomy is appropriate
for patients with at least a 3- to 5-year life expectancy with
perioperative stroke/death rates less than 3 % . In all other
circumstances, optimal medical therapy is preferred.5
• Surgical endarterectomy is the procedure of choice for
good-risk surgical patients with normal cervical anatomy.
For selected high-risk patients, such as those with tracheal
stoma, previously radiated neck, prior cranial nerve inj ury,
or lesions proximal to the clavicle or distal to C2 vertebral
body, transcatheter angioplasty and stenting is generally the
preferred approach. 5 Indications and technical guidelines for
carotid angioplasty and stenting procedures are discussed in
Part 6, Chapter 4 .
Carotid Artery Interposition Bypass
• Reconstruction for extensive bifurcation disease, injury to
the bifurcation during endarterectomy, or aggressive reste­
nosis following previous intervention (endarterectomy or
stem placement} is best accomplished by carotid resection
 C h a p t e r 3 CAROT I D S U R G E RY: I nterpos i t i o n/Endarterectomy ( I n c l u d i n g Evers i on)/L i g a t i o n
and interposition grafting. Other indications include the
following:
Significant diffuse CCA and ICA disease
Radiation-induced stenosis or other forms of arteritis
involving long arterial segments
Aneurysms (degenerative or traumatic) and invasive carotid
body tumors.
Ligation
• Ligation and resection of the proximal ICA may be indicated
in the setting of carotid stump syndrome, when persistent
distal embolization from the " cul-de-sac" of the occluded
ICA may reflux into collateral pathways, such as through
the ophthalmic artery into the distal ICA.
Preoperative Planning
• Similar outcomes are achieved with general anesthesia or
regional anesthesia.
• Use of shunt during CEA is dependent on operator prefer­
ence. Most surgeons either shunt selectively or use a shunt
for all cases. Some surgeons never shunt.6 Surgeons should
develop the methods they feel most comfortable with to opti­
mize outcome. Obj ective measures that may influence shunt
usage include stump pressure measurement, electroencepha­
lographic monitoring, and transcranial Doppler assessment.
Data supporting use of these adjuvants is inconsistent, and
none is considered standard of care nationally.
• Optimal neck extension is obtained by placing a towel or
gel roll behind the scapula. The head is rotated contralat­
eral to the operative side. In older patients, often with lim­
ited neck movement or prior cervical fusions, padding and
shay positioning must be sufficient to support the neck to
prevent hyperextension inj ury. The chin, angle of the man­
dible, lower earlobe, and sternal angle are prepped and pre­
liminarily draped within the operative field. The bed itself
CAROTI D E N DARTERECTOMY­
PATCH AN G I OPLASTY
Incision
• The s k i n i ncision is opti m a l ly p l aced a l o n g the a nte rior
border of the sternocleidomasto i d m uscle. This s h o u l d be
cu rved poste rol atera l ly near the a n g l e of the m a n d i b l e
t o avoid d i ssection i nto the pa rot i d g l a n d .
• Alternatively, a m o re transverse i n c i s i o n can be m a d e at
the level of the ca rotid bifu rcati o n . Alth o u g h p rovi d i n g
a n i m p roved cosmetic resu lt, expos u re o f t h e d i stal I CA
may be compromised with t h i s a p p roach (FIG 2) .
Carotid Exposure and Control
• As the i ncision is extended through the p l atysm a m u scle,
the a nterior border of the sternocleidomasto i d m uscle
is visual ized a n d retracted poste rol atera l ly. The g reater
a u ri c u l a r n e rve s h o u l d be i d e ntified and p rotected at the
s u pe rior exte nt of the i n c i s i o n .
1819
FIG 1 • Reco m m e n d e d patient position for a CEA p roced u re.
can be flexed with the head in relative extension to aid in
positioning ( FIG 1 ) .
• Arterial blood pressure monitoring i s necessary for optimal
anesthetic management. Bladder catheterization is performed
if the procedure is expected to extend beyond 2 hours. If end­
arterectomy is performed with regional anesthesia, an audi­
ble squeeze device is placed in the patient's contralateral hand
for indirect neurologic monitoring. Preoperative antibiotics
are administered routinely.
• Aspirin therapy is initiated well in advance of surgery and
continued throughout the perioperative period. Evidence
suggests that statin therapy, initiated preoperatively, reduces
postoperative neurologic events and mortality.7
• F o l l o w i n g fasc i a l i ncision, the fa c i a l ve i n i s identified a n d
secu rely l i g ated . T h i s ve i n u s u a l ly transverses t h e CCA
n e a r the bifu rcati o n . Fa i l u re to adeq uately secu re this
ve i n may lead to bleed i n g a n d a i rway co m p ro m i se d u r­
i n g postoperative co u g h spe l l s or Va lsa lva m a n e uvers.
• With i n the ca rotid sheath, the va g u s n e rve usua l ly ex­
te nds poste rior to, and p a ra l l e l with, the a rtery and ve i n .
H oweve r, t h i s posit i o n rel ative t o t h e oth e r contents of
the ca rotid sheath may va ry, a n d the va g u s s h o u l d a lways
be i d e ntified and p rotected in the cou rse of the d i ssec­
t i o n . The a nsa cervi ca l is n e rve is co m m o n l y m uch s m a l l e r
t h a n the va g u s a n d r u n s a nte rior t o the carotid bi furca­
tion. When co m p l etely iso l ated, the p roxi m a l a nsa a rises
from the i p s i l atera l hypog l ossa l (XI I ) cra n i a l n e rve. The
a nsa cervica l is can be d ivided to i m p rove exposure if n ec­
essa ry o r m o b i l ized suffi ciently to be gently retracted out
of the ope rative f i e l d .
• T h e CCA is circu mferentially d issected from surround­
i n g structu res i n sufficient length to provide adequate
exposure for proxi m a l clamping a n d contro l . The CCA is
1820 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

External carotid artery

Line of incision

Cornman carotid artery

Sternal head of
sternocleidomastoid
muscle

FIG 2 • The i n c i s i o n a l o n g the a nte rior border of sternocleidomasto i d (SCM) m uscle is the
m ost co m m o n l y used incision for a CEA proce d u re. A tra nsverse incision along a s k i n crease
in the vici n ity of the ca rotid b i f u rcation is an a lternative i n c i s i o n for a bette r cosmetic resu lt.
CCA, common ca rot i d a rte ry; I CA, i nte r n a l ca rotid a rte ry; ECA, exte r n a l ca rotid a rte ry.

opti m a l ly contro l led by p lacement of an a ppropriately • C l a m p i n g of I CA is performed fi rst, fo l l owed by control of

sized, atra u m atic vascu l a r cl am p such as a G regory pro­ the exte r n a l a n d c o m m o n ca rotid a rteries. This seq uence
funda c l a m p . The ratchet should be engaged o n ly to the is fo l l owed to m i n i m ize e m b o l ization risk associ ated with
m i n i m a l a m o u nt necessa ry to control bleed i n g to prevent cla m p i n g . When n ecessa ry, measurement of ICA stu m p
intimal injury and dissection at the site of c l a m p p l acement. p ressu re is o bta i n e d a t t h i s j u nctu re b y ca n n u lation of
• F o l l o w i n g co m m o n carotid control, the d issect i o n i s ex­ the ca rotid b i f u rcat i o n a n d sel ective remova l of the i n ­
tended cra n i a l ly and poste riorly a l o n g the poste rol at­ te r n a l carotid c l a m p .
e r a l border of the I CA. Deve l o p ment of the d i ssect i o n
p l a n e postero latera l l y a l o n g the proxi m a i i CA m i n i m izes
risk of hypogl ossa l n e rve i n j u ry. This d issect i o n is a l so
performed with m i n i m a l d is p l a cement a n d i nstr u m e nta­
tion of the ICA to red uce i ntraoperative e m b o l ization
risk (FIG 3) .
• To co m p l ete the n ecessa ry exposu re, the exte r n a l ca rot i d
a rtery (E CA) is d issected a n d m o b i l ized to at least the l evel
of the superior thyro i d a l a rte ry. The superior l a ryngeal
n e rve may a l so be encou ntered poste rior to the ca rot i d
b ifurcation i n t h i s a re a .
• F o l l o w i n g d i ssection, a n d p r i o r to c l a m p p l ace m e nt, suf­
ficient u nfract i o n ated h e p a r i n is a d m i n istered i ntrave­
nously to o bta i n an activated c l ott i n g t i m e (ACT) of more FIG 3 • Exposure o f ca rotid bi furcat i o n . Va g us n e rve a n d
than 200 seco nds. With n o r m a l c i rc u l ation t i m es, t h i s is hypog l ossa l n e rve a re most co m m o n ly encou ntered n e rves
usu a l ly acco m p l ished with i n 2 o r 3 m i n utes of i nject i o n . d u ri n g ca rotid d i ssect i o n .
 C h a p t e r 3 CAROT I D S U R G E RY: I nterpos i t i o n/Endarterectomy ( I n c l u d i n g Evers i on)/L i g a t i o n
Conventional Endarterectomy
• The a rteriotomy is i n itiated in a soft, u n i nvolved prox i m a l
seg ment of the CCA a n d exte nded ce p h a l a d w i t h Potts
scissors. It sh o u l d be positioned on the a nte r i o r- l atera l
su rface of the I CA to avo i d the f l ow d i v i d e r. (FIG 4A) .
• When an i n d we l l i n g s h u nt is i n d i cated or req u i red, the
d i sta l tapered e n d is ca refu l ly i n se rted i nto the I CA u n d e r
d i rect visi o n . W e p refer the Pru itt- l n a h a ra s h u nt, whi c h
has p i lot b a l loons at b o t h ends to m a i nta i n s h u n t posi­
t i o n and hem ostasis. Once the d i stal e n d is i n se rted, the
d ista l b a l loon is i n f l ated with l ess t h a n 1 m l of air u n t i l
the " po p-off" ba l l oo n i nfl ates o n the p i lot tube. Fa m i l ­
i a r ity with t h i s s h u n t p rio r t o i nsertion is esse ntial; if the
i nflation override cuff covers the " po p-off" b a l loon o n
t h e p i lot tu be, overi nflation may i nj u re o r r u pt u re t h e
d i sta l I CA. F o l l o w i n g d ista l I CA ca n n u lation a n d b a l loon
i nflation, the s h u nt is back-bled to confirm l u m i n a l p l ace-
ment a n d decant a i r. With the s h u nt actively back- b l eed-
ing, the p roxi m a l e n d is i nserted i nto the CCA fo l l owed
by p rox i m a l c l a m p rem ova l i nto the u n o bstructed l u m e n .
T h e p roxi m a l p i l ot t u b e is i n f l ated w i t h the p rovi ded sy-
r i n g e u n t i l the cuff is p a l p a b l e in the CCA, after whi c h
a p repositioned R u m e l to u r n i q uet is gently cinched
a r o u n d the a rte ry. When performed q u ick ly, with concur-
rent d i g ita l control of the CCA fo l l ow i n g c l a m p rem ova l
a n d p r i o r to s h u nt i nsertion, m i n i m a l b l eed i n g ensues.
When sa l i n e is a p p l ied to the s h u nt tubing, p u lsati l e flow
is a p p reci a b l e with h a n d h e l d D o p p l e r i nsonati o n .
• At the site of maxi m a l atherosc l e rot ic d isease in the CCA,
the Penfi e l d k n i fe is e m p l oyed to i d e ntify a n d deve l o p
the a p p rop riate e n d a rterectomy p l a n e with i n the m ed i a l
l ayer. W h e n t h e correct p l a n e is i d e ntified, t h e p l a q u e i s
easily a n d ra p i d ly e l evated f r o m the u n d e r l y i n g adven­
titi a . I n a reas conta i n i n g i ntra p l a q u e hemorrhage, i n ­
f l a m mation may i n crease a d h e rence of the p l a q u e t o t h e
adventitia, a n d ca re s h o u l d be taken n o t t o exte n d t h e
d i ssect i o n p l a n e i nto the adventitia itse lf.
• At the d ista l extent plaque, sufficient exposure should be
present to create a defined endpoint, a l lowi ng p lacement
of tacki ng sutu res if necessa ry, ensuring that no further po­
tentially mobile plaque rem a i ns. It is essential to "feather"
the plaque at the d ista l endpoint to m i n i m ize risk for d ista l
dissection or thrombus accu m u lation . If the plaque extends
past the point where feathering is feasib le, a d ista l endpoint
should be determi ned a n d created sharply with scissors or a
no. 1 5 blade (FIG 48). Tacking sutu res, placed circu mferen­
tial ly, ca n control d ista l plaque at the transection site. Care
should be taken, however, to place the m i n i m a l n u mber of
sutu res necessa ry to prevent dissection, or consider extend-
ing the a rteriotomy a n d endarterectomy to identify a more
suitable term i nation site. Successful sutu re placement re­
q u i res circu mferentia l dissection and opti m a l visu a l ization.
• O n ce the d i sta l e n d point is determ i n ed, resi d u a l p l a q u e
is rem oved f r o m the E C A b y eve rs i o n i nto the C C A a n d
c i rcu mferent i a l d i ssection a n d tract i o n . S uffi cient back­
bleed i n g is perfo rmed to remove a n y l u m i n a l debris
with i n the ECA.
• D i rect visua l i zation of the e n d a rterectomy bed fo l l ow­
i n g p l a q u e rem ova l com m o n ly identifies l oosely attached
182 1
res i d u a l m ed i a l e l e m e nts. These a re best rem oved with
fine forceps u n d e r m a g n ificat i o n . Co m p l ete remova l is
fa c i l itated by conti n u ous i rrigation to identify m o b i l e
m ed i a l e l e m ents. I nteg rity o f the d i sta l a n d p roxi m a l
e n d p o i nts is a lso verified u s i n g t h i s tech n i q u e .
Patch Placement
• An appropriately sized bovine pericard ia I or Finesse Dacron
kn itted po lyester patch is selected a n d trimmed as neces-
sa ry for closu re-assisted a n g ioplasty. Both bovi ne pericar­
d i a ! a n d po lyester patches have chiral ity considerations;
one su rface is preferred for l u m i n a l a pposition. Please con­
sult the accompanying i nstructions for use prior to i m plan­
tation. Closu re is secu red with running 6-0 polypropylene
suture i n itiated at the cephalad extent of the a rteriotomy
and conti nued proxi m a l ly a long the long axis of the patch.
• After 9 0 % o r m o re of the c i rcu mference of the patch is
secu red, fl ush i n g is acco m p l ished by seq uentia l c l a m p
rem ova l a n d l u m i n a l i rrigation with h e p a r i n ized sa l i n e .
C l o s u re is then co m p l eted pri or to resto ration of fl ow.
• The decl a m p i n g seq uence is of critica l i m po rtance. The
CCA is rel eased fi rst, fo l l owed by the ECA c l a m p . After
seve r a l card i a c cyc les have ensued, the d ista l I CA is
released (FIG 4C) .
• W e perform i ntraoperative comp l et i o n d u p lex i m a g i n g
of the e n d a rte rectomy site as we l l as the proxi m a l a n d
d i sta l ca rotid a rteri es, with p u rpose-des i g n ed, m i n iatur­
ized 7 M H z probes. Comp leti o n d u p lex sca n n i n g is q u i ck,
efficie nt, h i g h l y re p ro d u c i b le, a n d effective at identify­
i n g s i g n ificant res i d u a l l u m i n a l d efects. Deta i l ed descrip­
t i o n of the cha racte ristics of s i g n ificant l u m i n a l d efects
i d e ntified by co m p l etion u ltraso n o g raphy a re beyo n d
the scope of t h i s cha pter. I ntraoperative i nsonation i s
n ot poss i b l e t h ro u g h extruded po lytetrafl u o roethy l e n e
(ePTFE) patches a n d s h o u l d n o t be attem pted .
Closure
• Following adequate d u plex i m a g i n g a n d endpoint de-
termi nation, a nticoa g u l ation is reversed with prota m i n e
sulfate. S o m e p ractitioners a re re l u ctant t o reverse a ntico­
a g u lation due to u n certa i nty regarding thrombogenicity
at the endarterectomy site. In o u r experience, tech n ical
issues at the endarte rectomy site a re most p red ictive of
postoperative n e u rologic events, a n d these a re efficiently
identified a n d corrected, when p rese nt, with com p l etion
u ltrasonography. Following reversa l, the entire wou n d is
inspected for venous o r a rterial bleed i n g . The enti rety of
the patch a ngioplasty suture l i n e is reinspected for period­
icity of suture p lacement a n d potential leaks. Rei nforci n g
sutu res a re a p p l ied l i bera l ly as needed to ensure hemo­
stasis, but with expe rience a n d even suture spacing, the
need for additional sutu res should be rare. B leed i n g lymph
nodes should be sutu red a n d removed from the operative
field. Confirmation of hem ostasis, the pl atysma is reap­
proxim ated with r u n n i n g a bsorba b l e suture fo l l owed by
skin closure. We usua l ly a lso perform a Va lsa lva m a neuver
to identify occult venous inju ries that may not be apparent
with positive p ressure venti lation prior to closu re.
1822 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

I ntimal tacking
suture

Line of incision

FIG 4 • Arte riotomy is exte nded from the a nte rior

su rface of CCA to the a nterior su rface of I CA d i stal to
the lesion (A) . I n t i m a l f l a p is tacked down to e n s u re
sm ooth d i stal e n d po i nt (B) . Arte riotomy is cl osed with
a patch (C) . c
 C h a p t e r 3 CAROT I D S U R G E RY: I nterpos i t i o n/Endarterectomy ( I n c l u d i n g Evers i on)/L i g a t i o n 1823

CAROTI D E N DARTERECTOMY-EVERS I O N p l a q u e is su bseq uently removed by the Pe nfield kn ife

as i n d i cate d . The p roxi m a l CCA a rteriotomy may be ex­
Incision tended as n eeded to e n s u re co m p l ete rem ova l .
• See sect i o n under Ca rotid E n d a rterectomy-Patch
• Co m m o n a n d exte r n a l carotid p l a q u e is su bse q u e ntly re­
A n g i o p l asty. m oved by the Penfi e l d kn ife as i n d icate d . The prox i m a l
CCA a rteriotomy may be exte nded as poss i b l e to e n s u re
Dissection and Control of the Carotid Artery co m p l ete remova l (FIG SB) .

• See sect i o n u nder Ca rotid E n d a rterectomy-Patch Anastomosis

A n g i o p l asty.
• The I CA is reve rted a n d a n a stom osed e n d -to-e n d to the
Eversion endarterectomy proxi m a l CCA (FIG SC).
• If red u n d a nt res i d u a l ICA is p resent fo l l owi n g p l a q u e
• An o b l i q u e or c i rcu mferenti a l i ncision is m a d e at the j u nc­
rem ova l, the I CA spatu lation is exte nded, as is the CCA
tion of the b u l bous portion of the I CA and CCA (FIG SA) .
a rterioto my, a n d the two ends a re f u rther adva nced over
• T h e I CA adventitia is g rasped w i t h f i n e forceps a n d
each oth e r pri or to closure. Alternatively, a port i o n of
everted away, as gentle tract i o n is p l aced o n t h e p l a q u e
the red u n d a nt ICA may a lso be excised .
with i n t h e a rte ry. T h i s m a neuver i s exte nded d i sta l l y u n t i l
the feath e red e n d p o i nt i d e ntifies itself. Ta ck in g sutu res
Closure
a re not poss i b l e u s i n g this a p p roach, which can be a de-
terrent to a d o pt i o n by s u rgeons tra i n e d with conve n - • See section u nder Ca rotid E n d a rterectomy-Patch
t i o n a l e n d a rterecto my. C o m m o n and exte r n a l carot i d A n g i o p l asty.

External carotid artery

I nternal carotid artery

Artery everted

---- Common carotid artery

A B c
FIG 5 • Carotid evers i o n e n d a rte recto my. The I CA is d ivided from the CCA i n an o b l i q u e l i n e (A) . The d ivided I CA is everted on itse lf
until the plaque e n d point is encou ntered a n d the p l a q u e is removed from the I CA (B). Fol l ow i n g e n d a rterecto my, the I CA is reverted
a n d reattached to the CCA (C) .
1824 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

CAROTI D ARTERY I NTERPOS ITION BYPASS

Incision

• See sect i o n u nder Ca rotid E n d a rterectomy-Patch

A n g i o p l asty.

Dissection and Control of the Carotid Artery

• See sect i o n u n d e r Ca rotid E n d a rte rectomy-Patch

A n g i o p l asty.
• Alth o u g h reve rsed a utog en o u s ve i n is the p referred con­
d u it, when ava i l a b l e, ePTFE p rovid es a s u ita b l e a lterna­
carot i d
tive when n ecessa ry.8 artery

Anastomosis

• The d i seased seg ment of the ca rotid a rtery is resected .

C o m m o n ly, t h e ECA i s oversewn as wel l .
• E n d -to-e n d a n a stom oses a re performed i n sta n d a rd fash­
ion. Prior to comp letion, flush i n g m a n e uvers a re done to External carotid
evacuate p a rticu l a r m atte r o r resi d u a l a i r (FIG 6) . artery (ligated)

Closure

• See sect i o n u nder Ca rotid E n d a rterectomy-Patch

PTFE or vein interposition graft
A n g i o p l asty.

Common carotid artery ----

FIG 6 • Ca rotid i nterposition g raft. F o l l o w i n g resection of

the d iseased seg m e nt, a p rosthetic g raft o r a seg m e nt of
reversed g reater saphenous ve i n is used to bridge the CCA
a n d I CA in an end-to-e n d fash i o n .

CAROT I D ARTE RY LI GATION Endarterectomy

(CAROTI D STU M P SYN D RO M E) • The tech n i q u e is s i m i l a r to that for sta n d a rd I CA e n d a r­

Incision
• See sect i o n u nder
A n g i o p l asty.
Dissection and Control o f the Carotid Artery
• See sect i o n u nder
A n g i o p l asty.
terecto my, the d i fference b e i n g the a rte riotomy b e i n g
c a r r i e d out o n the d i stal C C A i nto the E C A (FIG 7A).
Ca rotid E n d a rte rectomy-Patch • The throm bosed I CA is resected, idea l l y in l i n e with the
common a n d exte r n a l carot i d a rterioto m i es. Closu re is
acco m p l ished via patch a n g i o p lasty (FIG 7B,C) .
Closure
Ca rotid E n d a rterectomy-Patch
• See sect i o n u nder Ca rotid E n d a rte rectomy-Patch
A n g i o p l asty.
 C h a p t e r 3 CAROT I D S U R G E RY: I nterpos i t i o n/Endarterectomy ( I n c l u d i n g Evers i on)/L i g a t i o n 1825

Resected i nternal

Occluded i nternal
carotid artery
Ligated i nternal
carotid artery

Endarterectomized Oversewn stu m p

external caroti d
�--- Patch
artery
closure

A B c

FIG 7 • Carotid l i gation. The occ l u d e d I CA is a m p utated a n d rem oved {A), a n d the I CA stu m p is oversewn {B) . The p l a q u e i n the
CCA a n d ECA is removed, a n d the a rteriotomy is c l osed with a patch {C) .

PEARLS AND PITFALLS

I ncision • On t ab l e d u p l ex sca n n i n g opti m i zes i n cision p l acement, p a rti c u l a rly for transverse expos u re .
Identify i n g the va g u s • Va g u s n e rve is l ocated posterolatera l to the carot i d a rtery, with i n the ca rotid s h e a t h a n d betwee n
n e rve a n d hypog l ossa l ca rot i d a rtery a n d i nte r n a l j u g u l a r ve i n . Hypog l ossa l n e rve typica l l y crosses I CA a ntero i nferiorly t o
n e rve posterosuperio rly. F o l l o w i n g the a nsa cervica l i s w i l l lead to hypog l ossa l n e rve.
Clamping • A " ro b i n b l u e " hue is often seen i n the d ista i iCA, which sign ifies a soft a rea for safe c l a m p p l acement.
S h u nt i n g • B e p re p a red in a l l cases for potential s h u nt p l acement. This s h o u l d be flushed and prepared o n the
back t ab l e prior to perform i n g the a rteri otomy.
Conventi o n a l • Lava g e the a rte r i a l l u m e n with h e p a r i n ized sa l i n e to ide ntify a n d rem ove l u m i n a l debris.
e n d a rte recto my
Evers i o n e n d a rte recto my • Use caution i n patients with high bifu rcati o n (difficu lty visu a l i z i n g a n d secu r i n g d i stal e n d p o i nt),
those who req u i re a s h u nt, o r those with a sma i i i CA. These p roced u res a re best su ited for patie nts
with red u n d a nt I CAs.
I nterposition bypass • Use the a n asto m otic suture l i n e to tack down d i sta l resi d u a l p l a q u e as n ecessa ry to p revent
a ntegrade d i ssect i o n .
E n s u r i n g tech n i c a l • A co m p l etion i m a g i n g study, e i t h e r a n o n -ta b l e a n g iogram o r a carot i d d u p l ex study, ca n h e l p t o
pe rfection e n s u re tec h n i c a l perfect i o n pri or to s k i n closure.
C l o s u re • If a closed suct i o n drain is p l aced, it should be rem oved o n postope rative day 1 .

POSTOPERATIVE CARE should be obtained t o identify a n d manage restenosis,

• Patients should be placed on continuous monitoring to assess
for blood pressure lability. Patients generally are discharged
on postoperative day 1 or 2 .
• A postoperative duplex should be obtained within
30 days of intervention to assess the reconstruction, pro­
vide a new baseline for long-term surveillance, and monitor
wound healing and plaque incorporation. Serial ultrasounds
which most commonly occurs in the first 2 years following
endarterectomy.
OUTCOMES
• The North American Symptomatic Carotid Endarterectomy
Trial (NASCET) demonstrated the 3 0-day CEA stroke and
death rate of 5 . 5 % for symptomatic patients. 1
1826 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY
• The Asymptomatic Carotid Atherosclerosis Study (ACAS)
demonstrated a combined 3 0-day CEA stroke and death rate
of 2.3 % .2
• More recently, the Carotid Revascularization Endarter­
ectomy versus Stenting Trial ( CREST) demonstrated the
3 0-day stroke, death, or rate of myocardial infarction (MI)
to be 5.4% in symptomatic patients and 3 . 6 % in asymp­
tomatic patients, and the 3 0-day death and stroke rates were
found to be 3 . 2 % in symptomatic patients and 1 .4 % in
asymptomatic patients undergoing CEA. In the periproce­
dural period, there is a lower rate of stroke with CEA versus
stenting (2.3 % vs. 4 . 1 %) but a higher rate of MI (2. 3 % vs.
1 . 1 % ) . Mortality rates are similar.9
COMPLICATIONS
• Cervical hematoma
• Hemodynamic instability
• Cerebral hyperperfusion syndrome manifested by severe
headache
• Cranial nerve palsy
• Stroke/MI
• Thrombosis ( early)
• Recurrent stenosis (late)
REFERENCES
1. North American Symptomatic Carotid Endarterectomy Trial Collabora­
tors. Beneficial effect of carotid endarterectomy in symptomatic patients
with high-grade carotid stenosis. N Eng/ I Med. 1991;325:445-453.
2. Walker MD, Marler JR, Goldstein M. Endarterectomy for asymptom­
atic carotid artery stenosis. Executive Committee for the Asymptom­
atic Carotid Atherosclerosis Study. IAMA. 1995;273:1421-1428.
3. 2011 ASNACCF/AHNAANNIAANS/ACRIASNR/CNS/SAIP/SCAJ/SIR
/SNIS/SVM/SVS guideline on the management of patients with extracra­
nial carotid and vertebral artery disease: executive summary. A Report
of the American College of Cardiology Foundation/American Heart
Association Task Force on Practice Guidelines, and the American Stroke
Association, American Association of Neuroscience Nurses, American
Association of Neurological Surgeons, American College of Radiology,
American Society of Neuroradiology, Congress of Neurological Surgeons,
Society of Atherosclerosis Imaging and Prevention, Society for Cardiovas­
cular Angiography and Interventions, Society of lnterventional Radiology,
Society of Neurolnterventional Surgery, Society for Vascular Medicine,
and Society for Vascular Surgery. Circulation. 2011;124(4):489-532.
4. American College of Cardiology Foundation/American Heart Asso­
ciation Task Force on Practice Guidelines, American Society of Echo­
cardiography, American Society of Nuclear Cardiology, et al. 2009
ACCF/AHA focused update on perioperative beta blockade incorpo­
rated into the ACC/AHA 2007 guidelines on perioperative cardiovas­
cular evaluation and care for noncardiac surgery. I Am Call Cardia/.
2009;54:e13-e118.
5. Ricotta JJ, Aburahma A, Ascher E, et a!. Updated Society for Vascular
Surgery guidelines for management of extracranial carotid disease.
I Vase Surg. 2011;54:e1-e31.
6. Samson RH, Showalter DP, Yunis JP. Routine carotid endarterectomy
without a shunt, even in the presence of a contralateral occlusion.
Cardiovasc Surg. 1998;6:475-484.
7. Mcgirt MJ, Perler BA, Brooke BS, et al. 3-Hydroxy-3-methylglu­
taryl coenzyme A reductase inhibitors reduce the risk of periopera­
tive stroke and mortality after carotid endarterectomy. I Vase Surg.
2005;42:829-835.
8. Dorafshar AH, Rei! TD, Ahn SS, et a!. Interposition grafts for difficult
carotid artery reconstruction: a 17-year experience. Ann Vase Surg.
2008;22(1):63-69.
9. Mantese VA, Timaran CH, Chiu D, et al. The Carotid Revasculariza­
tion Endarterectomy versus Scenting Trial (CREST): scenting versus
carotid endarterectomy for carotid disease. Stroke. 2010;41(suppl 10):
S31-S34.

Chapter 4 Carotid Surgery: Bifurcation
Stenting with Distal Protection
1 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Zhen 5. Huang
DEFINITION
• Carotid artery stenosis was first successfully treated via per­
cutaneous balloon angioplasty in 1 9 77 by Mathias and col­
leagues.1·2 This technique has evolved over time to include
use of self-expanding nitinol stents and distal embolic protec­
tion devices (EPD ) . Carotid angioplasty and stenting ( CAS)
is indicated as an alternative to open carotid endarterectomy
( CEA) in certain clinical scenarios where the patient's anat­
omy and/or physiology pose a greater risk for complications
with CEA. However, these specific clinical conditions are not
absolute and must be weighed against risks for endovascular
intervention.
• Distal EPD
According to the 20 1 1 ASA/ACCF/AHA/AANN/AANS/
A CRJASNR/CNS/SAIP/SCAIISIR/SNIS/SVM/SVS guide­
line on the management of patients with extracranial
carotid and vertebral artery disease, " EPD deployment
during CAS can be beneficial to reduce the risk of stroke
when the risk of vascular inj ury is low. " 3
A distal filter is placed in the internal carotid artery (ICA)
distal to the lesion but below the skull base, with the pur­
pose of capturing debris to prevent distal embolization
during CAS ( FIG 1 ) . The target lesion must be crossed by
the filter before deployment but this system allows for ce­
rebral protection with maintenance of blood flow to the
brain during subsequent steps of the procedure. The filter
is mounted on the same wire used to perform CAS and
after successful CAS, the filter is retrieved along with any
captured debris.
PATIENT HISTORY AND PHYSICAL
FINDINGS
• A thorough history should be obtained prior to interven­
tion and should include a detailed description of, if present,
symptoms ( quality, duration, etc . ) that may be indicative of
transient ischemic attacks (TIA) or prior stroke, past medical/
surgical history (e.g., prior cerebrovascular disease/interven­
tions), current medications (e.g., antiplatelet or anticoagula­
tion medications) , and social history (e.g., tobacco use ) .
• A comprehensive physical exam is mandatory a n d should in­
clude a complete vascular and neurologic/stroke evaluation.
A B
FIG 1 • D i stal E P D . A. F i lterWire EZ, B osto n Scientific. B. A n g i o g u a rd, Cord i s
E n d ovasc u l a r. C. RX Acc u n et, Ab bot Vasc u l a r.
I
�
Darren B. Schneider
Vascular exam should note the presence of palpable femoral
and distal lower extremity pulses and carotid bruits.
IMAGING AND OTHER DIAGNOSTIC
STUDIES
• Initial carotid duplex ultrasound is obtained to evaluate
the degree of stenosis and plaque morphology. Studies have
highlighted a higher potential for embolism during CAS
with hypoechoic lipid-containing plaque.4
• Angiographic imaging of the aortic arch and carotid and
cerebral arterial vasculature must be obtained to aid in
proper patient selection and procedural planning. This is ac­
complished through computed tomographic arteriography
( CTA) ( FIG 2 ) , magnetic resonance arteriography (MRA), or
catheter-based contrast arteriography.
Arch anatomy
Aortic arch morphology is variable and can change
with advancing age. The arch anatomy can be divided
into three types, dictated by the position of the innomi­
nate artery origin relative to two horizontal lines drawn
across the apices of the outer and inner aortic arch cur­
vatures ( FIG 3 ) .
Type I-the innominate origin arises a t o r above the
horizontal plane of the outer arch curvature ( FIG 3A)
Type li-the innominate origin arises in between the
two horizontal planes of the outer and inner arch cur­
vatures ( FIG 38)
Type III-the innominate origin lies below the horizon­
tal plane of the inner arch curvature ( FIG 3C)
The difficulty in gaining access to the carotid arteries in­
creases from types I to III. There is an increase in angle
acuity of the great vessel origins off the arch with in­
creasing arch types that make wire/catheter guidance/
exchange more difficult.
Bovine arch-congenital arch variations where the left
common carotid artery ( CCA) shares a common origin
with the innominate artery (more frequent) or the left
CCA branches off the innominate artery. In a pure bo­
vine arch (extremely rare ), the right subclavian, com­
mon carotid-both right and left-and left subclavian
all derive from one common arterial trunk off the aortic
arch.
c
182 7
1828 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

A B c
FIG 2 • CTA i m a g i n g of a o rtic a rch a n d g reat vessels d e m o nstrat i n g a l eft ICA ste nosis. A. Sag itta l i m a g e . 3-D
image reco nstructions from the CTA i m ages of the a o rtic a rch (B) a n d cervical l eft ca rotid a rte ry, d e m o n strat i n g
the l eft I C A ste nosis (C) .

Shaggy aorta-when extensive aortic wall irregularities
exist, there is a high risk for significant atheroembolism
and thus, this may be a contraindication to CAS.
Eggshell aorta-with severe aortic wall calcification,
there is increased risk of intimal disruption and diffi­
culty of wire/catheter manipulation/advancement.
Cerebral flow to both hemispheres is assessed to deter­
mine cerebral reserve.
Carotid vessel size, tortuosity, and calcification--carotid
artery diameter should be assessed to aid in determining
device sizes. In addition, severe carotid circumferential
calcification and vessel tortuosity may negatively impact
procedural success (e.g., difficulty with inserting stent,
placement of EPD in distal ICA) and may represent a con­
traindication to CAS.
• Preoperative brain imaging with computed tomography
( CT) or magnetic resonance imaging (MRI) is needed for
symptomatic patients to document prior infarcts and to rule
out preexisting hemorrhagic stroke prior to the initiation of
the procedure.

A B

FIG 3 • A. Type I a rc h . B. Type II a rc h . C. Type I l l a rc h . (White arrows

in B a n d C i n d icate wi re/catheter t i p traj ectory req u i red for sel ective
catheterization of the i n n o m i n ate/carotid a rteries with i n specific
c a rch type.
 C h a p t e r 4 CAROT I D S U R G E RY: Bifurcation Stenting with D istal Protection
SURGICAL MANAGEMENT
• The indications for any surgical intervention for carotid dis­
ease depend on the patient's clinical status (i.e., symptom­
atic or asymptomatic) and the characteristics of the carotid
lesion.
• It has been widely accepted that appropriate candidates for
CEA are symptomatic patients with carotid stenosis of 70%
to 9 9 % on noninvasive imaging and an anticipated periop­
erative risk of stroke or mortality of less than 6 % . Benefit
of intervention for symptomatic patients with lesser degrees
of stenosis ( 5 0 % to 69 % ) has also been shown but not for
symptomatic patients with less than 5 0 % carotid stenosis.
CAS is an alternative to CEA for symptomatic patients meet­
ing similar criteria along with anatomic and/or physiologic
factors unfavorable for CEA (Table 1 ) . 3 •5
• The recommendations/indications for CAS in asymptomatic
patients are still issues for debate and no consensus exists.
CAS may be considered for patients with asymptomatic ICA
stenosis between 70% and 9 9 % , but there are insufficient
data to recommend CAS for primary therapy in asymptom­
atic patients. Therefore, these patients need to be addressed
on a case-by-case basis with consideration of patient comor­
bidities and risks of CAS.
• The contraindications for CAS are predominantly related to
aortic arch and carotid artery anatomic factors (Table 2 ) .
Tab l e 1 : Anatom ic a n d Physiologic Factors
Favoring Carotid Ang ioplasty and Stenting
Anatomic Factor Physiologic Factor
Reoperative neck (e.g., prior C EA, prior radical U nstable angina
neck dissection)
H i story of cervical rad iation Recent M l (<30 days)
High carotid lesion (above C2) C H F with E F less than 30%
H i story of contra lateral CEA with associated Severe C O P D (FEV 1 <30%)
cranial nerve injury
Tracheostomy
Contralateral carotid occlusion
CEA, carotid endarterectomy; CHF, congestive heart failure; EF, ejection frac­
tion; COPD, chronic obstructive pulmonary disease; FEV1, forced expiratory
volume in 1 second
PERCUTANEOUS RETROGRADE FEMORAL
ARTERY ACCESS
• O bta i n retro g ra d e access via the c o m m o n fe m o ra l a rtery
(CFA) u s i n g a percuta neous m i cro p u ncture (2 1 -g a u g e
need l e) system u n d e r u ltraso u n d g u i d a nce. The CFA
s h o u l d be accessed i m m e d i ately proxi m a l to the fe moral
ARCH AORTOG RAPHY
• A g u idewire is adva nced i nto the aortic a rch fol l owed by
a pigta i l catheter. The pigta i l catheter is positioned in the
m id-ascending aorta and a rch aortog ra phy is performed i n a
45- to 60-deg ree left a nterior oblique p rojection in order to
adeq uately visual ize the origin of the g reat vessels (FIG 4).
1829
Preoperative Planning
• Patients are initiated on antiplatelet therapy with aspirin
325 mg per day and clopidogrel 75 mg per day for 5 days
prior to intervention. Alternatively, a clopidogrel loading
dose of 300 mg can be administered 4 to 6 hours prior to the
intervention.
• Antihypertensive medications can be held off the day of in­
tervention to prevent contribution to the possible periproce­
dural hypotension.
Positioning
• The patient is placed in the supine position with adequate
monitoring throughout the peri- and postprocedural period.
Minimal monitoring includes continuous electrocardiogram
( EKG), intraarterial blood pressure, and pulse oximetry.
The patient's neurologic status must be frequently evaluated
during the procedure via answering of simple questions and
squeezing a plastic sound toy (e.g., rubber duck squeaky toy)
in the contralateral hand.
• Intraarterial blood pressure monitoring is established usu­
ally via a radial arterial line.
• In order to maintain patient cooperation/comfort and frequent
neurologic monitoring, minimal or no sedation is administered
and only local anesthesia is infiltrated for the access site.
Tab l e 2: Anatomic and Physiologic Factors
Unfavora b l e for Carotid Angioplasty and
Stenting
Anatomic Factor Physiologic Factor
Severely angulated aortic arch (type I l l ) Ages 80 years and older
Shaggy/eggshell aorta Contraindication to anti platelet
therapy
Severe aortoiliac occl usive disease Severe renal dysfu nction
Severe ICA calcification/tortuosity
Severe carotid stenosis/string sign
Unstable carotid plaque
Fresh carotid thrombus
Decreased cerebra l reserve
ICA, internal carotid artery
bifurcati o n i n an a rea with m i n i m a l d isease. The r i g ht
C FA is the m ost conve n i ent s ite for r i g ht-h a n d e d opera­
tors. The left CFA and b rach i a l a n d ra d i a l a rteries a re a l ­
ternative access sites. U ltim ately, the safest a n d s i m p l est
access site to the target lesion s h o u l d be e m p l oyed .
• The m i c r o p u n ct u re sheath is then excha n ged for a 5-Fr
i ntroducer sheath over the 0.035-in access wire.
1830 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

FIG 4 • Arch a o rtog raphy with pigta i l catheter i n

m i d asce n d i n g a o rta.

SELECTIVE COM M O N CAROT I D

CATHETERIZATI O N
• B efore f u rt h e r m a n i p u l a t i o n of w i res/catheters i n the
a rc h a n d g reat vessel o r i g i ns, t h e patient i s a d m i n ­
istered syste m i c h e p a r i n a t 7 0 t o 1 00 U/kg i ntrave­
n o u s l y (IV) with a g o a l activated c l ott i n g t i m e of 2 5 0 to
300 seco n d s .
• W h i l e m a i nta i n i n g the l eft a nt e r i o r o b l i q u e (LAO)
p roj ect i o n that a l l ows for opti m a l v i s u a l i z a t i o n of t h e
g reat vessels o r i g i ns, a road m a p i m a g e i s used to as­
s i st in sel ective cathete r i z a t i o n of t h e CCA. The p i gta i l
catheter i s exc h a n g e d for t h e ope rator's catheter of
c h o i ce .
• M u lt i p l e cu rved catheters a re ava i l a b l e (FIG 5), each with
u n i q u e featu res that may be benefi c i a l i n d i fferent a n at­
o m i es. H owever, freq uent ly, sel ective com m o n ca rot i d
catheterization can be acco m p l ished w i t h a com b i nation FIG 6 • Type I a rch with bovi n e confi g u rati o n .
of a n a n g l ed o r simple c u rved catheter and a f l o p py an­
g l ed G l i dewi rerM
• H owever, a retroflexed or co m p l ex cu rved catheter (e . g . ,
S I M o r Vitek) may be n ecessa ry w i t h a d iffi c u l t a rch
a n atomy such as type I l l a rch o r bovi n e confi g u rat i o n
(FIG 6) .
• After the G l i dewi rerM has accessed the co m m o n carotid
Angled
Will JIU (but ta k i n g extreme care not to advance past the bi­
Gl ldl
fu rcation), the sel ective catheter is adva n ced over the
G l i dewi rerM i nto the common ca rot i d . Common ca rotid­
sel ective a n g i ogra ms a re then pe rfo rmed typica l l y i n the
a ntero poste rior, l atera l, a n d o b l i q u e p rojections (more
vi ews a re perfo rmed as needed) (FIG 7) . Contra l atera l
ca rotid a rteriogram can be performed as we l l if neces­
sa ry, but t h i s usua l ly is n ot performed d u ri n g CAS of a
u n i l atera l lesion.
• Cerebra l vessel a n g iography is then perfo rmed, typica l ly
FIG S • Va rious catheters can be used for sel ect ive in a nteroposte rior a n d l atera l views (FIG 8). Addit i o n a l
cathete rization of the co m m o n ca roti d . vi ews c a n be d o n e if n ecessa ry.
 C h a p t e r 4 CAROT I D S U R G E RY: Bifurcation Stenting with D istal Protection 183 1

A B c
FIG 7 • A. Sel ective l eft c o m m o n ca rotid a n g iog raphy, cra n ioca u d a l a ntero poste rior p roj ect i o n . B. Sel ective l eft
c o m m o n ca rotid a n g iography, o b l i q u e p roject i o n . C. Sel ective l eft co m m o n ca rotid a n g iog raphy, l atera l p roj ect i o n .

A B
FIG 8 • A. Cerebra l vessel a n g iography via l eft CCA, cra n i oca u d a l a nteroposte rior (AP) p roj ect i o n .
B. Cerebra l vessel a n g i og raphy via l eft CCA. latera l p roject i o n .

PLACEMENT OF G U I D I N G SH EATH
• After co m m o n ca rotid a n g i o g raphy is com p l ete, it is rec­
o m m e n d e d that the a ppropriate n ecessary e q u i p m e nt
to co m p l ete the p roced u re is sel ected prior to f u rther
sel ective ca n n u l at i o n of the ca rotid vesse ls (e . g . , access
sheaths, wi res, cath ete rs, fi lter and fi lter retrieva l system,
pre- and postd i l atation b a l loo ns, ste nt) .
• In order to advance a sheath i nto the p roximal common
carotid, adequate exchange suppo rt is needed with a stiff
g u idewire. To achieve this, the selective catheter is caref u l ly
adva nced over the floppy G l idewi rerM i nto a branch of the
external carotid a rtery (ECA) . The floppy G l idewi rerM is then
exchanged for a stiff g u idewire (e .g., long AmplatzrM Su­
perstiff wire with floppy tip). Caution needs to be exercised
to ensure the stiff wire tip does not inadvertently advance
and potentia l ly perforate the ECA branch. The catheter
is then rem oved leavi ng the stiff wire in pl ace in the ECA
(FIG 9). If there is significant atherosclerotic sten osis i nvolv­
ing the carotid bifu rcation, or if the ECA is severely stenotic/
occluded that p revents safe ECA access, an AmplatzrM wire
with a 1 -cm floppy tip may be left in the d ista l CCA.
• O n ce the s u p p o rtive w i re i s in p l ace, the g r o i n i ntroducer
sheath is exchanged for a 6-Fr 90-cm sheath. The sheath is
tracked over the stiff w i re and p l aced i nto the d i sta l CCA
prox i m a l to the bifu rcat i o n . It is i m perative that sheath
adva ncement is performed o n l ive f l u o rosco py, especi a l ly
when negotiat i n g the t u r n at the co m m o n ca rotid o r i g i n,
to e n s u re the sh eath is adva n c i n g a p p ropriately.
1832 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

FIG 9 • Stiff w i re with i n ECA to a l l ow g u i d i n g

sheath advancement i nto c o m m o n ca rot i d .

CROS S I N G T H E LESION WITH D I STAL

E M BOLIC PROTECTI O N DEVICES
• With the sheath i n p l a ce a n d u s i n g a road m a p i m a ge,
the I CA lesion is crossed with the 0. 0 1 4- i n w i re compo­
nent of the d ista l EPD. The d ista l E P D should be d e p l oyed
in a stra ight portion of the d i sta i i CA p roxi m a l to the pe­
trous portion at sku l l base (FIG 1 0) . It is i m porta nt not to
a l low i n a dvertent m i g ration of the EPD f u rther d i sta l ly
for risk of i n j u ry to the i ntracra n i a i i CA.

FIG 1 0 • D i sta l E P D d e p l oyed i n the d ista l I CA

p roxi m a l to the petrous port i o n at sku l l base.

PRE D I LATATION WITH AN G I OPLASTY

BALLOON
• After the d ista l E P D is i n position, the ca rotid lesion is
pred i l ated with a 3 - o r 4-m m coro n a ry a n g i o p lasty bal­
loon u p to n o m i n a l p ressu re (FIG 1 1 ) . A h i g h e r i nflation
press u re may be req u i red for heavily cal cified lesions.
Using a b a l loon l e ngth of 4 em should help to m i n i m ize
the risk of the b a l loon s l i p p i n g ("wate r m e l o n seed i n g " )
d u r i n g i nflation. I n a d d ition, it is i m po rtant t o be extra
vi g i l a nt in m o n itoring the patient's heart rate for possi b l e
bradycardia (or even asystole) d u ri n g l e s i o n predi l atation
a n d atro p i n e m ust be rea d i ly ava i l a b l e for a d m i n istrat i o n
before pred i l atat i o n .

FIG 1 1 • Left I CA l e s i o n p red i l atation w i t h 3 - m m coro n a ry

ba l l oo n .
 C h a p t e r 4 CAROT I D S U R G E RY: Bifurcation Stenting with D istal Protection 1833

STENTI N G AND POSTD I LATATI O N

• F o l l o w i n g p red i l atat i o n , a c h a n n e l is created that w i l l
acco m m o d ate t h e a d v a n c e m e n t o f t h e ste nt syste m .
A s e l f-expa n d i n g ste nt com pati b l e with t h e d i sta l E P D
syste m i s adva n ced over t h e w i re a n d d e p l oyed u n d e r a
road m a p . The d i sta l a n d p rox i m a l ste nt l a n d i n g z ones
m u st be at a reas of n o rm al ves s el wa l l an d t h i s w i l l f re­
q u e n t l y n ecessitate ste n t i n g a c ross t h e ECA o r i g i n with
t h e prox i m a l l a n d i n g z o n e i n t h e d i sta l CCA (FIG 1 3) .
After ste nt d e p l oy m e nt, it i s postd i l ated (us u a l ly u s i n g
a 5 to 6 m m x 2 em b a l l oo n ) , treat i n g o n ly t h e stented
p o rt i o n s of t h e I CA to m i n i m i ze i nj u ry to the n ative
vesse l wa l l (FIG 1 2) and over postd i l atat i o n i s strictly
avo i d e d to reduce r i s ks of e m b o l i z at i o n . D u r i n g post­
d i latat i o n , the p a t i e nt's h e a rt rate m u st be c l o s e l y
m o n itored for a n y c h a n g es a n d atro p i n e s h o u l d sti l l be
rea d i ly ava i l a b l e . FIG 12 • Ste nt postd i l atation with a 5 m m x 2 em b a l l o o n .

E M BOLIC PROTECTI O N DEVICE

RETRI EVAL A N D COMPLETI O N
ANG I O G RAM
• Co m p l et i o n a n g i o g ra p hy is p e rfo r m e d to assess ste nt
p l acement and postste nt carotid a ntegrade flow be­
fore t h e d i sta l EPD i s rem oved (FIG 1 3) . With n o r m a l
f l o w t h r o u g h t h e stent a n d n o fi l l i n g d efects p resent,
the f i l t e r i s ret r i eved . S l ow flow a n d/o r fi l l i n g d efects
at the fi lter can be seco n d a ry to s i g n ificant d e b r i s a n d
t h i s m u st be a s p i rated p r i o r t o retri eva l . T h e E P D re­
t r i eva l system i s adva nced ca refu l l y past t h e ste nt with­
out e n g a g i n g/catc h i n g o n t h e ste nt. With exte nsive
d e b ris p resent i n the f i l t e r, it i s i m p o rta nt not to f u l ly
reca ptu re t h e fi lter i n t h e retri eva l catheter as t h i s ca n
ext r u d e d e b r i s from the f i l t e r a n d c a u se d i st a l e m b o l i ­
zati o n . D i sta i ! CA vasos pasm c a n be p resent a s we l l a n d
FIG 1 3 • Comp letion a n g i og raphy is performed t o assess
it i s u s u a l l y seco n d a ry t o m i g ra t i o n of E P D d u ri n g t h e ste nt p l acement a n d poststent ca rotid a ntegrade fl ow. N ote
p roced u re . Typ i ca l l y, t h i s i s m a n a g e d conservatively b u t that t h i s ste nt i s p l aced across the ECA orig i n .
with s i g n ificant J CA spasm, n itrog lyce r i n ( 5 0 to 2 0 0 f.Lg)
ca n be a d m i n istered i n s m a l l d oses d i rectly i ntra a rteri­
a l l y i n t h e ! CA .

ACCESS H E MOSTAS I S
• The fe m o r a l a ccess a rte r i a l p u ncture can be cl osed u s i n g
sta n d a rd tech n i q ues e i t h e r w i t h a closure device o r by
d i rect m a n u a l co m p ress i o n . We p refer to use a closure
device a n d do not rout i n e l y reverse h e p a r i n a nticoa g u ­
l a t i o n w i t h p rota m i n e . For b rach i a l a rtery a ccess, d i rect
m a n u a l co m p ression is the p refe rred m ethod for a c h i ev­
i n g hemostasis.
1834 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

PEARLS AND PITFALLS

Sel ective c o m m o n ca rot i d
cath erization
Place m e nt of g u i d i n g sheath
Cross i n g the lesion with EPD
D i stal ICA spasm
Occ l u s i o n of flow p roxi m a l
t o E P D afte r ste nt p l acement
D i stal e m b o l i zation with
n e u ro l o g i c sym ptoms a n d/
or i ntracra n i a l a rte r i a l
occl usion
• To rtuous a o rtic a rch/g reat vessel a n atomy may req u i re a d d i t i o n a l m a n i p u lation with va rious
retroflexed catheters i n order to sel ect the c o m m o n ca rot i d . H owever, with i n creasi n g m a n i p u ­
l a t i o n , there is a g reater r i s k of e m b o l i zation/a o rtic i nj u ry. The refore, a o rtic a rch/g reat vessel
a n atomy should be a n a lyzed preoperatively and, when i n d i cated, suita b l e a lternative p l a n s
s h o u l d be p repa red if the i n it i a l m ethod p roves u nsuccessfu l .
• A n extremely d iseased a o rtic a rch m a y be a rel ative contra i n d ication t o CAS.
• When the ECA is occl uded, a s u p p o rtive g u idewire ca n n ot be p l aced to a l l ow track i n g of the
sheath and an a lternative method is needed. Alternatively, an A m p l atz g u idewire with a 1 -cm
floppy t i p in the d i sta l CCA may p rovide suffi cient s u p po rt for sheath p l acement. Sh uttle systems
that perm it tel esco p i n g the sheath i nto the CCA over a g u i dewire and catheter asse m b l y a re
a n other a ltern ative.
• D iffi cu lty cross i n g the lesion can be a d d ressed by c h a n g i n g the shape of the cross i n g w i re tip or
using a d i rect i o n a l catheter. Additi o n a l ly, c h a n g i n g the patie nt's head/neck posit i o n may m a ke a
vessel less a n g u l ated .
• Ce rta i n E P D such as the N av-6 (Abbott Vasc u l a r, Ab bott Pa rk, I L) a n d S p i d e r (Covi d i e n , Plymouth,
MN) a re i ntro d u ced over a w i re that is i ntrod uced i n d e pe n d e ntly before the fi lter. I ntrod u ction
of the i n dependent w i re may fa c i l itate su bseq uent i ntrod uct i o n of the fi lter across a t i g htly ste­
n otic lesion o r a lesion with an acute entry a n g l e .
• A " b uddy w i r e " (a d d i t i o n a l 0.0 1 4- i n w i re) can a lso be used t o p rovide extra s u p p o rt a n d faci l i ­
tate cross i n g a d iffi c u l t lesion.
• If the cross i n g p rofi l e of the E P D is too l a rg e to cross the ste n otic lesion, the ste notic lesion can
a lso be pred i l ated with a 2.5-mm b a l loon i n order to create a channel l a rge e n o u g h for EPD.
H oweve r, d i lating the lesion without a n E P D i n p l a ce i n c reases the risk of d i stal e m b o l izat i o n .
• Usua l ly caused b y d i stal E P D a n d reso lves after E P D a n d w i re a re remove d .
• S m a l l d oses of n itroglyce r i n a d m i n istered d i rectly to ca rotid may a i d i n reso l ut i o n .
• D i sta i i CA fi lter may be f u l l of debris ca u s i n g slow flow o r ICA occl u s i o n . The debris s h o u l d b e
aspi rated f r o m the fi lter u s i n g a n a s p i ration catheter a n d repeat a n g iogram i s performed after
to confirm return of flow p r i or to EPD retri eva l .
• If it is d ete r m i ned that occ l u s i o n i s d u e t o acute ste nt t h ro m bosis t h e n i m med iate convers i o n
to open exploration, ste nt rem ova l , a n d fo r m a l CEA may be n ecessa ry. Preparations for ca rot i d
stenti n g s h o u l d a l ways i n c l u d e t h i s poss i b i l ity.
• N e u ro rescue tech n i q ues a re used to treat d ista l e m b o l i zation or throm bosis, i n c l u d i n g the
fo l l owi n g :
• Catheter- d i rected throm bolysis w i t h tissue p l a s m i nogen activato r (tPA)
• Mech a n ical t h ro m bolysis with a s p i ration
• G lycop rote i n (G P) l l a/l l l b i n h i bitor a d m i n i strati o n
• D i rect remova l w i t h s n a re (intra a rte r i a l )
• D i rect b a l loon a n g i o p lasty to restore a l u m e n
N o t e : I ntracra n i a l n e u rorescue tech n i q ues shou l d be perfo rmed by physicians w i t h a p p ropriate
expe rience a n d tra i n i n g .

POSTOPERATIVE CARE
• Neurologic status i s immediately evaluated after completion
of the procedure and continuous invasive blood pressure
monitoring and pulse oximetry are maintained. Typically,
CAS patients are observed in a monitored step-down unit
overnight.
• Goal systolic blood pressures should be based on preop­
erative measurements . Vasopressor and/or inotropic sup­
port may be required to compensate for hypotension and/
or bradycardia likely due to carotid sinus distension re­
lated to the procedure until the carotid sinus adapts to the
presence of the stent. Other causes of hypotension need to
be excluded prior to attributing the cause to angioplasty/
stenting alone. Conversely, antihypertensives should be
used as needed to prevent hypertension and potential ce­
rebral hyperperfusion.
• The patient needs to remain on bed rest in the supine posi­
tion for 4 to 6 hours after access site hemostasis is achieved.
The head of the bed can be inclined to a maximum 30 de­
grees to promote patient comfort and respiratory function.
Afterward, the patient can ambulate as tolerated.
• Immediate head and neck imaging along with neurology
consultation are mandatory if the patient experiences a post­
operative neurologic event.
• Antiplatelet therapy with clopidogrel should be continued
for at least 1 month post-CAS, whereas aspirin is continued
indefinitely.
OUTCOMES
• Studies prior to year 2000 failed to define the role of CAS
in treating carotid artery disease due to numerous factors.
More recent randomized controlled trials (RCTs ) were
 C h a p t e r 4 CAROT I D S U R G E RY: Bifurcation Stenting with D istal Protection
performed in order to elucidate CAS' role in carotid disease,
namely as a noninferior alternative to CEA.
• The Stenting and Angioplasty with Protection in Patients
at High Risk for Endarterectomy (SAPPHIRE) trial6 ran­
domized symptomatic patients with 5 0 % or greater carotid
stenosis or asymptomatic patients with 8 0 % or greater ste­
nosis with comorbidities that increased their risk of surgery
to receive either CEA or CAS. For the CAS patients, they
all had self-expandable nitinol stents (S.M.A.R.T. or PRE­
CISE; Cordis, Miami Lakes, FL) placed with EPD (Angio­
guard or Angioguard XP; Cordis, Miami Lakes, FL). The
primary endpoint was composite incidence of death, stroke,
or myocardial infarction (MI) within 30 days postprocedure
or death or ipsilateral stroke between 31 days and 1 year.
Only 334 patients were randomized- 1 6 7 to CEA and 1 6 7
t o CAS (trial stopped early due t o poor enrollment) . N o sig­
nificant difference in the primary composite endpoint rate
was detected in the periprocedural period ( 3 0 days) for CAS
compared to CEA. However, 1 -year primary composite end­
point rate was lower in CAS compared to CEA ( 1 2.2% vs.
2 0 . 1 %; P = .004) with a more pronounced difference in
asymptomatic ( 9 . 9 % in CAS vs. 2 1 . 5 % in CEA; P = .02)
than in symptomatic patients ( 1 6 . 8 % in CAS versus 1 6 . 5 %
i n CEA; P = . 9 5 ) . This difference vanished i n long-term
follow-up and at 3 years, the major secondary endpoint (pri­
mary endpoint plus death or ipsilateral stroke 1 to 3 years)
cumulative incidences were 24. 6 % for CAS vs. 2 6 . 9 % for
CEA; P . 7 t . l Thus, the SAPPHIRE authors concluded that
= stroke, death, or MI during the periprocedural period or any
CAS with EPD was not inferior to CEA in patients with se­
vere carotid artery stenosis and increased surgical risk.
• However, these results were not mirrored in two large
European multicenter RCTs-Stent-Supported Percutaneous
Angioplasty of the Carotid Artery versus Endarterectomy
( SPACE)8 and Endarterectomy Versus Angioplasty in Pa­
tients with Symptomatic Severe Carotid Stenosis (EVA-3 S ) 9
trials. Both of these studies failed t o show noninferiority o f
CAS compared t o CEA i n their respective study populations.
In SPACE, the primary endpoint (rate of death or ipsilateral
ischemic stroke 3 0 days postprocedure) was 6 . 8 4 % in CAS
and 6 . 3 4 % in CEA ( absolute difference 0 . 5 1 %, 9 0 % CI
- 1 . 8 9 % to 2 . 9 1 %; noninferiority P = . 0 9 ) . In EVA-3S, the
results demonstrated greater rates of stroke and death in the
CAS group as compared to the CEA group: 3 0-day incidence
of stroke or death was 9 . 6 % in CAS ( 9 5 % CI, 6.4 to 1 4 . 0 )
a n d 3 . 9 % i n CEA ( 9 5 % C I , 2.0 t o 7.2 ) ; the relative risk o f
any stroke o r death after CAS as compared with CEA was
2.5 ( 9 5 % CI, 1 .2 to 5 . 1 ) . At 6 months, the incidence of any
stroke or death was 1 1 . 7% after CAS and 6. 1 % after CEA
(P .02). However, long-term data at 4 years from EVA-3S
=
did not demonstrate significant differences in the risk of any
stroke or death in between both CAS and CEA; the hazard
ratio (HR) was 1 . 3 9 ( 0 . 9 6 to 2.00; P = . 0 8 ) . 1 0 The authors
interpreted these results to " suggest that carotid stenting is
as effective as carotid endarterectomy for middle-term pre­
vention of ipsilateral stroke, but the safety of carotid stenting
needs to be improved before it can be used as an alternative
to carotid endarterectomy in patients with symptomatic ca­
rotid stenosis . "
• A more recent international multicenter RCT, the Interna­
tional Carotid Stenting Study (ICSS ), demonstrated that
1835
CEA was safer than CAS as treatment for patients with
symptomatic carotid stenosis of 5 0 % or greater ( enrolled
1 , 7 1 3 patients; CAS, n = 8 5 5 ; CEA, n = 8 5 8 ) .U The pri­
mary composite endpoint, 120-day incidence of stroke,
death, or MI was higher in CAS compared to CEA ( 8 . 5 %
v s . 5 . 2 % ; HR, 1 . 69; 9 5 % CI, 0 . 1 6 t o 2.45; P = . 0 0 6 ) . The
adverse events occurring with the 3 0-day postprocedure pe­
riod accounted for the maj ority observed at 120 days where
the cumulative incidence of stroke, death, and MI was 7.4%
in CAS compared to 4 . 0 % in CEA (P = .003 ) . The authors
concluded that CEA should remain the treatment of choice
for symptomatic carotid stenosis patients that are suitable
for surgery while awaiting the long-term follow-up data of
ICSS.
• The Carotid Revascularization Endarterectomy versus Stent­
ing Trial ( CREST) is a U.S. trial that is the most recent and
largest RCT to compare the efficacy between CAS and CEA
in standard-risk patients. 12 Two thousand and five hundred
two patients with asymptomatic carotid stenosis of 70 %
or greater (based on ultrasound criteria ) or symptomatic
carotid stenosis of 5 0 % or greater ( based on angiographic
North American Symptomatic Carotid Endarterectomy
Trial criteria) were randomized to either CAS (n = 1 ,262;
RX Acculink stent; Carotid Stent System, Abbott Vascular,
Abbott Park, IL) and a distal EPD (RX Accunet Embolic
Protection System, Abbott Vascular, Abbott Park, IL) or
CEA (n = 1 ,240 ) . The primary composite endpoint was
ipsilateral stroke within 4 years. During the periprocedural
period, the primary endpoint incidence was similar with
CAS and CEA ( 5 . 2 % and 4 . 5 % , respectively; HR for stent­
ing 1 . 1 8 ; 9 5 % CI, 0 . 8 2 to 1 .6 8 ; P . 3 8 ) . However, the rates
=
of individual endpoints differed between CAS and CEA:
greater risk of stroke in CAS (4. 1 % vs. 2 . 3 % , respectively;
P = . 0 1 ) , greater risk of MI in CEA ( 1 . 1 % vs. 2.3 % , re­
spectively; P = . 0 3 ) , no difference in death ( 0 . 7 % vs. 0 . 3 % ,
respectively; P = . 1 8 ) . The periprocedural risk o f stroke or
death was higher after CAS for symptomatic patients ( 6 . 0 %
vs. 3.2%; P = . 0 2 ) . There was n o significant difference in
the estimated 4-year rate of the primary endpoint between
CAS and CEA (7.2% vs. 6 . 8 % , respectively; HR, 1 . 1 1 ;
P . 5 1 ; 9 5 % CI, 0 . 8 1 to 1 . 5 1 ) . CREST also demonstrated
=
an interaction between age and treatment efficacy (P = .02)
where CAS tended to show greater efficacy at younger than
70 years of age and CEA at older than 70 years of age.
• Overall, CAS as a noninferior or equivalent alternative treat­
ment compared to CEA has not been definitively established
and further studies are needed.
COMPLICATIONS
• Postoperative complications
Stroke-the incidence of stroke is higher with CAS than
CEA.1 1 Risk factors include advanced age, symptomatic
carotid stenosis, and complex anatomy. Postoperative
stroke needs to be addressed immediately with full neuro­
logic evaluation and potential intervention.
Hypotension-frequently observed post-CAS; however, it
usually will resolve spontaneously. Patients may require
transient blood pressure support with vasopressors/volume.
1836 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY
Cerebral hyperperfusion syndrome-may occur within
the first week post-CAS and is usually associated with
poorly managed underlying hypertension. It presents as a
unilateral headache and can progress to seizures, intracra­
nial hemorrhage, and/or coma. Head CT is obtained and
focal cerebral edema may be observed. The treatment is
aggressive blood pressure management.
MI---c a rdiac complications, namely MI, may occur during
the periprocedural period for CAS. This is likely due to
the typically high-risk patient population selected for CAS
given that most are poor candidates for CEA.
Access site complications-the most common access site
complications that are inherent to endovascular proce­
dures are hematoma, pseudoaneurysm, retroperitoneal
hematoma, and arteriovenous fistula. To minimize the
risk for these complications, we recommend direct visu­
alization of the access vessel under ultrasound and using
a micropuncture access system. In addition, proper use
of vessel arteriotomy closure devices and/or manual ves­
sel compression is mandatory to reduce the risk for these
complications.
Stent restenosis-restenosis will occur in any current stent
placed in the body and can be managed with reinterven­
tion as needed.
REFERENCES
1. Mathias K. A new catheter system for percutaneous translumi­
nal angioplasty (PTA) of carotid arrery stenoses. Fortschr Med.
1977;95(15):1007-1011.
2. Mathias K, Mittermayer C, Ensinger H, et al. Percutaneous catheter
dilatation of carotid stenoses. Rofo. 1980;133(3):258-261.
3. Brott TG, Halperin JL, Abbara S, et al. 2011 ASA/ACCF/AHA/AANN/
AANS/ ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on
the management of patients with extracranial carotid and vertebral
arrery disease: executive summary. A report of rhe American College
of Cardiology Foundation/American Hearr Association Task Force on
Practice Guidelines, and the American Stroke Association, American
Association of Neuroscience Nurses, American Association of Neuro­
logical Surgeons, American College of Radiology, American Society
of Neuroradiology, Congress of Neurological Surgeons, Society of
Atherosclerosis Imaging and Prevention, Society for Cardiovascular
Angiography and Interventions, Society of Interventional Radiology,
Society of Neurolnterventional Surgery, Society for Vascular Medicine,
and Society for Vascular Surgery. Circulation. 2011;124(4):489-532.
4. Biasi GM, Froio A, Diethrich EB, et al. Carotid plaque echolucency
increases the risk of stroke in carotid stenting: the Imaging in Ca­
rotid Angioplasty and Risk of Stroke (ICAROS) study. Circulation.
2004;110(6):756-762.
5. Ricotta JJ, Aburahma A, Ascher E, et al. Updated Society for Vascu­
lar Surgery guidelines for management of extracranial carotid disease.
J Vase Surg. 2011;54(3):e1-e31.
6. Yadav JS, Wholey MH, Kuntz RE, et al. Protected carotid-artery
stenting versus endarterectomy in high-risk patients. N Eng/ J Med.
2004;351(15):1493-1501.
7. Gurm HS, Yadav JS, Fayad P, et al. Long-term results of carotid
stenting versus endarterectomy in high-risk patients. N Eng/ J Med.
2008;358(15):1572-1579.
8. Ringleb PA, Allen berg ], Briickmann H, et al. 30 day results from the
SPACE trial of stent-protected angioplasty versus carotid endarrer­
ectomy in symptomatic patients: a randomised non-inferiority trial.
Lancet. 2006;368(9543 ):1239-1247.
9. Mas JL, Chatellier G, Beyssen B, et al. Endarterectomy versus stenting
in patients with symptomatic severe carotid stenosis. N Eng/ J Med.
2006;355(16):1660-1671.
10. Mas JL, Trinquarr L, Leys D, et al. Endarrerectomy Versus Angio­
plasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S)
trial: results up to 4 years from a randomised, multicentre trial. Lancet
Neural. 2008;7(10):885-892.
11. Ederle ], Dobson ], Featherstone RL, et al. Carotid artery stenting
compared with endarterectomy in patients with symptomatic carotid
stenosis (International Carotid Stenting Study): an interim analysis of
a randomised controlled trial. Lancet. 2010;375(9719):985-997.
12. Brott TG, Hobson RW II, Howard G, et al. Stenting versus endar­
terectomy for treatment of carotid-artery stenosis. N Eng/ J Med.
2010;363(1):11-23.
- I

Chapter 5 Carotid Surgery:

Distal Exposure and Control
Techniques and Complication
I
Management
:
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ·
I

Cheong J. Lee

DEFINITION • Although duplex scanning provides accurate and reproduc­

ible assessment of the presence and severity of carotid ste­
• The carotid artery typically bifurcates at the level of the
nosis, precise anatomic detail required for surgical planning
C3-C4 cervical spine. High carotid bifurcations and lesions
is optimally obtained from computed tomographic angiog­
that extend to the C l -C2 level pose technical challenges that
raphy ( CTA) or magnetic resonance arteriography (MRA).
may increase perioperative risk of stroke and cranial nerve
Localization of the carotid bifurcation in regard to cervical
injury. Ideally, the need for high access in carotid surgery
landmarks, as well as the distal extent of internal carotid ar­
should be anticipated preoperatively, with familiarity of the
tery (ICA) disease, is best assessed by CTA or MRA ( FIG 1 ) .
anatomy and exposure necessary for distal carotid control.
IMAGING AND OTHER DIAGNOSTIC
PATIENT HISTORY AND PHYSICAL
STUDIES
FINDINGS
• Current indications for carotid endarterectomy were re­
• As with any medical therapy, the clinician must first clearly
viewed in Part 6, Chapter 3 . 1-3
define the goals of treatment and thoroughly review the op­ • In recent years, CTA and MRA have assumed preeminent
erative risk with the patient.
roles in carotid intervention planning. Improved resolu­
• Optimal medical therapy must be instituted prior to inter­
tion has enabled highly accurate characterization of plaque
vention (e.g., antiplatelet agent, statin, beta-blocker) .
morphology, which may provide useful guidance regarding
• Patients with hostile neck anatomy, such as those with his­
plaque vulnerability during operative manipulation.
tory of high-dose neck radiation or severe systemic comor­ • MRA and CTA also provide essential information regarding
bidities contraindicating general or cervical block anesthesia,
potential collateral arterial flow through the circle of Willis
should be offered carotid angioplasty and stenting ( CAS) as
and the need for adjuvant maneuvers such as shunt place­
an alternative procedure.
ment during carotid revascularization ( FIG 2 ) .
• Patients with prior contralateral carotid revascularization
procedures should have laryngeal, hypoglossal, and glosso­
SURGICAL MANAGEMENT
pharyngeal nerve function documented prior to ipsilateral
dissection and exposure. When evidence of prior inj ury to Preoperative Planning for Distal Cervical Carotid
CN IX, X, or XII is evident, CAS should be considered as Exposure
an alternative. If CAS is not feasible under these circum­
• Knowledge of patient-specific cervical anatomy is essential
stances, the potential need for tracheostomy to manage
to successful management of distal carotid disease. When
postoperative airway obstruction should be reviewed with
recognized as necessary, specifying nasotracheal, rather
the patient.
than orotracheal, intubation for general endotracheal

FIG 1 • Refo rm atted CTA of a ca rotid body t u m o r exte n d i n g to FIG 2 • Rendered CTA d e m o nstrating i ncom pete n cy of the c i rcle
the d ista l I CA at the C1 cervical s p i n e leve l . of Wi l l is.

1837
1838 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY
Positioning
• The patient is positioned supine, with the head extended
• Arms are tucked t o the p atient's side t o allow the opera­
• The patient is placed in the " beach chair" position to limit
FIG 3 • N a sotrachea l i ntu bation fac i l itates exposu res of the
d i sta i i CA by open i n g the angle between the masto i d p rocess and
the m a n d i b l e (black lines).
anesthesia is a simple and highly effective maneuver to im­
prove exposure. Nasotracheal intubation allows the mouth
to stay closed during surgery, providing more room between
the ramus of the mandible and mastoid process for distal
dissection.
• Temporomandibular subluxation may further advantage
carotid exposure cephalad to the C2 cervical spine. Sub­
luxation of the ipsilateral mandibular condyle, performed
ANTERIOR APPROACH TO T H E D I STAL
I NTERNAL CAROT I D ARTE RY
Incision
• A vertical, rath e r t h a n tra nsverse, cervical i n c i s i o n is rec­
o m m e n d e d for o pti m a l d ista i iCA access (FIG S) .
• Sta n d a rd expos u re of the ca rotid a rtery i n the sh eath
was previously described in Part 6, Cha pter 3 .
FIG 5 • Anato m i c l a n d m a rks for ca rot i d exposu res i n c l u d e
the m asto i d p rocess, the a n g l e of the m a n d i b l e, a n d t h e
ste r n a l n otch . S k i n i n c i s i o n f o r ca rotid exposu res a re p l aced
a nterior to the sternocleidom asto i d m uscle (SM) (solid line).
If d ista l exposu re is a ntici pated, the i n c i s i o n can be ca rried i n
front o f t h e e a r (dotted line).
via intraoral wiring, facilitates exposure from infratemporal
ICA to the skull base. Subluxation is distinguished from dis­
location, which is more injurious and can potentiate long­
term temporomandibular j oint pain syndromes.
and rotated away from the operative site. Shoulder rolls
and shays are placed to stabilize the neck and optimize
extension. The nasotracheal tube is secured over the head
( FIG 3 ) .
tor and the assistant to maneuver and stand comfortably.
This position also facilitates C-arm positioning when
needed.
venous hypertension ( FIG 4) .
FIG 4 • Patient i n t h e " beach c h a i r " posit i o n .
Exposure o f the Internal Carotid Artery Distal t o the
Bifurcation
• Key structu res that lie superior to the carotid bifurcation a re
the posterior bel ly of the digastric muscle, the hypoglossa l
nerve, crossing veins from the sternocleidomastoid m uscle to
the i nternal j u g u l a r vein, and m uscu lar arterioles of the pos-
terior branches of the external carotid a rtery (ECA) (FIG 6) .
• The hypog lossa l nerve is identified safely using a posterolat­
eral to a nteromed ial dissection of the ICA. Movi ng cepha-
lad, the hypog lossa l nerve is d issected free from the medial
surface of the d i gastric m uscle. Crossing artery and veins of
the SCM often tether this nerve closer to the bifu rcation.
M eticulous identification and control led d ivision of these
tetheri ng vessels w i l l enable mobilization of the nerve.
Tracing the cou rse of the descending branch of the ansa
cervica lis back to the hypog lossa l itself provides positive con­
fi rmation of the location and cou rse of the nerve (FIG 7).
• The poste r i o r d i g a stric m uscle b e l l y may be retracted o r
d ivided as req u i red for exposu re, fo l l ow i n g r e l e a s e of
the a d h e rent hypog l ossa l n e rve.
• Additional cepha lad exposu re at this j u nctu re req u i res d ivi­
sion of the occipita l branch of the ECA. This further rel eases
the hypogl ossa l nerve. This m a neuver a lso req u i res d ivision
of the styloid m uscu lature (styloglossus, stylopharyngeus).
• Conti n u e d c e p h a l a d d i ssection exposes the g l ossopha­
ryn g e a l n e rve, seen as a single o r double tru n k cross i n g
the I CA anteriorly a n d cours i n g poste rior to the ex­
te r n a l carot i d . Ca re m u st be taken in separat i n g the
hypog l ossa l and g l osso p h a ryngeal n e rves, as sma l l motor
C h a p t e r 5 CAROT I D S U R G E RY: Distal Exposure and Control Techniques and Complication Management
PBD
Arterial
branch to
XII
I CA
sternocleidomastoid
FIG 6 • Once the ca rotid sheath is e ntered, expos u re of the
d ista i iCA from an a nterior a p p roach beg i n s with identification
and d i ssection of the hypo g l ossa l n e rve (XI I), the poste rior
b e l l y of the d i g astric m uscle (PB D), a n d the cross i n g ve i n s and
a rteries to the sternocleidomasto i d m uscle.
FIG 7 • Fol lowing d ivision of the d i g astric m u scle a n d the
cross i n g m uscu l a r vein a n d a rteries to the sternocleidom asto id,
the d esce n d i n g a nsa cervica l i s n e rve (DAC) can be l i g ated
to f u rther m o b i l ize the hypog l ossa l n e rve (XI I) . To f u rther
fac i l itate hypog l ossa l m o b i l ization, the occ i pital a rtery co m i n g
off t h e E C A h a s been l i g ated a n d d iv i d e d .
1839
FIG 8 • M o b i l ization of the hypo g l ossa l n e rve (XI I) a l l ows
expos u re of the d i sta l I CA.
fi bers exit i n g the vagus n e rve a lso cou rse in this p l a n e .
D a m a g e to these n e rves o r the g l osso p h a ryngeal ca n
cause swa l l owi n g dysfu ncti o n . Classical ly, i n j u ry to the
g l osso p h a ryngea l n e rve i n t h i s reg i o n may i m p a i r the
a b i l ity of the soh p a l ate to rise suffi ciently with swa l l ow­
i n g to p reve nt naso p h a ryngeal l i q u i d reflux.
• When these ste ps a re safe ly co m p l eted, the ICA may be
adeq uately exposed for reco nstruct i o n u p to the l evel of
C2 (FIG 8). F u rther exposure to the level of C1 fo l l owi n g
t h i s cou rse req u i res sty l o i d ectomy a n d/or preoperative
m a n d i b u l a r s u b l uxat i o n .
• D ista l d i ssect i o n may a l so be fa c i l itated by m o b i l ization
of the pa rotid g l a n d a n d fac i a l n e rve. This is most safe ly
acco m p l ished with assista nce from oto l a ryn g o l o g i sts o r
cra n i o m axi l l ofa c i a l surgeon. T o provide t h i s m e t h o d o f
exposu re, the s k i n i n c i s i o n is c a r r i e d ce p h a l a d a nterior to
the e a r (FIG 9) . This e n a b les m o b i l ization of the pa rot i d
g l a n d superiorly a n d m ed i a l ly.
• The p a rotid fasci a is entered a n d the b ra nches of the fa­
cial n e rve a re d i ssected, i d e ntified, and p rotected before
d i vi d i n g the poste rior belly of the d i g astric m uscle.
• Ca re is a g a i n taken to ide ntify the g l osso p h a ryngeal
n e rve a n d the motor fi bers of the va g u s n e rve (FIG 1 0) .
• D ista l contro l o f t h e I CA a t h i g h C 1 -C2 level m a y req u i re
speci a l ized i n strum entati o n . S m a l l detach a b l e occl u d i n g
c l a m ps (s uch as t h e Heifetz o r Yasa rg i l c l i ps) m a y p rovide
i m p roved expos u re co m p a red to tra d i t i o n a l " h a n d l e d "
vasc u l a r c l a m ps i n t h i s reg i o n . When u s e d , however,
1840 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY
FIG 9 • If f u rther exposure of the I CA is req u i red a n d
m a n d i b u l a r s u b l uxation is n o t fea s i b le, i n c i s i o n can be carried
i n front of the e a r for m o b i l ization of the p a rotid g l a n d .
care m ust be taken to avo i d c l a m p d islodgement i n t h i s
crowded a n d moving field, which when it does h a p p e n
u s u a l l y d o e s so at the maxi m a l ly i n conve n ient t i m e .
• A s a n a ltern ative t o d ista l c l a m p control, short occl u d i n g
i ntra l u m i n a l catheters can be used, s u c h as a # 2 Fogarty
e m bolectomy catheter with stopcock. Extreme ca re m ust
be taken in positio n i n g a n d deploying embolecto my bal­
loons i n this a rea, however, as i nflation with i n the petrous
portion or overinflation i n any reg ion may p rec i p itate d is­
section, a rterial rupture, or throm bosis. Only the lowest
a m o u nt of i nflation req u i red to p revent back-b leed i n g
s h o u l d be used. T h e carotid a rtery is thi n-wa l led a t t h i s
level a n d easily tra u m atized b y bal loon i nflation . Late
RETROJ U G U LAR APPROACH TO THE
D I STAL I NTERNAL CAROT I D ARTERY
Retrojugular Dissection
• A t h i rd a p p roach to the d i stal I CA is p rovided by retro­
j u g u l a r access. The i ntern a l j u g u l a r (IJ) ve i n a n g les a n ­
te riorly as it ascends f r o m the b a s e of the n eck t o t h e
base of the sku l l a n d overl ies the d i stai i CA as the a rtery
a p p roaches the transverse p rocess of C l .
• U s i n g the poste rior a p p roach, d i ssect i n g beh i n d the IJ
ve i n , obvi ates the need for hypog l ossa l exposu re a n d re­
l ocation, as that n e rve passes a nte riorly over the I CA.
Identification of the Spinal Accessory Nerve
• The retroj u g u l a r d i ssect i o n uses t h e s a m e i n c 1 s 1 o n s
as ot h e r a p p ro a c h e s to t h e d i sta l i nter n a l carotid,
with t h e i n c i s i o n made vertica l ly, a nt e r i o r to t h e S C M
m u sc l e .
F I G 1 0 • O nce t h e pa rotid fascia is entered, t h e branches of
the fac i a l nerve (VI I ) a re identified fo l l owed by the division of
the poste rior belly of the d i g astric m uscle (PBD). Dissection is
then carried a nterior to the I CA from the hypog l ossa l nerve (XI I )
d ista l ly t o identify the g l ossopharyngeal nerve (IX) . M otor fi bers
from the vagus nerve (X) a re ca refu l l y identified a n d p rese rved.
com p l ications a lso include pseudoa n e u rysm or a rteriove­
nous fistula fo rmation. The infl ated catheter should be se­
cured to p revent its m i g rati o n . Stay sutu res may be placed
in the d i stal carotid to m a i nta i n access should control be
lost due to ref l ux of the bal loon from the d i sta l a rtery or
bal loon p u ncture d u ri n g suture closure of the a nastomosis.
• Using this a p p roach, it is essenti a l to identify the s p i n a l
accessory n e rve where it exits 2 t o 3 em below the edge
of the m asto i d p rocess, a nterior to the SCM. The SCM is
fu l ly m o b i l ized to fa c i l itate t h i s exposure.
• O n ce the s p i n a l accesso ry n e rve is i d e ntified a n d isol ated,
the I J ve i n i s d issected a l o n g its poste rior border. The
va g u s n e rve is i d e ntified and refl ected a nterio rly. With
the ve i n and vagus n e rve m o b i l ized a nte riorly, the hypo­
g l ossa l n e rve re m a i n s a nterior to the d i sta i i CA (FIG 1 1 ) .
Identification o f the Superior Laryngeal Nerve
• I n the retroj u g u l a r space, the I CA ca n be d i ssected a l o n g
i t s poste rior latera l wa l l superiorly whereupon the s u ­
p e r i o r l a ryngea l n e rve w i l l be encou ntered exit i n g the
va g u s n e rve and l o o p i n g a r o u n d the d i sta l I CA. Often,
the superior cervical g a n g l i o n can be i d e ntified j u st l at­
e r a l to t h i s l o o p i n g point (FIG 1 2) .
• F o r a d d e d exposu re, the n e rve is ca refu l l y l i fted from t h e
I CA adventit i a .
C h a p t e r 5 CAROT I D S U R G E RY: Distal Exposure and Control Techniques and Complication Management 1841

IJV

FIG 1 1 • Retroj u g u l a r exposu re of the ICA: D i ssection is
carried beh i n d the IJ ve i n a n d the va g u s n e rve (X) m o b i l ized
a nterior to the I CA. Care i s taken i n i d e ntify i n g the s p i n a l
accessory n e rve (XI) at the s u p e r i o r aspect of the d i ssect i o n .
This a p p roach a v o i d s m o b i l ization of the hypog l ossa l n e rve
(XI I ) as the p l a n e of d i ssection re m a i n s poste rior to the n e rve.
FIG 12 • At the d ista l aspect of this retroj u g u l a r space, the
I CA will be looped by the super l a ryngeal n e rve (SLN) as it
comes off the vag us n e rve (X) . Ofte n, the s u peri or cervical
g a n g l i o n (SCG) se rves as a l a n d m a rk for where the SLN
e m a n ates.

PEARLS AND PITFALLS

Ind ications • M a ke n ote of s i g n ificant radiation o r surgery to the neck, whi c h may i nform the choice of p roced u re
(su rg e ry vs. ste nt) .
• M a ke ce rta i n the patie nt's cra n i a l n e rve status is d o c u m e nted, especi a l ly i n the sett i n g of p r i o r neck
o perations.
I ma g i ng • Alt h o u g h d u p l ex i m a g i n g a l o n e i s suffi c i e n t to plan m ost rout i n e ca rot i d s u r g e ry, cross-sect i o n a l
i m a g i n g (CTA/M RA) p rovides esse n t i a l g u i d a n ce for co m p l ex exposu res a n d reco nstructive
tech n i q ues.
• The status of the c i rcle of W i l l is s h o u l d be defi ned i n the cou rse of preoperative p l a n n i n g .
Technique • F o r lesions exte n d i n g t o t h e C 1 -C2 cervica l spi ne, co nsider a t a m i n i m u m n asotracheal i ntubation.
• I n extreme situatio ns, m a n d i b u l a r s u b l uxati o n may p rovi d e critical additional deg rees of freed o m .
• M a n d i b u l a r d i s location is n ot reco m m e n d e d a n d s h o u l d n ot be pe rfo rmed t o assist carotid surgery.
• Knowledge of cranial nerve anatomy is the most important determinant of success.
• Any n e u r a l tissue cross i n g a nterior to the ca rotid bi furcation a n d the I CA s h o u l d not be d i v i d e d .
• M o b i l ization of d iseased a rte r i a l seg m e nts, i n c l u d i n g the carotid bifu rcation, s h o u l d be avoided o r
m i n i m ized prior to h e p a r i n izat i o n .
• Anterior d ista i i CA expos u re is dependent o n the extent to which the hypog l ossal n e rve ca n be safe ly
m o b i l ized.
• Poste rior, retroj u g u l a r expos u re req u i res early i d e ntification of the spinal a ccesso ry n e rve a n d a nte r i o r
reflection of the vag u s n e rves to vis u a l ize the superior l a ryngea l n e rve e n c i rc l i n g the d ista l i nte r n a l
ca rot i d .
• B a l loon occ l u s i o n may fac i l itate far d i stal ca rotid control, but ove radva ncement a n d overi nflation a re
rea l risks that m ust be considered. P l a ce m e nt of stay sutu res w i l l fac i l itate future control m a n e uvers
s h o u l d the catheter become d i s l o d g e d .
1842 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY
POSTOPERATIVE CARE
• Following carotid revascularization, the immediate post­
operative care is focused on close neurologic surveillance.
Patients are recovered typically in an intensive care unit or
monitored setting to facilitate ready identification of evolv­
ing neurologic deficits.
• Careful blood pressure monitoring and management is also
essential. Following carotid revascularization, patients need
to avoid the extremes of blood pressure, which may elicit
hemodynamic stroke and intracerebral hemorrhage.
• Immediate postoperative ( <24 hours ) neurologic deficits
should be assumed to be thromboembolic in nature, most
commonly associated with a technical (surgical) error. Fur­
ther imaging studies are unlikely to alter decision making
and should not delay immediate reoperation. Neurologic
deficits arising later in the postoperative period (> 24 hours)
may be due to intracranial hemorrhage; in these cases, com­
puted tomography ( CT) or magnetic resonance (MR) imag­
ing may assist the decision-making process and should be
considered when etiologic circumstances are less certain.
• Bleeding complications following carotid surgery are rare
but potentially serious or fatal. These may occur during the
first several hours after surgery or even later, particularly in
patients resuming anticoagulation therapy for existing con­
ditions early in the postoperative period. Recognition and
expeditious control of the airway is of utmost importance
as a wound hematoma develops, as cord and airway edema
rapidly worsen in response to reduced venous and lymphatic
drainage. Reopening a carotid incision prior to anesthetic
induction may facilitate emergency endotracheal intuba­
tion; however, this dramatic maneuver is best performed in a
controlled environment with resuscitation equipment avail­
able should complications ensue. Ideally, preparations are
made for wound decompression as endotracheal intubation
is being attempted, with the wound being opened as a last
step maneuver prior to emergency cricothyroidotomy. Cord
edema in these circumstances may be profound, however,
and visualization may not improve sufficiently after hema­
toma evacuation to enable orotracheal or nasotracheal intu­
bation. Therefore, cricothyroidotomy may become necessary
in extreme circumstances, and all carotid surgeons should be
facile in this maneuver as a matter of course.
OUTCOMES
• Although carotid endarterectomy is a well-established tech­
nique continually refined over several decades, good out­
comes are not limited to regional centers of excellence. Data
provided to the American Board of Surgery regarding surgi­
cal case experience in the 12 months preceding application
for recertification in vascular surgery, carotid endarterec­
tomy is recorded as one of the most common procedures per­
formed by contemporary vascular surgeons. A recent query
of the Nationwide Inpatient Sample (NIS ) identified 259,0 8 0
carotid revascularization procedures performed during 2003
and 2004. Although the study examined and compared out­
comes of both carotid endarterectomy and carotid artery
stenting, endarterectomy outcomes alone demonstrated an
impressive overall stroke rate of 0 . 8 8 % and operative mor­
tality rate of 0 . 3 9 % .4 Similarly, data prospectively obtained
from National Surgical Quality Improvement Program
(NSQIP) participation reviewed 1 3 ,622 carotid endarterec­
tomies performed between 2000 and 2003 at 123 Veterans
Affairs and 14 private sector academic medical centers dem­
onstrated a combined stroke and death rate of 3 . 4 % . 5
• Data describing outcome of distal ( base of skull) carotid re­
vascularizations is based on more limited, institution-specific
case series. In these circumstances, outcomes are more diffi­
cult to benchmark. One recent series reported that one of five
patients requiring a distal ICA bypass for aneurysm repair
suffered a stroke; 6 0 % suffered varying degrees of cranial
nerve deficit. 6 The largest experience reported to date is that
of Sessa et a!./ who reported a 3% and 6% rate of periop­
erative stroke and restenosis at 1 year, respectively. When
distal carotid/skull base exposure appears to be necessary
to safely manage an occlusive lesion, consideration should
again be given to CAS as a lower risk alternative technique
to open endarterectomy or interposition grafting.
COMPLICATIONS
• Stroke
• Cranial nerve injury
• Horner's syndrome
• Seroma
• Infection
REFERENCES
1. North American Symptomatic Carotid Endarterectomy Trial. Meth­
ods, patient characteristics, and progress. Stroke. 1991;22:711-720.
2. Endarterectomy for asymptomatic carotid artery stenosis. Executive
Committee for the Asymptomatic Carotid Atherosclerosis Study.
JAMA. 1995;273:1421-1428.
3. Randomised trial of endarterectomy for recently symptomatic carotid
stenosis: final results of the MRC European Carotid Surgery Trial
(ECST). Lancet. 1998;351:1379-1387.
4. McPhee JT, Hill JS, Ciocca RG, et al. Carotid endarterectomy was per­
formed with lower stroke and death rates than carotid artery scenting in
the United States in 2003 and 2004. J Vase Surg. 2007;46:1112-1118.
5. Stoner MC, Abbott WM, Wong DR, et al. Defining the high-risk
patient for carotid endarterectomy: an analysis of the prospective
National Surgical Quality Improvement Program database. J Vase
Surg. 2006;43:285-295; discussion 295-296.
6. Eliason JL, Netterville JL, Guzman RJ, et al. Skull base resection with
cervical·to·petrous carotid artery bypass to facilitate repair of distal
internal carotid artery lesions. Cardiovase Surg. 2002;10:31-37.
7. Sessa CN, Morasch MD, Berguer R, et al. Carotid resection and re­
placement with autogenous arterial graft during operation for neck
malignancy. Ann Vase Surg. 1998;12:229-235.

Chapter 6 Vertebral Transposition
Techniques and Stenting
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I
Mark D. Morasch
t
DEFINITION
• Treatment for occlusive lesions involving the origin of the
vertebral artery (V1 segment) is undertaken to relieve pos­
terior brain circulation ischemia, otherwise known as ver­
tebrobasilar insufficiency. Revascularization options include
open surgical and endovascular techniques. The most com­
mon operation is a proximal vertebral to common carotid
transposition. Endoluminal treatment includes balloon
angioplasty and (typically) stenting.
DIFFERENTIAL DIAGNOSIS
• Other medical conditions mimicking posterior circulation
ischemia include postural hypotension, cardiac arrhythmias,
anemia, brain tumors, and benign vertiginous states. A thor­
ough investigation consists of ruling out ( 1 ) inner ear pa­
thology, (2) cardiac arrhythmias, ( 3 ) internal carotid artery
stenosis/occlusion, and (4) complications of excessive blood
pressure control (Table 1 ) .
• Evaluation o f patients with posterior circulation isch­
emia requires defining the precise circumstances that
elicit symptoms. Vertigo, instability, and occasional loss
of consciousness often accompany positional changes and
standing in older individuals due to reduced sympathetic
venous tone. This is particularly common in p atients
with diabetes. The presence of orthostatic hypotension
should be evaluated as a common alternative cause for
vertebrobasilar symptoms. Any decreases in basilar ar­
tery perfusion pressure may precipitate hemodynamic
symptomatology, with or without concomitant vertebral
occlusive disease .
• The next most common cause of brainstem ischemia is re­
duced cardiac output. When suspected, evaluation includes
24-hour Holter monitoring and echocardiography. In pa­
tients with vertebrobasilar insufficiency, palpitations may be
noted with the onset of symptoms. Transesophageal echo­
cardiography may be necessary to rule out structure heart
ISSUeS.
• Inner ear pathology, including rare cerebellopontine angle
tumors, produces symptoms suggestive of vertebrobasilar
Table 1 : Nonvascular and Cardiac Conditions
that M i m i c Vertebrobas i l a r Ischem i a
Cardiac a rrhyth mia
Pacemaker ma lfunction
Cardioemboli
Antihypertensive medications
Labyrinth i n e dysfunction
Cerebellopontine angle tumors
Cerebellar degeneration
Myxedema
Electrolyte imbalance
Hypog lycemia
I
�
insufficiency. Benign vertiginous states should also be
considered. Physical examination can alert the physician to
the possibility of subclavian steal in patients with differences
in brachial blood pressure greater than 25 mmHg or with
diminished left upper extremity pulses. Reversed flow in the
ipsilateral vertebral artery demonstrated on duplex scanning
is pathognomonic for subclavian steal physiology and sub­
clavian steal syndrome in patients with appropriate symp­
toms at rest or following exercise in the ipsilateral upper
extremity.
• Patients may relate symptoms of vertebrobasilar insuffi­
ciency to positional changes, including turning or extending
their head. These dynamic symptoms usually appear when
turning the head to one side. In this circumstance, symptoms
may be elicited by extrinsic compression of the dominant or
sole vertebral artery (in the case of unilateral occlusion) by
adj acent arthritic bone spurs. 1
PATIENT HISTORY AND
PHYSICAL FINDINGS
• In general, ischemic mechanisms in vertebrobasilar insuf­
ficiency can be categorized as hemodynamic or embolic.
Symptoms of vertebrobasilar insufficiency include dizziness,
vertigo, drop attacks, diplopia, perioral numbness, alternat­
ing paresthesia, tinnitus, dysphasia, dysarthria, and ataxia.
When two or more of these symptoms are present, verte­
brobasilar ischemia is more likely to be the inciting cause.
Unlike other regions of the brain, strokes in the posterior
circulation territory occur due to large artery occlusive
diseases.
• Patients with "hemodynamic " ischemia experience transient
vertebrobasilar symptoms due to inadequate vertebral artery
inflow or collateral circulation. Symptoms are typically short
lived, repetitive, somewhat predictable, and rarely result in
stroke. Postural hypotension may precipitate serious trau­
matic injury, however, when patients lose their balance with
standing.
• Embolic events may also precipitate vertebrobasilar ischemia
as well as cerebellar and brainstem infarction. Microemboli
from the heart, aortic arch, or any arteries leading directly
to the basilar artery may arise from atherosclerotic lesions,
intimal defects, repetitive trauma, fibromuscular dysplasia
lesions, aneurysms, or dissections. Although much less com­
mon than hemodynamic vertebrobasilar insufficiency, when
present, microemboli are much more likely to cause fatal
events or debilitating infarcts. 2-4
• Timing of the onset of symptoms following positional
changes may help differentiate vertebrobasilar insufficiency
from labyrinthine disorders. In the latter circumstance,
rapid head movement invokes immediate symptoms. In
the case of vertebrobasilar insufficiency, however, a short
delay usually precedes the onset of symptoms, including
nystagmus.
1843
1844 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY
IMAGING AND OTHER DIAGNOSTIC
STUDIES
Duplex ultrasound, an otherwise excellent tool for the assess­
ment of extracranial cerebrovascular disease, has limitations in
the diagnosis of vertebral artery pathology. Direct visualization
of the second portion is obscured by the transverse processes
of C2-C6 . As previously mentioned, however, duplex imaging
reliably identifies subclavian steal physiology, as well as detect
proximal velocity increases consistent with orificial vertebral
or proximal subclavian stenosis.5
• Magnetic resonance imaging (MRI) provides safe, nonin­
vasive, and detailed evaluation of the aortic arch and great
vessels, the extracranial and intracranial arterial vascula­
ture, as well as the presence of mass lesions, fluid collections,
or parenchymal defects in the posterior fossa. Contrast­
enhanced magnetic resonance angiography (MRA), with
three-dimensional reconstruction and maximum image inten­
sity techniques, provides excellent image quality in high reso­
lution ( FIG 1 ) . As in other applications, however, in low-flow
circumstances, excessive signal dropout may result in overes­
timation of lesion severity based on signal intensity alone.
• In contrast to computed tomographic ( CT) imaging, trans­
axial MRI readily diagnoses both acute and chronic brain
infarctions in the posterior fossa. Brainstem infarctions are
typically small and as such may be overlooked with noncon­
trast CT imaging. Brain MRI is performed in symptomatic
patients prior to vertebral artery intervention to identify in­
farctions when they are present and provide baseline images
for future comparison.
• Evaluation of vertebral anatomy via catheter-based, contrast
arteriography requires acquisition of images in multiple pro­
j ections to fully evaluate the entire extent of both vertebral
arteries. Evaluation begins with the aortic arch to deter­
mine the origin of the bilateral vertebral arteries. Anoma­
lous origin of the left vertebral artery, arising directly from
the aorta proximal to the left subclavian, is present in 6 %
o f patients. Much less frequently, the right vertebral artery
originates from the innominate or right common carotid
artery. This anomaly often accompanies an aberrant right
subclavian artery, which itself may precipitate symptoms of
dysphagia lusoria.
• Usually, right and left posterior oblique proj ections are suf­
ficient to comprehensively evaluate the Vl (first) vertebral
artery segment from the origin to the transverse process of
C6. In most patients, the left artery is usually dominant, but
FIG 1 • Verte b ra l M RA (with the ca rot i d i m a g e su btracted).
a number of normal variants may be encountered, including
congenital atresia of either vertebral artery.
• The vertebral artery origin may not be visualized adequately
with either duplex ultrasonography or MRA. O blique pro­
j ections are required during arteriography due to superim­
position of the subclavian artery over the vertebral origin.
Additional projections, including craniocaudal tube an­
gulation, may also be required to optimize visualization.
The presence of a poststenotic dilatation in the first centi­
meter of the vertebral artery is a clue that should prompt
further projections to isolate the origin from the overlying
subclavian artery.
• Dynamic arteriography, incorporating provocative position­
ing, may be required to assess the possibility of extrinsic
vertebral artery compression. Finally, delayed imaging may
demonstrate reconstitution of patent distal extracranial ver­
tebral arteries through cervical collaterals when the origin
initially appears occluded.
SURGICAL MANAGEMENT
• Some degree of vertebral artery orificial stenosis is present
in 2 0 % to 4 0 % of patients with other manifestations of
cerebrovascular disease.2 A number of operative approaches
will satisfactorily address Vl segment disease and orificial
stenosis. 6•7 Vertebral transposition, or repositioning of the
origin of the vertebral artery onto the adj acent common
carotid artery is the most common. Endoluminal dilata­
tion, with or without stenting, is also appropriate in selected
circumstances.
Vertebral to Common Carotid Transposition
• General endotracheal anesthesia is preferred. Positioning su­
pine, with the back of the table slightly elevated toward a
chair position with the head rotated away from the planned
incision site facilitates additional deep mediastinal exposure
when required.
• Proximal vertebral artery exposure is similar to that re­
quired for subclavian-to-carotid transposition. One finger­
breadth above the clavicle, a transverse incision is created
directly over the two heads of the sternocleidomastoid mus­
cle ( SCM) . Between the SCM heads, the omohyoid muscle
is identified and divided. Lateral retraction of the internal
j ugular vein and vagus nerve exposes the carotid sheath
medially. Maximal proximal carotid artery exposure, facili­
tated by positioning of the primary operator at head of the
patient, is necessary to ensure an optimal result ( FIG 2 ) .
• The sympathetic ganglia are identified running behind and
parallel to the carotid artery. On the left side, the thoracic
duct is divided between ligatures to minimize lymphatic
leaks. The proximal end should be doubly ligated, avoid­
ing transfixion sutures. Accessory lymph ducts-often seen
on the right side-should also be ligated and divided when
identified. The entire dissection is confined medial to the
prescalene fat pad covering the scalenus anticus muscle and
phrenic nerve. These latter structures are left unexposed lat­
eral to the field. The inferior thyroid artery, running trans­
versely across the field, is also ligated and divided.
• The vertebral vein is next identified emerging from the
angle formed by the longus colli and scalenus anticus and
 C h a p t e r 6 VERTEBRAL TRA N S P O S I T I O N TEC H N I Q U E S A N D STE NTI N G 1845

A B

I nferior thyroid artery

Vag us
nerve
Thoracic d uct

Subclavian artery Internal

jugu lar vein

FIG 2 • A. Access to the p roxi m a l vertebra l a rtery betwee n the sternoc l e i d o m asto id m uscle
b e l l ies. B. Tra nspositi o n of the proxi m a l verte bral a rtery to the poster i o r wa l l of the common
carot i d a rte ry.

overlying the vertebral artery and, at the bottom of the field, is performed in open fashion with continuous 6-0 or 7-0 poly­
the subclavian artery. Unlike its sister artery, the vertebral propylene suture while avoiding any tension on the vertebral
vein has branches. It is ligated in continuity and divided. artery, which tears easily. Before completion of the anastomo­
Below the vertebral vein lies the vertebral artery. It is im­ sis, any slack in the suture is tightened appropriately with a
portant to identify and avoid injury to the adj acent sym­ nerve hook, standard flushing maneuvers are performed, and
pathetic chain. The vertebral artery is dissected superiorly the suture is tied to reestablish flow ( FIG 3 ) .
to the tendon of the longus colli and inferiorly to its origin
in the subclavian artery. The vertebral artery is freed from
the sympathetic trunk resting on its anterior surface without
damaging the trunk or the ganglionic rami. Preserving the
sympathetic trunks and the stellate or intermediate ganglia Common
resting on the artery usually requires freeing the vertebral carotid
artery from these structures, and after dividing its origin, the artery
latter is transposed anterior to the sympathetics.
• Once the artery is fully exposed, an appropriate site for re­
implantation in the common carotid artery is selected. The
patient is systemically anticoagulated with intravenous hep­
arin. The distal portion of the Vl segment of the vertebral
artery is clamped below the edge of the longus colli with a
microclip placed vertically to indicate the orientation of the
artery and to avoid axial twisting during its transposition.
The proximal vertebral artery is closed by transfixion with
5-0 polypropylene suture immediately above the stenosis at
its origin. The artery is divided at this level, and its proximal
stump is further secured with a hemoclip. The artery is then
brought to the common carotid artery and its free end is
spatulated for anastomosis.
• The carotid artery is then cross-clamped. An elliptical 5- to
7-mm arteriotomy is created in the posterolateral wall of the
common carotid artery with an aortic punch. The anastomosis FIG 3 • Proxi m a l vertebra l-to-co m m o n ca rotid tra nspositi o n .
1846 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY
Vertebral Artery Angioplasty and Stent Placement
• In the past decade, endovascular treatment of vertebral artery
disease has gained increasing acceptance. For endovascular
intervention, patients are pretreated with dual antiplatelet
therapy (aspirin and clopidogrel) . The procedure is usually per­
formed with local anesthesia and conscious sedation, enabling
continuous neurologic monitoring of the patient. The patients
are positioned supine and prepped to allow percutaneous
entry into the chosen access vessel. Most cases are performed
from a femoral approach (93 % ) , although transbrachial ( 3 % )
PEARLS AND PITFALLS
P l acement of i ncision • It i s i m porta nt to p l ace the i ncision m ed i a l ly e n o u g h to d i ssect between the heads of the
sternocleidom asto i d . An a p p roach l atera l to this struct u re will make the transposition c h a l l e n g i ng, if
n ot i m poss i b le, to co m p l ete.
O r i e ntation • Enough of the V 1 seg ment of the verte bral a rte ry, u p to n e a r where it d isappears i nto the tra nsverse
p rocess of C6, needs to be m o b i l ized. Al so, p l a n a h ead and see where o n the ca rotid is best to
re i m p l a nt the verte bral before creati n g the ca rotid a rteriotomy.
Closure • A d ra i n is usua l ly h e l pf u l , especi a l ly on the l eft side where the thoracic d uct crosses the exposu re, j ust
in case a tie comes off of a l a rg e lymp hatic. The d ra i n a l l ows for early d i ag nosis of t h i s co m p l icat i o n .
POSTOPERATIVE CARE
• Following surgical transposition, absent significant lym­
phatic drainage from the wound, the patient may be safely
discharged on the first or second postoperative day. Simi­
larly, after endoluminal therapy, patients are kept overnight
to ensure neurologic stability.
OUTCOMES
• After proximal vertebral-to-common carotid transposition,
patency rates at 5 and 10 years equal or exceed 9 5 % and
9 1 % , respectively. When selected appropriately, more than
8 0 % of patients will experience symptomatic relief follow­
ing proximal surgical reconstruction.9
• Appropriate reconstruction and subsequent reperfusion of the
brainstem in patients experiencing hemodynamic vertebrobas­
ilar symptoms may also improve hypertension management.
• Overall, retrospective reviews suggest that endoluminal ver­
tebral artery intervention is reasonably safe, although a se­
lection bias exists. A 2005 Cochrane review identified 3 1 3
interventions for vertebral artery stenosis, with j ust over half
using stem placement as part of the treatment. The technical
success rate was 9 5 % , and the 3 0-day stroke and death rate
was 6 .4 % .1 0
• Despite high technical success rates, vertebral artery an­
gioplasty alone, especially when used for the treatment of
disease at the origin of the vessel, appears to have an unac­
ceptably high rate of restenosis. Adjuvant stent placement
adds to the clinical durability but adds potential morbidity
such as malposition or potential fracture. In their series of 105
patients who underwent endovascular stenting for symptom­
atic vertebral artery disease, Jenkins et alY achieved 1 0 0 %
radiographic improvement (residual stenosis � 3 0 % ) . The
authors reported immediate ( 30-day) periprocedural risk of
death of 1 % and periprocedural complication rate of 4. 8 % .
and transradial ( 5 % ) access has also been used as noted in
one recent review. 8 The stenotic lesions are crossed and then
dilated with 0.014- or 0 . 0 1 8 -in guidewires and small coronary­
diameter balloons. If a stem is chosen, these are usually
bare metal type, but drug elution has also been used. The
same 0.0 14- or 0 . 0 1 8 -in guidewires are used as platforms
over which the stems are delivered and then deployed. Post­
deployment angioplasty may be necessary in selected cases.
Procedures can be performed with or without the assistance
of embolic protection, although most vertebral arteries are too
small to accommodate most distal protection devices.
Complications included transient ischemic attack, flow-limit­
ing dissection, hematoma, and catheter-access-site problems.
At 1 year of follow-up, six patients had died and five had ex­
perienced a vertebrobasilar stroke, and at approximately 2.5
years of follow-up, 70% of patients remained symptom free,
but 1 3 % of patients had restenosis requiring retreatment.11
• A recent systematic review of the available literature noted
a weighted mean technical success rate of 97% . The authors
estimated mean periprocedural stroke and death rate from
combined angioplasty and stenting to be around 1 . 1 % .
Transient ischemic events occurred i n 1 .5 % o f patients.
Recurrent symptoms occurred in 8 % of patients within a
reported range of follow-up of 6 to 54 months and greater
than 5 0 % restenosis developed in 23 % of the subset of
patients who underwent follow-up imaging. 8
COMPLICATIONS
• Proximal vertebral to common carotid transposition has
been reported to have a combined stroke and death rate
of 0 . 9 % . 9 Among patients undergoing this operation, in
one report, there were no deaths or strokes in those who
underwent only a vertebral reconstruction. Berguer and
coauthors reported four instances of immediate postop­
erative thrombosis ( 1 .4 % ) . Three of the four patients had
vein grafts interposed between the vertebral artery and the
common carotid because of a short V1 segment. The grafts
kinked and thrombosed. Other complications that are par­
ticular to proximal reconstruction include vagus and recur­
rent laryngeal nerve palsy ( 2 % ) , Horner's syndrome ( 8 .4 %
t o 2 8 % ) , lymphocele ( 4 % ) , and chylothorax ( 0 . 5 % ) .
• Periprocedural risks for angioplasty and stenting include ac­
cess complications, distal embolization and stroke, arterial
rupture, stent malposition, and vessel thrombosis or dissec­
tion. Later, restenosis and stent fracture are not uncommon
( FIG 4) .
 C h a p t e r 6 VERTEBRAL TRA N S P O S I T I O N TEC H N I Q U E S A N D STE NTI N G
FIG 4 • Verte bral a rte ry ste nt with fractu re a n d i n -ste nt
reste nosis (Fro m : Cronenwett J L, J o h nsto n KW, eds. Rutherford's
Vascular Surgery. 7th e d . P h i l a d e l p h ia, PA: S a u n d e rs; 2 0 1 0, with
permission.)
1847
REFERENCES
1. Bauer R. Mechanical compression of the vertebral arteries. In: Berguer
R, Bauer R, eds. Vertebrobasilar Arterial Occlusive Disease: Medical
and Surgical Management. New York: Raven; 1 9 84:45-7 1 .
2. Caplan LR, Wityk RJ, Glass TA, e t al. New England Medical Center
Posterior Circulation registry. Ann Neurol. 2004; 5 6 : 3 8 9-3 9 8 .
3. Caplan L , Tettenborn B. Embolism i n the posterior circulation. In:
Berguer R, Caplan L, eds. Vertebrobasilar Arterial Disease. St. Louis,
MO: Quality Medical; 1 992:52-65.
4. Pessin M. Posterior cerebral artery disease and occipital ischemia. In:
Berguer R, Caplan L, eds. Vertebrobasilar Arterial Disease. St. Louis,
MO: Quality Medical; 1 992:66-75 .
5. Berguer R, Higgins R, Nelson R. Noninvasive diagnosis of reversal of
vertebral-artery blood flow. N Eng/ ] Med. 1 9 8 0 ; 3 02 : 1 349-1 3 5 1 .
6. Edwards WH, Mulherin J L Jr. The surgical approach t o significant
stenosis of vertebral and subclavian arteries. Surgery. 1 9 8 0 ; 8 7:20-2 8 .
7. Roon A], Ehrenfeld WK , Cooke PB, e t al. Vertebral artery reconstruc­
tion. Am ] Surg. 1 9 79; 1 3 8 :29-3 6 .
8. Antoniou GA, Murray D, Georgiadis GS, et al. Percutaneous trans­
luminal angioplasty and stenting in patients with proximal vertebral
artery stenosis. ] Vase Surg. 2 0 1 2;55 : 1 1 6 7-1 1 77.
9. Berguer R, Flynn LM, Kline RA, et al. Surgical reconstruction of the
extracranial vertebral artery: management and outcome. ] Vase Surg.
2000;3 1 :9-1 8 .
10. Coward LJ, Featherstone RL, Brown MM. Percutaneous transluminal
angioplasty and stenting for vertebral artery stenosis. Cochrane Data­
base Syst Rev. 2005 ; ( 2 ) : CD0005 1 6 .
1 1 . Jenkins J S , Patel SN, White CJ, e t al. Endovascular stenting for verte­
bral artery stenosis. J Am Coli Cardia/. 2 0 1 0;55 ( 6 ) : 5 3 8-542.
 -

Chapter 7 Neurogenic T horacic Outlet

Syndrome Exposure and
Decompression: Supraclavicular
I
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - � - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ·

Robert W Thompson Chandu Vemuri

which promotes scalene/pectoralis muscle spasm, fibrosis,

DEFINITION
• Thoracic outlet syndrome (TOS) is a group of conditions
caused by compression of one of the neurovascular structures
that serve the upper extremity.1-3 Neurogenic thoracic outlet
syndrome (NTOS) is the most frequent of these, occurring in
8 5 % to 90% of thoracic outlet patients. It is caused by com­
pression and irritation of the brachial plexus nerves within the
supraclavicular scalene triangle and/or underneath the pecto­
ralis minor muscle tendon in the subcoracoid space ( FIG 1 ) .
NTOS tends t o occur i n patients between the ages o f 1 5 and
40 years, typically manifesting as neck and upper extremity
pain, paresthesias, and functional limitations in the ipsilateral
arm. Although relatively uncommon, clinical recognition and
appropriate treatment are crucial to optimizing outcome in
young active individuals with NTOS-related disability.4
• The causes of NTOS include anatomic variations ( anoma­
lous scalene musculature, aberrant fibrofascial bands, and/
or cervical ribs) and previous neck or upper extremity injury,
and other pathologic changes.4 These muscular alterations,
in turn, lead to compression and irritation of the adj acent
brachial plexus nerves. The presence of a cervical rib is often
cited as a risk factor for NTOS; however, few NTOS patients
(approximately 1 0 % ) have a definable cervical rib, and de­
velopment of NTOS symptoms are rare in cervical rib pa­
tients in the absence of predisposing inj ury.5
• NTOS often occurs in individuals involved in occupational or
recreational activities requiring repetitive overhead activities
with the arms and/or heavy lifting, occasionally aggravated
by injury (e.g., motor vehicle collisions or falls upon the out­
stretched arm ) . Other predisposing conditions include low­
grade repetitive strain injury (e.g., prolonged keyboard use) ,
poor posture, and dysfunctional shoulder girdle mechanics.
• Surgical treatment for NTOS may be effectively accomplished
by several different approaches, including transaxillary 1 st rib
resection and anterior (supraclavicular) decompression. The su­
praclavicular approach has long been a mainstay in the surgical

Scalene triangle

� Middle scalene
muscle

Anterior scalene

P h renic nerve Long thoracic

nerve
Subclavian
artery -�':31•

Subclavian
plexus nerve
vein
roots (C5-T1 )
Fi rst rib

Subcoracoid space

FIG 1 • Anatomy of the thoracic

outlet, with em phasis o n the su pra­
Axi l lary artery
Pectoralis m i nor clavicu l a r sca lene tri a n g l e and the
m uscle i nfraclavicu l a r su bcoraco i d space.
1848
 C h a p t e r 7 N E UROG E N I C T H O RA C I C OUTLET S Y N D R O M E EXPO S U R E A N D D E C O M P R E S S I O N
Tab l e 1 : Differential Diagnosis of Neurogenic
Thoracic Outlet Syndrome
Acro m ioclavicu lar a rthropathy Fi bromyalgia and fibromyositis
Arterial atheroem bolism Nerve sheath neoplasm
B rach ial plexus (stretch) injury Pancoast tumor (lung apex)
Carpal tunnel syndrome (median nerve) Parsonage-Turner syndrome
Cervical dystonia Psychogenic syndrome
Cervical spine degenerative a rthritis Radial nerve compression
(extensor forearm)
Complex regional pain syndrome Raynaud syndrome
Cervical spine degenerative disc disease Rotator cuff tendinitis
Cervical spine (m uscular) stra in Scleroderma
C u bital canal syndrome (ulnar nerve) Vascul itis
treatment of NTOS, providing excellent exposure for safe and
definitive decompression of the relevant neurovascular struc­
tures as well as the flexibility to manage the entire spectrum of
circumstances that may be encountered intraoperatively.6-1 0
DIFFERENTIAL DIAGNOSIS
• NTOS-related symptoms may mimic or overlap those ob­
served in other upper extremity neurologic and muscu­
loskeletal disorders, expanding the differential diagnosis
(Table l ) Y·12 Successful intervention requires differentiation
of NTOS from other cervical-brachial syndromes as well as
optimal patient and procedural selectionY
• NTOS should be readily differentiated from venous TOS,
which produces marked arm swelling, cyanotic discoloration,
and distention of subcutaneous veins around the shoulder and
chest walL Venous TOS often presents clinically as axillary­
subclavian vein " effort-related thrombosis " (Paget-Schroetter
syndrome) . NTOS should also be distinguished from arterial
TOS, which causes either fixed subclavian artery obstruction
or poststenotic aneurysm formation. The former may precipi­
tate arm or hand pain with exercise ( " arm claudication" ) , the
latter aneurysm thrombosis and distal embolization, hand
ischemia, rest pain, and/or digital ulceration and necrosis.
• Some NTOS patients exhibit severe upper extremity pain
and hypersensitivity, with digital swelling and discoloration,
suggesting the presence of sympathetic nerve overactivity. In
such cases, the coexistence of reflex sympathetic dystrophy
(complex regional pain syndrome [CRPS] ) should be deter­
mined by assessing the symptomatic response to a temporary
cervical sympathetic (stellate ganglion) anesthetic block.
PATIENT HISTORY AND PHYSICAL FINDINGS
• Symptoms attributable to brachial plexus nerve compres­
sion include pain, numbness, and tingling (paresthesia)
in the neck, shoulder, arm, and hand. The distribution of
symptoms in the hand often extends beyond that expected
for either the median or ulnar nerves, involving all fingers.
Patients with NTOS attributable to compression at the pec­
toralis minor tendon often describe upper anterior chest and
axillary pain. The intensity of symptoms of NTOS can vary
with the extent of upper extremity activity and are usually
reliably exacerbated with arm elevation and abduction.
• Many NTOS patients experience relatively mild symptoms,
with gradual progression in severity punctuated by peri­
odic exacerbations. Others experience steady, progressive
1849
worsening of symptoms and related disability. Hand muscle
weakness and atrophy ( Gilliatt-Sumner hand) are rare, typi­
cally following long-standing brachial plexus compression
due to an associated cervical rib or similar bony anomaly.
• Physical examination typically identifies reproducible ten­
derness to palpation over the supraclavicular scalene trian­
gle and/or the infraclavicular subcoracoid space ( FIG 2 ) .
• Most NTOS patients experience recurrent upper extremity
symptoms in response to provocative positional maneuvers,
such as the upper limb tension test (ULTT) or the 3-minute
elevated arm stress test (EAST) ( FIG 2 ) . Positional dampen­
ing of the radial artery pulse at the wrist during arm ab­
duction and external rotation (Adson's test) is nonspecific
and inaccurate and is generally not useful in establishing or
excluding a diagnosis of NTOS.
• Directed physical examination is performed to determine the
presence of cervical spine degenerative disease or peripheral
nerve compression (carpal tunnel and cubital canal syn­
dromes) as potential alternative sources of NT OS-like symp­
toms as well as evidence of arterial or venous compromise
to the affected extremity. Signs of increased upper extremity
sympathetic tone are also sought, including digital swelling,
discoloration, and skin hypersensitivity ( allodynia) .
• Documentation o f patient-reported symptoms and quantifi­
cation of disability prior to treatment are accomplished by
completion of standardized outcomes measurement tools
such as the Disabilities of the Arm, Shoulder, and Hand
(DASH) questionnaire and quality-of-life instruments.14
Repeated use of these instruments at various intervals before
and after treatment has provided increasing insight into the
relative value of alternative management strategiesY
IMAGING AND OTHER DIAGNOSTIC
STUDIES
• Although imaging and other diagnostic studies may provide
helpful ancillary information, there is no definitive test to
confirm or exclude the diagnosis of NTOS. Diagnosis re­
mains quintessentially clinical and dependent on experi­
enced pattern recognition.
• Plain anteroposterior chest radiographs will identify a cervical
rib when present. No other currently available imaging study
adds significant value to the clinical diagnosis of NTOS ( FIG 3 ) .
• Conventional electrophysiologic tests (electromyography and
nerve conduction studies) are often performed to exclude pe­
ripheral nerve compression disorders or cervical radiculopa­
thy. These tests are usually negative or nonspecific in NTOS
and cannot be used to establish or exclude the diagnosis.
• Vascular laboratory studies (Duplex ultrasound) may detect
alterations in upper extremity blood flow attributable to
subclavian artery compression during arm elevation. How­
ever, positional subclavian artery compression may represent
an incidental and unrelated vascular finding and does not
establish a diagnosis of neurogenic or arterial TOS. As they
do not assess the presence or severity of brachial plexopathy,
vascular laboratory studies add little specificity beyond the
clinical diagnostic criteria.
• Performance of image-guided anterior scalene and/or pec­
toralis minor muscle anesthetic blocks may assist the
clinical diagnosis of NTOS.16 A positive block, character­
ized as temporary relief or improvement in the presenting
1850 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

E Office Chert Dlegrem

3m -EAST ULTT DASH
(minutes) (+ or -) (0-1 00)
+
D D D 1m 30s 76.8

D D D D 0 0 +++
*

Scalene Scalene
Subcoracoid Subcoracoid
D D D D 0 0 ++
*

R L

Exemple: Left-Sided NTOS with Brechtel

Plexus Compression et Both Scelene
Trlengle end Subcorecold Spec•

FIG 2 • Physica l exa m i nation reveals local ized te n d e rness to p a l pat i o n over the s u p raclavicu l a r sca l e n e tria n g l e (A) a n d/o r the
i nfraclavicu l a r su bcoraco i d space (B) . The U LTT (C) a n d the 3-m i n ute EAST (D) use p rovocative posit i o n a l m a n e uvers that ra p i d ly e l icit
reprod u ction of upper extrem ity sym ptoms i n patie nts with NTOS. E. An office c h a rt d i a g ra m is used to easily s u m m a rize physica l
exa m i nation f i n d i ngs for patie nts b e i n g eva l u ated for NTOS.

symptoms, strongly supports the clinical diagnosis of NTOS.
A positive block may predict symptomatic relief from surgi­
cal decompression and is therefore highly useful in select­
ing candidates for 1 st rib resection. Unfortunately, however,
failure of temporary symptom resolution following muscle
blockade does exclude the diagnosis of NTOS and should
not preclude consideration of surgical management in other­
wise compelling clinical candidates.
• Initial treatment for NTOS is based on physical therapy
to relieve scalene/pectoralis minor muscle spasm, improve
 C h a p t e r 7 N E UROG E N I C T H O RA C I C OUTLET S Y N D R O M E EXPO S U R E A N D D E C O M P R E S S I O N
FIG 3 • A left-s ided cervical r i b i d e ntified by p l a i n ch est
rad i o g ra phy (arrow).
posture, enhance functional limb mobility, strengthen asso­
ciated shoulder girdle musculature, and diminish repetitive
strain exposure in the workplace. Incorrect approaches to
physical therapy can result in worsening of symptoms and
failure of conservative management. In many NTOS patients,
significant symptomatic improvement may be experienced
in response to physical therapy, particularly in the first 4 to
6 weeks. Because NTOS is commonly chronic, however, and
subject to acute symptomatic "flare ups " (often related to
overuse activities or new injury), such patients should con­
tinue prescribed physical therapy exercises during long-term
follow-up. Patients that fail a conscientious and effective
physical therapy, as well as alternative conservative mea­
sures, are referred for consideration of surgical intervention.
SURGICAL MANAGEMENT
• Supraclavicular decompression (scalenectomy, 1 st rib resec­
tion, and brachial plexus neurolysis) is recommended on
the basis of ( 1 ) sound clinical diagnosis of NTOS, (2) sub­
stantial resulting disability (interference with daily activities
and/or work), and ( 3 ) an inadequate response to standard
physical therapy. Supraclavicular decompression may also
provide relief from persistent or recurrent NTOS symptoms
FIG 4 • Patient position and p l a n ned i ncisions for l eft-sided su praclavicu l a r thoracic outlet deco m p ression with pectora l i s m i n o r ten otomy.
185 1
following prior surgery, particularly when continued conser­
vative measures prove ineffective.
• For patients with symptoms referable to the subcoracoid
space, release of the pectoralis minor tendon should be
included in the supraclavicular thoracic outlet decompres­
sion procedure. Pectoralis minor tenotomy may also be per­
formed as a stand-alone procedure when nerve compression
symptoms are limited to this areaY·18
• Decompression should be performed as a staged, sequen­
tial procedure in patients with bilateral NTOS symptoms.
The initial supraclavicular decompression, with or without
pectoralis minor tenotomy, is performed on most symptom­
atic or dominant extremity. If symptoms remain present or
progress, contralateral supraclavicular decompression may
be performed within 6 to 12 weeks of the initial procedure.
Normal phrenic nerve function should be verified on the side
of the previous procedure, by chest fluoroscopic examina­
tion, before contralateral intervention.
Preoperative Planning
• The supraclavicular surgical site is marked in the preoperative
holding area, including the subcoracoid space when concomi­
tant pectoralis minor tenotomy is planned. Prophylactic antibi­
otics are administered within an hour of the planned procedure.
Positioning
• After the induction of general endotracheal anesthesia, the pa­
tient is positioned supine with the head of the operating table
elevated 30 degrees. The neck is extended and turned to the
opposite side; a small inflatable pillow is placed behind the
shoulders; and the neck, chest, and affected upper extremity
are prepped into the field. The arm is wrapped in stockinette
to permit free range of movement during the operation and
then held comfortably across the abdomen ( FIG 4} . Lower
extremity sequential compression devices are used for throm­
boprophylaxis. Neuromuscular blocking agents are not used
following the initial induction of anesthesia.
Pectoralis Minor ---.
Incision
1852 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

SUPRACLAVICULAR DECOMPRESSION the sca l e n e fat pad. The sternocleidomasto i d m uscle is

retracted med i a l ly but is not d ivided (FIG S) .
Incision and Mobilization o f the Scalene Fat Pad
• O n e of the keys to s i m p l ify i n g the s u p raclavicu l a r expo­
• A tra nsverse neck i n cision is m a d e p a ra l le l to a n d j u st s u re is proper m o b i l ization and latera l reflection of the
a bove the clavicle, beg i n n i n g at the l atera l edge of the sca l e n e fat p a d . This beg i n s with d eta c h m e nt of the fat
sternocleidom asto i d m u scle and exte n d i n g to the a nte­ pad a l o n g the latera l edge of the i nte r n a l j u g u l a r vei n
rior edge of the tra pezius m uscle. The i n c i s i o n is carried a n d t h e superior edge o f t h e clavicle, with l i gation of
through the su bcuta neous layer, the p l atys m a m uscle is sma l l blood vessels and l y m p h atic tissues. The thoracic
d ivided, a n d s u b p l atysm a l f l a ps a re d eve loped to expose d u ct, u s u a l l y observed n e a r the j u nct i o n of the i nternal

FIG S • A. The s k i n i n c i s i o n is m a d e j u st a bove a n d p a ra l l e l to the clavicle, exte n d i n g from the

latera l border of the sternocl e i d o m asto i d m uscle to the a nterior border of the tra pezius m u scle.
B. S u b p l atysm a l f l a ps a re created to expose the u n d e r l y i n g sca l e n e fat p a d . The sca lene fat pad
is m o b i l ized, beg i n n i n g with its m ed i a l attac h m e nts to the i ntern a l j u g u l a r ve i n (IJV) (C), a n d the
o m o hyo id m u scle is d ivided (D) .
 C h a p t e r 7 N E UROG E N I C T H O RA C I C OUTLET S Y N D R O M E EXPO S U R E A N D D E C O M P R E S S I O N 1853

Tab l e 2 : Critica l Views Obta i ned d u r i n g S upraclavicular Thoraci c Outlet Decompression

1 . View of the operative field after lateral reflection of the sca lene fat pad, with visual ization of the interna l jugular vein, anterior scalene m uscle, phrenic
nerve, brach ial plexus, subclavian artery, middle scalene m uscle, and long thoracic nerve
2. View of the lower part of the anterior scalene m uscle where it attaches to the 1 st rib, with space sufficient to al low a fi nger to pass behind the anterior
sca lene m uscle and in front of the brachial plexus and subclavian artery, prior to division of the anterior scalene m uscle insertion from the top of the 1 st rib
3 . View of the upper part of the anterior scalene m u scle at the level of the C6 transverse process, in relation to the C S and C6 nerve roots, prior to d ivision of
the a nterior scalene muscle origin
4. View of the i nsertion of the middle sca lene m u scle on the 1 st rib, with each of the five nerve roots of the brach ial plexus and the subclavian a rtery re­
tracted medially and the long thoracic nerve retracted lateral ly, prior to division of the middle sca lene m uscle insertion from the top of the lateral 1 st rib
5 . View of the posterior neck of the 1 st rib, with the T 1 nerve root passing from underneath the rib to join the C8 nerve root to form the i nferior trun k of the
brachial plexus, prior to division of the posterior 1 st rib
6 . View of the anterior portion of the 1 st rib, with placement of the rib shears medial to the sca lene tubercle, prior to division of the anterior 1 st rib

j u g u l a r and subclavian vei ns o n the l eft side (a p ro m i nent
accessory thoracic d u ct may a l so exist o n the r i g ht side),
may be l i g ated and d ivided. The o m o hyo i d m u sc l e is rou­
tinely d ivided (FIG S) .
• The sca l e n e fat pad is prog ressively e l evated i n a med i a l
t o latera l d i rection, b y gentle f i n g e rt i p d i ssection over
the su rface of the a nte rior sca l e n e m uscle. The p h r e n i c
n e rve i s o bse rved pass i n g i n a latera l to m ed i a l d i rection
as it descends along the m u scle su rface. Gentle m a n i p u­
lation of the p h re n i c n e rve prod uces a " d a rt l e " (d i a ­
p h ra g matic sta rt le) response.
• U p o n f u rther l atera l rotati o n of the sca l e n e fat pad, the
brach i a l p l exus n e rve roots (poste rior a n d latera l to the
a nterior sca l e n e m u scle) a n d the m i d d le sca l e n e m uscle
(be h i n d the b rach i a l p l exus) are brought i nto vi ew. The
latera l aspect of the 1 st r i b is p a l pated and visua l i zed,
and the long thoracic n e rve is i d e ntified as it e m e rges
from the body of the m i d d l e sca l e n e m uscle to cou rse
past the l atera l p a rt of the 1 st r i b . The sca l e n e fat pad is
then h e l d in posit i o n with sever a l s i l k retraction sutu res
a n d the exposure is m a i ntained with a H e n ley self-reta i n ­
i n g retractor (usi n g the t h i rd a r m t o h o l d the e d g e of t h e
sternocleidom asto i d m uscle). The res u l t i n g expos u re rep­
resents the fi rst and most i m portant of six "critical views"
to be o bta i n e d d u r i n g s u p raclavicu l a r deco m p ress i o n
(Ta b l e 2) (FIG 6) .
the posteri or aspect of the m uscle often pass a r o u n d the
subclavian a rtery to form a teth e r i n g " sl i n g " a n d s h o u l d
a lso be resected to fu l ly release the a rtery. Any sca l e n e
m i n i m u s m u scle fi bers fo u n d to be present (pass i n g be­
twee n the roots of the b rach i a l p l exus) a re d ivided as
the a nte rior sca lene m uscle is m o b i l ized. As the a nterior
sca l e n e m uscle is l i fted f u rther, it is passed u n d e rn eath
and m ed i a l to the p h r e n i c n e rve and its posteri or attach­
m e nts a re d ivided with d i rect visua l i zation and p rotec­
tion of the u p per brach i a l p l exus n e rve roots. D i ssection
of the m u scle is carried su periorly to its orig i n o n the C6
transverse p rocess, whi c h is easily p a l pated i n the u p pe r
aspect of the operative f i e l d (the a pex of the " sca l e n e t r i ­
a n g l e " ) . The a nte rior sca l e n e m u scle is then d ivided with
scissors from its orig i n o n the transverse p rocess u n d e r
d i rect vision a n d the entire m uscle is removed, w i t h a

Anterior Scalenectomy

• Attention is turned to the i n se rtion of the a nte rior sca­

lene m uscle o n the 1 st r i b . At the l ower latera l edge of
the a nterior sca l e n e m uscle, the subclavian a rtery a n d
brach i a l p l exus a re ca refu l ly m o b i l ized u n t i l a f i n g e rt i p
ca n be e a s i l y passed beh i n d the m uscle j u st a bove the 1 st
r i b, thereby d i s p l a c i n g the n e u rovasc u l a r structures pos­
tero latera l ly. B l u nt f i n g e rt i p d i ssect i o n is conti n u ed be­
h i n d the m u scle to its m ed i a l edge, ta k i n g ca re to avo i d
the p h r e n i c n e rve. O n ce the i nsertion of the a nterior
sca l e n e m uscle onto the 1 st r i b has been isol ated u n d e r
d i rect vision to p rotect the p h r e n i c n e rve, the s u b c l a v i a n
a rte ry, a n d the b rach i a l p l exus, it is sharply d ivided from
the top of the bone with scissors (FIG 7) .
FIG 6 • F o l l ow i n g latera l reflection of the sca l e n e fat pad,
• The e n d of the d ivided a nte rior sca l e n e m uscle is e l evated d i rect visua l i zation is o bta ined of the i nter n a l j u g u l a r ve i n
a n d its attac h m e nts to the u n d e rlying extra p l e u r a l fascia (IJV), a nterior sca l e n e m uscle (ASM), p h r e n i c n e rve (PhN),
a re sharply d ivided (el ectroca ute ry is not used to avo i d b rach i a l p l exus (BP), subclavian a rtery (SCA), m i d d l e sca l e n e
i n advertent n e rve i n j u ry) . M u sc l e fi bers exte n d i n g from m u scle (MSM), a n d l o n g t h o r a c i c n e rve (LTN).
1854 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

A B

FIG 7 • A. The a nterior sca l e n e m uscle (AS M) i n se rtion is isol ated by d i s p l a c i n g the u n d e r l y i n g subclavian a rtery (SCA) a n d
b rach i a l p l exus ( B P), u s i n g b l u nt f i n g e rt i p d i ssect i o n beh i n d the m u sc l e, a n d the m uscle is s h a r p l y d ivided f r o m the t o p of the 1 st
r i b . B. The e n d of the d ivided a nterior sca l e n e m u scle is l i fted a n d sharply d i ssected free of structu res lyi n g beh i n d the m uscle,
i n c l u d i n g the subclavian a rte ry. C. As it is m o b i l ized, the a nte rior sca l e n e m uscle is passed u n d e rneath and to the m e d i a l side
of the p h r e n i c n e rve (Ph N ) . D. The d i ssection is carried u p to the l evel of the C6 transverse p rocess where the a nte rior sca l e n e
m uscle can be safely d ivided f r o m i t s orig i n a n d removed .

typ ical speci m e n we i g h i n g 5 to 1 0 g . Any m i n o r bleed i n g
from t h e e d g e o f t h e d ivided m uscle o r i g i n is contro l l ed
with sma l l polypropyl en e sutu res rather t h a n e l ectroca u ­
tery, g iven the p rox i m ity of the n e rve roots (FIG 7) .
• A n o m a l o u s f i b rofasc i a l b a n d s may be o bse rved after a n ­
terior sca l e n e m uscle resection, typ i ca l ly pass i n g i n front
of the lower b rach i a l p l exus n e rve roots. These structu res
a re a lso resected as they a re encou ntered to e n s u re thor­
o u g h deco m p ress i o n a n d fu l l n e rve root m o b i l ity.
Mobilization of the Brachial Plexus and Middle
Scalenectomy
• The b rach i a l p l exus n e rve roots a re n ext sepa rated from
the front edge of the m i d d l e sca l e n e m uscle. B l u nt f i n ­
g e rt i p d i ssection a l o n g the l atera l aspect of the n e rves is
used to exte n d the exposure deeper to the i n n e r cu rve of
the 1 st rib a n d the extra p l e u ra l space, and a sma l l m a l ­
l e a b l e retractor is p l a ced between the brach i a l p l exus
 C h a p t e r 7 N E UROG E N I C T H O RA C I C OUTLET S Y N D R O M E EXPO S U R E A N D D E C O M P R E S S I O N
FIG 8 • The brach i a l p l exus is sepa rated f r o m the a ntero­
m e d i a l border of the m i d d l e sca l e n e m uscle down to the level
of the 1 st rib and extra p l e u r a l fascia and gently retracted
m ed i a l ly to visu a l ize a l l five n e rve roots (C5 to T 1 ) .
n e rves a n d the m i d d l e sca l e n e m uscle. With gentle me­
d i a l retract i o n of the brach i a l p l exus, each n e rve root
from C5 to T1 is seq uenti a l l y i d e ntified (FIG 8).
• The tra nsve rse cervica l a rtery and ve i n s h o u l d be l i g ated
and d ivided where they pass t h ro u g h the brach i a l p l exus
a n d m i d d l e sca l e n e m uscle to avo i d bleed i n g shou l d
these vessels be avu lsed d u ri n g retract i o n .
• A seco n d m a l l e a b l e retractor i s p l aced l atera l to t h e
m i d d l e sca l e n e m uscle a n d 1 st r i b, to d isplace the l o n g
thoracic n e rve poste riorly. The o b l i q u e atta c h m ent of t h e
m i d d l e sca l e n e m uscle a l o n g the top of the poste rol at­
e ra l 1 st rib i s expose d . This m uscle i n se rtion is ca ref u l ly
d ivided from the su rface of the bone with the e l ectro­
ca ute ry, u s i n g a perioste a l e l evato r as the d i ssect i o n
proceeds poste riorly, exte n d i n g to a p o i nt o n the 1 st r i b
t h a t is p a ra l l e l w i t h the u n derlyi n g T 1 n e rve root. T h e
b u l k of the m i d d l e sca l e n e m uscle a nterior to the l o n g
thoracic n e rve is then s h a r p ly excised, w i t h a typical
spec i m e n we ight of 3 to 8 g (FIG 9) . Minor bleed i n g
from t h e c u t e d g e o f t h e m i d d l e sca l e n e m uscle shou l d
be contro l l ed w i t h sutu res rath e r t h a n the e l ectrocautery
to avo i d therm a l i nj u ry to the C8 n e rve root or l o n g tho­
racic n e rve.
First Rib Resection
• O n ce the sca l e n ecto my has been co m p l eted, the i nter­
costa l m u sc l e atta c h i n g to the latera l edge of the 1 st
r i b is sepa rated from the bone with the e l ectroca ute ry.
The 1 st r i b is f u l l y exposed poste riorly, where the T1
n e rve root e m e rges from u n d e rn eath the bone to j o i n
t h e C8 n e rve root i n form i n g the l ower tru n k o f t h e
1855
brach i a l p l exus. A rig ht-a n g l e c l a m p is passed u nd e r­
n eath the poste rior neck of the 1 st r i b a n d gently spread
to detach a d d it i o n a l i nte rcosta l tissues. A mod ified Sti l l e­
G i e rtz rib cutter is i nserted a r o u n d the neck of the 1 st r i b .
After verify i n g p rotection of the C8 a n d T 1 n e rve roots,
the bone is sharply d ivided. A Kerrison bone rongeur is
used to sm ooth the poster i o r e n d of the bone, to a level
m ed i a l to the u n derlying T 1 n e rve root, and the e n d of
the bone i s sea led with bone wax (FIG 9) .
• The free e n d of the d ivided poste rior 1 st r i b is e l evated,
and b l u nt fi n g e rt i p d i ssection is used to sepa rate the
re m a i n i n g extra p l e u r a l fasci a a n d i nte rcosta l m uscle
atta c h i n g to the u n de rs u rface of the r i b, prog ress i n g
a nteriorly t o t h e level of the sca l e n e tu bercle (the p revi­
ous site of atta c h m e nt of the anterior sca l e n e m uscle).
N o effort is m a d e to avo i d o pe n i n g the p l e u ra d u r i n g
1 st r i b resection, as the opened p l e u ra l space w i l l a l l ow
better d r a i n a g e of posto perative f l u i d s away from the
brach i a l p l exus (which m i g ht otherwise promote peri­
neural a d h esions).
• The soft tissues u n d e rneath the c l a v i c l e, i n c l u d i n g the
s u bc l a v i a n ve i n , are e l evated with a sma l l R i c h a rdson
ret racto r. The poste r i o r 1 st r i b i s d i s p l aced i nferiorly
with f i n g e rt i p p ressure to o p e n t h e a nterior costoc la ­
vicu l a r spa ce, a nd t h e s u b c l a v i a n a rtery a n d brach i a l
p l exus a re d i s p l aced latera l ly with a s m a l l m a l l e a b l e
ret racto r. The Sti l l e-G i e rtz r i b cutter is p l aced a r o u n d
the a nterior 1 st rib, i m m e d i ately m e d i a l to the sca l e n e
tu bercle (FIG 1 0) . The 1 st r i b i s t h e n d ivi ded u n d e r d i ­
rect v i s i o n , a n d the i ntact spec i m e n is extracted from
t h e o p e rative field (FIG 1 1 ) . The re m a i n i n g a nterior end
of the 1 st rib i s remodeled to a sm ooth su rface with a
b o n e ro n g e u r, to a l evel we l l u n d e rneath the c l a v i c l e .
Oxid ized ce l l u lose fa b r i c (Ethicon, I n c., S o m e rvi l l e, NJ) is
p l aced with i n the bed of the resected 1 st r i b as a to p i c a l
h e m ostatic a g e n t .
• Cervical r i bs a rise with i n the p l a n e of the m i d d l e sca­
lene m u sc l e, poster i o r to the brach i a l p l exus and sub­
clavian a rtery a n d anterior to the l o n g thoracic n e rve.
I n c o m p l ete cervica l r i bs typica l ly have a l i g a m e ntous
exte n s i o n to the 1 st r i b, whereas com p l ete cervica l r i bs
attach to the latera l 1 st r i b i n the form of a true j o i nt.
The poste r i o r portion of a cervica l rib is thereby rea d ­
i l y encou ntered d u r i n g d i ssection of the m i d d l e sca l e n e
m uscle a n d i s d ivided i n a m a n n e r s i m i l a r t o the poste­
rior 1 st r i b . The a nterior atta c h m e nt of the cervical r i b
is then d ivided a n d the bone is removed pri or to 1 st r i b
resect i o n . When there i s a t r u e j o i n t between a co m p l ete
cervical r i b a n d the 1 st r i b, the a nte rior portion of the
cervical r i b is l eft atta ched while the 1 st r i b resection is
co m p l eted, a n d the two a re rem oved togeth e r as a s i n g l e
speci m e n (FIG 1 1 ) .
Brachial Plexus Neurolysis
• T h e l a st ste p of s u p ra c l av i c u l a r deco m p ress i o n is to
fu l ly m o b i l i ze each of t h e i n d i v i d u a l n e rve roots con­
t r i b u t i n g to t h e b r a c h i a l p l ex u s . E a c h n e rve root from
C 5 to T 1 i s meti c u l o u s l y d i ssected free of a n y a d h e r­
ent p e r i n e u r a l f i b r o u s sca r tissue that m i g h t i m p a i r
1856 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

Anterior scalene m uscle (7 grams)

A
Middle scalene muscle (7 grams)
B

c D

FIG 9 • A. After d eta c h i n g the m i d d l e sca l e n e m u scle ( M S M ) from the top of the posterolatera l 1 st r i b u s i n g the e l ectrocautery,
the m uscle tissue lyi n g anterior to the l o n g thoracic n e rve (LTN) is excised. B. Typ i c a l ope rative spec i m e n s of the a nte r i o r
a n d m i d d l e sca l e n e m uscles. C. The poste rior 1 st r i b is exposed w i t h visu a l i zation of the C8 a n d T 1 n e rve roots, a n d the r i b
is d ivided w i t h a mod ified G i e rtz-St i l l e r i b cutter. D. T h e poste rior e d g e of the 1 st r i b is f u rther re modeled w i t h a Kerrison
ro n g e u r to o bta i n a sm ooth edge i m med iately m ed i a l to the T 1 n e rve root.

m o b i l ity (exte r n a l n e u ro l ysis) . I n spect i o n of the m ost
p roxi m a l aspect of the C8 a n d Tl n e rve roots w i l l
often revea l a s m a l l fi b rofasc i a l b a n d ove r l y i n g th ese
n e rves, w h i c h s h o u l d be specifica l ly s o u g ht out a n d re­
sected . This a s pect of t h e o p e r a t i o n i s n ot c o n s i d e red
co m p l ete u n t i l each n e rve root h a s b e e n co m p l etely
c l e a re d t h r o u g h o u t its cou rse i n t h e o p e rative field
(FIG 1 2) .
Drain Placement and Closure
• U po n the com p l etion of su praclavicu l a r deco m p ression,
the a pex of the p l e u r a l m e m brane is opened to promote
postope rative d r a i n a g e of f l u i d i nto the chest cavity,
away from the brach i a l p l exus. 1 9-Fr cl osed suction d r a i n
i s p l aced t h r o u g h a sepa rate sta b wound i nto the opera­
tive field, p l aced poste rior to the brach i a l p l exus with its
 C h a p t e r 7 N E UROG E N I C T H O RA C I C OUTLET S Y N D R O M E EXPO S U R E A N D D E C O M P R E S S I O N 1857

A B

FIG 1 0 • A. With t h e poste r i o r e n d of t h e 1 st r i b p u s h e d downward to o p e n t h e a nt e r i o r costo c l a v i c u l a r s p a ce, t h e

a nt e r i o r p o rt i o n of t h e 1 st r i b i s e x p o s e d u n d e r neath t h e c l a v i c l e a n d t h e s u b c l a v i a n ve i n . B. The s u b c l a v i a n a rtery (S CA)
a n d b r a c h i a l p l ex u s (B P) a re p rotected, a n d the a nt e r i o r 1 st r i b i s d i v i d e d with a r i b cutte r i m m e d i ately m ed i a l to t h e
sca l e n e t u b e r c l e .

t i p exte n d i n g i nto the poste rior p l e u r a l space. Two m u l ­

t i h o l e perfusion catheters a re p l aced with i n t h e wound,
positioned adjacent to the brach i a l p l exus a n d with i n the
bed of the resected 1 st r i b, a n d conn ected to a n osmotic
pump for conti n u ous postope rative i nfusion of loca l an­
esthetic (0 . 5 % b u pivaca i n e for 3 days) . A b i o resorba b l e
polylactide fi l m (Eth icon, I n c., Somervi l l e, NJ) is p l aced
a r o u n d the b rach i a l plexus to s u p p ress deve l o p m ent of
postope rative peri n e u r a l f i b rosis and h e l d in p l ace with
seve ral 5-0 polydioxa n o n e sutu res. The sca l e n e fat pad is
restored to its a n ato m i c position overlyi n g the brach i a l
p l exus a n d h e l d i n p l ace with seve ral ta c k i n g sutu res to
the back of the sternocleidomasto i d m uscle a n d to the
pericl avic u l a r su bcuta neous fasc i a . The p l atysm a m uscle
layer is rea p p roxim ated with i nterru pted sutu res and the
skin is closed with a n a bsorba b l e su bcuticu l a r stitc h .

FIG 1 1 • Operative speci mens fol lowing 1 st rib resection (A) and
fol lowi ng combi ned resection of a cervica l rib a n d 1 st rib (B) .
1858 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

F I G 1 2 • A-C. F i brous sca r tissue i s rem oved

from each of the brach i a l p l exus (BP) n e rve
roots by exte r n a l n e u rolysis. SCA, s u bclavian
a rte ry.

PECTORALIS M I N OR TENOTOMY Division of the Pectoralis Minor Muscle Tendon

Incision and Exposure • The pecto ra l i s m i n o r m u s c l e t e n d o n is i d e ntified w h e re

it ext e n d s from t h e a nt e r i o r c h est wa l l to t h e coracoid
• A short vertical i n c i s i o n is m a d e i n the d e ltopecto ral
p rocess. T h e fasci a a l o n g its m e d i a l b o r d e r i s opened
g roove, beg i n n i n g at the level of the coracoid p rocess.
and t h e m u scle is e n c i rc l e d using b l u nt fi n g e rt i p d i s­
The d e ltoid and pecto ra l i s major m uscles a re gently
sect i o n . The fasc i a a l o n g t h e l a t e r a l b o r d e r of t h e pec­
sepa rated and the plane of deeper d issection is ca rried
tora l i s m i n o r m u s c l e i s o p e n e d to e n s u re its s e p a r a t i o n
med i a l to the cepha l i c ve i n . The latera l edge of the pec­
from t h e s h o rt h e a d of t h e b i ceps m u s c l e, w h i c h a l so
tora l i s major m uscle is gently l ifted with a sma l l Deaver
i n se rts on the coraco i d p rocess. Ta k i n g ca re to p rotect
retractor, and the p l a n e u n d e rn eath the m u scle is sepa­
the u n d e r l y i n g n e u rovasc u l a r b u n d le, the pecto ra l i s
rated from the u nd e r lyi n g fascia by b l u nt f i n g e rt i p d is­
m i n o r te n d o n i s t h e n e l evated w i t h u m b i l i ca l ta pe o r
sect i o n . The fasci a over the pecto ra l i s m i n o r m uscle is
r u b b e r t u b i n g a n d i t s i n se rt i o n o n t h e coraco i d p ro­
exposed, where the m u scle can be easily i d e ntified by
cess i s exposed with a s m a l l R i c h a rdson ret racto r. A
p a l pation (FIG 1 3) .
fi n g e r is p l aced beh i n d t h e m u s c l e to p revent t h e r m a l
 C h a p t e r 7 N E UROG E N I C T H O RA C I C OUTLET S Y N D R O M E EXPO S U R E A N D D E C O M P R E S S I O N 1859

Pectoralis
major
m uscle
Pectoralis
minor
muscle

Coracoid process

A
Cephalic vein
B
FIG 13 • A. Pecto ra l i s m i n o r tenotomy is performed t h ro u g h a short vertica l i n cision in the d e ltopecto ral
g roove j u st below the coraco i d p rocess. B. The plane of d i ssect i o n is carried m e d i a l to the ce p h a l i c ve i n , a n d the
pectora l i s major m uscle is l i fted to expose the fasci a over the pectora l i s minor m uscle.

i nj u ry to t h e n e u rovasc u l a r st r u ct u res and t h e i n se r­
t i o n of t h e pectora l i s m i n o r t e n d o n is d iv i d e d with t h e
e l ectroca utery. After t h e pecto ra l i s m i n o r m u s c l e h a s
b e e n d i v i d e d , t h e l ower e d g e w i l l retract i nfe r i o r l y to
release any co m p ress i o n of t h e n e u rovasc u l a r b u n d l e
(FIG 1 4) .
• T h e i n ferior edge o f t h e d ivided pecto ra l i s m i n o r m uscle
is oversewn with a r u n n i n g sutu re to e n s u re hemostasis
a n d to faci l itate contraction of the m uscle u n d e rneath
the pectora l i s major m u scle. The rema i n i n g clavi pecto ral
fasc i a is a lso i ncised to the level of the clavicle, a l o n g
w i t h a n y oth e r a n o m a l o u s fasci a l b a n d s t h a t m i g ht b e
present over the brach i a l p l exus, s u c h as La n g e r's axil­
l a ry a rch, but n o f u rther d i ssection of the brach i a l p l exus
n e rves o r the axi l l a ry vesse ls i s performed. The edge of
the pectora l i s major m u scle is i nfi ltrated with a long­
acti n g loca l a n esthetic a n d the wo u n d is irri gated, then
c l osed i n layers without a d ra i n .

Pectoralis
minor muscle Pectoralis
(encircled) minor muscle
(divided) A:'T--- Coracoid
process
Neurovascular
bundle --------::

A
Pectoralis B
major
muscle
FIG 14 • A. The pecto ra l i s m i n o r m uscle is e n c i rcled n e a r its i nsert i o n on the coracoid p rocess a n d then
d ivided with the e l ectrocautery. B. The retracted edge of the d ivided pectora l i s m i n o r m uscle is oversewn
with a cont i n uous suture.
1860 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

PEARLS AND PITFALLS

I n d i cations
M o b i l ization of the
sca l e n e fat pad
Anterior sca l e necto my
M o b i l ization of the
b rach i a l p l exus
M i d d l e sca l e n ecto my
1 st rib resection
B rach i a l p l exus neu rolysis
D ra i n p l acement a n d
closure
Pecto ra l is m i n o r
tenotomy
• Operative treatment of NTOS shou l d be based o n a so u n d c l i n ical d i a g nosis, a su bsta nt i a l l evel of d i s­
a b i l ity, a n d fa i l u re of sym ptoms to i m p rove with an a d e q u ate tri a l of conservative m a n a g e ment.
• I m a g i n g stu d i es, e l ectro phys i o l o g i c tests, and vasc u l a r l a b o ratory exa m i nations a d d l itt l e i n the eva l­
uation of NTOS but may be usefu l i n exc l u d i n g oth e r cond itions.
• A positive a nte rior sca l e n e m uscle block s u p p o rts the d i a g nosis of NTOS a n d i n d i cates a stro n g l i ke l i ­
h o o d of responsiveness t o s u r g i c a l treatment.
• Assess the potential co ntri bution of brach i a l p l exus c ompress i o n at the level of the su bcoraco i d space
a n d i n c l u d e pectora l i s m i n o r te n otomy if p resent.
• Avo i d d ivision of the sternoc l e i d o m asto i d m u sc l e .
• P r o p e r m o b i l ization a n d l atera l reflection of the sca l e n e f a t pad is a k e y s t e p i n s i m p l ify i n g su p ra­
clavicu l a r expos u re for thoracic outlet deco m p ress i o n . This perm its the critica l view to be o bta i ned
i n which all of the relevant structu res can be v i s u a l ized i n the same operative fi eld (inte r n a l j u g u l a r
ve i n , p h r e n i c n e rve, a nterior sca l e n e m uscle, b rach i a l p l exus, m i d d l e sca l e n e m uscle, 1 st r i b, a n d l o n g
thoracic n e rve) .
• Ligate a n d d ivide the thoracic d u ct, if necessa ry, to p reve nt postoperative lym p h leak.
• Visu a l ize a n d p rotect the p h r e n i c n e rve.
• D ivide a l l fi bers pass i n g from the poste r i o r aspect of the a nterior sca l e n e m uscle to the subclavian
a rtery a n d extra pleural fasc i a .
• D ivide a n y sca l e n e m i n i m u s m uscle encou nte red .
• Pass the a nterior sca l e n e m uscle u nd e rneath the p h r e n i c n e rve to fac i l itate d i ssection of the m uscle
u p to its superior orig i n o n the C6 tra nsve rse p rocess.
• Visu a l ize a l l five n e rve roots of the brach i a l p l exus.
• Ligate a n d d ivide the tra nsverse cervical vessels where they pass t h ro u g h the b rach i a l p l exus and
m i d d l e sca l e n e m uscle.
• Visu a l ize and p rotect the l o n g thoracic n e rve.
• Control m i n o r bleed i n g from the cut edge of the m uscle with s i l k sutu res rath e r than e l ectrocautery.
• Visu a l ize the T1 a n d C8 n e rve roots at the level of the poste rior 1 st rib, p r i o r to d ivision of the bone,
to avo i d n e rve i n j u ry.
• Rem ove a sma l l seg m e nt of the d ivided poste rior 1 st r i b to fac i l itate f i n g e rt i p d i ssect i o n u n d e rneath
the re m a i n i n g l atera l and a nterior portions of the bone.
• Do n ot try to avo i d o pe n i n g the p l e u ra .
• D ivide the a nte rior 1 st r i b at a level m e d i a l to the sca l e n e tu bercle, u n d e rneath the clavicle a n d s u b ­
c l a v i a n ve i n , w h i l e p rotect i n g the subclavian a rtery a n d b rach i a l p l exus.
• Resect a n y cervical r i b present along with the 1 st rib.
• Thoro u g h l y rem ove f i b rous scar tissues from around each n e rve root (CS to T1 ) of the brach i a l p l exus
to avo i d o n e of the ca uses of persistent sym ptoms.
• Resect a ny sma l l fi b rofasc i a l bands overlyi n g the p roxi m a l aspect of the C8 and T 1 n e rve roots.
• Wra p the brach i a l p l exus with a b i o resorba b l e fi l m to m i n i m ize peri n e u r a l f i b rosis.
• Place a cl osed suct i o n drain beh i n d the brach i a l p l exus with its t i p exte n d i n g i nto the p l e u r a l space.
• Use conti n u o u s postoperative i nfusion of a local a n esthetic to d i m i n ish the need for o p i ate p a i n
med ications.
• I nc l u d e pectora l i s m i n o r te n otomy as p a rt of the s u p raclavicu l a r deco m p ress i o n if there a re conco m i -
t a n t sym ptoms of NTOS refera b l e to the su bcoraco i d space.
• D ivide the pectora l i s m i n o r tendon cl ose to its i nsertion o n the coracoid p rocess.
• Oversew the d ivided edge of the pectora l i s m i n o r m uscle for hem ostasis.
• It is n ot n ecessa ry to p l ace a sepa rate d ra i n i n the su bcoraco i d space.

prescribed at hospital discharge and for at least several

POSTOPERATIVE CARE
• An upright chest radiograph is performed in the recovery
room and each morning for 3 days, and any small air or
pleural fluid collections are observed with the expectation of
spontaneous resolution. Postoperative analgesia is provided
by continuous-infusion perineural local anesthesia ( discon­
tinued on postoperative day 3) and patient-controlled intra­
venous opiates until adequate pain control is achieved by
oral medications alone. Oral narcotics, a muscle relaxant,
and a nonsteroidal antiinflammatory agent are routinely
weeks following surgery. Postoperative hospital stay is typi­
cally 3 to 4 days. The closed suction drain is removed in the
outpatient office when its output is less than 50 mL per day,
usually 5 to 7 days after surgery.
• Physical therapy is resumed the day after surgery to maintain
range of motion and limit muscle spasm. The patient is al­
lowed to use the extremity as tolerated, with no use of a sling
or other restraint. Physical therapy is continued after hospital
discharge, with advice to avoid excessive reaching overhead
or heavy lifting with the affected upper extremity and other
 C h a p t e r 7 N E UROG E N I C T H O RA C I C OUTLET S Y N D R O M E EXPO S U R E A N D D E C O M P R E S S I O N
activities that might result in muscle strain, spasm, and sig­
nificant pain in the sternocleidomastoid, trapezius, and other
neck muscles. Further rehabilitation is overseen by a physi­
cal therapist with expertise in the management of NTOS,
usually in conj unction with a physical therapist located near
the patient, emphasizing a gradual steady return to normal
use of the upper extremity.
• The maj ority of patients are permitted cautious light duty
work activities by 4 to 6 weeks. Restrictions on upper ex­
tremity activity are progressively lifted between 6 and
1 2 weeks, when recovery from surgery is typically consid­
ered complete. Patients are seen in follow-up every 3 months
in the first year to assess long-term results. Physical therapy
and other aspects of care are continued as long as necessary
to achieve an optimal level of function.
OUTCOMES
• In properly selected patients with disabling NTOS, approxi­
mately 8 0 % to 8 5 % can expect a substantial improvement
in symptoms and increased functional use of the upper ex­
tremity within several months of supraclavicular decompres­
sion.1-3 ·19 This estimate is elevated to approximately 90% to
9 5 % in those who exhibited a positive anterior scalene/pecto­
ralis minor muscle block prior to treatment. Factors that tend
to diminish responsiveness to treatment include extremely
long-standing ( > 5 years) and debilitating symptoms, wide­
spread pain syndromes, multiple previous operations (cervical
spine, shoulder, or peripheral nerves), depression, older age
( > 5 0 years), and preexisting use of opiate pain medications.
• Patients with long-standing NTOS can often display residual
symptoms that may not be completely eliminated by tho­
racic outlet decompression. Although these symptoms may
be tolerable and are expected to gradually improve, the sur­
geon must provide continuing support and reassurance dur­
ing the prolonged period of recovery and rehabilitation.
• Patients in the adolescent age-group ( < 2 1 years) tend to
have even better outcomes than adults, based on assessment
of patient-reported survey instruments and postoperative
use of opiate pain medications. 14 Patients that have been
selected for isolated pectoralis minor tenotomy can exhibit
early outcomes similar to those of patients that have un­
dergone combined supraclavicular decompression and pec­
toralis minor tenotomy but require ongoing follow-up for
recurrent symptoms to determine if supraclavicular decom­
pression may be warranted at a later time. 17•18
• Recurrent symptoms of NTOS that might warrant reoperation
occur in 1 % to 2% of patients, usually within the first 2 years
of treatment. Reoperations for NTOS are generally performed
using the supraclavicular approach, because this provides the
most complete exposure of the anatomy with the greatest mar­
gin of safety.2° Following lateral reflection of the scalene fat
pad, the brachial plexus nerve roots are carefully exposed and
mobilized. Great care must be taken during this dissection to
avoid nerve and blood vessel injury, given the dense fibrous
scar tissue that is usually present witltin the operative field. Any
structures that were retained at the initial operation are then
resected, including the scalene muscles, anomalous fibrofascial
bands, and/or the 1 st rib. A complete brachial plexus neuroly­
sis is performed and the nerves are protected with a bioabsorb­
able film and soft tissue coverage with the scalene fat pad.
186 1
COMPLICATIONS
• Persistent pain, numbness, and/or paresthesias
• Postoperative bleeding, localized hematoma, or hemothorax
• Wound infection (cellulitis or abscess)
• Pleural effusion ( serosanguineous)
• Persistent lymph leak, chylothorax
• Brachial plexus nerve dysfunction (temporary or sustained)
• Phrenic nerve dysfunction (temporary or sustained)
• Long thoracic nerve dysfunction (temporary or sustained)
• Recurrent NTOS
REFERENCES
1. Sanders RJ, Haug CE. Thoracic Outlet Syndrome: A Common Sequelae
of Neck Injuries. Philadelphia, PA: JB Lippincott; 1991.
2. Molina JE. New Techniques for Thoracic Outlet Syndromes. New York,
NY: Springer; 2012.
3. Illig KA, Thompson RW, FreischlagJA, et al. Thoracic Outlet Syndrome.
1st ed. London, United Kingdom: Springer-Verlag; 2013.
4. Thompson RW, Driskill M. Thoracic outlet syndrome: neurogenic.
In: Cronenwett JL, Johnston KW, Rutherfod R, eds. Rutherford's
Vascular Surgery. 7th ed. Philadelphia, PA: Elsevier; 2010:1878-1898.
5. Sanders RJ, Hammond SL. Management of cervical ribs and anom­
alous first ribs causing neurogenic thoracic outlet syndrome. 1 Vase
Surg. 2002;36(1):51-56.
6. Hempel GK, Rusher AH Jr, Wheeler CG, et al. Supraclavicular resec­
tion of the first rib for thoracic outlet syndrome. Am 1 Surg. 1981;
141(2):213-215.
7. Sanders RJ, Raymer S. The supraclavicular approach to scalenectomy
and first rib resection: description of technique. 1 Vase Surg. 1985;2:
751-756.
8. Reilly LM, Stoney RJ. Supraclavicular approach for thoracic outlet
decompression. 1 Vase Surg. 1988;8:329-334.
9. Thompson RW, Petrinec D, Toursarkissian B. Surgical treatment of tho­
racic outlet compression syndromes. II. Supraclavicular exploration and
vascular reconstruction. Ann Vase Surg. 1997;11(4):442-451.
10. Sanders RJ, Hammond SL. Supraclavicular first rib resection and total
scalenectomy: technique and results. Hand Clin. 2004;20:61-70.
11. Sanders RJ, Hammond SL, Rao NM. Diagnosis of thoracic outlet syn­
drome. 1 Vase Surg. 2007;46(3):601-604.
12. Emery VB, Rastogi R, Driskill MR, et al. Diagnosis of neurogenic
thoracic outlet syndrome. In: Eskandari MK, Morasch MD, Pearce
WH, et al, eds. Vascular Surgery: Therapeutic Strategies. Shelton, CT:
People's Medical Publishing House; 2010:129-148.
13. Jordan SE, Ahn SS, Gelabert HA. Differentiation of thoracic outlet
syndrome from treatment-resistant cervical brachial pain syndromes:
development and utilization of a questionnaire, clinical examination
and ultrasound evaluation. Pain Physician. 2007;10(3):441-452.
14. Caputo FJ, Wittenberg AM, Vemuri C, et al. Supraclavicular decom­
pression for neurogenic thoracic outlet syndrome in adolescent and
adult populations. J Vase Surg. 2013;57(1):149-157.
15. Povlsen B, Belzberg A, Hansson T, et al. Treatment for thoracic outlet
syndrome. Cochrane Database Syst Rev. 2010;(1):CD007218.
16. Jordan SE, Machleder HI. Diagnosis of thoracic outlet syndrome using
electrophysiologically guided anterior scalene blocks. Ann Vase Surg.
1998;12(3 ):260-264.
17. Sanders RJ, Rao NM. The forgotten pectoralis minor syndrome:
100 operations for pectoralis minor syndrome alone or accompanied
by neurogenic thoracic outlet syndrome. Ann Vase Surg. 2010;24:
701-708.
18. Vemuri C, Wittenberg AM, Caputo FJ, et al. Early effectiveness of iso­
lated pectoralis minor tenotomy in selected patients with neurogenic
thoracic outlet syndrome. J Vase Surg. 2013;57(5):1345-1352.
19. Hempel GK, Shutze WP, Anderson JF, et al. 770 consecutive supra­
clavicular first rib resections for thoracic outlet syndrome. Ann Vase
Surg. 1996;10(5):456-463.
20. Ambrad-Chalela E, Thomas GI, Johansen KH. Recurrent neurogenic
thoracic outlet syndrome. Am 1 Surg. 2004;187(4):505-510.

Chapter 8 Neurogenic T horacic Outlet
Syndrome Exposure and
I
Decompression: Transaxillary
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - � - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
George J. Arnaoutakis
DEFINITION
• In 1 82 1 , Sir Astley Cooper recognized the constellation
of neurovascular symptoms involving the thoracic outlet.
Ochsner called this the scalenus anticus syndrome in 1 9 3 6
and described the presence o f muscle abnormalities second­
ary to repetitive trauma. Peet assigned this condition its
contemporaneous moniker thoracic outlet syndrome (TOS)
in 1 96 6 . 1
• T O S is a condition defined as compression o f one o r more of
the neurovascular structures contained within the thoracic
outlet.
• The thoracic outlet is a narrowly defined anatomic region
encompassing the space between the neck and the shoulder,
cephalad to the thoracic cavity, and beneath the clavicle.
From the surgeon's point of view the thoracic outlet can be
visualized as an anatomic triangle: the two sides being the
anterior and middle scalene muscles with the 1 st rib serving
as the base of the triangle. The scalene muscles, which origi­
nate from the lower cervical spine, may hypertrophy with
repetitive neck motion or minor trauma. This hypertrophy
is believed to contribute to compression of thoracic outlet
structures.
• TOS is subdivided into three discrete entities .
Neurogenic
Venous
Arterial
• Appropriate classification of the type of TOS is important
in guiding perioperative management, as well as surgical
approach. This chapter focuses on transaxillary decompres­
sion and 1 st rib resection for neurogenic TOS.
DIFFERENTIAL DIAGNOSIS
• Carpal tunnel syndrome
• Ulnar nerve compression
• Rotator cuff tendinitis
• Pectoralis minor syndrome
• Cervical spine strain
• Cervical disc disease
• Cervical arthritis
• Brachial plexus injury
• Fibromyositis
PATIENT HISTORY AND PHYSICAL FINDINGS
• A careful history and physical examination enables proper
classification of TOS.
• The neurogenic form accounts for the maj ority of cases in
modern series ( > 9 5 % ).2 Symptoms of neurogenic TOS,
which is more prevalent in women, include paresthesia; pain;
and impaired strength in the affected shoulder, arm, or hand
along with occipital headaches and neck discomfort. There
1862
-
�
Thomas Reifsnyder Julie Ann Freischlag
is commonly an antecedent history of hyperextension neck
injury or repetitive neck trauma. Patients frequently manifest
tenderness on palpation in the supraclavicular fossa over the
anterior scalene muscle. A careful vascular physical examina­
tion should confirm the presence of normal circulation.
Three physical examination maneuvers support the diag­
nosis of neurogenic TOS.
Rotation of the neck and tilting of the head to the op­
posite side elicit pain in the affected arm.
The upper limb tension test in which the patient first
abducts both arms to 90 degrees with the elbows in
a locked position, then dorsiflexes the wrists, and fi­
nally, tilts the head to the side. Each subsequent step
imparts greater traction on the brachial plexus, with
the first two positions causing discomfort on the ipsilat­
eral side and the head-tilt position causing pain on the
contralateral side.
During the elevated arm stress test (EAST), the patient
raises both arms directly above the head and repeatedly
opens and closes the fists. Characteristic upper extrem­
ity symptoms arise within 60 seconds in patients with
neurogenic TOS.
• Approximately 4 % of patients with TOS present with ve­
nous involvement. Venous TOS patients typically present
with acute onset of dull aching pain of the upper extrem­
ity associated with arm edema and cyanosis. Paresthesias
may be present but are due to hand swelling instead of tho­
racic outlet nerve involvement. A history of strenuous and
repetitive work or athletics involving the affected extrem­
ity is common, and most patients are young. This specific
condition is also known as Paget-Schroetter syndrome or
effort vein thrombosis, as the entrapped subclavian vein
has progressed to thrombosis. Some patients will present
less acutely with nonthrombotic subclavian vein occlusion
or stenosis manifested by intermittent swelling with activity.
Regardless, the etiology of venous TOS is mechanical, and
treatment is ultimately aimed at eliminating not only the ve­
nous obstruction but also the muscular bands and ligaments
that have entrapped and damaged the vein.
• Arterial TOS typically presents in one of three ways:
( 1 ) asymptomatic, (2) arm claudication, and ( 3 ) critical isch­
emia of the hand. The majority of these patients have a cervical
rib, which may or may not be fused to the 1 st rib and is most
commonly posterior to the subclavian artery. The etiology is
chronic repetitive injury to the subclavian artery as it exits the
thoracic outlet. This injury may cause subclavian artery steno­
sis but more commonly leads to ectasia or a true aneurysm.
In asymptomatic patients, a pulsatile mass or supracla­
vicular bruit can be detected on physical examination.
Arm claudication is caused by areas of stenosis which may
be static due to long-standing repetitive injury or dynamic,
occurring only with arm abduction or extension.
 C h a p t e r 8 N E UROG E N I C T H O RA C I C OUTLET S Y N D R O M E EXPO S U R E A N D D E C O M P R E S S I O N
Critical ischemia is due to emboli of fibrinoplatelet aggre­
gates that originate from an ulcerated mural thrombus in
the aneurysmal segment.
PREOPERATIVE EVALUATION AND OTHER
DIAGNOSTIC STUDIES
• In young patients ( <40 years of age) with a classic presenta­
tion of neurogenic TOS, there is no need for extensive pre­
operative testing.
• Older patients and those with a history of neck trauma
should undergo magnetic resonance imaging (MRI) to rule
out cervical disc pathology.
• Preoperative physical therapy should be attempted for at
least 8 weeks in patients with a diagnosis of neurogenic TOS.
The aims of therapy are to improve posture and achieve
greater range of motion. Patients with persistent symptoms
of neurogenic TOS despite 8 weeks of physical therapy merit
surgical intervention. At least 60% of patients will improve
with physical therapy and lifestyle alterations.
• A radiographically guided anterior scalene block with local
anesthetic ( lidocaine) inj ection may provide a few hours of
symptomatic relief. Patients with suspected neurogenic TOS
often present with a wide constellation of physical com­
plaints, not all of which are directly attributable to the disor­
der. A scalene block not only helps confirm the diagnosis but
also simulates the expected postoperative result, especially
in older patients. 3 This provides the patient and the surgeon
reassurance that surgical intervention will be of benefit and
demonstrates which symptoms can be reliably expected to
improve.
• As an alternative to surgical therapy, patients can then opt
for a Botox (Allergan, Irvine, CA) injection. The Botox takes
an average of 2 weeks to work and may be repeated. This
may provide symptomatic relief for 2 to 3 months, allow­
ing participation in physical therapy. However, not all TOS
patients respond to Botox. This practice is especially helpful
in patients who have had cervical spine fusions or shoulder
operations as they can strengthen the muscles of their neck
and back, which may alleviate the TOS symptoms.
• Plain film chest x-ray is recommended for all patients under­
going surgical intervention for TOS to rule out a cervical rib.
• Nerve conduction studies are typically normal in neurogenic
TOS but may be useful in ruling out nerve compression such
as carpal tunnel or cubital compression syndrome.
• Duplex ultrasonography is the initial diagnostic modality to
confirm pathology in patients with arterial TOS. Although
useful to confirm axillosubclavian vein thrombosis in pa­
tients with suspected venous TOS, venography often sup­
plants it for both diagnostic and therapeutic reasons. Lastly,
venous TOS is frequently bilateral.
SURGICAL MANAGEMENT
Surgical Approach
• Patients with a diagnosis of TOS who are appropriate surgi­
cal candidates should undergo surgical decompression of the
thoracic outlet.
• The optimal approach should be individualized depending on
the patient's symptoms, anatomy, and surgeon's experience.
1863
• The transaxillary approach is preferred by many surgeons
because of its relative ease, low-risk profile, and documented
improvement in patients' quality of life.4•5 This approach ef­
fectively decompresses the thoracic outlet and is generally
reserved for patients with neurogenic or venous TOS.
• If vessel reconstruction is anticipated, a different approach
should be considered as the transaxillary approach limits
vessel exposure.
Surgical Anatomy
• The subclavian artery and the five nerve roots ( C5-T 1 ) to the
brachial plexus are located within the thoracic outlet. The
artery courses anterior to the brachial plexus nerve roots
and exits the mediastinum in its course over the 1 st rib be­
hind the posterior border of the anterior scalene muscle. The
cervical spine nerve roots j oin to form the initial trunks of
the brachial plexus within the thoracic outlet and are located
posterior to the subclavian artery. Subsequent merging and
branching of these trunks into divisions, cords, and terminal
nerves occurs outside the thoracic outlet.
• Other significant nerves within the thoracic outlet are the
phrenic and long thoracic nerves.
The phrenic nerve receives fibers from C3-C5 and courses
in a descending oblique direction from the lateral to the
medial edge of the middle portion of the anterior scalene
muscle. The phrenic nerve approaches the mediastinum
posterior to the subclavian vein.
The long thoracic nerve, composed of nerve fibers from
CS-C7, passes through the center of the middle scalene
muscle and heads toward the chest wall to innervate the
serratus anterior muscle.
• The subclavian vein technically does not course through
the thoracic outlet. It passes over the 1 st rib anterior to the
anterior scalene muscle. However, the middle segment of
the vein remains susceptible to compression between the
anteromedial 1 st rib, clavicle, and the subclavius muscle
( FIG 1 ) . Hypertrophy of the subclavius muscle and ten­
don may occur in athletes and is often implicated in ve­
nous TOS.
• Several anatomic anomalies are relevant to the surgeon, as
they predispose patients to the development of TOS.
The most common is a cervical rib, and a preoperative
chest radiograph is adequate for its detection. When pres­
ent, cervical ribs appear as extensions of the transverse
process of C7. Cervical ribs may be complete or partial,
with the anterior end attaching to the 1 st rib or floating
freely. Additionally, the anterior end may be fibrous and
not calcified and thus not completely visualized on chest
radiograph. By rigidly confining the thoracic outlet, cervi­
cal ribs render the neurovascular structures more prone to
compression. Although present in the general population
with an incidence of 0 . 5 % to 1 % , they are found in 5 %
t o 1 0 % o f all TOS patients.
A prominent C7 transverse process or bifid 1 st rib is also
associated with TOS.
Positioning
• General endotracheal anesthesia is induced and sequential
compression devices are applied.
1864 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

Anterior scalene
muscle
Subclavian artery

C8-T1 nerve root

Middle scalene

Subclavian vein
FIG 1 • R i g ht-sided thoracic outlet a n atomy from
Subclavius muscle the su rgeo n 's perspective as viewed t h ro u g h the
operative f i e l d i n a transaxi l l a ry a pproach. Inset,
First rib
n o r m a l a n ato m i c relati onshi ps of i m portant thoracic
outlet structu res.

• The patient is then moved to the lateral decubitus position
using a beanbag to facilitate positioning.
Care should be taken to pad the dependent axilla and sup­
port the head. The sterile field incorporates the arm, axilla,
and shoulder.
• An adj ustable Machleder arm support is affixed to the
operating table with the vertical support bar attached to the
operating table at the level of the patient's chin.
Generous padding around the patient's arm prior to place­
ment in the arm holder protects the median and ulnar nerves
from compression as they cross the elbow joint ( FIG 2) .

F I G 2 • A p h otog raph d e p i cti n g p r o p e r patient positi o n i n g

f o r r i g ht tra nsaxi l l a ry 1 st r i b resection a n d u s e of the
Machleder a r m support with g e n e rous pad d i n g to p reve nt
co m p ression n e rve i n j u ry. A padded axi l l a ry ro l l is p l a ced u n d e r
the dependent (l eft) axi l l a, a n d the patient is sta b i l ized i n t h e
l eft l atera l decubitus w i t h the a i d of a bea n b a g . The dashed
line i n d i cates the p referred locat i o n of the skin i n c i s i o n .
(Repri nted f r o m Arnaoutakis G, Freisc h l a g J A , Reifsnyd e r T.
Tra nsaxi l l a ry r i b resection for thoracic outlet syn d ro m e . I n :
Ca m b r i a R , C h a i kof E, eds. Atlas o f Vascular a n d Endovascular
Surgery: Anatomy and Technique. P h i l a d e l p h i a, PA: E l sevier;
2 0 1 4 : 1 93-203, with permission from E l sevier.)

I NCISION m uscle and the poste r i o r s u rface of the pectora l i s major

• Prophylactic a ntibiotics are a d m i n istered. A fi rst-generation
cephalosporin is preferred. In patients with penici l l i n a l lergy,
clindamycin or vancomycin is used .
• After secu r i n g the a rm i n the retractor, the s u rgeon
i d e ntifies the a nterior border of the l atissi m u s d o rs i
m uscle.
• A tra nsverse s k i n l i n e i n cision should be m a d e i n the
i nferior axi l l a ry h a i r l i n e exte n d i n g between these two
m uscle borders.

EXPOSURE chest wa l l-a n d if i n the correct a nato m i c plane-gentle

• E l ectroca utery is used to d ivide the su bcuta neous tissue until
t h i n a reo l a r tissue superficial to the chest wa l l is encoun­
tered . A self-reta i n i n g Cerebe l l a r o r Weitl aner retractor
is then inserted i nto the wou n d . Upon enco u nteri ng the
b l u nt d issection with the surgeon's fingers or a pair of
Kittner or pea n ut d i ssectors easily sepa rates the soft tissues
from the chest wa l l . This d i ssection is i n a cepha lad d i rec­
tion a n d the 2nd rib w i l l ra p i d ly come i nto view.
 C h a p t e r 8 N E UROG E N I C T H O RA C I C OUTLET S Y N D R O M E EXPO S U R E A N D D E C O M P R E S S I O N 1865

Anterior scalene

Subclavian artery
Subclavian
vein
C8- T1 nerve root

Middle scalene

I ntercostal muscle Fi rst rib

detachment
FIG 3 • A perioste a l e l evato r is used to
d i ssect a l o n g the superior su rface of the
1 st r i b i n order to d ivide i ntercostal m u scle
atta c h m e nts.

• The i nte rcostobrach i a l n e rve is l ocated in the 2 n d i nter­ detach the sca l e n e m e d i u s fi bers from the r i b . The l o n g
costa l space. Alth o u g h freq uently d iffic u l t to avoid, ca re thoracic n e rve cou rses a l o n g the latera l edge of t h e
s h o u l d be taken not to i m pa rt excess traction as i n j u ry sca l e n e m e d i u s m u scle but i s g e n e ra l ly n o t visu a l ized.
resu lts i n n u m b n ess or dysesthesia of the m e d i a l aspect Avo i d i n g sharp d i ssect i o n and c l osely adhering to the
of the proxi m a l a r m . su rface of the r i b d u r i n g b l u nt d issection p revents i n j u ry
• R a i s i n g t h e M a c h l ed e r a rm s u p p o rt at t h i s p o i n t a l - to the l o n g thoracic n e rve.
l ows f o r o pt i m a l access to t h e 1 st rib and t h o r a c i c • The a nte rior sca l e n e m uscle sho u l d n ow be clearly identi­
o u t l et. T h e aid of fi beroptic- l i g hted Deaver retrac­ fied as it a rises from the m ed i a l superior aspect of the
tors fa c i l itates v i s u a l i za t i o n d u r i n g this p o rt i o n of the 1 st rib (FIG 4) . A rig ht-a n g led c l a m p is passed b e h i n d the
d i ssect i o n . A l t e r n ative l y, t h e s u rg e o n s h o u l d wear a a nte rior sca l e n e m uscl e near its i n se rtion o n the sca lene
h e a d l i g ht. tu bercle. Gently l ifti n g the a nterior sca lene with the
• The 1 st r i b is identified n e a r its i nsertion at the sterno­
c l avicu l a r j o i nt a n d g e n e ra l ly encou ntered h i g h e r than
a ntici pated . A Kittner o r peanut d i ssecto r is then used to
gently sweep away the loose fibrous tissue overlyi n g the
1 st r i b p a rti a l ly expos i n g the b rach i a l p l exus, subclavian
a rtery a n d vein, a n d sca l e n e m uscles. There i s occasion­
a l ly a sma l l branch of the subclavian a rtery that m ust be
l i g ated and d ivided i n order to f u l l y expose the operative
field.
• The n ext ste p is to fu l ly expose the r i b . Depe n d i n g o n
the patie nt's a n atomy, it g e n e ra l ly is easi est to fi rst clea r
off the i ntercosta l m uscles l atera l ly. A Cobb perioste a l
e l evator works best, but a ny type of l o n g e l evato r may
be used (FIG 3) . The d i ssect i o n p roceeds i n the a nte rior
a n d poste rior d i rections u n t i l all the i nte rcosta l m uscle
attac h m e nts a re d ivided from the r i b . The e l evator can
FIG 4 • An image of the g ross anatomy from a close-up
then be used to e l evate the 1 st ri b, thus separat i n g the
perspective of the rig ht-sided thoracic outlet. The i m portant
r i b from the u nd e r lyi n g parietal pleura. This m o b i l ization
re lationsh i ps between the 1 st rib, a nterior sca lene m uscle, and
should cont i n u e from beh i n d the brach i a l p l exus i n the subclavian vessels ca n be seen. (Repri nted from Arnaoutakis G,
poste rior d i rection to beyo n d the subclavian ve i n i n the Freischlag JA, Reifsnyder T. Tra nsaxi l l a ry rib resection for thoracic
a nte rior d i rect i o n . outlet syndrome. In: Cambria R, Chaikof E, eds. Atlas of Vascular
• Atte ntion is then d i rected to the superior b o r d e r of t h e and Endovascular Surgery: Anatomy and Technique. Philadelph ia,
1 st r i b, w h e r e the perioste a l e l evator is u s e d to b l u ntly PA: Elsevier; 20 1 4 : 1 93-203, with permission from Elsevier.)
1866 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

Anterior scalene

Subclavian
vein
C8-T 1 nerve root

Middle scalene
muscle

FIG S • A rig ht-a ng led clamp is insinuated

behind the a nterior sca lene muscle. Gentle
elevation p u l l s the m uscle away from the
u nderlying subclavian artery thereby protecting
the artery prior to d ivid ing the m uscle with
scissors. The subclavius m uscle is a crescent­
shaped liga mentous attachment to the 1 st rib
First rib adjacent to the subclavian vei n . The subclavius
m uscle is sharply d ivided with scissors with ca re
not to injure the subclavian vei n .

rig ht-a n g led c l a m p p rotects the subclavian a rtery as it
cou rses poste rior to the m uscle (FIG S) . It is i m portant
to free seve ral ce ntimete rs of the m u scle prior to d ivid-
i n g it with M etze n b a u m scissors (FIG 6) . This m a n euver
faci l itates resection of a portion of the a nte rior sca lene
m uscle, which has been shown to reduce recu rrence rates
when c o m p a red w i t h d ivision at i t s i n se rtion p o i nt o n
the r i b .
• Lastly, the su bclavius m uscle w i l l a p pea r as a crescent­
sha ped l i g a m e ntous attac h m e nt to the 1 st rib adjacent to
the subclavian ve i n . With care n ot to i nj u re the su bclavian
ve i n , the s u bclavius m uscle is sharply d ivided with scissors.

FIG 6 • The 1 st rib is seen in the foreg ro u n d of the operative

photo taken d u r i n g a l eft 1 st rib resect i o n . M etze n b a u m
scissors a re u s e d t o s h a r p l y d ivide the anterior sca l e n e m uscle,
with the rig ht-a n g l e d c l a m p e l evat i n g the m u scl e to p rotect
the subclavian a rtery as it cou rses beh i n d the m u scle. The
d ivided ends of the te n d i n o u s anterior sca l e n e fi bers can be
see n . (Repri nted from Arnaoutakis G, Freisc h l a g JA, Reifsnyd e r
T. Tra nsaxi l l a ry r i b resection for t h o r a c i c outlet syn d ro m e . I n :
Ca m b r i a R , C h a i kof E , eds. Atlas of Vascular a n d Endovascular
Surgery: Anatomy and Technique. P h i l a d e l p h ia, PA: E l sevier;
20 1 4: 1 93-203, with permission from E l sevier.)

RIB RESECTI O N • A bone rongeur is used to rem ove res i d u a l r i b a n d to

• With the r i b co m p l etely m o b i l ized, a bone cutter is used
to d ivide the 1 st rib. G e n e ra l ly, it is d ivided a nteriorly
a n d then poste riorly; h owever, the patie nt's body h a bitus
may make the reverse order easier (FIG 7) .
• I n i t s a nterior extent, t h e r i b i s d ivided adjacent to t h e
s u b c l a v i a n ve i n , a n d i n the poste r i o r d i rect i o n , it is d i ­
vided j u st a nterior t o t h e brach i a l p l exus; t h i s e n s u res
that the n e rve roots a re n ot i n a dve rte ntly i n j u re d . The
rib i s then removed .
sm ooth the cut ends u nt i l there is no resi d u a l n e rve i m ­
p i n g e m e nt. A Roos retractor o r s i m i l a r i nstr u m ent m a y
be used t o p rotect the n e rves d u r i n g u s e of the r o n g e u r
(FIG 8).
• It is i m portant to e n s u re that no resi d u a l fi bers from the
a nterior sca l e n e m uscle crosses beneath the subclavian
a rte ry a n d i n se rts onto the t h i ckened su rfa ce at the a pex
of the p l e u ra, k n own as S i bso n 's fasc i a . Any such fi bers
s h o u l d be i d e ntified and d i v i d e d .
 C h a p t e r 8 N E UROG E N I C T H O RA C I C OUTLET S Y N D R O M E EXPO S U R E A N D D E C O M P R E S S I O N 1867

Anterior scalene
muscle

Subclavian artery Subclavian

vein

C8-T1 nerve root Subclavius

muscle

FIG 7 • A bone cutter is used to d ivide the 1 st

r i b i n its a nterior a n d poste rior d i rect i o n . Once
First rib
removed, the ro n g e u r is used to ach ieve smooth
rib edges.

�r.�{rr:·��
I
...
�-:__,. .
. '
·;·
•
. \',
4 .._
FIG 8 • From the top of the image in the cl ockwise d i rection,
the instru ments depicted a re (1) Roos retractor, (2) Alexander
peri osteotome, (3) Kerrison p u nch upbiting i nstrument,
(4) double-action bone cutter, (5) Cobb periosteal elevator,
a n d (6) Rongeur. (Repri nted from Arnaoutakis G, Freischlag
- /
,
JA, Reifsnyder T. Tra nsaxi l l a ry rib resection for thoracic outlet
' I synd rome. I n : Cambria R, Chaikof E, eds. Atlas of Vascular and
I '
Endovascular Surgery: Anatomy and Technique. Philadelphia,
PA: Elsevier; 2 0 1 4 : 1 93-203, with perm ission from E lsevier.)

CLOSURE tube may not be n ecessa ry. I n this situation, a 1 2- o r

• The s u r g i ca l fie l d is n ext i n spected for b l eed i n g . Te m po­
rarily packing the wo u n d re l i a bly controls m i n o r b l eed­
ing. The wound is then reins pected, and hemostasis is
co m p l eted with j u d icious use of e l ectrocautery.
• The wound is then fi l led with sa l i n e . Several positive p res­
s u re venti lations a re a d m i n istered with sa l i n e l eft in the
wound to assess for a n air leak i n d i cative of a posto pera­
tive p n e u m othorax. If a n a i r leak is p resent, a sma l l ca l i be r
( 1 2 F r e n c h [Fr]) ch est tube is warra nted prior to c l o s u r e .
• If the i rrigation d ra i ns i nto the p l e u r a l space but there
is no a i r l e a k, the p l e u ra has been breached, but a ch est
1 4-Fr r e d r u b b e r catheter is p l aced i nto the b e d of t h e
1 st r i b a n d atta ched t o g e n t l e suct i o n . T h e M a c h l e d e r
a r m h o l d e r i s lowered to fa c i l itate a tensio n-free closure .
The su bcuta neous fascia is then cl osed a r o u n d the tube.
While suction is a p p l ied to the red rubber catheter, the
a n esthesia tea m p rovides a susta i n ed Va lsa lva a n d the
fasc i a l sutu re i s tied as the suct i o n tube is ra p i d ly re­
m oved . This m a n euver g e n e ra l ly avo i d s a c l i n ica l ly sig­
n ificant postope rative p n e u m othorax.
• Closure is perfo rmed with a bsorba b l e 2-0 suture i n the
fasc i a a n d a 4-0 su bcuticu l a r skin closure.

PEARLS AND PITFALLS

Operative m a ntra • Look twice and cut once. Always d o u b l e-check p l acement of the bone cutters before d i v i d i n g the 1 st
rib.
I ncorrect d i a g nosis • A su ccessf u l operation h i nges o n a n accu rate p reoperative d i a g nosis. A thoro u g h h i story a n d physica l
a n d the a nterior sca l e n e b l ock h e l p to i d e ntify patients l i kely to benefit from 1 st r i b resect i o n .
B rach i a l p l exus i n j u ry • Proper positio n i n g a n d caref u l retraction h e l p p revent excessive traction a n d i nj u ry to the brach i a l plexus.
M isidentification of • D u r i n g i n it i a l exposu re, the 2nd rib is often m ista ken for the 1 st rib. The ce p h a l a d su rface of the 1 st r i b
the 1 st r i b is f l a t u n l i ke the 2 n d , w h i c h i s m o r e co n cave.
1868 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY
I n c o m p l ete 1 st r i b • I nco m p l ete 1 st r i b resect i o n has been associ ated with recu rrent TOS. After cutt i n g a n d remov i n g the
resection ri b, take your t i m e to trim back the ends with the ro n g e u r.
H e m ostasis • To keep a cl ean ope rative field, pack a 4 x 4 g a uze i nto the wound, lower the a r m retractor, a n d wait a
co u p l e of m i n utes. T h i s often a i d s i n hem ostasis.
POSTOPERATIVE CARE
• A chest x-ray is performed in the recovery room.
Small, clinically asymptomatic pneumothoraces may be
observed with a follow-up chest x-ray the next morning.
• Patients are typically discharged from the hospital when ad-
equate oral analgesia has been achieved.
Activity is restricted by the amount of postoperative pain.
Occasionally, a sling is required for patient comfort, but it
is preferable to have the arm as mobile as tolerated.
• Physical therapy should be prescribed after 2 weeks in
all patients undergoing transaxillary 1 st rib resection,
regardless of the cause, to restore range of motion and
strength.
OUTCOMES
• Improvement after surgery for neurogenic TOS is somewhat
subjective and based on the patient's perception of disability
before and after decompression. Improvement in symptoms
exceeds 9 0 % . 6
• Over time, the durability of these results may decrease, rein­
forcing the need for close follow-up of these patients beyond
2 years?•8
• Factors that predict surgical failure include major depression,
chronic symptoms, work-related inj ury, lack of response to
anterior scalene muscle blocks, and a short segment of di­
vided anterior scalene muscle.9
COMPLICATIONS
• Vascular injury
A national query identified injury to the subclavian vessels
as the most common complication following transaxillary
rib resection for neurogenic TOS, occurring in 1 % to 2 %
o f cases.4
Patients experiencing a vascular inj ury have greater
lengths of stay as well as increased hospital charges.
It is difficult to obtain proximal control of these vessels
from the transaxillary approach, and therefore, the sur­
geon should exercise extreme caution when dissecting
near these vessels.
• Nerve injury
Major nerve inj ury has been traditionally regarded as the
most common complication following surgery for TOS.
However, large contemporary series disprove this belief,
with rates of brachial plexus injury for patients undergo­
ing transaxillary 1 st rib resection approaching 0 % .4•8
Temporary or permanent numbness of the upper medial
arm due to excessive traction or division of the intercos­
tobrachial nerve occurs in up to 1 0 % . Frequently, these
symptoms will improve over time.
• Pneumothorax
This complication occurs in 2% to 1 0 % of patients.8 Ac­
cordingly, an upright chest x-ray is routinely performed in
the recovery room.
Radiographically detected pneumothoraces only require a
chest tube if symptomatic or enlarging.
Adhering closely to the inferior surface of the 1 st rib dur­
ing blunt dissection will help protect against postoperative
pneumothorax.
• Recurrence
Symptoms of TOS recur in 1 0 % to 2 0 % of patients. 1 0-12
Two intraoperative factors are known to reduce recur­
rence rates.
Resecting a significant portion (2 to 3 em) of the ante­
rior scalene muscle as opposed to simply dividing it at
its insertion point
Ensuring that the posterior edge of the 1 st rib is resected
sufficiently so as to leave as short a rib stump as techni­
cally feasible
Patients with spontaneous recurrence compared to those
that are reinjured have worse outcomes when reoperation
is performed.
REFERENCES
1. Roos DB. Transaxillary approach for first rib resection to relieve tho­
racic outlet syndrome. Ann Surg. 1 9 6 6 ; 1 6 3 : 3 54-3 5 8 .
2. Sanders RJ, Hammond SL, Rao NM. Diagnosis of thoracic outlet syn­
drome. ] Vase Surg. 2007;4 6 : 6 0 1-604.
3. Lum YW, Brooke BS, Likes K, et al. Impact of anterior scalene lido­
caine blocks on predicting surgical success in older patients with neu­
rogenic thoracic outlet syndrome. ] Vase Surg. 2 0 1 2;55 : 1 3 70-1 375.
4. Chang DC, Lidor AO, Matsen SL, et al. Reported in-hospital com­
plications following rib resections for neurogenic thoracic outlet syn­
drome. Ann Vase Surg. 2007;21 : 5 64-5 70.
5. Chang DC, Rotellini-Coltvet LA, Mukherjee D, et al. Surgical inter­
vention for thoracic outlet syndrome improves patient's quality of life.
J Vase Surg. 2009;4 9 : 6 3 0-63 5 ; discussion 635-637.
6. Roos DB. The place for scalenectomy and first-rib resection in thoracic
outlet syndrome. Surgery. 1 9 82;92 : 1 077- 1 0 8 5 .
7. Rochlin D H , Gilson MM, Likes K C , e t al. Quality-of-life scores in
neurogenic thoracic outlet syndrome patients undergoing first rib re­
section and scalenectomy. J Vase Surg. 2 0 1 3 ;57:436-44 3 .
8. Altobelli G G , Kudo T, Haas BT, et al. Thoracic outlet syndrome: pat­
tern of clinical success after operative decompression. J Vase Surg.
2005;42 : 1 22-1 2 8 .
9.
Axelrod DA, Proctor MC, Geisser ME, e t al. Outcomes after surgery
for thoracic outlet syndrome. j Vase Surg. 200 1 ; 3 3 : 1 220-1 225.
10. Mingoli A, Feldhaus RJ, Farina C, et al. Long-term outcome after trans­
axillary approach for thoracic outlet syndrome. Surgery. 1 9 9 5; 1 1 8 :
840-844.
11. Mingoli A, Sapienza P, di Marzo L, et al. Role of first rib stump length
in recurrent neurogenic thoracic outlet syndrome. Am J Surg. 2005;
190:156.
12. Sanders RJ, Haug CE, Pearce WH. Recurrent thoracic outlet syn­
drome. J Vase Surg. 1 9 9 0 ; 1 2 : 3 9 0-3 9 8 ; discussion 3 9 8-400.
 I

Chapter 9 Venous and Arterial T horacic

Outlet Syndrome
. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 1 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - �

Jason T. Lee

DEFINITION Brachial plexus

Overlying Subclavian artery

• Venous thoracic outlet syndrome (vTOS), also known as effort
thrombosis or Paget-von Schrotter syndrome, involves repeti­ clavicle Subclavian vein
tive subclavian venous compression that leads to endothelial
Subclavius tendon
injury and intermittent stasis that ultimately contributes to and muscle
acute thrombosis of the axillosubclavian venous system. The Costoclavicular ligament
external compression of the vein occurs between the clavicle
and subclavius muscle from above and by the 1 st rib and the
anterior scalene muscle insertion from below ( FIG 1 ) .
• Arterial thoracic outlet syndrome (aTOS) i s the least com­
Fi rst
mon presentation of thoracic outlet syndrome and most
rib
often involves subclavian artery compression leading to ex­
trinsic compression, poststenotic dilatation, aneurysmal de­
generation, and subsequent distal embolization. 1 Bony and
muscular abnormalities are typically present in patients with
aTOS and can include a cervical rib, anomalous 1 st rib, an­
terior or middle scalene muscle bands, or hypertrophic cal­
lus from a healed clavicular inj ury or fracture ( FIG 2 ) .

DIFFERENTIAL DIAGNOSIS Middle Anterior

• Compared to neurogenic thoracic outlet syndrome (TOS),
vTOS and aTOS are much more straightforward in their di­
agnostic workup. vTOS patients with swelling must be distin­
guished from secondary causes of axillosubclavian thrombosis,
namely iatrogenic catheterization or instrumentation of the
venous system leading to thrombosis, which is obvious upon
eliciting a careful history. Also, a hypercoagulable state or
malignancy can present as isolated upper extremity venous
thrombosis and there is some debate about the need for addi­
tional medical workup in patients suspected of having vTOS.2
scalene scalene
muscle muscle
FIG 1 • N o r m a l stru ctu res in the thoracic outlet that can
contrib ute to ve n o u s c ompress i o n .
• Because aTOS usually involves distal embolization t o the
hand from thrombus in a subclavian aneurysm, a thorough
workup for a cardiogenic source should be sought before
assigning the etiology to aTOS. Transesophageal echocar­
diography, with bubble enhancement to identify paradoxical

Anterior
scalene
muscle

FIG 2 • A b n o rm a l a nt e r i o r a n d m i d d l e
sca l e n e b a n d s a n d a b n o r m a l cervica l
r i bs l e a d to co m p ress i o n a n d s u bseq u e nt
postste n ot i c d i l at a t i o n of t h e s u b c l a v i a n
a rte ry, ca u s i n g a rter i a l T O S .
1869
1870 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

mass or bruit may be present in the supraclavicular fossa or

a bony prominence in that region may hint toward a cervical
rib or muscular abnormality. Symptoms often are gradual
and unnoticed by patients until occurring more frequently or
when complete thrombosis occurs and the patient presents
with critical upper extremity ischemia.

IMAGING AND OTHER DIAGNOSTIC

STUDIES
• Patients suspected of having vTOS should undergo duplex
ultrasound of the affected area. Axillosubclavian venous im­
aging can be challenging due to the clavicle's location as well
as many of these patients being quite muscular. Color flow
duplex, phasicity of flow with respiration, and augmenta­
tion with compressive maneuvers can all aid in confirming
the diagnosis of deep venous thrombosis (DVT). An expe­
rienced vascular sonographer and interpreter can make the
diagnosis with high accuracy based on duplex alone. Cross­
FIG 3 • 1 8-yea r-o l d baseba l l catcher present i n g with a r m sectional imaging with magnetic resonance imaging (MRI)
swe l l i ng, p a i n , cya n osis, a n d promi nent superfi c i a l vasc u l at u re or computed tomography ( CT) venography is rarely needed
after a stre n u o u s workout after a g a m e .
or indicated in the workup of vTOS. Catheter-based venog­
raphy is the key confirmatory imaging study to document
the extent of vTOS and leads to the initial recommended
emboli, m a y be necessary t o exclude cardiogenic emboli.
therapeutic strategy of thrombolysis and reduction of clot
Computed tomography angiography ( CT-A) of the arch and
burden.
upper extremity vessels would also be reasonable to exclude
• Patients presenting with digital ischemia suspicious for aTOS
other arterial causes including axillary branch artery aneu­
should undergo plain radiographic imaging to assess for a
rysms, congenital abnormalities, or traumatic injuries and
cervical rib ( FIG 4) . Digital plethysmography of bilateral
dissections of the axillosubclavian arterial system, which
upper extremities can be performed to visualize blood flow
can be seen in high-performance athletes and individuals
to each finger and can rule out Raynaud's type etiologies in
performing repetitive upper extremity motions.
the differential diagnosis. Wrist-brachial indices should be
documented prior to any further intervention to establish
PATIENT HISTORY AND PHYSICAL
baseline flow characteristics. CT-A of the neck and upper
FINDINGS extremity in provocative positioning ( arms at 1 8 0 degrees
• Most patients with vTOS are young, healthy, and often overhead) provides the most definitive visualization of the
athletically inclined who present with the abrupt onset of affected region, confirming the presence of the cervical rib,
unilateral arm swelling in their dominant arm after repeti­ delineating the amount of thrombus in the subclavian aneu­
tive, strenuous use for sport, work, or recreation. Athletes rysm, and documenting the proximal and distal vasculature
affected can include baseball pitchers, rowers, swimmers, for operative planning ( FIG 5) .
water polo players, weightlifters, volleyball players, surfers,
football quarterbacks, or any others relying on repetitive
upper extremity effort. The swelling is noted in the shoulder,
arm, and hand and can be accompanied by aching, throb­
bing, or tightness that worsens with more activity. Because
most patients are otherwise young and healthy, an orthope­
dic cause such as strain, muscle pull, or j oint inj ury is often
considered initially. Cyanosis of the affected extremity, vis­
ible chest wall venous collaterals, or progressively worsening
symptoms suggest a vascular etiology, prompting referral to
an interventionalist. On exam, the arm is swollen, tender to
palpation, warm, and often has visible superficial collaterals
that track onto the anterior chest wall ( FIG 3 ) . Range of mo­
tion of the affected extremity can be impeded due to patient
discomfort.
• aTOS patients will present with mild hand ischemia due to
distal embolization, which manifests as digital ischemia or
splinter hemorrhage. The diagnosis is often delayed due to
the fact that these patients have no typical atherosclerotic
risk factors and are mostly young and athletic. A pulsatile FIG 4 • Ch est x-ray d e m o nstrating l eft cervica l r i b (arrow).
 C h a p t e r 9 V E N O U S A N D ARTERIAL THORACIC OUTLET S Y N D R O M E
FIG 5 • CT-A reco nstruction of 1 9-yea r-o l d co l l eg iate te n n i s
p l ayer with cervical r i b (arro ws) t h a t l e d to subclavian a n e u rysm
formati o n . Patient presented with f i n g e rt i p e m b o l i after p l a y i n g
l o n g matches.
SURGICAL MANAGEMENT
Preoperative Planning
• vTOS patients diagnosed with acute axillosubclavian
DVT should be anticoagulated with weight-based dosing
of unfractionated heparin or low-molecular-weight hepa­
rin. Depending on the resource availability, admission for
thrombolysis or urgent referral to a center capable of cath­
eter-directed interventions has been generally accepted as
standard of care. 3 There are patients that are simply put on
anticoagulation that get referred much later (more than 2
weeks) due to lack of recognition of the TOS etiology of the
DVT and this leads to a diminished success rate of throm­
bolysis.4
• Successful thrombolysis involves a combination of chemical
and mechanical thrombectomy and is often quite effective
in decreasing clot burden and reducing long-term sequelae
of upper extremity DVT ( FIG 6A,B ) . Technical details of
thrombolysis are well described and can be performed with
minimal morbidity.5
• Definitive therapy for vTOS after thrombolysis involves
thoracic outlet decompression, consisting of anterior and
middle scalenectomy, resection of the subclavius tendon,
1 st rib resection, and venolysis or venous reconstruction.
Timing of definitive surgery after thrombolysis is somewhat
controversial and is limited by anecdotal reports and vari­
ous surgeon biases.6 Successful outcomes can be achieved
with definitive thoracic outlet decompression performed
during the same hospitalization as the thrombolysis7 and up
to 3 months later with nonresolution of mild venous ob­
structive symptoms/ leading some to adopt a more selective
approach for offering rib resection. This lack of consensus
provides some flexibility in offering definitive surgery as
many of these young patients are often student-athletes and
cannot miss certain periods of the school year. Management
of anticoagulation during this time also impacts decisions
about planning surgery, as intolerance to blood thinners or
difficulty with maintaining adequate anticoagulation can af­
fect the urgency of the required definitive decompression.
If there is a delay in scheduling definitive rib resection, a
187 1
B
FIG 6 • A. I n it i a l venogram d e m o nstrat i n g right axi l l os u bc l a v i a n
occl usion w i t h l a rg e co l l atera l deve l o p m ent. W i re was passed
t h r o u g h this reg i o n and p h a rmacomech a n ical throm bolysis
i n itiated . B. Fo l l ow-u p ve nogram 24 h o u rs l ater with reso l ution
of majority of thrombus l o a d . Ve i n sti l l sh ows s i g n s of d isease and
sca rri n g p a rticu l a rly i n the reg i o n of co m p ress i o n .
duplex immediately prior to surgery after successful throm­
bolysis is important to document the status of the vein dur­
ing the immediate pre-operative period.
• In contradistinction to the numerous pathways for vTOS
surgery planning aTOS in the presence of an ipsilateral cervi­
cal rib and subclavian aneurysm presents a strong indication
for definitive surgical intervention. Preoperative planning
consists mainly of ensuring adequate and healthy vascula­
ture proximal and distal to the diseased segment and de­
termining a bypass route that is reasonable. Extraanatomic
bypass via a carotid-subclavian or carotid-axillary with in­
terval ligation may be necessary, depending on the size and
length of the subclavian aneurysm and thrombus. Direct
repair of the subclavian aneurysm with interposition graft­
ing can be accomplished only when there is a short segment
of disease that limits itself to the visualized region in the
supraclavicular fossa. The preoperative CT-A provides the
best road map to help decide amongst these reconstructive
strategies. Endovascular techniques of the subclavian artery
such as stent grafting in the setting of a TOS are generally
not recommended, given the age of the typical patient, the
compression that can occur from scarring even after cervical
1872 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

or 1 st rib decompression, and the likely desire to resume
prior activities that often brought about these symptoms in
the postoperative period.
Positioning
• vTOS decompression will often involve an infraclavicular
incision (some prefer only this incision; some prefer a para­
clavicular approach; still others prefer transaxillary), which
is facilitated by positioning the patient with a small bump
between the shoulder blades and in a " head up" position
of 30 degrees. The affected arm is prepped out and placed
in a stocking on the side of the patient to allow full move­
ment during the case. This affords the anterior visualization
of the 1 st rib and particularly the subclavius tendon and
costoclavicular ligament for safe and effective decompres­
sion. The entire ipsilateral neck, shoulder, arm, and anterior
chest wall are prepped into the field as well as a region on
the lateral chest wall should there be a small pneumothorax
postprocedure.
• aTOS decompression with cervical rib is most often per­
formed with a supraclavicular approach. When arterial re­
construction is planned, preparations should be made for
saphenous or femoral vein harvesting.

VENOUS THORACIC OUTLET SYN DROM E

Infraclavicular Approach

• A 5-cm tra nsverse i n c i s i o n is m a d e o n e f i n g e r b readth

below the c l avicle, sta rt i n g a l o n g the edge of the ster­
n u m trave l l i n g latera l l y, a n d is carried through the subcu­
ta neous tissue a n d pector a l i s fasc i a to expose the u p per
fi bers of the pectora l i s m uscles (FIG 7) . Gentle sprea d i n g
between m uscle fi bers i n t h i s reg i o n exposes t h e a ntero­
m e d i a l q u a d rant of the axi l l a ry fat pad and a l l ows easy
p a l pation of the 1 st r i b . Appropriate retractors can be
p l aced to fu l ly expose the m ost a nte rior portion of the
1 st r i b beneath a layer of axi l l a ry fat (FIG 8).
• W h e n t h e r i b is v i s u a l i ze d , c a u t e ry is used to sepa rate
t h e i n fe r i o r- l y i n g i nte rcosta l m u scu l a t u re from t h e r i b,
with c u rved d i ssect i o n h e a d i n g s u p e r o l atera l l y a l o n g
t h e C c u rve of t h e r i b (FIG 9) . L u n g p l e u ra a re often v i ­
s u a l ized i m med iately beneath t h e rib a n d c a r e s h o u l d FIG 8 • I ncision is ca rried down t h ro u g h pectora l i s fascia,
b e t a k e n to n o t i n j u re l u n g p a re n c hym a . S u p e r i o r ly, then the m uscle fibers a re s p l it u nt i l axi l l a ry fat that covers
t h e s u b c l a v i u s t e n d o n a n d costoc l a v i c u l a r l i g a m e nt the 1 st rib is reach e d .
a re t a k e n d o w n s h a r p l y with c a u t e ry to free u p t h e
a nt e r i o r p o rt i o n of t h e 1 st r i b f r o m t h e ove r h a n g i n g

FIG 9 • F u rther d i ssection a r o u n d the 1 st r i b i n vo lves s h a r p

F I G 7 • I nfraclavi c u l a r i n c i s i o n is m a d e o n e f i n g e rb readth d i ssection of i nte rcosta l m u scu lature a l o n g i nfe rior aspect o f
below clavicle. 1 st r i b (arrows) .
 C h a p t e r 9 V E N O U S A N D ARTERIAL THORACIC OUTLET S Y N D R O M E 1873

c l a v i c l e . F o l l o w i n g a l o n g t h e s u p e r i o r a s p ect of t h e 1 st
r i b , t h e a nt e r i o r sca l e n e f i b e rs a re a l so s h a r p l y t a k e n
down a n d f u rt h e r s u p e r i o r d i ssect i o n t a k e s p l ace
a l o n g t h e l atera l e d g e of t h e 1 st rib u n t i l p a l p a t i o n of
t h e s u b c l a vi a n a rtery i s n ote d . This l ev e l i s a s f a r neces­
s a ry to d e co m p ress t h e s u b c l a v i a n vei n . Oft e n , movi n g
t h e a rm i n a s u p e r i o r p o s i t i o n fa c i l itates m o re s u p e r i o r
exposure of t h e 1 st r i b n e a r t h e a rte ry.
• W h e n the r i b is c l e a r on its s u p e r i o r, latera l , a n d i nfe­
rior e d g e, a rib cutter can be i n s e rted s u p e r i o rly, ta k i n g
c a r e to vis u a l ize the j a ws, a n d t h e n t h e s u p e r i o r c u t i s
m a d e i n t h e r i b . The i nf e r i o r cut i s d o n e n e a r the m a ­
n u b r i a l j u n ct i o n , co m m o n l y w i t h a p o w e r saw. A s the
r i b i s p u l l e d away from the body, sharp cautery c a n be
used to fa c i l itate h e m ostas i s of i n d iv i d u a l m u sc l e f i b e rs
(i nte rcosta l s, a nt e r i o r a n d m i d d l e sca l e n e) h o l d i n g the FIG 11 • If more p roxi m a l expos u re is n eeded to c l a m p
1 st r i b i n p l a ce. f o r control, exte nsion of the i n c i s i o n i nto t h e m a n u b r i u m
a n d towa rd ste r n a l n otch a l l ows w i d e r visu a l ization of t h e
Venous Reconstruction orig i n of subclavian ve i n a n d j u n ction w i t h j u g u l a r i nto t h e
i n n o m i n ate.
• With t h e a nt e r i o r h a lf to two-t h i rd s of t h e r i b rem oved
from t h i s i n fraclavi c u l a r a p proach, the ve i n i s often p a l ­
p a b l e i n a b e d of tissue a n d m u s c l e fi b e rs i m m e d i ately
a n d can be pe rfo r m e d with a d e q u ate prox i m a l a n d
b e l o w t h e c l a v i c l e . Ve n o lysis c o n s i sts of free i n g up
d i sta l control of t h e ve i n u n d e r d i rect v i s u a l i za t i o n
t h ese m u s c l e fi b e rs to expose t h e ve i n (FIG 1 0) . M o re
(FIG 1 2) .
prox i m a l expos u re of t h e ve i n c a n be acco m p l i s h e d v i a
a tra n s m a n u b r i a l exte n s i o n of t h e i n f ra c l a vi c u l a r i n c i ­
Closure
s i o n to t h e center of t h e ste r n u m a n d vertica l l y u p t o
t h e ste r n a l n otch (FIG 1 1 ) . T h i s c a n b e n ecessa ry to o b ­ • Ca refu l attention to the stu m p of r i b re m a i n i n g for he­
ta i n a d e q u ate vasc u l a r control for patch i n g of c h r o n i - m ostasis is pe rfo rmed, as we l l as the reg i o n of ve i n after
ca l l y d i seased ve n o u s seg m e nts. W h e n a st r i ct u red veno lysis a n d/o r reco nstruct i o n .
s e g m e n t of ve i n i s l oca l ized, sa p h e n o u s ve i n o r bovi n e • If the p l e u ra or l u n g parenchyma has been i n j u red, a
p e r i c a rd i a ! o r bovi n e p e r i c a rd i a ! patc h i n g p rovides a n s m a l l-ca l i be r ( 1 2 Fr) pediatric ch est tube can be p l a ce i n
exce l l e nt strategy f o r resto rat i o n o f l u m i n a l d i a meter t h e a nterior p l e u r a l space u n d e r d i rect visual izati o n .

FIG 1 0 • After 1 st r i b is resected, ca refu l d i ssection a r o u n d

ve i n w i t h venolysis a n d takedown of fi bers su rrou n d i n g v e i n FIG 12 • Sten otic reg i o n of the su bclavia n ve i n repa i red with
a l l ows a d e q u ate visua l i zation to c h e c k for ste n otic reg ions. patch ve n o p l asty u s i n g g reater saphenous ve i n .
1874 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

ARTE RIAL THORACI C OUTLET SYN D ROME

Supraclavicular Approach

• A 7-cm i n c i s i o n is m a d e o n e f i n g e r b readth a bove t h e

c l a v i c l e, sta rti n g l atera l to t h e p a l p a b l e edge of the
ste r n a l head of t h e ste r n o c l e i d o m asto i d m u scle a n d car­
ried t h r o u g h t h e p l atys m a . T h i s exposes the clavicu l a r
h e a d o f t h e ste r n o c l e i d o m asto i d , w h i c h i s tra n sected
with a cuff to sew back toget h e r later, w h i c h n ow ex­
poses the a nterior sca l e n e fat pad (FIG 1 3) . The fat pad
i s d i ssected along th ree borders, i nferio rly, l atera l ly, a n d
m e d i a l ly, t o a l low i t swi n g n o rthward t o expose t h e a n ­
t e r i o r sca l e n e m u scle a n d the p h r e n i c n e rve (FIG 1 4) .
When o p e rati n g o n t h e l eft s i d e , extra c a r e is t a k e n to
visu a l ize the thoracic d u ct w h e n p resent, w h i c h i s s u ­
t u re l i gated to p revent posto pe rative chyle l e a ks if it
becomes i nj u re d .
• With the p h re n i c n e rve s l u n g a n d p rotected, tra nsect i o n
of the a nte rior sca l e n e m uscle off the su perior edge o f
the 1 st r i b i s d o n e u s i n g b i p o l a r scissors. C a r e is t a k e n t o
stay o n the bone d u r i n g this portion so as n o t to i n j u re
FIG 14 • With the sca l e n e fat pad retracted superiorly, the
a nte rior sca lene m u scle a n d p h r e n i c n e rve a re clearly see n .
the u n d e r l y i n g subclavian a rtery. After the i nfe rior edge
T h e n e rve is s l u n g w i t h a s i l astic loop.
of the a nterior sca l e n e i s removed, a port i o n of m uscle
can be transected to a l low room for f u rther visua l i zation
a n d su bseq uent d i ssect i o n around the brach i a l p l exus
(FIG 1 5) . The long thoracic n e rve is identified latera l ly, surro u n d i n g it, a n d can be fused to the 1 st r i b (FIG 1 6) .
a n d the entire n e rve structures a re s l u n g a r o u n d a t h i c k C a r e is taken t o d i ssect n e rves a n d vesse ls away f r o m t h e
cle a r s i l astic loop. a b n o r m a l r i b o r its osse us portions t h a t may n o t have
• A cervica l r i b, when p resent, is ofte n visual ized at a p pe a red o n r a d i o g r a p hy.
t h i s t i m e, with a b n o r m a l vascu lature or m uscu lature • The 1 st r i b is visua l i zed by m a neuve r i n g the subclavian
a rtery a n d the n e rve bundle back a n d forth while d i ssect­
i n g m i d d l e sca l e n e fi bers a n d i nte rcosta l m uscu lature off
the 1 st r i b (FIG 1 5) . This can be d o n e s h a r p l y w i t h b i po­
lar scissors o r by u s i n g a perioste a l e l evator. One s h o u l d

FIG 1 3 • S u p ra c l a v i c u l a r i n c i s i o n o n e f i n g e rbreadth a bove

the c l a v i c l e cont i n ues after tra nsect i n g clavicu l a r head of t h e FIG 1 5 • The 1 st r i b is clea red o n both s i d e s of the subclavian
sternocl e i d o m asto i d a n d expos u re of t h e a nterior sca l e n e a rtery a n d the b rach i a l p l exus fibers, which a re all slung to
fat pad. a l low easy m o b i l izati o n .
 C h a p t e r 9 V E N O U S A N D ARTERIAL THORACIC OUTLET S Y N D R O M E 1875

FIG 1 6 • I n t h i s case, a fused cervical r i b to the 1 st r i b is FIG 17 • Rem ova l of the congen ita l ly fused cervical r i b to
p ro m i n e ntly te nting u p the s u bclavian a rtery a n d brach i a l the 1 st r i b as a n e n b l oc p i ece, a l lowing the n e u rovasc u l a r
p l exus fibers. b u n d l e t o return t o its n o r m a l position without b e i n g k i n ked
o r d i s p l aced .

avo i d the use of cautery i n this a rea as it is l i kely to trans­

m i t to the brach i a l p l exus or p h r e n i c n e rve.
• When the rib is clear from the reg i o n i nfe rior to the sub­
clavian a rtery a n d superior to the u p p e r aspect of the
brach i a l p l exus, a power saw can be used to tra nsect the
r i b . If there i s a fused portion of cervica l r i b, it should be
attem pted to be rem oved as a s i n g l e piece (FIG 1 7) to
assure that a l l bony a b n o r m a l ities have been freed u p to
a l l ow for a d e q u ate decom p ress i o n .
Arterial Reconstruction
• S u bclavian a n e u rysm resection, when needed, consists of
a p propriate bypass p r i n c i p les a n d replacement with a n
a utog enous o r p rosthetic i nterpositi o n g raft o r extra a n a ­
tom i c bypass o f carotid to d ista l s u b c l a v i a n o r carotid to
axi l l a ry g raft. Typica l sizes a n d types req u i red for p ros­
thetic g rafts i n c l u d e 6- o r 8-mm r i n g e d polytetrafl u oro­
ethyl e n e (PTF E) o r Dacro n .

PEARLS AND PITFALLS

I n d i cations • vTOS defi n itive thera py co nsists of prompt d i a g n osis, ve nography a n d su bseq uent thrombo lysis, a n d a p p ro­
pri ate selecti o n of patients to u n dergo thoracic outlet decom p ress i o n .
• aTOS patie nts often p resent w i t h h a n d isc h e m i c sym ptoms t h a t w i l l h a v e s o m e delay i n m a n a g e m ent d u e
t o a wide d i fferenti a l . Abnorm a l b o n y o r m uscu l a r a n atomy a l o n g w i t h p resence of subclavian a n e u rysm a l
d isease req u i res defi n itive repa i r i n c l u d i n g a rte r i a l reco nstruct i o n .
Preope rative • Ve nous d u p l ex, venography, a n d p h a rmacomech a n i ca l t h ro m bolysis provides the opti m a l red u ct i o n of clot
workup b u rd e n to restore fu n cti o n a l venous patency i n patients with vTOS . Ti m i n g of r i b resection and defi n itive
thoracic outlet deco m p ression a re somewhat va r i a b l e and the a p p roach s h o u l d be i n d iv i d u a l ized.
• aTOS patie nts should u n dergo plain rad i o g ra p h y to sea rch for a cervica l r i b a n d CT-A to d ete r m i n e the por­
tions of d iseased subclavian a rtery that m i g ht need resect i o n .
Patient set u p • Pre p p i n g the affected a r m i n the vTOS patie nts affo rds the a b i l ity to m ove the a rm a n d, f r o m the i nfracla­
vicu l a r a p p roach, gain access to the majority of the r i b that is resp o n s i b l e for ve nous compress i o n .
• For cervical r i b a n d a rte r i a l reco nstruct i o ns, the s u p raclavicu l a r a p p roach g i ves n u m e rous options for recon ­
struct ive p u r p oses as we l l as the poss i b i l ity o f the ca rotid a rtery as a n i nflow sou rce.
I nfraclavic u l a r • Visual ization of the subclavius te n d o n and its fi bers as we l l as the costoclavicu l a r l i g a ment i s p a r a m o u n t i n
a p p roach decom p ress i n g t h e reg i o n that co m p resses t h e subclavian ve i n i n vTOS .
• Liberal patc h i n g of the subclavian vein a n d exte nsive ve nolysis provi d e the best l o n g -term pate ncy resu lts
after vTOS deco m p ress i o n .
S u p ra c l avicu l a r • Ca refu l ly m o b i l i z i n g the a nterior sca l e n e f a t pad a l l ows good visua l i zation of the a n t e r i o r sca l e n e m uscle
a pp roach and p h r e n i c n e rve.
• When perform i n g left-sided su praclavicu l a r TOS deco m p ression, o n e m u st be ca ref u l to i d e ntify and l i gate
the thoracic d u ct.
• S l i n g i n g the subclavian a rtery and brach i a l p l exus fi bers a l l ows gentle traction back and forth to exped i­
tiously d i ssect free the entire 1 st rib.
1876 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY
POSTOPERATIVE CARE
• At the conclusion of the procedure, patients are extubated
and an immediate chest x-ray is obtained to ensure there
is no pneumothorax. A small pneumothorax can be treated
with oxygen and incentive spirometry, but a 25 % lung vol­
ume reduction requires a chest tube to suction for 24 hours.
• Patients do not need a sling for their arms. They are given
range-of-motion exercises immediately to encourage
strengthening and are given a taper of muscle relaxant and
opioid narcotics for pain control. Most patients are dis­
charged the following day after surgery.
• Anticoagulation for vTOS patients is usually resumed 3
to 4 days postoperatively at home, typically consisting of
Lovenox for a week, then they return for postoperative ve­
nography to see if further balloon venoplasty is necessary.8
• Anticoagulation for aTOS patients, especially if arterial re­
construction was performed, consists of anti platelet therapy
with aspirin.
OUTCOMES
• Patients treated for vTOS with lysis and subsequent thoracic
outlet decompression have a very low recurrence rate of
thromboembolic disease. Morbidity and mortality is mini­
mal, as these are often young and healthy patients, but typi­
cally revolve around wound issues and bleeding given the
need for a short course of anticoagulation. Satisfactory qual­
ity of life scores and return to full function are reported in
the 8 0 % to 9 0 % range, and most patients can be counseled
to expect a near full return to sport.9
• aTOS and the cervical rib patients often have the most dra­
matic recovery, as they are often the most symptomatic to
begin with. Although the literature is much sparser with re­
gard to this entity, results are uniformly positive with reso­
lution of hand ischemic symptoms and lack of significant
disease recurrence .
COMPLICATIONS
• Perioperative complications related to either form of tho­
racic outlet decompression revolve around lung injury and
wound issues. Pneumothoraxes are often self-limited and
treated effectively with chest tubes. Wound complications
can include chyle leaks, seromas, and skin breakdown. Most
of these are managed expectantly. Brachial plexus injuries
may also occur, most commonly as a function of not recog­
nizing important anatomic structures or not providing suf­
ficient exposure to eliminate collateral damage during rib
transection and removal.
• Timing of restarting anticoagulation in vTOS patients
can lead to postoperative bleeding, which can manifest as
delayed hemothorax. The cause of this bleeding is often re­
lated to recent thrombolysis and raw surfaces of muscle and
cut bone, and this has led to the general recommendation of
holding off on restarting anticoagulation until 3 or 4 days
postoperation.
REFERENCES
1. Lee JT. Clinical incidence and prevalence. In: lllig KA, Thompson RW,
Freischlag J, et al, eds. Thoracic Outlet Syndrome. London, United
Kingdom: Springer-Verlag; 2013.
2. Cassada DC, Lipscomb AL, Stevens SL, et al. The importance of
thrombophilia in the treatment of Paget-Schroetter syndrome. Ann
Vase Surg. 2006;20:596-601.
3. Urschel HC, Razzuk MA. Paget·Schroetter syndrome: what is the best
management? Ann Thorac Surg. 2000;69:1663-1669.
4. Johnston PC, Conte MS, Eichler CM, et al. Infraclavicular first rib
resection for focused and effective treatment of venous thoracic outlet
syndrome. J Vase Surg. 2010;52:525-526.
5. Lee JT, Karwowski JK, Harris EJ, et al. Long·term thrombotic recur·
renee after non-operative management of Paget-Schroetter syndrome.
J Vase Surg. 2006;43:1236-1243.
6. Lee JT. Timing of first rib resection after thrombolysis. In: Illig KA,
Thompson RW, Freischlag J, et al, eds. Thoracic Outlet Syndrome.
London, United Kingdom: Springer-Verlag; 2013.
7. Angle N, Gelabert HA, Farooq MM, et al. Safety and efficacy of early
surgical decompression of the thoracic outlet for Paget·Schroetter syn­
drome. Ann Vase Surg. 2001;15:37-42.
8. Chang KZ, Likes K, Demos J, et al. Routine venography following
transaxillary first rib resection and scalenectomy (FRRS) for chronic
subclavian vein thrombosis ensures excellent outcomes and vein pa­
tency. Vase Endovasc Surg. 2012;46:15-20.
9. Chandra V, Little C, Lee JT. Thoracic outlet syndrome in high perfor­
mance athletes [published online ahead of print May 14, 2014]. ] Vase
Surg. doi:10.1016/j.jvs.2014.04.013.

Chapter 10 Proximal to the Wrist: Upper
Extremity Reconstruction/
Revascularization
, _ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Mohamed A. Zayed
DEFINITION
• The content discussed in the following text assumes the reader
has familiarity with standard upper extremity arterial anatomy
and its most common variations. For additional information,
the reader may refer to excellent existing references.1•2
• Various occlusive and/or aneurysmal disease processes in the
upper extremity arterial system may necessitate revascular­
ization or reconstruction (Table 1 ) .
• Acute upper extremity ischemia i s less common than i n the
lower extremity due to the rich preexisting collateral cir­
culation in both the upper arm and forearm. The maj ority
( 5 0 % ) of acute ischemic complications in the upper extrem­
�
ity occur in elderly females as a result of embolic phenomenon
rather than primary vessel thrombosis (which accounts for
� 25 % of acute ischemic events) . 3 The differential diagnosis
for embolic sources includes intracardiac sources, proximal
arterial atherosclerotic plaque, proximal arterial aneurysm
thrombus, endocarditis, or paradoxical embolus from venous
circulation.
• Chronic arterial occlusive disease is rarely symptomatic.
Associated comorbid conditions include diabetes, chronic
atherosclerotic occlusive disease, subclavian or arteriove­
nous steal syndromes, or failure of prior arterial repair or
grafting. 4•5
• Venous occlusive disorders in the upper extremity are common
and are usually associated with iatrogenic injury, indwelling
catheters, or thoracic outlet pathology. For further informa­
tion regarding venous thoracic outlet disorders. Distal to the
thoracic outlet, venous occlusive disorders are for the most
part managed expectantly with anticoagulation therapy. Open
surgical and endovascular therapies are rarely used and, due to
high recurrence and failure rates, are not enthusiastically rec­
ommended. For further recommendations regarding upper ex­
tremity venous disease management, please refer to additional
references. 6•7
Tab l e 1 : Upper Extremity Vascu lar D i sease
Pathology Etiology
Arterial stenosis or occl usion • Atherosclerosis
• Dissection/tra u m a
• Extrinsic compression
• Vasculitis
• Hypercoagulable state
Arterial aneurysmal degeneration • Atherosclerotic degeneration
• B l u nt or penetrating tra u m a
• Connective tissue disorder
• Iatrogenic injury
Venous stenosis or occl usion • Deep venous thrombosis
• Hypercoagulable state
• Extrinsic compression
I
�
Ronald L. Dalman
PATIENT HISTORY AND PHYSICAL
FINDINGS
• Initial evaluation should include an assessment of associated
comorbidities, including cardiac pathologies (myocardial in­
farction, arrhythmia, heart failure, or prior coronary artery
revascularization), hypertension, hyperlipidemia, diabetes,
hypercoagulability, smoking, prior upper or lower extremity
arterial intervention, or index extremity trauma.
• Symptoms and signs of acute arterial ischemia include pain,
paresthesia, pulselessness, paralysis, and/or poikilothermia.
A thorough vascular, sensory, and motor examination will
help assess the severity of arterial insufficiency. Although
dated, the Rutherford classification system remains useful
for prognostic determinations. 8 For classes 5 and 6 ischemia,
urgent or emergent intervention may be necessary to pre­
serve limb function and viability. Prompt removal of embolic
debris in limbs with sufficient residual viability produces
excellent long-term results. 3
• Chronic limb ischemia may also present with symptoms of
rest pain, pain with extremity use, paresthesia, pulselessness,
poikilothermia, and/or ulcerations/wounds/gangrene of fin­
gers or fingertips. Subjects should be asked to describe what,
if any, activities exacerbate these potential symptoms (i.e., lift­
ing or carrying material with affected arm/hand, arm raising,
or repetitive arm/hand movement) . Patients with vocational
or recreational activities that require regular or frequent use of
their upper extremities should describe convincing symptoms
they experience in relation to these activities. More commonly,
chronic upper extremity arterial ischemia is asymptomatic,
particularly in older and less physically active individuals.
In general, revascularization is not necessarily indicated in
these circumstances. Discrepancy in upper extremity pulses, or
brachial blood pressure differential of more than 15 mmHg,
is a hallmark of chronic upper extremity arterial insufficiency
with or without accompanying symptoms.
• Traumatic or iatrogenic injury accounts for 25 % of patients
presenting with acute upper extremity arterial insufficiency.
Consideration of the mechanism of injury ( blunt, penetrat­
ing, hyperextension, or avulsion) will help delineate the likely
nature of the resulting arterial disruption (transection, dissec­
tion, or thrombosis, with or without ongoing extravasation).
Following completion of the trauma primary survey, determi­
nation of extremity arterial continuity should be performed
following reduction of obvious ipsilateral upper extremity frac­
tures and dislocations. In complex injuries, including avulsions
and crush injuries, baseline sensory and motor status should be
documented early to formulate the most appropriate course of
therapy. When severe arterial injury is associated with transec­
tion or avulsion of the brachial plexus and compound long
bone fractures, meaningful functional recovery, despite ulti­
mately successful revascularization, may not be possible.9
1877
1878 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY
• More commonly, upper extremity arterial injuries can be more
subtle and are frequently missed on primary or secondary
surveys. The extensive collateral network present around the
elbow often masks the presence of brachial artery thrombosis
following posterior elbow dislocation, or dissection and throm­
bosis following brachial artery catheterization. When physical
signs suggest asymmetric or reduced upper extremity arterial
perfusion, objective imaging should be obtained promptly to
direct therapy and maximize long-term function. Depending
on hand perfusion and viability, occasionally, immediate re­
vascularization can be at least temporarily deferred to allow
for more urgent resuscitation and stabilization procedures to
proceed. Similarly, non-flow-limiting dissections may be moni­
tored without immediate intervention, particularly when the
patient's overall condition merits observational management.
IMAGING AND OTHER DIAGNOSTIC
STUDIES
• Depending on clinical circumstances, revascularization may
be undertaken on the basis of clinically apparent injuries and
limb ischemia. More commonly, physiologic assessment is
indicated and necessary to determine the most efficacious
method of revascularization. Arteriography, typically per­
formed during or immediately prior to revascularization,
remains an essential tool to guide intervention and confirm
procedural success. As a general observation, physiologic
testing helps determine when intervention is necessary,
whereas arteriography provides the necessary anatomic
information to ensure procedural and functional success.
• Computed tomography (CT) arteriography can poten­
tially add useful information to surgical planning for upper
extremity revascularization. However, unlike in the abdomen
and lower extremities, significant insight into disease local­
ization and severity in the upper extremities can be gleaned
from physical examination and nonionizing imaging modali­
ties such as ultrasound. The potential additional diagnostic
benefit associated with CT angiography needs to be balanced
with the not insignificant radiation dosage delivered with
this imaging modality, particularly in regard to the longer
life expectancy of younger patients. When vascular disease is
known to be limited to the extrathoracic upper extremity arte­
rial system, CT angiography provides little additional, useful
information over diagnostic arteriography alone, especially
when the latter can be paired with a therapeutic intervention.
• Noninvasive vascular testing for evaluation of the upper
extremities includes segmental systolic pressure measure­
ments using a Doppler flow detector, digital plethysmography,
and arterial duplex scanning.
• Serologic tests are the basis for the workup of patients with
suspected vasculitic pathologies (e.g., Takayasu's arteritis,
giant cell arteritis, Buerger's disease, and/or scleroderma) .
Customary tests include baseline complete blood count, plate­
lets, fibrinogen, C-reactive protein ( CRP), and erythrocyte
sedimentation rate (ESR } . 1 0 •1 1 In certain circumstances, color
duplex evaluation may also provide additional clues to aid
in the diagnosis.12 Additional serial serologies and rheumato­
logic consultation may be necessary depending on the severity
and progression of the suspected vasculitic disease process.
• Young patients with acute primary arterial thrombosis,
patients with recurrent arterial thrombosis, or patients with a
prior history of unprovoked deep venous thrombosis preced­
ing an arterial event should be considered for a hypercoagu­
lability workup and hematology consultation. Initial testing
may include protein C function, free protein S, antithrombin
III activity, anticardiolipin antibodies, factor V Leiden muta­
tion, prothrombin mutation, and homocysteine level. 13
SURGICAL MANAGEMENT
Preoperative Planning
• Prior to attempted upper extremity arterial repair or revas­
cularization, a clear understanding of the extent and loca­
tion of arterial pathology is essential. This knowledge guides
the location of arterial exposure or optimal method of arte­
rial access, the identification of optimal inflow sources and
outflow targets, and the most effective and efficient methods
of reconstruction. When uncertainty persists, intraoperative
arteriography provides essential and timely guidance.
• As in all methods of peripheral arterial reconstruction, hepa­
rin is typically administered when an interventional sheath
is first placed, or arterial control is anticipated. Typically,
1 00 units/kg of intravenous heparin is administered, with
additional anticoagulation guided by the activated clotting
time monitored during the course of the procedure.
• As discussed in Part 6, Chapter 2, the preferred extratho­
racic method of innominate or proximal left subclavian
artery surgical reconstruction is carotid subclavian bypass.
Frequently, however, endovascular options are available and
preferable in patients who cannot tolerate the risks or mor­
bidity associated with open reconstruction. For example, in
the setting of uncontrolled, life-threatening hemorrhage from
penetrating or crush injuries or limb avulsion, bleeding may
be controlled by insertion of covered, self-expanding stents
across the area of injury in the subclavian or axillary arteries.
However, with few other exceptions (such as lesions associ­
ated with giant cell or Takayasu's arteritis), angioplasty and
stenting of arterial lesions at or distal to the clavicle is poorly
tolerated and ill advised. Stents placed in this area are at high
risk for fragmentation and subsequent arterial thrombosis,
pseudoaneurysm formation, or stent migration.
• Surgical management of arterial pathology distal to the sub­
clavian artery ( surgical management of arterial disease of the
arch vessels and subclavian artery are discussed in Part 6,
Chapters 1, 2, and 9) and proximal to the wrist (surgical
management of arterial disease distal to the wrist is discussed
in Part 6, Chapter 1 1 ) will depend on acuity, cause/type of
pathology (penetrating trauma, blunt trauma, occlusion, ste­
nosis, or aneurysm), severity of patient symptoms, patient
comorbidities, and required durability of the planned repair.
• Axillary artery exposure is guided by the nature of the
planned reconstruction. The proximal artery is most easily
exposed via a transverse infraclavicular incision. Exposure
of the second and third portions requires deltopectoral or
axillary approaches, respectively. 1
• Acute symptomatic embolic occlusion of the axillary or brachial
arteries are best managed by open, preferably image-guided,
balloon catheter or direct thromboembolectomy.1•2 Essential
elements required for thromboembolectomy include ( 1 ) de­
termination of the optimal treatment environment (operating
room [OR] with portable vs. fixed imaging), (2) arterial access
(level of incision), ( 3 ) acquisition of catheters and guidewires
 C h a p t e r 1 0 PROXIMAL TO T H E WRI ST: Upper Extre m ity Reconstruct i o n/Revascu l a rization
required to transverse the embolus and accumulated luminal
thrombus, (4) availability of balloon and over-the-wire
embolectomy catheters, (5) need for adjuncts such as aspira­
tion catheters (ExportTM catheter, Medtronic, Minneapolis,
MN) and thrombolytic agents (tissue plasminogen activator
[tPA] ), (6) options for managing postischemic hyperemia
and elevated compartment pressures, and (7) consideration
of treatment alternatives should preexisting atherosclerotic
occlusive disease preclude or complicate catheter-directed
thromboembolectomy.
• For symptomatic axillary or brachial artery thrombosis
not amenable to direct or catheter-based, image-guided
thromboembolectomy, open surgical bypass or interposi­
tion grafting is the preferred method of repair. When con­
sidering open bypass or interposition grafting distal to the
clavicle, key planning elements include ( 1 ) determination of
optimal inflow and outflow, (2) conduit ( almost exclusively
autogenous vein), and ( 3 ) assessment of distal compartment
pressures and potential need for fascial release. Commonly,
more vasospasm is engendered by injury and surgical manip­
ulation in the upper extremity arteries as compared to those
of the lower extremities, and accommodations may need to
be made to ensure graft and bypass patency in this context.
• Branch vessel injuries and aneurysms, particularly those
arising from the axillary and brachial arteries, are best treated
with ligation and excision.14 Preoperative planning of these
procedures involves selection of an appropriate exposure
through the muscles of the upper extremity that will facilitate
rapid recovery and minimize risk of disability in a usually
young and active patient cohort.
• The relatively superficial location of the brachial artery in
the antecubital fossa increases its vulnerability to traumatic
and iatrogenic injuryY Most brachial inj uries are associated
with penetrating trauma; however, blunt injuries also occur,
particularly in the distal brachial artery, following posterior
elbow dislocations and supracondylar fractures (the latter
more commonly in children). 16 In these situations, key ele­
ments for repair will include inspection of injured arterial
segment on preoperative imaging for possible intimal dis­
ruption, short segment thrombosis, or thrombosis extending
distally into the forearm.
• An increasing number of cardiac catheterizations and coronary
interventions are performed via radial or brachial accessY
Cannulation site complications, including thrombosis or pseu­
doaneurysm formation, often necessitate operative repair.17•18
For these patients, preoperative planning will include identi­
fying the extent of injury, options for graft conduit (smaller
diameter vein), and alternative management options including
arterial ligation in extenuating circumstances.
• The ulnar artery at the wrist is the dominant hand artery in
the maj ority of patients. Achieving or maintaining sufficient
arterial outflow at the wrist is essential to the hemodynamic
and clinical success of forearm revascularization procedures.
The status of the radial and ulnar arteries at the wrist should
be confirmed in the course of evaluating all patients for
upper extremity revascularization options.
Operating Room Setup
• The majority of upper extremity revascularization procedures
are suited for a hybrid operating environment, or an OR
1879
equipped with a radiolucent, floating-point carbon fiber oper­
ating table and fluoroscopy radiation source and image inten­
sification system, preferably equipped with digital subtraction
angiography and last-image hold capabilities. When optimal
x-ray penetration and resolution is not available, or in cir­
cumstances when diagnostic angiography alone is anticipated,
less sophisticated portable imaging systems may suffice.
• Elective and emergent upper extremity surgical revascular­
ization procedures may be performed with either regional or
general anesthesia. Considerations include the overall status
of the patient, ability to tolerate the specific challenges asso­
ciated with either anesthetic techniques, and the abilities of
the anesthesiologist responsible for anesthetic management.
• For the maj ority of upper extremity procedures, the opera­
tive limb is typically extended at 90 degrees. For optimal
surgical exposure, we prefer arm positioning systems that
move freely with the OR table rather than those with sepa­
rate floor extensions. To avoid exacerbation of potential
brachial plexus injuries in appropriate clinical settings, care
should be taken to avoid hyperabduction and extension of
the limb. The operative field should include, at a minimum,
the ipsilateral axilla, chest, and neck, with the head rotated
and extended to the contralateral side. A shoulder roll may
be positioned under the ipsilateral shoulder to aid with neck
and shoulder extension ( FIG 1 A) . Alternatively, for optimal
deltopectoral exposure of the axillary artery, the arm can be
externally rotated and abducted at 3 0 degrees relative to the
lateral chest.
• In situations where venous interposition conduit may be
needed, a lower extremity should also be prepared into the
surgical field to allow for greater or lesser saphenous vein
harvest as indicated by the estimated diameter of the target
artery. In the setting of extensive traumatic injuries, vein
should be harvested from the least affected lower extremity.
A
FIG 1 • A. With the patient s u p i ne, the a r m of i nte rest is
pronated a n d exte nded at 90 deg rees rel ative to the ch est. The
head is externa l ly rotated to the contra latera l side to expose the
i psi latera l neck seg m e nt. (contin ued)
1880 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY
Cephalic vein Pectoralis m ajor
Clavi pectoral fascia
Pectoralis minor
c nerve
B
Interposition
graft repair
Injured
axillary
artery
vein
D p a rt i a l transect i o n .
• Syste m i c a nticoa g u lation s h o u l d be considered whenever
major open or e n d ovascu l a r revasc u l a r izations a re u n d e r­
take n . Exceptions i n c l u d e profo u n d syste m i c coag u lopa-
thy o r concern rel ated to conco m ita nt risks such as occult
i ntracra n i a l hemorrhage. S ufficient i ntraven o u s u nfrac­
tionated h e p a r i n s h o u l d be a d m i n istered to a c h i eve a n
activated clott i n g t i m e o f m o re t h a n 2 5 0 seco nds.
PROXI MAL AXI L LARY ARTERY
First Step
• Exposu re of the p roxi m a l (fi rst) portion of the axi l l a ry
a rtery is best ach ieved t h r o u g h a n i n c i s i o n p l a ced o n e
f i n g e rb readth below the m i d d l e t h i rd of the clavicle
(FIG 1 8) . Deep to the su bcuta neous tissue, the pecto-
ral fascia is opened l o n g itud i n a l ly. The pectora l i s major
m u scle is d ivided with a m uscle-sp l itt i n g i n ci s i o n . The
u n d erlying clavi pecto ral fascia is then sharply i n cised to
expose the proxi m a l axi l l a ry sh eath . Ad d it i o n a l exposu re
Thoracoacromial Lateral Axillary
artery cord artery
Lateral pectoral Clavi pectoral
fascia
FIG 1 • (continued) B. I nfraclavicu l a r expos u re of the proxi m a l
axi l l a ry a rte ry. C. Components of the i nfraclavicu l a r axi l l a ry sheath.
D. I nterpos ition g raft repa i r of a proxi m a l axi l l a ry a rtery tra u matic
• Open surgical revasc u l a rization a n d repa i r tec h n i q ues
are described i n the sections in the following text rela­
tive to u pper extrem ity a nato m i c l ocat i o n .
• T h e last sect i o n descri bes general e n d ovasc u l a r tech­
n i q ues used for upper extrem ity i nte rventions.
is a i ded by l atera l retract i o n or d ivision of the pecto ra l i s
m i n o r m uscle.
Second Step
• F i n e d i ssection s h o u l d be used to expose a n d control the
axi l l a ry a rtery deep to the clavi pecto ral fasc i a . Ca refu l
d i ssection a n d retraction m i n i m izes i n j u ry to the cords
of the brach i a l p l exus su rrou n d i n g the a rte ry. The latera l
pecto ral n e rve a n d prox i m a l cepha l i c ve i n a re a l so prone
to i n j u ry d u r i n g d i ssection o r tract i o n from m i spl aced
self-reta i n i n g retraction devices.
 C h a p t e r 1 0 PROXIMAL TO T H E WRI ST: Upper Extre m ity Reconstruct i o n/Revascu l a rization
T hird Step
• The axi l l a ry ve i n l i es a nterior a n d ca u d a l to the a rtery
with i n the axi l l a ry sheath. M o b i l ity of the ve i n is ach ieved
with gentle d i ssection, l i gation of associated ve nous trib­
utari es, a n d mild ca u d a l retraction with a c i rcu mferent i a l
vessel l o o p o r s m a l l h a n d h e l d retractor (FIG 1 C) .
• I n s m a l l e r patients, d ivision of the thoracoacro m i a l a rtery
a n d ve i n may be req u i red to fa c i l itate p roxi m a l axi l l a ry
exposure. O n ce a g a i n , i n j u ry to the latera l pecto ral n e rve
is avoid e d by gentle, d e l i be rate d i ssect i o n .
Fourth Step
• O n ce c i rcu mferent i a l d i ssect i o n a n d expos u re of the
prox i m a l axi l l a ry a rtery is co m p l ete, the a rtery is opti­
m a l l y contro l led with s i l asti c vessel loops (FIG 1 C) .
• Fa m i l i a r a n ato m i c relati onsh i ps may be l ess recog n iz a b l e
d u r i n g r e d o o r com p l ex exposu res, o r i n the sett i n g o f
tra u m atic i n j u ries, o n g o i n g extravasation, a n d h e m a ­
to m a format i o n . The risk of associ ated brach i a l p l exopa­
thy is h e i g htened i n these situations. Exte n d i n g expos u re
t h r o u g h the d e ltopecto ra l g roove may h e l p d e l i n eate
otherwise i n d ist i n ct tissue p l a n es. Reposit i o n i n g the a r m
t h r o u g h o u t the range of ava i l a b l e a b d uction may a lso
red uce position-related a n ato m i c d i storti o n .
Fifth Step
• For axi l l ofe moral bypass g raft in g , the fi rst or most p roxi-
m a l axi l l a ry seg ment is chosen for a n asto motic access
to m i n i m ize the risk of traction a n d potential g raft d is­
r u pt i o n from s h o u l d e r a n d arm m ovement. Locat i n g
t h e a n asto m osis as prox i m ate t o the clavicle as possi b l e
opti m i zes l o n g-term pe rfo r m a n ce a n d d u ra b i l ity. Based
o n the patie nt's body ha bitus and p l a n ned g raft con­
fig u ration (uni- o r bifemoral), a n a p p ro p riately sized (6,
8, o r 1 0 m m ) externa l ly s u p p o rted expanded polytetra­
f l u o roethyl e n e (ePTFE) is e m p l oyed . For m ost patie nts,
in most situations, an 8-m m d i a m eter, rem ova b l e r i n g
g raft is opti m a l . The axi l l a ry a rteriotomy is a lways cre­
ated p roxi m a l to the overlyi n g pectora l i s m i n o r m u scle,
whic h is itse lf usua l ly d ivided to f u rther m i n i m i ze u n d u e
traction o n t h e g raft.
• When co nsidering d i rect i p s i l atera l axi l l o-ax i l l o o r axi l l o-
brach i a l bypass g rafting, co n d u it choice depends on surgi-
ca l context. I n conta m i n ated fields (with open penetrati n g
o r avulsion i nj u ries of the axi l l a ry a rte ry), ve i n is p referred
and is sou rced from the l o n g o r short sa phenous o r super­
ficial femora l ve i n s in the (least i nvolved) lower extre m ity,
o r contra l atera l a r m ve i n . For e l ective revasc u l a r i zation
p roced u res, depe n d i n g on the age of the patient, bypass
length, target a rtery d i a m eter, and i n d ications for reco n-
struction, ePTFE or kn itted po lyeste r p rosthetic g rafts
may provide accepta b l e a ltern atives. H owever, in nearly
all situations req u i ri n g u p per extrem ity bypass at o r d is-
ta l to the clavicle, a utogenous ve i n is o pti m a l and h i g h ly
p refe rred.
• For i p s i l atera l revasc u l a rization, g raft is tun neled p a ra l l e l
t o the existing axi l l a ry a rtery ben eath the pectora l i s major
a n d minor m uscles to the a nterior axi l la ry l i n e .
1881
• For u p per extrem ity revascu l a rization p roced u res, tun­
neling is extended d ista l ly t h ro u g h su bcuta neous p l a nes
a l o n g the arm and forearm as n ecessa ry to reach the
ta rget a rte ry. I n the case of axi l l ofe moral bypass g rafting,
the ePTFE g raft t u n n e l is created retrog rade, exte n d i n g
f r o m the fe moral i ncision su periorly to the exposed a x i l ­
l a ry a rtery, w i t h ca re bei ng t a k e n to position the g raft
a nterior to the a nterior su perior i l iac crest a n d advanced
u pward along the anterior axi l l a ry l i n e . The t u n n e l m ust
n ot breach the a b d om i n a l fascia or thoracic cavity. With
a t u n n e l i n g device of sufficient length, a counterincision
is n ot usu a l ly n ecessa ry to reach the axi l l a ry a rte ry. At the
i nferior border of the pectora l i s m uscle, the t u n n e l transi­
tions to a su bfasc i a l plane exte n d i n g below the pectora l i s
m a j o r m uscle to reach the exposed axi l l a ry a rtery m ed i a l
t o its i ntersection with t h e pectora l i s m i n o r m uscle. U s e of
a p u rpose-specific t u n n e l i n g device for this m a n euver wi l l
n ot o n l y o bviate the need for a cou nteri ncision b ut a lso
m i n i m ize risks of k i n king, twisting, o r g raft co m p ress i o n .
• The co n d u it s h o u l d be beve led a p p ro p riately for e n d -to­
side a n a stom oses at both ends. At the axi l l a ry a n a sto­
m osis, s l i g htly m o re g raft l e n gth red u n d a n cy is needed
to prevent excessive tract i o n o n the a n asto mosis and
l ate g raft o r a rte r i a l i nj u ry. The use of stretch po lytetra­
f l u o roethy l e n e (PTFE) is a l so p refe rred for this reaso n .
Sixth Step
• Tra u m atized, t h ro m bosed, o r a n e u rysm a l p roxi m a l a x i l ­
l a ry a rtery seg m e nts may be tra n sected o r resected as
n ecessa ry, reconstituted by i nterpositi o n g raft i n g with
ve nous o r p rosthetic co n d u it (FIG 1 0) .
• F o r i nterposition g rafting, the d a maged o r d iseased a rte­
r i a l seg ment is fu l ly tra nsected and remove d . The l u m e n
with i n the p rox i m a l a n d d ista l a rte r i a l seg m e nts s h o u l d b e
i n spected f o r tra u ma, d i ssection, o r thrombus formati o n .
I n t h e case of the d ista l a rtery, f l u s h i n g w i t h h e p a r i n ized
sa l i n e may help confi rm patency and sufficient r u n off.
Retrog rade f l u s h i n g of d iseased o r damaged b rach i a l ,
axi l l a ry, o r s u b c l a v i a n a rteries i s n o t reco m m ended g iven
the potent i a l risk for verte bral a rtery e m b o l ization of
res i d u a l l u m i n a l detritus and su bseq uent centra l n e rvous
system (CNS) i nfa rction o r i nj u ry.
• When uncerta i nty exists rega rd i n g the extent of axi l l a ry
injury, f u rther exposu re may be necessa ry to ensure success.
In ra re and exte n u ating c i rcu msta nces, clavicu l a r resection
a n d replacement (or remova l) may be req u i red for satis­
factory a rterial exposu re. S i m i l a rly, when fragmented o r
chro n ica l ly infected, the clavicle should be removed a s
necessa ry t o optim ize long-term g raft patency a n d l i m b
viabil ity.
• For u p p e r extrem ity a rte r i a l reco nstruction, once expo­
s u re i s co m p l ete and the a p p ropri ate t u n n e l i s created,
the a p p ropriate co n d u it is selected for use and p repa red
for i nterposit i o n g raft i n g (FIG 1 D) . The co n d u it shou l d
be fashioned t o a n a p p ro p ri ate l e n gth t o avo i d potenti a l
k i n k i n g d u ri n g futu re a r m motions. Prox i m a l a n d d ista l
a n astomoses a re performed end-to-e n d or e n d -to-s i d e
d e pe n d i n g o n the respective d i a m eters of the i nflow a n d
outflow seg me nts.
1882 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

Seventh Step a nteg rade e m b o l ecto my proxi m a l l y from an a ntec u b ital

• Catheter e m b o l ecto my s h o u l d be pe rfo rmed as necessa ry,
often u s i n g over-the-wi re, i m a g e-g u i ded tech n i q u es, to
remove l u m i n a l thrombus from i nflow or outflow a rte­
r i a l seg m e nts as necessa ry. Ca re s h o u l d be taken with
proxi m a l l y d i rected e m b o l ecto my to avo i d d i s l od g i n g
c l ot fra g m e nts i nto t h e ve rte b ra l a rte ry.
• To m i n i m ize iatroge n i c i n j u ry from e m b o l ecto my cath­
eters, proxi m a l e m b o l ecto my i s best i n itiated at the l evel
of the axi l l a ry rath e r than brach i a l a rte ry. Attem pt i n g
b rach i a l access incision risks tra u matic i n j u ry to the axi l­
l a ry o r b rach i a l a rtery at the origin of the deep b rach i a l
a rtery, where t h e d i a meter o f t h e b rach i a l a rtery de­
creases s i g n ificant ly, j u st d ista l to the axi l l a ry fossa .
• Appropriately sized Fog a rty throm becto my catheters for
u p p e r extrem ity e m bo l ecto my i n c l u d e si zes 2 throu g h
5 Fr, d e p e n d i n g o n t h e d i a m eter o f the a rtery b e i n g
i n st r u m e nted a n d the tech n i q u e (antegrade o r retro­
g ra d e) b e i n g e m p l oyed .

M I D-D ISTAL AXI L LARY ARTERY
First Step
• The m i d-d ista l axi l l a ry a rtery may be exposed via an ax­
i l l a ry o r d e lto pecto ral i n c i s i o n . For d i stal exposu re, the
i ncision is exte nded through the poste rolatera l border of
the pectora l i s major m uscle to a l low for pa rti a l m o b i l iza­
t i o n a n d m ed i a l retraction of that m uscle (FIG 2A) . I n the
superior aspect o f t h e surgical i n cision, t h e coracobrachi­
a l is m uscle wi l l be visual ized at 90 deg rees rel ative to the
med i a l ly retracted pecto ra l i s major m uscle. With i n this
a n g le, gentle b l u nt d i ssection is a p p l ied to i d e ntify the
axi l l a ry sheath r u n n i ng along the i n feroposteri or border
of the coracobrac h i a l i s m uscle.
• For d e ltopecto ral exposu re, d i ssect i o n is performed a l o n g
the a nte r i o r border of the d e ltoid m uscle, exte n d i n g

A
Muscu locutaneous
Coracobrachialis Axi llary sheath Clavicle nerve
muscle Coracoid Deltoid
Biceps process muscle
(short head)

Coracobrachialis
muscle

Median nerve

Axillary artery

Course of
axi llay artery

Clavi pectoral fascia

Pectoralis Pectoralis
major Axi l lary Clavi pectoral
B mi nor
c muscle vein fascia muscle

FIG 2 • A. R i g ht u pper extrem ity a rteriogram demonstrati n g d ista l axi l l a ry a n d brach i a l a rtery occl usion, with su bsta nti a l fi l l i n g of
u n named co l l atera l a rterioles. B. Axi l l a ry exposu re of the m id-d ista l axi l l a ry a rtery. C. Deltopectora l expos u re of a long seg ment
of axi l l a ry a rtery. (continued)
 C h a p t e r 1 0 PROXIMAL TO T H E WRI ST: Upper Extre m ity Reconstruct i o n/Revascu l a rization
Medial Lateral Pectoralis
minor
vein
Coracobrachialis
muscle Posterior cord U l nar nerve
D E
FIG 2 • (continued) D. Expos u re of the d i sta l axi l l a ry a rte ry a n d associ ated axi l l a ry sheath struct u res. E. Exposure of the
m i daxi l l a ry a rtery via reflection of the pectora l i s m i n o r m uscle.
t h ro u g h the su bcuta neous tissue i n the d e ltopecto r a l
g roove (FIG 28) . W i t h m e d i a l retract i o n of the pectora l i s
major, the n e u rovascu l a r b u n d l e is t h e n exposed i n t h e
u n d e rl y i n g clavi pecto ral fasc i a .
Second Step
• U p o n entry of the axi l l a ry sheath, t h e axi l l a ry a rtery is
visu a l i zed d i rect ly u n d e r the m e d i a n n e rve. At the l at­
e r a l border of the pectora l i s m a j o r m u scle, the m e d i a l
a n d latera l cords f o r m t h e med i a n n e rve f o r m ove r t h e
a nterior su rface o f the axi l l a ry a rte ry. The u l n a r n e rve
a n d axi l l a ry a rtery a re visu a l i zed a l o n g the i nferopos­
terior border of the m i d - d i sta l axi l l a ry a rtery i n this ex­
posure. I d e ntificat i o n of s u rrou n d i n g st ructu res d u ri n g
axi l l a ry expos u re m i n i m izes risks o f i n a dvertent i nj u ry.
E l evat i o n a n d ca u d a l retract i o n of the exposed axi l l a ry
a rtery with vessel loops a l so a u g m e nts expos u re a n d
red u ces r i s k of adjacent n e rve i n j u ry d u r i n g a rt e r i a l
c l a m p i n g (FIG 2C) .
T hird Step
• When f u rther expos u re of the seco n d portion of the
axi l l a ry is req u i red, the pectora l i s minor m uscle is d ivided
n e a r its i n se rtion o n the coraco i d p rocess. The pecto ral
n e rves should be i d e ntified a n d p rotected d u ri n g t h i s
m a n e uver. Ca u d a l retraction of the m uscle a l l ows for ex­
pos u re of the u n derlyi n g n e u rovasc u l a r b u n d l e (FIG 20) .
• I n the seco n d portion, the axi l l a ry a rtery is s u rrounded
o n t h ree sides by b rach i a l p l exus n e rves, leavi n g the an­
te rior su rface of the a rtery u n cove red . For sufficient c i r­
cu mferential expos u re of the vessel, the thoracoacro m i a l
a rtery ca n be l i g ated a n d d ivided at its orig i n . H owever,
1883
Ligated
thoracoacrom ial
Pectoral lis minor artery
insertion (cut)
Axillary artery
\
d u r i n g m o b i l ization of the axi l l a ry a rtery seg m e nt, care
s h o u l d be taken to not i nj u re the l atera l thoracic a rtery
and the latera l and m ed i a l cords as they j o i n over the
d ista l axi l l a ry a rte ry to form the m ed i a n n e rve.
Fourth Step
• S i m i l a r to the steps o ut l i ned for reco nstruction of i n j u ries
to the fi rst o r seco n d portion, tra u m atized, throm bosed,
o r a n e u rysm a l seg m e nts in the seco n d o r t h i rd portions
of the axi l l a ry a rtery may be tra n sected o r bypassed, with
i nterposition g raft i n g o r bypass as n ecessa ry.
• Repa i r of axi l l a ry branch i n j u ries a n d a n e u rysms req u i res
sufficient seg mental exposure of the axi l l a ry a rtery itse lf,
as we l l as the branch a rte ry of co ncern. S u bsca p u l a r, me­
d i a l h u m era l circumflex, o r latera l h u meral c i rcu mfl ex
branch a rtery a n e u rysms can be exposed t h r o u g h the ax­
i l l a ry fossa a n d d ivided free from the axi l l a ry a rtery once
l i g ated to p revent persistent d i sta l a rte r i a l e m b o l i zation
a n d hand isch e m i a i n the sett i n g of c h ro n i c overuse o r
ath l etic i n j u ries. Occasi o n a l ly, a n e u rysm a l degen eration
of the branch co m p ro m ises the i nteg rity of the axi l l a ry
a rtery itse lf, a n d i nterposition g raft i n g may be req u i red
for o pti m a l reconstitution of d ista l l i m b b l ood fl ow.
Autogenous ve i n (or a rtery h a rvested from the d i stal i n ­
te r n a l i l i a c circulation i n the pelvis) i s the opti m a l cond u it
choice for this a p p l ication (FIG 3) .
• Axi l l a ry o r b r a n c h a rte ry i n j u ries resu lting i n su bsta nti a l
d ista l a n d sym pto matic u p p e r extrem ity a rte r i a l emboli
a n d d i g ita l isch e m i a may benefit from a t r i a l of i ntra a r­
te r i a l thrombo lytic thera py, a d m i n istered preoperative ly,
to i m p rove r u n off, g raft paten cy, h a n d perfus ion, a n d
fu ncti o n a l status.
1884 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

A
B

Axi llary
artery

Subscapular /""
artery

Anterior
circu mflex Posterior
artery circumflex
artery
E

Microembolus
c

D
FIG 3 • A. Relative a n atomy of the d ista l axi l l a ry a rtery and associated anterior and poste rior
c i rcu mflex h u m eral a rteries. B. Axi l l a ry a rtery i n j u ry at the origin of a c i rcu mflex h u meral branch
repa i red with a n i nterposit i o n ve i n g raft. C. Ci rcu mflex h u meral branch a n e u rysm . D. CTA of r i g ht
u p p e r extrem ity ci rcumflex h u meral branch a rtery a n e u rysm (arrow). Catheter-based a n g iogram
d e m o n strates hypodens ity i n the circumflex h u meral branch, consistent with i ntra l u m i n a l
thrombus (middle panel). O p e n operative expos u re o f t h e ci rcu mflex h u meral branch o r i g i nating
from the axi l l a ry a rtery (isola ted b y red silastic sling). E. B ra n c h a n e u rysm thrombus ca u s i n g d ista l
m icroem b o l i can be treated with resect i o n a n d i nte rva l l i gation of the branch vesse l .

BRACH IAL ARTERY tered i n t h i s d i ssect i o n a n d s h o u l d be p rotected from

First Step
• I n the u p pe r a rm, the prox i m a l brach i a l a rtery is opti-
m a l ly exposed via a 5- to 8-cm l o n g itud i n a l i n cision in the
med i a l g roove between the b i ceps a n d triceps m uscles
(FIG 4A) .
• As the su bcuta neous tissue is d i ssected, care s h o u l d be
taken to vis u a l i ze a n d avo i d i nj u ry to the bas i l i c ve i n as it
crosses n e a r the b rach i a l sheath in the d i sta l u p per a r m .
To a i d i n exposu re, the bas i l ic ve i n can be retracted i nto
the poste r i o r wo u n d , a n d vein b ra n ches cross i n g over
the brach i a l a rtery sheath can be l i gated and d i v i d e d .
S i g n ificant p l exus of sensory n e rves a re a l s o e n c o u n -
i n j u ry.
Second Step
• By i n c i s i n g the deep fasc i a at the m ed i a l border of the
b i ceps m uscle, the n e u rovasc u l a r b u n d l e may be f u rther
expose d . The median n e rve will be the fi rst struct u re to
be encou ntered i n the b rach i a l sheath with this expo­
sure. Wide m o b i l ization of the n e rve a l l ows for its gentle
retra cti o n i nto the a nte rior wound (FIG 48).
• J ust deep to the m e d i a n n e rve, the b rach i a l a rtery w i l l be
visu a l i zed a l o n g with two f l a n k i n g brach i a l ve i n s . I nter­
co n n ecti n g com m u n ications between these ve i n s may be
l i g ated to aid i n f u rther expos u re of the b rach i a l a rte ry.
 C h a p t e r 1 0 PROXIMAL TO T H E WRI ST: Upper Extre m ity Reconstruct i o n/Revascu l a rization 1885

Median Brachial
nerve artery

c
FIG 4 • A. I ncision created for exposure of the p roxi m a l brach i a l a rtery in the u p p e r a r m . B. The b rach i a l a rtery in the u p per
a r m is adjacent to the m ed i a n a n d u l n a r n e rves. C. Tra u m atic transect i o n of the brach i a l a rtery with associated inti m a l d a m a ge,
a l o n g with p a rt i a l i nj u ry to the m e d i a n n e rve. S u bseq uent repa i r is perfo rmed with a b rach i a l a rtery i nterposition g raft u s i n g
a ve i n co n d u it a n d m ed i a n nerve repa i r.

T hird Step brach i a l a rte ry with vessel loops prior to c l a m p i n g can

• Exposure of the brach i a l a rtery i n the m i d-upper arm may
req u i re identification and control of the deep brac h i a l
a rtery, w h i c h a rises o n the postero m ed i a l s u rface o f t h e
brach i a l a rtery, j u st d ista l to the l atera l border o f the teres
major m uscle in the d ista l axi l l a ry fossa. In the d ista l upper
arm, the superior a n d inferior ulnar collatera l a rteries
may a lso req u i re control d u r i n g brach i a l a rtery exposure.
Fourth Step
• Alternatively, the b rach i a l exposu re can be g a i ned
through a n o b l i q u e i ncision along the a ntici pated cou rse
of the brach i a l a rte ry in the d ista l u p per arm p rox i m a l to
the a ntec u b ital fossa .
• O n ce a g a i n , ca re s h o u l d be taken to avo i d i n j u ry of the
m e d i a n n e rve, wh ich can be found postero med i a l rel ative
to the brach i a l a rtery i n this a rea (FIG 5) . E l evati o n of the
decrease the cha nce of n e rve i n j u ries during t h i s p rocess.
Fifth Step
• Pse u d o a n e u rysm o r tra nsection of the brach i a l a rtery can
be repa i red fo l l owi n g p roxi m a l and d i sta l b rach i a l a rtery
expos u re a n d contro l . In the sett i n g i m m i n e n t r u pt u re
or exsa n g u i nation, prox i m a l control in this a rea may be
o bta i n e d with a proxi m a l ste r i l e to u r n i q u et. Fol lowing
to u r n i q u et control, the i n j u red b rach i a l a rtery seg ment
o r pse u d o a n e u rysm sac can be isolated a n d exp l o red
with confidence. This tech n i q u e is p a rtic u l a rly usefu l in
p reventing catastro p h i c r u pt u re and conta m i nation of
the OR envi ro n m ent with b l ood-borne pathogens in the
sett i n g of iatrog e n i c o r self- i n f l i cted mycotic a n e u rysms.
• P u n ct u re wo u n d s may be a m e n a b l e to p r i m a ry suture
repa i r o r m i n i m a l resection of the i n j u red seg ment a n d
p r i m a ry reapprox i m ati o n . La rger d efects a n d p a rt i a l
1886 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

Biceps brachii
muscle

Brachialis

Brachiorad ialis

nerve

Brachial
artery

A
B

Radial Acute embolic

artery

U l nar Brachial
artery artery

c
FIG S • A. Typical i n c i s i o n s used for expos u re of the d i sta l b rach i a l a rtery a n d proxi m a l ra d i a l a n d u l n a r a rteries at the
a ntec u b ita l fossa . B. R e l ative a n atomy of the brach i a l , rad i a l , a n d u l n a r a rteries a n d adjacent median n e rve. C. Acute
e m b o l i c occl usion of the brach i a l a rtery bifu rcation can be treated fo l l owi n g p roxi m a l and d i stal control of the b rach i a l ,
rad i a l , a n d u l n a r a rteries. Arte riotomy is created over the occ l u d e d vasc u l a r seg ment. Fol l ow i n g d i sta l t h ro m becto my o f
the u l n a r a n d ra d i a l a rteri es, a Fog a rty throm becto my catheter can a lso be u s e d t o extract t h r o m b u s f r o m the b rach i a l
a rte ry.
 C h a p t e r 1 0 PROXIMAL TO T H E WRI ST: Upper Extre m ity Reconstruct i o n/Revascu l a rization
tra nsections may req u i re patch a n g i o p l asty for satisfac­
tory repa i r (FIG 4C) .
• When u n certa i n as to whether a p r i m a ry repa i r is i n d i -
cated or even poss i b le, the m ost re l i a b l e cou rse of a ction
i s i nterposition ve i n g raft in g , usu a l l y h a rvested from a
l o n g saphenous ve i n , with ca re taken to account for d if­
ferences in l e n gth based o n m ovement at the e l bow (e.g.,
avo i d kinking while l i m it i n g te nsion). Risk of k i n k i n g is
a l s o red u ced by reconstruct i n g oth e r i n j u red structures
in the a ntecu bita l fossa (e . g . , b i ceps brach i a l i s te n d o n) to
l i m it g raft motion d u ri n g e l bow flexi o n .
• D i sta l forea rm throm becto my is best pe rfo rmed t h ro u g h
a b rach i a l i n c i s i o n created i n the a ntec u b ital fossa .
Exposu re of the d ista l brach i a l a rtery may be n ecessa ry to
seq uenti a l ly cath ete rize the i n d ivid u a l forea rm a rteries.
Alternatively, proxi m a l sheath access i n the axi l l a ry
fossa may fac i l itate i m a g e-g u i ded access of the forea rm
a rteries a n d ove r-the-wi re e m b o l ecto my.
• I n the a ntecu b ita l fossa, d ista l throm boem b o l ecto my may
be pe rfo rmed with a 2- or 3-Fr Fog a rty catheter (FIG SC) .
F u rther e n d ovascu l a r i m a g i n g a n d treatment (see in the
RAD IAL ARTERY
First Step
• D i rect open exposure of the rad i a l a rtery can be performed
at a l m ost every level proxi m a l to the wrist. As with other
a rterial seg m ents, exposure of the rad i a l a rtery should be
sufficient to a l low both p roxi m a l and d ista l a rterial contro l .
• T h e b rach i a l a rtery typ i ca l l y bifu rcates to g ive r i s e t o t h e
ra d i a l a rtery a n d u l n a r/inte rosse us tru n k at the level o f
the ra d i a l t u b e rosity (FIG SB) . H owever, n o t infrequently,
the ra d i a l a rtery orig i n ates from the u p p e r a r m brach i a l
a rtery o r eve n t h e axi l l a ry a rtery ( u p to 1 5 % i n ci d e n ce
i n cadaveric stud i es) . 1 9 Seve ra l c l i n ical circumstances
h i g h l ight the s i g n ifica nce of t h i s a n o m a ly, i n c l u d i n g the
need to base d ista l bypass o r a rterioven o u s a ccess p roce­
d u res off the " b rach i a l " a rtery in the a ntecu bita l fossa.
To e n s u re a d e q u ate a rte r i a l i nfl ow, it is esse n t ial to iden­
tify which a rte r i a l co n d u its are p resent and i d e ntified
i n the a ntecubital fossa. Preoperative CT a n g iog raphy,
catheter-based contrast a rteriograp hy, or u ltrasonog ra­
phy can provide essenti a l i nformation i n this reg a r d .
• Alternative expos u re o p t i o n s exist f o r the brach i a l
bifu rcation a n d proxi m a l rad i a l a rtery i n t h e a ntec u b ital
fossa. A 4- to 5-cm tra nsve rse i ncision, two f i n g e rb readths
d ista l to the a ntec u b ital crease, p rovides opti m a l expo­
s u re for the d i stal b rach i a l a rtery as we l l as the o r i g i n s
of the forea rm a rteries (i nte rosseus, ra d i a l , a n d u l n a r) .
Alternative ly, for m o r e extensive brach i a l a rtery expo­
su re, an 5-shaped i n cision is e m p l oyed exte n d i n g from
the m e d i a l aspect of the b i ceps m uscle te ndon, through
the m i d po i nt of the a ntecubita l fossa, a n d toward the
latera l aspect of the vo l a r forea rm (FIG SA) .
• Exposu re of the m i d - or d i stal rad i a l a rtery can be per-
formed t h ro u g h 4- to 5-cm l o n g itu d i n a l i n cisions a l o n g
the latera l aspect of the vo l a r forea rm (FIG 6A) . A usefu l
l a n d m a rk for these i ncisions is the i m a g i n a ry l i n e exten d -
1887
fo l l owi n g text) may be req u i red to opti m a l ly restore d is­
ta l a rte r i a l perfusion.
• Apropos the prior d i scussion reg a r d i n g axi l l a ry expos u re
a n d e m b o l ecto my, atte m pt i n g remova l of p rox i m a l e m ­
b o l i f r o m a ntec u b ital brach i a l access (e . g . , " retrograde"
posit i o n i n g of the e m b o l ecto my catheter i nto the p roxi­
mal b rach i a l and axi l l a ry a rteri es) carries a s i g n ificant risk
of cathete r-re lated i n j u ry to the prox i m a l brach i a l a rtery
at the o r i g i n of the deep b rach i a l a rte ry, where a sig­
n ificant d i a m eter red uction occu rs d u e to the b i f u rcation
of su perfi c i a l and deep brach i a l a rteries. For prox i m a l
e m b o l ecto my, the safer a p p roach i s t o g e n e ra l ly g a i n ac­
cess in the axi l l a ry rath e r than a ntec u b ital fossa.
• B rach i a l occ l u s i o n associated with e l bow o r shoulder d is­
l ocat ion typica l l y res u l ts from i nti m a l d i s r u ption o r d is­
section beg i n n i n g at the p o i nt of i nj u ry a n d exte n d i n g
d i sta l l y. Accord i n g ly, w h e n foca l a rte r i a l i n j u ry i s present
in the sett i n g of co m p l ete occl usion, the i n j u red seg­
ment is opti m a l ly re p a i red by resection and replacement
rath e r t h a n atte m pts at a nticoa g u lation or e m b o l ecto my
alone.
i n g from the m i d po i n t of the a ntec u b ital crease to the
styloi d p rocess of the radi us, whi c h often a n ato m i ca l ly
corresponds to the g roove of the m e d i a l edge of the bra­
c h i o ra d i a l i s m u scle.
Second Step
• S u perfi c i a l , su bcuta neous ve i n s overlyi n g the ta rget
a rteries (med i a l a ntecu b ita l ve i n in the a ntec u b ital fossa
a n d cepha l i c ve i n branches in the forea rm) may be m o b i ­
l i zed o r l i g ated to a i d with the expos u re p rocess. Prior t o
l i gation, ca re s h o u l d be t a k e n to consider the tota l ity o f
re m a i n i n g forea rm r u n off vei ns, especia l ly i n the sett i n g
of b l u nt o r avu lsive tra u matic i n j u ries.
• I n the proxi m a l forearm, the a ntebrach i a l fasc i a w i l l need
to be excised a l o n g the m ed i a l edge of the brach i o ra d i a l is
m uscle a l o n g the l e n gth of the i n c i s i o n . The ra d i a l a rte ry
ca n then be visual ized with latera l retraction of the b ra­
c h i orad i a l is m uscle.
• S i m i l a r ly, i n the m idforea rm, the ra d i a l a rtery can be vi­
s u a l ized fo l l owi n g excision of the overlyi n g a ntebrach i a l
fasc i a a n d retract i n g a p a rt the brach i o ra d i a l is a n d prona­
tor teres m uscles (FIG 6A) .
• D u ri n g exposu re maneuvers, ca re shou ld be taken to vi­
sual ize and avoid injury to closely associated rad i a l a rtery
structures. This incl udes the paired rad ial a rtery veins that
acco m pany the rad i a l a rtery throug hout its cou rse i n the
forearm. The superficia l rad i a l nerve is a lso closely associ­
ated with the latera l aspect of the rad i a l a rtery in the mid­
forearm a n d can be preserved with gentle latera l retraction.
Third Step
• G iven the d o m i n a nce of the u l n a r circulation i n most p a ­
tients, isol ated d ista l ra d i a l reco nstruction may be optional,
depen d i n g on the tota l ity of coexisting conditions a n d
inju ries. S u perim posed acute o r c h ro n i c tra u m atic inju ry,
1888 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

Pseudoaneurysm sac

Radial artery

Su perficial rad ial nerve

Radial artery

Brachiorad ialis
muscle ----1=----

B
A

U l nar artery

U l nar nerve

Flexor carpi
FIG 6 • A. Exposure of the ra d i a l a rtery in the proxi m a l a n d
ulnaris muscle
d i sta l forea r m . B. F o l l o w i n g proxi m a l a n d d i stal ra d i a l a rtery
control, a p r i m a ry repa i r of a ra d i a l a rte ry pse u d o a n e u rysm is
pe rfo rmed. C. Exposure of the p roxi m a l m i d u l n a r a rtery i n the
c forea r m .

ren a l fa i l u re, d i a betes m e l l itus, o r chronic embol ization
may j u stify rad i a l reconstruction, p a rticu larly i n circum­
sta nces where hand via b i l ity is at s i g n ificant risk.
• Rad i a l a rtery transections o r pseudoa n e u rysms, l i ke a l l
types o f a rterial reconstruction, a re best a p p roached fol­
lowing adequate exposure and p roxima l/d ista l contro l .
Deta iled exp loration a n d a rterial expos u re fo l l ows shortly
thereafter. Depend i n g o n extent of injury and i nteg rity of
the a rterial l u men at the site of inju ry, either p r i m a ry repa i r
or i nterposition g rafting may be considered (FIG 68).
• Acute embolic occl usions of the rad i a l a rtery can be
removed through retrog rade embol ectomy, performed
thro u g h a control led p roxi m a l , tra nsverse a rterioto my.
G iven the ca l i ber of the forearm a rterial system, a 2-Fr
Fog a rty catheter is best su ited for this p u rpose. As was the
case more p roxi m a l ly i n the u pper extrem ity a rterial sys­
tem, image-g u ided, over-the-wi re embol ectomy, com b i ned
with j u d icious use of i ntra a rterial throm bolytic agents such
as tPA (see " U pper extrem ity a n g iography a n d stent i n g "
section i n the fol l owing text), may be n ecessa ry t o achieve
satisfactory runoff a n d h a n d a n d d i g ital perfusion. Th us,
arra ngements should be made p reoperatively to i n itiate
the e m bolectomy proced u re in an ope rati n g environment
that can support image-gu ided i ntervention.
• Both forea rm a rteries at the wrist may provide a p p ropri­
ate i n f l ow for d i a lysis access p roced u res. Considerations
for a rteriovenous a ccess creati o n a n d m a i nte n a nce a re
beyo n d the scope of t h i s c h a pter. I nte rested rea d e rs a re
refe rred to other refe ren ces for options reg a rd i n g d i a ly­
sis access creat i o n .
 C h a p t e r 1 0 PROXIMAL TO T H E WRI ST: Upper Extre m ity Reconstruct i o n/Revascu l a rization
U LNAR ARTERY
First Step
• S i m i l a r to the rad i a l a rte ry, the u l n a r a rtery may a lso be
exposed a l o n g its cou rse i n the forea rm, a n d the exte nt
of expos u re w i l l depend o n the site and type of path o l ­
o g y as we l l as a b i l ity to o bta i n a d e q u ate proxi m a l a n d
d i sta l a rte r i a l control (FIG 6C) .
• The p roxi m a l u l n a r a rtery can a lso be exposed at the
b rach i a l b i f u rcation i n the a ntecu bital fossa t h ro u g h an
S-shaped incision (see " R a d i a l a rtery" e a r l i e r; FIG SA,B) .
• Alth o u g h m o re cha l l e n g i n g, the proxi m a l u l n a r a rtery
may a l so be exposed in the m ed i a l aspect of the proxi m a l
forea r m . F o u r f i n g e rbreadths below t h e med i a l epicon­
dyle, a 7- to 9-cm l o n g itud i n a l i n c i s i o n can be created
a l o n g a l i n e exte n d i n g from the m ed i a l e p icondyle to
the pisiform bone. I n c i s i n g the deep fasci a fac i l itates ex­
posure of the u l n a r a rtery t h ro u g h the space between
the fl exor carpi u l n a r i s and flexor d i g itorum s u p erfi c i a l i s
m uscles (FIG 6C).
• The d ista l u l n a r a rte ry, proxi m a l to the wrist, is opti m a l ly
exposed through a l o n g itud i n a l i n c i s i o n j ust l atera l to
UPPER EXTRE M ITY A N G I OGRAPHY AND
STENTI N G
First Step
• Access depends l a rgely on the a rea a n d type of a ntici pated
a rte r i a l path o l ogy. For i n n o m i nate o r proxi m a l subcla­
v i a n a rtery d i sease o r i n j u ry, retro g rade transbrach i a l o r
transfe m o ra l a rtery a p p roach may both suffice. For d ista l
d i a g nostic or i nterventi o n a l proce d u res, retrog rade ra­
d i a l o r a ntegrade access may be co nsidered.
• Sta n d a rd S e l d i n g e r tech n i q u e is used for percuta neous
a rte r i a l access, u s i n g either u ltraso n o g r a p h i c o r f l u o ro­
sco p i c g u i d a n ce. Placement of a 4-Fr m icrosheath may
h e l p sta b i l ize the i n it i a l ca n n u l ation s ite a n d a l low for
prel i m i n a ry d i a g n ostic i m a g i n g .
Second Step
• I ntraarterial pharmacologic adj u n cts may be a d m i n istered
through appropriately positioned a rteria l i nfusion systems.
• For a rterial throm bosis, catheter-d i rected, l i m b-specific,
i ntra a rterial tPA is a d m i n istered in doses rel ated to the ex­
tent of thrombus load, ra n g i n g from 0.25 to 2.0 mg per
hour, fo l lowi ng a n i n itial "seed i n g " dose of 4 mg across the
reg ion i n q u estion over 10 to 30 m i n utes. Combined phar­
macolog idmech a n i ca l thrombus disruption systems usefu l
in other a rterial a n d venous beds, i n c l u d i n g the Tre l l isTM
system (Covid ien, M a nsfi eld, MA), may be too large or u n ­
w i e l d y f o r t h e upper extrem ity a rterial vasc u l ature. Newer
l ow-profile systems, however, such as the M icrolysUSTM
i nfusion catheter (EKOS Corporation, Bothell, WA), may
be more usefu l a n d appropriate i n this a p p l icatio n . Care
should always be taken to account for risk of particulate
embolus in the vertebral a rtery when p l a n n i n g embolec­
tomy or throm bectomy proced u res in the upper extrem ity.
1889
the flexor ca rpi u l n a ris m uscle. The u l n a r n e rve l ies me­
dial to the a rtery at this level and is prone to i nj u ry with
this exposure. Care s h o u l d be taken to i d entify and mo­
b i l ize it safely. The su perfi c i a l pa l m a r branch of the u l n a r
a rtery a n d n e rve a lso crosses su perfi c i a l t o t h e a ntecu b i ­
ta l fascia at the wrist l e v e l , a n d c a r e s h o u l d be t a k e n t o
p revent traction o r co m p ression i n j u ries to these struc­
tu res d u r i n g u l n a r a rtery exposure.
Second Step
• Throm becto my of the u l n a r a rte ry p roceeds i n a fas h i o n
s i m i l a r to t h a t p reviously described for the rad i a l a rte ry.
• U l n a r a rtery tra u matic tra nsections may be repa i red pri­
m a r i ly o r with a n a p p ropriately sized i nterposition ve i n
g raft. Ve i n ha rvested from t h e dorsum o f t h e foot fre­
q u ently serves this p u rpose wel l .
• U l n a r a rtery a rteriovenous d i a lysis accesses a re rarely
performed due to t h i s vesse l 's rel ative d ifficu lty i n ex­
posure compared to the ra d i a l a rte ry, its cl ose proxi m ity
to the u l n a r n e rve t h ro u g h out its l e n gth, a n d its rel ative
d o m i n a n ce in m a i nta i n i n g a d e q u ate perfu sion to the
hand.
• S i m i l a rly, the u pper extrem ity a rte r i a l system is particu­
l a rly prone to vasospasm d u ri n g catheterizat i o n . D u r i n g
d i a g n ostic exa m i nations, p a rticula rly i n yo u n g e r patie nts,
care s h o u l d be taken to avo i d catheterization d ista l to the
a ntecu bita l fossa to m i n i m ize a rtifact u a l degradation of
the a n g iogra p h i c i m a g e due to vasospasm. S i m i l a rly, usi n g
warm flush so l utions may m i n i m ize this effect. When the
rad i o g r a p h i c a p pearance of vasospasm is encou ntered
("str i n g s i g n " or " stri n g of beads" a p pearance), d i rect i n ­
tra a rteri a l i nfusion o f papaveri ne ( 1 0 t o 50 mg) or n itro­
g lyceri ne (50 to 200 J.Lg) may i m p rove i m a g e reso l ution i n
h a n d o r d i g ita l a rteries. Papaveri ne w i l l prec i p itate o u t of
so l ution when exposed to heparin and may not be opti­
mal for all potential c l i n ical a p p l ications for this reaso n .
T hird Step
• If further endovascu l a r diag nostic or i nterventiona l
procedu res a re plan ned, wire access with a 0.0 1 8-in o r
0.035-in g u i dewi re t o t h e a rteria l seg ment o f i nterest must
be achieved .
• From a brach i a l a rtery a p p roach, a short g u i d e sheath
and a g u ide catheter co m b i nation usua l ly a l l ows for
successf u l catheterization of adjacent proxi m a l u p pe r
extrem ity a rte r i a l seg m e nts.
• From a fe moral a rtery a p p roach, a long (90 em) 6- or 7-Fr
sheath is typica l l y adva nced over the g u idew i re to faci l i ­
tate sta b l e catheterization o f i n n o m i n ate o r prox i m a l l eft
subclavian a rte ry. Long, c u rved 5-Fr catheters (i.e., a n g led,
JB 2, h e a d h u nter, or verteb r a l catheter) may be used to
aid i n successf u l ca n n u lation a n d su bseq uent cath ete riza­
tion of the a rch vesse l of i nterest. Confi rmatory a n g ie­
g ra m s will h e l p co nfirm successf u l ca n n u lation a n d a i d in
i d e ntify i n g the a rteri a l seg ment of i nte rest (FIG 7A) .
• O n c e sta b l e catheterization of the ta rget vessel i s
a c h i eved, m a g n ified a n g i og ra m s may be o bta i n e d i n the
1890 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

a ppropriate o b l i q u ities to accu rately a ssess the a rte r i a l
seg m e nts o f i nterest. Additi o n a l r u n off i m a g i n g may b e
necess a ry to eva l u ate the a rte r i a l o utflow d ista l to t h e
d i seased seg ment. The operator s h o u l d i nspect these
a n g iograms to determ i n e once a g a i n the ca n d idacy for
e n d ovasc u l a r treatment and o bta i n a d d i t i o n a l measu re­
m e nts to fac i l itate a p p ro p riate device select i o n .
Fourth Step
• S u ccessf u l w i re adva ncement across the lesion of i nte rest
is the n ext step in order to fac i l itate any p l a n ned treat­
m e nts with a n g i o p l asty o r stent i n g .
• With t h e g u i d a nce o f a 4 - or 5-Fr g u ide catheter, a O.D1 8-i n or
0.035-in hydrophilic wire ca n be advanced across a hemody­
nam ica l ly sign ificant stenosis (e.g., i n nomi nate a rtery, proxi­
mal subclavian a rtery, or u pper a rm brach ial a rtery) . During
adva ncement, care should be taken to rema i n i ntra l u m i n a l
as m uch as possible t o m i n i m ize t h e risk o f dissection and re­
entry. Adeq uate wire p u rchase should be acq u i red past the
stenosis after crossing the lesion of interest to decrease the
cha nce of losing subseq uent wire access across the lesio n .
• I n s i t u a t i o n s w h e r e ste noses o r occl usions p rec l u d e ac-
cess from a " p refe rred " side, cross i n g the lesion from the
a lternate side a n d adva n c i n g a w i re f r o m the opposite
d i rection u s i n g a s n a re tech n i q u e may be req u i re d .
• S i m u ltaneous a ntegrade a n d retrog rade, t h r o u g h and
through (" body floss") ca n n u l ation may faci l itate l ifesavi ng
management of tra u m atic subclavian a rtery inju ries. I n d i re
circu msta nces where a rterial cont i n u ity has been com­
pletely lost, and tra nsl u m i n a l wire passage is not possib le,
advancing snare a n d wire from opposite d i rections s i m u l ­
ta neously, e m ployi n g m u ltiple-a n g led view m a y a l low for
successful snaring i n perivasc u l a r soft tissue and su bse­
q uent spa n n i n g of the a rteria l tissue defect with a flexible
covered stent (e.g., Viabah nTM). This tech n i q u e may gener­
ate i m mediate a n d effective hemostasis whi le m a i nta i n i n g
l u m i n a l patency a n d l i m b viabil ity, especia l ly as a n a lterna­
tive to l igation or emergency embol ization (FIG 7).
Fifth Step
• Proxi mal subclavian a rtery and i n n o m i nate stenoses a re typ­
ica l ly wel l managed by precise p lacement of stiff, bal loon­
expa ndable stents or stent g rafts. Compared to the axi l l a ry
a rtery, proximal to the costoclavicu lar j u nction, there is l ittle
or no movement i n the proximal su bclavia n a rtery. I n the
setting of a prior i nternal mammary-to-coronary a rtery
revascula rization, or a history of vertebra l-basilar insuf­
ficiency, precise stent placement is tantamount to proce­
d u ra l success. For this reason, appropriately sized covered
(e.g., Atrium iCASD or bare meta l (e.g., O m n i l i n k, Abbott,
Redwood City, CA; Pa l maz, Cordis Endovascu lar, Wa rren,
NJ.) balloon-expa ndable stents a re genera l ly preferred.
• Appropriately size-matched, covered ste nts a re a l so es­
senti a l a dj u ncts for m a nagem ent of proxi m a l s u bclavian
a rtery i n j u ries o r c h ro n i c pse u d o a n e u rysms (FIG 7) .
• As n oted e a r l i e r, however, stents of a n y k i n d s h o u l d n ot
be d e p l oyed in p roxi m ity to the j u n ction of the 1 st r i b
a n d clavicle, as c h r o n i c tra u matic d a m a g e f r o m c ompres­
s i o n between th ese bony struct u re w i l l cause ce rta i n
stent fa i l u re a n d f u rther comprom ise l i m b v i a b i l ity.

Hematoma
Anterior
scalene
muscle

I njured
subclavian
artery

Clavicle
B

Nondeployed Deployed
Tri lobed snare
stent graft stent graft

c D E
FIG 7 • A- Retrog rade ca n n u l ation of the p roxi m a l l eft s u bclavian a rte ry u s i n g a triaxi a l flex i b l e
sheath, a n g led catheter, a n d g l idewire co m b i nation. B- Tra u m atic i n j u ry to the l eft subclavi a n
a rte ry. C . Th ro u g h a n d through (body fl oss) w i re accesses t h e i n j u red s u bclavian a rtery. D,E.
Posit i o n i n g a n d d e p l oyment of a cove red stent to seal the s u bclavian a rte r i a l wa l l d i s r u pt i o n
w h i l e m a i nta i n i n g l u m i n a l fl ow.
 C h a p t e r 1 0 PROXIMAL TO T H E WRI ST: Upper Extre m ity Reconstruct i o n/Revascu l a rization 1 89 1

PEARLS AND PITFALLS

U p per extrem ity n e rve
i n j u ries
Iatrog e n i c n e rve i n j u ry
d u ri n g axi l l a ry a rtery
expos u re
Arte r i a l repa i r fo l l owi n g
seg m enta l resection
I nflow assessment
O utflow assessment
C o m p a rtment syn d ro m e
of the up p e r extrem ity
• U p per extrem ity a rte r i a l i n j u ries freq uently a re associated with concomitant n e rve i n j u ries.20
Early recog n ition a n d d i a g nosis of these associated i n j u ries is p a r a m o u n t to l o n g -term f u n cti o n a l
restorat i o n .
• When n e rve i n j u ry is ide ntified o r suspected, prompt repa i r i n the same sett i n g is reco m m e n d e d .
P l astic s u rg e ry co nsu ltat i o n i n these circumstances is usua l ly req u i re d .
• A s a g e n e r a l r u l e of t h u m b, whenever poss i b le, axi l l a ry expos u re proxi m a l to the axi l l a s h o u l d be
acq u i red as p rox i m a l as poss i b le, to l i m it the risk of n e rve i n j u ry, as the cords of the brach i a l p l exus
become m o re i n t i m ately rel ated to the axi l l a ry a rtery as it p roceeds l atera l ly from the clavicle.
Also, the a m o u nt of axi l l a ry a rtery d isplacement a n d tract i o n as a result of a r m m ovement is m i n i ­
m i zed with fa r proxi m a l a n a stomotic positi o n i n g .
• U n l ess repa i r o f t h e axi l l a ry a rtery req u i res a d e ltopecto ra l exposu re, t h e p referred choices for
axi l l a ry a rtery exposure are prox i m a l o r d ista l to the seco n d portion of the axi l l a ry a rte ry.
• I n the sett i n g of a rte r i a l tra u m a , the extent of a rte r i a l i n j u ry s h o u l d be p recisely determ i n e d pri or
to attem pts at reco nstruct i o n . Fa i l u re to co m p l etely d e l i neate the extent of i n j u ry wi ll co m p l i cate
atte m pts at repa i r.
• As a g e n era l r u l e of t h u m b, a l l i nvolved a rte r i a l seg ment s h o u l d be resected a n d/o r bypassed prior
to attem pts at reco nstruct i o n . Alth o u g h p r i m a ry repa i r with native a rte r i a l preservati o n is ofte n
a p pea l i ng, l o n g-te rm success typ i ca l ly req u i res i nterposition ve i n g raft i n g for a nyth i n g m o re t h a n
the s i m p l est of i nj u ries. 1 5•21
• Prior to comp letion of a n u p pe r extrem ity a rte r i a l repa i r, the o perator m ust e n s u re that a rte r i a l
in fl ow is a d e q u ate.
• This can be confirmed o n preoperative CTA if ava i l a b l e, o r a lternatively, with an i ntraoperative
a n g i o g ra m .
• Adeq u ate a rteri a l outflow is p a ra m o u nt t o m a i nta i n patency o f proxi m a l re pa i rs a n d h e l p a l l evi ate
potential extrem ity isch e m i c symptoms.
• Some a uthors reco m m e n d ro uti n e outflow assessm e nts fo l l owi n g u p per extrem ity revasc u l a riza­
t i o n . 22 H oweve r, if t h i s strategy is n ot reg u l a rly e m p l oyed, i ntraoperative outflow assessment
should be performed i n c i rcu msta nces where the d i sta l arm a n d/o r wrist vascu l a r exa m i nation is
a b n o r m a l fo l l owi n g ope rative revasc u l a rizat i o n .
• B e c a u s e the u l n a r a rtery is the d o m i n a nt vessel of the d i stal forearm a n d h a n d , restoration of flow
to this o utflow vessel is often n ecessa ry to avo i d su bseq uent com p l ications.
• With prolonged acute i sc h e m i a (>4-6 h o u rs), u p pe r extrem ity c o m p a rtment release via fasci oto­
m i es is h i g h ly reco m m e n d e d .
• U p per arm fasci oto m i es i n c l u d e two i n cisions i nto the brach i u m 's two compartments.
• Forea rm fasci oto m i es a re performed with th ree o r m o re d i screte i n cisions to deco m p ress the vo l a r
forea rm, d o rsa l forea rm, a n d m o b i l e wad n
• The h a n d may a lso req u i re deco m p ression via m u lt i p l e i ncisions.24 A carpal t u n n e l release may be
n ecessa ry if med i a n a n d u l n a r nerve dysfu nct i o n is evident. Consu ltation with h a n d or p l astic s u r­
geons is reco m m e n d e d when cons i d e r i n g the potenti a l benefit of h a n d fasciotomy to maxi m i ze
compartmenta l release a n d l o ng -term f u n ct i o n a l a n d cosmetic recove ry.

POSTOPERATIVE CARE
• At the conclusion of arterial reconstructive procedures, re­
versal of heparin-induced coagulopathy with protamine may
or may not be indicated, depending on the status of the limb,
the patient, and the reconstructive procedure itself. Care
should be taken to provide a test dose of protamine before
full reversal, if indicated, to minimize associated hypoten­
sion when antiprotamine antibodies are present.
• Motor and sensory examination as well as determination
of upper extremity arterial status (including a Doppler and
pulse examination) should be performed immediately post­
operatively to determine the new baseline for subsequent
serial examinations and to document improvement.
• Patients are typically observed for an extended period ( at least
several hours) following upper extremity arterial intervention
to ensure procedural success and recovery from anesthesia.
During this period, the patient is observed for bleeding, he­
matomas, or change in serial vascular examinations.
• Patients treated for primary thrombosis or occlusion of an
arterial segment are typically managed with long-term, ad­
j unctive systemic anticoagulation. The length of treatment
period is debated and is variable between practitioners but
may be directed by severity of presenting symptoms, fre­
quency of prior occurrences, or history of a hypercoagulable
condition.25
• Patients who presented with a presumed embolic occlusion
of an arterial segment should undergo a medical workup for
possible cardiac, proximal arterial atherosclerotic, endocar­
ditis, paradoxical, or tumor embolic sources.
• Patients who underwent angioplasty or stenting of an arte­
rial segment in the upper extremity are typically initiated
on a single-agent antiplatelet regimen with either aspirin or
clopidogrel.
1 892 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY
• Patients who had a concomitant nerve injury or required fas­
ciotomy compartment release should be engaged in rehabili­
tation activities promptly to aid in restoration of extremity
function.2 3
• Postoperative surveillance of patients with upper extrem­
ity arterial interventions is necessary. Duplex evaluation of
the repaired arterial segment 1 to 3 months following inter­
vention is usually recommended followed by serial duplex
evaluations every 6 months for at least 1 to 2 years. Patients
with no evidence of repair site compromise may then be
imaged on a yearly basis. If there is evidence of arterial seg­
ment compromise (stenosis, decreased flow, or occlusion) ,
primary assisted patency a n d secondary patency may b e
enhanced with reintervention.
OUTCOMES
• Upper extremity revascularization with open arterial bypass
has a reported average primary patency of 82% to 87% and
excellent limb salvage rates.26
• Some series suggest arterial graft patency is lowest in fe­
male smokers with long bypass segments that cross multiple
j ointsY
• Because acute embolic episodes more commonly occur in el­
derly patients, the perioperative mortality and morbidity in
this patient cohort is higher compared to age-matched back­
ground populations.28
• Catheter-based revascularization of the proximal subclavian
artery and innominate artery have a high reported technical
success rate ( > 9 8 % ) , with excellent primary rates and low
associated procedure morbidity.Z9
• Percutaneous treatment of upper extremity traumatic ar­
terial injuries of subclavian artery are associated with de­
creased operative time and intraoperative blood loss while
maintaining equivalent patency rates to standard open
repairs. 3 0 • 3 1
• Axillary artery branch vessel repair outcomes are met with
high success rates of symptom resolution and lack of re­
currence if distal emboli are lysed and proximal branch
vessel embolic source is completely isolated from the
circulation.14
COMPLICATIONS
• Intraoperative arterial vasospasm or occlusion
• Missed concomitant venous or nerve injuries during trau­
matic arterial injuries
• Iatrogenic brachial plexus, median, or ulnar nerve injuries
from intraoperative electrocautery, traction, or accidental
transection
• Iatrogenic inj ury to the brachial artery when attempting
retrograde catheter embolization, especially when failing to
take into account the significant taper present in the proxi­
mal brachial artery
• Arterial bypass graft stenosis or thrombosis
• Repair site bleeding
• Wound or graft site infection
• Digital or vertebral artery embolization, complicating
thromboembolectomy
• Postrevascularization compartment syndrome in the arm
or hand
• Stent failure when deployed in proximity to the clavicle/1st rib
REFERENCES
1. Valentine RJ, Wind GG. Axillary artery. In: Valentine RJ, Wind GG,
eds. Anatomic Exposures in Vascular Surgery. Philadelphia, PA:
Lippincott Williams & Wilkins; 2003:155- 175.
2. Valentine RJ, Wind GG. Brachial artery. In: Valentine RJ, Wind GG,
eds. Anatomic Exposures in Vascular Surgery. Philadelphia, PA:
Lippincott Williams & Wilkins; 2003:177- 1 8 8.
3. Stonebridge PA, Clason AE, Duncan AJ, et a!. Acute ischaemia of
the upper limb compared with acute lower limb ischaemia; a 5-year
review. Br I Surg. 1989;76:515-51 6 .
4. Ahn S S , Kudo T. Thoracic outlet syndrome and vascular disease o f
the upper extremity. In: Moore W S , e d . Vascular a n d Endovascular
Surgery: A Comprehensive Review. Philadelphia, PA: Saunders Else­
vier; 2006:675-693.
5. Yeager RA, Moneta GL, Edwards JM, et a!. Relationship of hemodi­
alysis access to finger gangrene in patients with end-stage renal disease.
I Vase Surg. 2002;36:245-249.
6. Engelberger RP, Kucher N. Management of deep vein thrombosis of
the upper extremity. Circulation. 20 1 2;1 26:768-773.
7. Kucher N. Clinical practice. Deep-vein thrombosis of the upper extremi­
ties. N Eng/ I Med. 201 1;364:861-869.
8. Rutherford RB, Baker JD, Ernst C, et a!. Recommended standards for
reports dealing with lower extremity ischemia: revised version. I Vase
Surg. 1997;26:517-538.
9. Slauterbeck JR, Bitton C, Moneim MS, et a!. Mangled extremity
severity score: an accurate guide to treatment of the severely injured
upper extremity. I Orthop Trauma. 1994;8:282-285.
10. Maksimowicz-McKinnon K, Hoffman GS. Large vessel vasculitis. Clin
Exp Rheumatol. 2007;25:S58-S59.
1 1 . Lazarides MK, Georgiadis GS, Papas IT, et a!. Diagnostic criteria and
treatment of Buerger's disease: a review. Int I Low Extrem Wounds.
2006;5:89-95.
1 2. Schmidt WA, Wernicke D, Kiefer E, et a!. Colour duplex sonography
of finger arteries in vasculitis and in systemic sclerosis. Ann Rheum
Dis. 2006;65:265-267.
13. Macik BG, Ortel TL. Clinical and laboratory evaluation of the hyper­
coagulable states. Clin Chest Med. 1995; 1 6:375-387.
14. Dalman RL, Olcott C. Upper extremity revascularization proximal to
the wrist. Ann Vase Surg. 1997;1 1 :643-650.
15. Degiannis E, Levy RD, Sliwa K, et a!. Penetrating injuries of the
brachial artery. Injury. 1995;26:249-252.
1 6 . Slowik GM, Fitzimmons M, Rayhack JM. Closed elbow dislo­
cation and brachial artery damage. j O rthop Trauma. 1 993;7:
558-56 1 .
17. Tonnessen BH. Iatrogenic inj ury from vascular access and endo­
vascular procedures . Perspect Vase Surg Endovasc Ther. 20 1 1 ;23:
1 28- 1 35.
18. Machleder HI, Sweeney JP, Barker WF. Pulseless arm after brachial­
artery catheterisation. Lancet. 1972;1:407-409.
19. Rodriguez-Niedenfuhr M, Vazquez T, Nearn L, et a!. Variations
of the arterial pattern in the upper limb revisited: a morphological
and statistical study, with a review of the literature. I Anat. 200 1 ;
199:547-566.
20. Shaw AD, Milne AA, Christie J, et a!. Vascular trauma of the upper
limb and associated nerve injuries. Injury. 1995;26:515-518.
21. Fitridge RA, Raptis S, Miller JH, et a!. Upper extremity arterial injuries:
experience at the Royal Adelaide Hospital, 1969 to 1 99 1 . I Vase Surg.
1994;20:941 -946.
22. Zaraca F, Ponzoni A, Sbraga P, et a!. Does routine completion an­
giogram during embolectomy for acute upper-limb ischemia improve
outcomes? Ann Vase Surg. 20 1 2;26:1064-1070.
23. Gelberman RH, Garfin SR, Hergenroeder PT, et a!. Compartment syn­
dromes of the forearm: diagnosis and treatment. Clin Orthop Relat
Res. 1981;(1 6 1 ):252-26 1 .
24. K o JH, Hanel DP. Technique o f fasciotomy: hand. Tech in Orthop.
20 1 2;27:38-42.
25. Guyatt GH, Akl EA, Crowther M, et a!. Executive summary: anti­
thrombotic therapy and prevention of thrombosis, 9th ed: American
College of Chest Physicians evidence-based clinical practice guidelines.
Chest. 20 1 2;141:7S-47S.
 C h a p t e r 1 0 PROXIMAL TO T H E WRI ST: Upper Extre m ity Reconstruct i o n/Revascu l a rization
26. Hughes K, Cubangbang M, Blackman K, e t al. Upper extremity bypass
for chronic ischemia-a national surgical quality improvement pro­
gram study database study. Vase Endovaseular Surg. 2 0 1 3 ;47: 1 92-194.
27. Hughes K, Hamdan A, Schermerhorn M, et al. Bypass for chronic
ischemia of the upper extremity: results in 20 patients. J Vase Surg.
2007;46 : 3 03-307.
28. Licht PB, Balezantis T, Wolff B, et al. Long-term outcome following
thromboembolectomy in the upper extremity. Eur J Vase Endovase
Surg. 2004;2 8 : 5 0 8-5 1 2 .
1 893
2 9 . Patel S N , White CJ, Collins TJ, e t al. Catheter-based treatment o f
the subclavian and innominate arteries. Catheter Cardiovase Interv.
200 8 ; 7 1 : 963-9 6 8 .
30. Carrafiello G , Lagana D, Mangini M, et a l . Percutaneous treatment o f
traumatic upper-extremity arterial injuries: a single-center experience.
J Vase Interv Radio/. 2 0 1 1 ;22:34-3 9 .
3 1 . Xenos ES, Freeman M, Stevens S, et al. Covered stents for
inj uries of subclavian and axillary arteries. J Vase Surg. 2 0 0 3 ; 3 8 :
4 5 1 -4 5 4 .

Chapter 11
I
to the Wrist
I
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - r - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Michael G. Galvez
DEFINITION
• Arterial reconstruction and revascularization distal to the
wrist requires reconstituting the complex vascular supply to
the hand. This includes the ulnar and radial arteries, superfi­
cial and deep palmar arches, and common and proper digital
arteries. This reconstitution is performed with either end­
to-end primary vascular repair, interposition vascular graft
bypass with proximal and distal anastomoses, or address­
ing the digital arteries individually. Additionally, fasciotomy
for compartment syndrome following trauma or reperfusion
inj ury may be a necessary adjunct.
DIFFERENTIAL DIAGNOSIS/PRECIPITATING
CAUSES OF HAND ISCHEMIA
• Arterial inj ury
Traumatic (laceration, high energy or crush injury, etc . )
or iatrogenic inj ury ( including inadvertent o r intentional
cannulation for vascular access).
• Proximal embolization
• Intraluminal thrombosis
Hypothenar hammer syndrome occurs when the base of
the hypothenar eminence sustains repeated blunt trauma
resulting in chronic inj ury to the distal ulnar artery and
the superficial palmar arch. In this scenario, compression
occurs between the roof of Guyon's canal and the hook
of the hamate bone, resulting in aneurysmal degeneration
of the ulnar artery, luminal thrombus accumulation, and
digital embolization (typically the ring and small finger) .
This typically occurs o n the dominant hand o f individu­
als participating in vocational or avocational activities
involving repeated palmar impact (e.g., pipe fitters and
mountain bike riders) .
Spontaneous radial artery thrombosis may b e associated
with Buerger's disease and is not as common as ulnar
artery thrombosis.
• Chronic digital ischemia secondary to vasospastic and rheu-
matologic disease:
Primary Raynaud's syndrome refers to cold-induced va­
sospasm present in the absence of concomitant disease.
The etiology of this condition remains uncertain but is
likely due to an exaggerated adrenergic receptor-mediated
response to cold exposure.
Secondary Raynaud's syndrome refers to digital vasospasm
which occurs in the setting of known autoimmune colla­
gen vascular diseases and related rheumatologic disorders
(such as rheumatoid arthritis) . In this circumstance, a nor­
mal vasospastic response to cold or environmental stimuli
is superimposed on chronic digital artery occlusive dis­
ease. Differentiation from primary Raynaud's syndrome
1894
-
Upper Extrem ity Arterial
Reconstruction and
Revascularization Distal
•
James Chang
is most commonly made based on digital ulceration and
tissue loss, conditions which uniformly develop in second­
ary Raynaud's syndrome.
CREST syndrome encompasses the most common phe­
notypic presentation of systemic scleroderma/sclerosis:
halcinosis, Raynaud's phenomenon, �sophageal stenosis,
�clerodactyly, and associated telangiectasias.
Buerger's disease, or thromboangiitis obliterans, rep­
resents a progressive, recurring necrotizing arteritis
of small and medium vessels closely linked to tobacco
exposure.
• Compartment syndrome occurs in response to increased
pressure within a fixed osteofascial anatomic space, lead­
ing to decreased arterial perfusion, irreversible myonecrosis,
neuropathy, and potential limb loss. In the hand, compart­
ment syndrome most commonly develops following crush
injuries; however, intravenous infiltration, external compres­
sion, and other mechanisms may also induce increased com­
partment pressure.
PATIENT HISTORY AND
PHYSICAL FINDINGS
• Determine the hand dominance of the patient and relevant
history of trauma, tobacco use, medical history (coagulo­
pathic disorders ), and occupational exposures. Additionally,
the presence of palpable masses, pain, sensory changes, or
color changes should be evaluated.
• An Allen's test may provide additional information regard­
ing the relative contribution of the ulnar and radial arteries
to hand perfusion. This test is performed by manual com­
pression of both the radial and ulnar arteries, with eleva­
tion and successive opening and closing performed to drain
venous blood from the hand. The time differential to reper­
fusion, following respective arterial release, provides quali­
tative insight into relative radial or ulnar dominance. In most
cases, however, the ulnar artery is dominant, and modern
quantitative arterial perfusion assessment by duplex imaging
and digital plethysmography has largely supplanted subjec­
tive physical exam findings in the assessment of adequacy of
arterial inflow.
• Patients with hypothenar hammer syndrome can have com­
plaints of pain and tenderness of the hypothenar mass, with
cold sensitivity and numbness of the ring and small finger
secondary to digital embolization and direct ulnar nerve
compression. A pulsatile mass may, on occasion, be appre­
ciable in the palm. Discoloration of the lateral three fingers
of the hand may also be present as a result of chronic digital
embolization.
• Patients with spontaneous radial artery thrombosis present
with pain, numbness, and discoloration of the tips of the
 C h a pt e r 1 1 UPPER EXTREM ITY ARTE RIAL RECONSTRUCTION A N D REVASC U LARIZAT I O N 1 89 5

radial-sided digits. The area o f occlusion i s commonly be­

neath the first and third extensor compartments and can be
related to compression of the radial artery by the extensor
pollicis longus. 1
• Patients with Raynaud's syndrome report ischemic symp­
toms and digital discoloration on exposure to cold. Cold­
induced vasospasm may be elicited by cold emersion testing
in an ice bath. A positive test is elicited by the elimination of
plethysmographic pulsatile phasicity on exposure to cold, in
addition to the onset of symptoms. Most patients, however,
cannot tolerate this provocative test, and the clinical use of
eliciting vasospastic symptoms, particularly in the presence
of existing digital ulceration, is uncertain.
• Compartment syndrome is a clinical diagnosis. Cardinal
signs include persistent and progressive pain unrelieved with
immobilization/elevation, tightness of skin, pain with pas­
FIG 1 • Anatomy of the h a n d i l l u strat i o n : schematic d ra w i n g of
sive extension, and decreased sensation. Reduced skin tem­
the vascu l a r s u p p l y of the h a n d , d e m o n strati n g the u l n a r a rtery as
perature, pallor, and pulselessness are often late findings. it passes G uyo n 's ca n a l and becomes the superfi c i a l pa l m a r a rch,
The intrinsic compartments are tested for pain with pas­ ra d i a l a rtery as it becomes the deep pa l m a r a rch, the co m m o n
sive adduction and abduction of the fingers. The thenar d i g ita l a rteri es, a n d the proper d i g ita l a rteries.
compartment is tested by adduction of the thumb. The
adductor of the thumb is tested by passive palmar abduc­
tion. The hypothenar compartment is tested by adduction completed by the superior branch of the ulnar artery, the
of the small finger. inferior branch of the ulnar artery, or both in about 97% of
Normal intracompartment pressures are less than patients.
1 0 mmHg; between 10 and 20 mmHg is considered high • The main branches from the superficial palmar arch are the
but not enough to cause muscle necrosis. An acute com­ three common digital arteries, which go to the index-middle,
partment syndrome is assumed if the measured interstitial middle-ring, and ring-small finger webspaces, as well as the
tissue pressures are within 30 mmHg of the mean arte­ proper digital artery to the ulnar aspect of the small finger.
rial pressure or 20 mmHg of the diastolic blood pressure.2 Each digit has a dual blood supply from the radial and ulnar
Hand pressures are typically difficult to assess on the basis proper digital vessels.
of direct measurement, given the extensive septation of • The thumb has blood supply from the princeps pollicis
the fascial compartments, underscoring the importance of artery, which variably arises from the radial artery, the deep
clinical diagnosis. When in doubt, it is prudent to proceed palmar, or superficial palmar arch.
with operative fasciotomy. • Catheter-directed, contrast-enhanced, digital subtraction
hand arteriography provides highly detailed anatomic in­
IMAGING AND OTHER DIAGNOSTIC formation and represents the gold standard in vascular im­
STUDIES aging { FIG 2 ) . However, there are risks from this invasive
procedure, which include contrast allergic reaction, vaso­
• As previously mentioned, noninvasive vascular imaging and spasm, contrast-induced nephropathy, thromboembolic
physiologic assessment are essential to establishing the di­ events including digital embolization and stroke, and drug
agnosis of hand and digital ischemia as well as providing a reactions precipitated by intraarterial inj ection of vasoac­
physiologic corollary to subsequent arterial imaging studies tive agents including Priscoline and nitroglycerin. Hence,
obtained to outline the relevant anatomy. Noninvasive test­ catheter-based arteriography is best suited to operative
ing informs and should always precede anatomic imaging planning in patients already determined to need reconstruc­
studies regardless of modality. tive surgery.
• Imaging provides essential identification of normal and
variant arterial anatomy, recognition of the location and
extent of obstructive and aneurysmal disease, and operative
planning.
• The vascular anatomy of the hand includes the ulnar artery,
radial artery, and sometimes a persistent median artery ( 5 %
o f the population). The ulnar and radial arteries anastomose
to form the superficial and deep palmar arches, with the
ulnar artery being the main contributor to the superficial
arch and the radial artery the main contributor to the deep
palmar arch { FIG 1 ) . There is significant variation in the vas­
cular patterns of the superficial and deep palmar arches.
• The superficial palmar arch is completed by either the
branches of the deep palmar arch, radial artery, or median FIG 2 • Hand a n g i ogram: normal hand ang iogram demonstrating
artery in about 8 0 % of patients. The deep palmar arch is com plete superficial a n d deep palmar a rches.
1 896 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

• Magnetic resonance arteriography (MRA) is another op­ attempted first, prior to surgical management.5 Evidence of
tion for imaging that is noninvasive, eliminating risks of gangrene, osteomyelitis, and so forth of the involved digit
radiation, contrast reaction, and vasospasm. However, the may require debridement or digital amputation.
resolution of MRA is not sufficient for detailed surgical • Periarterial sympathectomy in the hand, which involves
planning. stripping the adventitial layers from affected arteries,
• Computed tomographic arteriography ( CTA) is also nonin­ removes sympathetic nerve input to the media and has
vasive, although contrast and (significant) radiation exposure proven effective in promoting distal finger lesion healing in
are required for image acquisition. Similar to MRA imaging, scleroderma patients. In scleroderma specifically, the thick­
the resolution of CTA is typically not sufficient to support ened adventitia apparently contributes to decreased digital
detailed surgical planning. arterial flow. 6•7
• Measuring compartment pressures of the hand can be per­
formed with the Stryker Intra-Compartmental Pressure Positioning
Monitor (Kalamazoo, Michigan), which involves placing the
• Hand surgery is usually performed with the patient in the
device needle perpendicular to the skin and evaluating indi­
supine position. The operated hand is placed on a hand sur­
vidual compartments including sites of maximum swelling
gery table, which is stabilized by two legs. Reconstructive
of the thenar, hypothenar, and interosseous compartments.
surgery may be performed under tourniquet, depending on
The compartment being measured should be at the level of
systemic comorbidities and the adequacy of arterial inflow.
the heart. In an intensive care unit setting, using an arterial
For tourniquet control, the upper arm is well padded with
pressure line connected to a strain gauge, zeroed at the level
Webril (cotton) wrapped circumferentially, and then an 1 8-in
of needle entry into the hand, can also provide rapid and
(or appropriately sized) pneumatic tourniquet is secured
accurate compartmental measurements. A 20-gauge needle
around the upper arm ( FIG 3 ) . Alternatively, depending on
is inserted into the compartment and flushed, with measure­
inflow status, the tourniquet may be placed at the forearm or
ment acquired after the flush bolus has disseminated in the
wrist. Finally, an impervious barrier (3M Steri-Drape 1 000)
compartment and the pressure spike from the flush returns
is placed circumferentially j ust distal to the tourniquet to
to baseline.
prevent see page of the sterile prep solution. The arm/hand
are then sterilely prepped and draped.
SURGICAL MANAGEMENT
• Intraoperatively, the arm is exsanguinated with an elastic ban­
Preoperative Planning dage (Esmarch bandage) wrap and elevation immediately prior
to tourniquet inflation. In adults, the tourniquet is typically in­
• The overall goal is to restore distal blood flow to baseline/
flated to 250 mmHg; in children, it is set 1 00 mmHg above the
maximal levels, given anatomic constraints, available arte­
systolic pressure. The tourniquet inflation should last no more
rial conduit, central arterial perfusion pressure and cardiac
output, and end-organ (hand) viability.
• Treatment of thromboembolic disease can include medical
management and catheter-based chemical and mechanical
thrombolysis, angioplasty, and scenting to maximize arte­
riolar outflow and arterial inflow, respectively. Upper ex­
tremity revascularization techniques are discussed in Part 6,
Chapter 1 0 .
• End-to-end primary vascular repair can be performed i f ar­
teries are tension free after mobilization, and the zone of
inj ury is accurately identified to be uninvolved in the site of
anastomosis. If there is any difficulty in approximating the
vessels ends, then vascular grafts are preferred.
• In ulnar or radial artery thrombosis, reconstruction is pre­
ferred over ligation. Proximal reconstructions are attempted
even in the setting of more distal occlusions, based on the
rationale of augmenting collateral flow via direct or indirect
means. 3
• Determining venous or arterial graft harvest site is impor­
tant for preoperative planning. Dorsal hand or foot veins
provide the most appropriate size match for intrinsic arter­
ies of the hand (and feet ) . Donor sites for arterial graft con­
duits include the deep inferior epigastric artery, subscapular
artery, thoracodorsal artery, or descending branch of the
lateral femoral circumflex artery. Typically, arterial grafts
FIG 3 • Position i n g i l l ustrat i o n : s u p i n e pos1t 1 o n i n g of patient
patency rates are superior to those obtained with venous with a r m being operated o n p l aced out o n hand ta b l e . We bri l
grafts.4 g a u z e is wrapped c i rcu mferent i a l l y a r o u n d the a r m a n d fo l l owed
• For chronic ischemia, medical management including phar­ by to u r n i q u et p l acement. Appropriate to u r n i q u et p ress u re is
macologic treatment with vasodilators, topical nitroglycerin, set. F i n a l ly (not pictu red) a 3 M Ste ri-D rape 1 000 is wrapped
calcium channel blockers, or botulinum toxin should be ci rcu mferent i a l ly.
 C h a pt e r 1 1 UPPER EXTREM ITY ARTE RIAL RECONSTRUCTION A N D REVASC U LARIZAT I O N 1 897

than 2 hours and must be deflated for a 20-minute interval
to allow reperfusion prior to reinflation, if needed. Consider­
ation should be made to establishing systemic anticoagulation
prior to tourniquet inflation when indicated.
• Appropriate concurrent sterile prep should be performed on
graft harvest sites as necessary.
• Microsurgery prep includes ensuring that the operating scope
is working properly and sterilely draped. Positioning is ex­
tremely important to reduce surgeon fatigue, which includes
ensuring good table height, working height (with appropriate
padding support of the wrists with stacks of surgical towels),
and sitting position. Microsurgery instruments should be
available as necessary, depending on the level of revascular­
ization considered. 9-0 and 1 0-0 sutures are employed for
more distal reconstructive procedures and digital reimplan­
tation. For proximal radial and ulnar reconstruction proce­
dures, at or immediately adj acent to the wrist, 2 . 5 X to 3 . 5 X
surgical loupe magnification will provide adequate anatomic
resolution and suture placement for operators with normal
visual acuity.

U LNAR ARTERY RECON STRUCTION Resection of Ulnar Aneurysm

Placement o f Incision • O n ce the deep pa l m a r fascia is i n cised, the a n e u rysm i s

• I d e ntify the u l n a r a rtery a n e u rysm (FIG 4A), a n d i n cise
the skin l o n g itu d i n a l ly over the u l n a r a rtery as it crosses
G uyo n 's ca n a l . Exte nsion across the m i d pa l m a r crease
may be n ecessa ry to expose the d ista l u l n a r a rtery as it
cu rves ra d i a l ly to become the su perfi c i a l p a l m a r a rc h .
• The vo l a r carpa l l i g a m e nt, the roof of G uyon's ca n a l , i s
a conti n u ation of the deep pa l m a r fascia a n d fi bers o f
the flexor carpi u l n a r i s a n d m ust be ca refu l ly i ncised f o r
access to the u l n a r a rtery a n d n e rve.
• The u l n a r n e rve, p a rticu l a rly the motor branch, m ust be
ca refu l l y p rotected .
g e n e ra l ly recog n iz a b l e (FIG 48 AND FIG SA) . The a n e u ­
rysm itse lf may be throm bosed o r tortuous o r e l o n g ated
as a result of c h r o n i c posttra u matic remod e l i n g . M icro­
vasc u l a r c l a m ps a re p l a ced o n the u l n a r a rte ry p roxi m a l
a n d d ista l t o the a n e u rys m .
• Prese rve t h e co m m o n d i g ital a rteries a n d oth e r l a rg e
b r a n c h e s d i sta l to the t h ro m bosed seg ment. P l a ce
m i c rovasc u l a r c l a m ps a n d vessel loops as needed on ves­
sels that w i l l req u i re revasc u l a rizat i o n .
• Resect the affected a rtery a n d trim the ends sharply.
• The adventitia is excised as needed, and the intima i nspected
at the proxi mal and d ista l end of the a nastomoses to ensure

c D
FIG 4 • U l n a r a rtery reco nstruct i o n : A. H a n d a n g i o g r a m d e m o n strat i n g a l a rge u l n a r a rtery a n e u rysm i n G uyon's
ca n a l . B. U l n a r a n e u rysm seg m e nt is isolated p roxi m a l ly a n d d ista l ly. C. A d i rect e n d -to-en d a n a stom oses was
performed. D. In a n other patie nt, a long ve i n g raft i s used to exte n d from a m o re proxi m a l u l n a r a rte ry.
1 898 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

that the entire disease seg ment is removed . Fa i l u re to A B

remove the enti rety of diseased a rtery may precipitate early
g raft throm bosis and recu rrent d i g ita l embol ization.

Vein Graft Interposition

• Occasi o n a l ly, suffi cient red u n d a ncy is p resent i n the u l n a r

a rtery t o a l l ow d i rect p r i m a ry repa i r (FIG 4C); i n m ost
cases, i nterposition ve i n g raft i n g (FIG 40) is req u i red to
co m p l ete the reco nstruction without tensi o n .
• When the s u p erfi c i a l pa l m a r a rch a n d adjacent common
d i g ita l a rteries a re i nvolved, then a m o re co m p l ex
" p a l m a r a rc h " reconstruct i o n may be necessa ry to restore
perfus i o n to the dependant d i g its (FIG 58), with end-to­
side a n astomoses of the c o m m o n d i g ital a rteries i nto the
d ista l extent of the ve i n g raft.
• Ve i n h a rvest is typica l ly chosen from the h a n d a n d foot
ve i n s . Length of ve i n ha rvest s h o u l d be several centime­
te rs longer to a l l ow for tri m m i n g .
• M a r k i n g t h e s u p erfi c i a l su rface o f t h e ve i n h e l p s avoid
twist i n g o r k i n k i n g of the ve i n g raft. M a r k i n g o n e end
(typica l l y d i stal) p rovi d es a re m i n d e r to reverse the g raft
p rior to i m p l a ntati o n . If needed, ends with valves a re ex­
cised . Arte r i a l g raft may a lso be used when ava i l a b l e a n d
o f suitable d i a meter a n d length.
• Longer g rafts may a lso be used (FIG 40) when m o re
proxi m a l a rte r i a l i nflow is req u i re d .
• M i c rovasc u l a r a n asto m osis of vessel g raft.
• Anastomosis co m p l et i o n may req u i re m i crosu rgical
tec h n i q ue, g iven that com m o n d i g ital a rteries may
be 1 to 2 m m i n d i a m eter.
• Both ends of the vessels a re held in pl ace by an appro­
priately tensioned microvascu l ar doub le-armed clamp.
Interposition
Throo>bosed
Vein Graft
Segment
FIG 5 • U l n a r a rtery reco nstruction i l l ustrat i o n . Exploration
of the u l n a r a rtery co nfirms f i n d i ngs of a n g iogram
d e m o nstrat i n g (A) u l n a r a rte ry throm bosis to the orig i n of the
common d i g ita l a rteries. Reconstruction req u i res h a rvest i n g a
Y branch of a saphenous ve i n g raft, whi c h is then reversed
pri or to i nterposit i o n . B. E n d -to-side d ista l a n a stomosis, end­
to-e n d a n asto mosis of the ve i n branch to the co m m o n d i g ital
a rte ry, a n d end-to-s ide a n a stomosis to c o m m o n d i g ital a rtery
a re performed.
• After i rrigation with h e p a r i n ized s a l i ne, i nterru pted
sutu res a re p l a ced c i rcu mferenti a l ly u s i n g a t r i a n g u ­
lation tech n i q u e .
• The p rox i m a l a n asto mosis is pe rfo rmed fi rst, then
flushed with hepa r i n and c l a m ped to a l l ow the ve i n
g raft to exte n d t o l e n gth before prepa r i n g a n d
co m p l et i n g the d i sta l a n a stom os(e)s.

S N U FFBOX RADIAL runs betwee n the fi rst and t h i rd extensor co m p a rtments

ARTERY RECON STRUCTI O N
Placement o f Incision
• At the level of wrist, the ra d i a l a rte ry turns d o rsa l l y u n ­
d e rneath t h e fi rst extensor c o m p a rtment (conta i n i n g t h e
a b d ucto r p o l l icis l o n g u s a n d exte nsor p o l l icis b revis), then
(extensor p o l l icis l o n g us) in the a rea known as the " a n a ­
tomic sn uffbox. " The d i seased seg ment a n d d i sta l targets
shou l d be confi rmed by refe rence to the specific p reoper­
ative i m a g i n g stu d i es (FIG 6A, B) . A s k i n i ncision is m a d e
o n the d o rs u m of the h a n d d i rectly o v e r the a n ato m i c
snuffbox p a ra l l e l to the seco n d m etaca rpal (FIG 7A) .
• T h e su perfi c i a l ra d i a l n e rve is i d e ntified a n d preserved .

B
6 • S n uffbox ra d i a l a rtery reco nstruction a n g i o g rams: A.B. Angiograms d e m o nstrating cutoff of
ra d i a l a rtery (arrow d e m o n strates fi l l i n g d efect correspo n d i n g to occ l u d e d segment) at the level of the
a n atomic sn uffbox.
 C h a pt e r 1 1 UPPER EXTREM ITY ARTE RIAL RECONSTRUCTION A N D REVASC U LARIZAT I O N 1 899

A
B

FIG 7 • S n u ffbox rad i a l a rtery reco nstruct i o n : A.

I n c i s i o n over the ra d i a l a rtery over the a n ato m i c
sn uffbox w i t h m i cro backgro u n d p l aced u n d e r
a rtery. B. Rad i a l a rtery is c l a m ped d i sta l ly. C. Vesse l
is c l a m ped proxi m a l ly a n d isol ated w i t h vessel loops
c p r i o r to ve i n g raft i n g .

Resection/Bypass of Diseased Segment Vein Graft Interposition

• This d i ssection is conti n u e d d i sta l ly betwee n the heads of
the fi rst d o rsa l i nterosseous m uscle, a l lowi n g f u rther mo­
b i l ization of the d ista l ra d i a l a rtery a n d visua l ization of
the o r i g i n of the deep p a l m a r a rc h .
• M icrovasc u l a r c l a m ps a re p l aced proxi m a l a n d d i sta l t o
the throm bosed seg ment of the ra d i a l a rte ry.
• A l l branches from the t h ro m bosed seg m e nt s h o u l d be
l ig ated a n d rem oved e n bloc (FIG 7B) .
• The ve i n g raft s h o u l d be reversed a n d p l aced s u p e rfi c i a l
to the exte nsor p o l l icis l o n g u s a n d exte nsor p o l l icis brevis
( m a k i n g the g raft i m med iately ben eath the skin) a n d
t h e n sutu red e n d -to-e n d t o the ra d i a l a rtery proxi m a l l y
a n d e n d -to-en d t o t h e d e e p a rch d ista l ly (FIG 7C) . See
the " U l n a r Artery Reco n struct i o n " sect i o n for f u rther de­
script i o n o n vein ha rvest and m icrovasc u l a r a n a stomosis
tech n i q u e .

HAN D FASCIOTOMY
Placement of Incisions

• The 1 0 co m p a rtm ents of the h a n d i n c l u d e the t h e n a r, hy­ """"'

poth e n a r, a d d u ctor, a n d 4 d o rsa l and 3 vo l a r i nterosse i lnlefoeaei

co m p a rtments. Four i n c i s i o n s a re req u i red to release a l l

1 0 compartments.
• The dorsa l a n d vo l a r i nterosseous com p a rtme nts a re de­
co m p ressed with two d o rsa l i n cisions over the i n d ex f i n g e r
a n d r i n g f i n g e r m etaca rpal (FIG SA) . These i ncisions a re
carried down to either side of the m etaca rpal to release a

the d o rsa l i nterosse i . D i ssection along the u l n a r and rad i a l

aspects o f t h e i n dex metaca rpal m ust be suffi ciently deep
(FIG SC) to release the fi rst d o rsal p a l m a r i nterosseous
and the a d d u ctor com p a rtments. S i m i l a rly, to release the
rema i n i n g p a l m a r i nterosse i, deep d i ssection is req u i red
a l o n g the u l n a r and rad i a l aspects of the ring m etaca rpa l .
M eti c u l o u s release a l o n g t h e length o f t h e metaca rpal i s
FIG S • H a n d fasciotomy i l l u strat i o n : fasciotomy i n c i s i o n s of
the h a n d . A. Dorsa l i n c i s i o n s over the i n dex (c) a n d r i n g (b)
essential t o e n s u re adequate deco m p ress i o n .
f i n g e r metaca r pa l . B. Vo l a r i n c i s i o n s over the hypoth e n a r (d)
• The t h e n a r co m p a rtment is b o u n d by t h e n a r fasc i a a n d
a n d t h e n a r (a) m u scles. C. Cross sect i o n at the level of the
conta i n s the a b d u ctor pol l icis b revis, flexor p o l l icis b revis, m etaca rpals of the hand d e m o n strat i n g that both d o rs a l and
and the opponens pol l icis. This co m p a rtment is decom­ i nte rosseo u s co m p a rtments a n d the a d d ucto r com p a rtment
p ressed with a l o n g itu d i n a l i n c i s i o n along the ra d i a l/ to the thumb can be released t h ro u g h these four i n cisions
vo l a r (FIG SA) aspect of the t h u m b metaca r pa l . with a p p ropri ate d i rection a n d d e pth as o ut l i ned (a-d) .
1 900 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

• The hypot h e n a r c o m p a rtment is b o u n d by the hypothe- • A l o n g itud i n a l pa l m a r i n c i s i o n is m a d e j ust d i sta l to the

n a r fasc ia a n d conta i n s the a b d u ctor d i g iti m i n i m i , flexor
d i g iti m i n i m i , and opponens d i g iti m i n i m i . This c o m p a rt­
m e nt is deco m p ressed with a l o n g itud i n a l i n cision a l o n g
the u l n a r/vo l a r (FIG 88) aspect of the sm a l l m etaca rpa l .
• The finger ca n a lso have com p a rtment syn d rome if there
is excessive swe l l i ng a n d depend i n g on c l i n ical assessment.
H e re, the fasc i a l com p a rtments a re bound by C l e l a n d 's and
G rayson 's l i g a m ents. The finger fasciotomy is performed
by m a k i n g m idaxial i ncisions along the u l n a r aspect of
the i n d ex, ring, and long fingers and o n the rad i a l aspects
of the t h u m b a n d s m a l l finger. O nce i n cisions a re made,
b l u nt d issection is cont i n ued through C l e l a nd 's l i ga m ent
(fi rm fascia bands that r u n from side of the p h a l a n ges
to the skin and a re d o rsa l to the neu rovascu l a r b u n d le),
retract i n g the n e u rovasc u l a r b u n d l es i n a vo l a r d i rection
a n d re m a i n i n g vo l a r to the flexor tendon sheath.
Carpal Tunnel Release
• If a n y compartment press u re is e l evated in the h a n d ,
then a l l c o m p a rtme nts s h o u l d be rel eased i n c l u d i n g t h e
carpa l t u n n e l .
vo l a r wrist crease a n d exte n d i n g d i sta l ly for 3 to 4 em in
the p rox i m a l p a l m a l o n g the cou rse of the rad i a l aspect
of the r i n g f i n g e r.
• The p a l m a ris fasci a is d ivided l o n g itu d i n a l ly to expose
the u n d e r l y i n g tra nsve rse carpal l i g a m e nt, whi c h is then
i ncised u n d e r d i rect visu a l izatio n .
• The i n ci si on is exte nded at least 2 em i nto the forearm to
e n s u re release of the deep a ntebrach i a l fasc i a .
• The carpa l t u n n e l release i n cision is cl osed p r i m a r i l y with
i nterru pted nylon sutu res.
Wound Care
• Fasciotomy wounds a re left open for a m i n i m u m of
48 h o u rs o r u nt i l swe l l i n g has resolved .
• Seco n d a ry closure with wet-to-d ry d ress i n g s may occ u r
over open i ncisions.
• Event u a l ly, these wo u n d s may need spl it-thickness s k i n
g raft i n g .
• The h a n d s h o u l d be s p l i nted i n a safe position (70 to
90 deg rees of m etaca rpo p h a l a n g e a l [ M C P] flexion a n d
p roxi m a l i nte rpha l a n g e a l [ P I P] j o i nts stra i g ht) .

PEARLS AND PITFALLS

• Alth o u g h a throm bosed u l n a r a rtery ca n be l i g ated, reco nstruction of the u l n a r a rtery can reconstitute n o r m a l flow a n d s h o u l d
be atte m pted .
• H a n d vasc u l a r repa i r a n d g raft i n g req u i res meticu l ous m icrovascu l a r tech n i q u e .
• T h e d o rsal s i d es of t h e h a n d a n d foot have ve i n s of s i m i l a r s i z e t h a t a re i d e a l f o r ve i n g raft reco nstruct i o n .
• Periarte r i a l sym path ecto my is p a rticu l a r l y effective i n scleroderma because the vessels a re encased i n adventit i a l sca rri n g .
• E a r l y d i a g nosis a n d treatment f o r h a n d c o m p a rtment syn d ro m e i s critica l : W h e n i n d o u bt, release a l l compartme nts.

POSTOPERATIVE CARE
• Postoperative monitoring of the hand after vascular re­
construction is similar to finger replantations and can be
performed with pencil Doppler monitoring or with pulse
oximetry ( FIG 9) .
• Aspirin 8 1 m g i s given for 6 weeks postoperatively after
vessel reconstruction.
• For periarterial sympathectomy, immediate digital range of
motion is encouraged, and cold temperature and vasocon­
strictive drugs or substances (smoking, caffeine, etc . ) are
avoided for at least 6 weeks.
• For compartment syndrome, aggressive strengthening and
range of motion should be started once wounds have stabilized.

OUTCOMES
• Radial artery reconstruction patency in a study of 1 3 patients
found that all vein grafts were patent after mean follow-up
of 22 months, with a significant decrease in pain; however, FIG 9 • H a n d postope rative m o n itori n g : Revasc u l a rizat i o n of
no difference in numbness was seen. 3 In another study of d i g its can be m o n itored with basic p u lse oxi m etry at the tip of
145 patients, an overall patency of vein grafts of 8 5 % over the d i g its.
 C h a pt e r 1 1 UPPER EXTREM ITY ARTE RIAL RECON STRUCTI O N A N D REVASCULARIZAT I O N 1 90 1

a n average follow-up period o f 34 months was found a s well • Stiffness of the fingers
as 1 0 0 % with arterial grafts.4 • Continued ischemia, pain, and ulcerations
• Long-term recovery after compartment syndrome release
depends on the extent of inj ury and requires long-term hand REFERENCES
therapy for recovery of hand function. Compartment release
1. Pomahac B, Hagan R, Blazar P, et al. Spontaneous thrombosis of the ra­
of the hand can result in normal function; however, contrac­ dial artery at the wrist level. Plast Reconstr Surg. 2004;1 14(4):943-946.
tures can develop, which may need eventual reoperation for 2. Leversedge FJ, Moore TJ, Peterson BC, et al. Compartment syndrome
contracture release. of the upper extremity. J Hand Surg Am. 20 1 1 ;3 6 ( 3 ) :544-559.
3 . Ruch DS, Aldridge M, Holden M, et al. Arterial reconstruction for
COMPLICATIONS radial artery occlusion. J Hand Surg Am. 2000;25 (2):2 82-290.
4. Masden DL, Seruya M, Higgins JP. A systematic review of the out­
• Infection comes of distal upper extremity bypass surgery with arterial and
• Dehiscence of incisions and other wound healing complica- venous conduits. J Hand Surg Am. 2012;37( 1 1 ) :23 62-2367.
5 . Porter SB, Murray PM. Raynaud phenomenon. J Hand Surg Am.
tions
2 0 1 3 ; 3 8 ( 2 ) : 3 75-3 77. doi: 1 0 . 1 0 1 6/j .jhsa.20 1 2 . 0 8 . 0 3 5 .
• Failure of revascularization
6. Hartzell T L , Makhni E C , Sampson C. Long-term results of periarterial
• Distal emboli sympathectomy. J Hand Surg Am. 2009;34 ( 8 ) : 1454-1460.
• Thrombosis at anastomosis 7. Bogoch ER, Gross DK. Surgery of the hand in patients with systemic scle­
• Long-term patency rosis: outcomes and considerations. J Rheumatol. 2005;32(4):642-648 .

Chapter 12 Exposure and Open Surgical
Reconstruction in the Chest:
' The Thoracoabdominal Aorta
'
------------------------------------ � ----------------------------------------------------
Germ a n o Melissa n o
Roberto Chiesa
DEFINITION
• A thoracoabdominal aortic aneurysm (TAAA) involves the
aorta at the diaphragmatic crura and extends variable dis­
tances proximally and/or distally from this point ( FIG 1 ) . 1
TAAAs can be classified in terms of their causes, the two
most common being medial degeneration and dissection.
• Open treatment of TAAAs consists of graft replacement with
reattachment of the main aortic branches: The inclusion tech­
nique was introduced by S. E. Crawford in the 70s and refined
by subsequent surgeons in the following decades. TAAA re­
pair, especially in extensive aortic disease, is associated with
greater operative risk than repair of other aortic segments. The
main sources of morbidity are spinal cord (SC) ischemia and
renal as well as respiratory and cardiac complications.
• Experienced surgical centers now report lower mortality and
morbidity rates for TAAA repair,2 largely due to multimodal
approaches to reduce surgical trauma and maximize organ
protection. 3
IMAGING AND OTHER DIAGNOSTIC
STUDIES
•
To plan the best possible treatment strategy for each patient,
our preferred modality is computed tomographic arteriogra­
phy ( CTA ) . The acquisition of computed tomography ( CT)
FIG 1 • An a n e u rysm is defi ned as thoracoabd o m i n a l when
the h i g h l i g hted reg i o n i s i nvolved . Crawfo rd's cl assificati o n was
deve loped to i m p rove stratification of perio perative p a ra p l e g i a
r i s k . S u bcl assificat i o n s i n c l u d e the fo l l ow i n g : Exte nt I i n c l udes
the t h o racic and a bdom i n a l a o rta, from the l eft subclavian a rtery
to the level of the r e n a l a rteries; extent I I i n c l udes the enti re
desce n d i n g a o rta from the level of the l eft subclavian a rtery to
t h e a o rtic bifu rcation; extent I l l i n c l udes a o rta beg i n n i n g at the
T6 level exte n d i n g to the bifurcat i o n o r l ower; extent IV i n c l udes
t h e enti re abdom i n a l a o rta sta rt i n g at the level of the d i a p h ra g m
(T 1 2) to the a o rtic bifu rcati o n o r lower.
1902
-
·
Efrem Civilini Enrico Rina ldi
data in particular has benefited from spectacular progress,
including multirow detectors, higher rotation and transla­
tion speeds with reduced scan times (single breath-hold),
cardiac cycle synchronization, and better postprocessing
capabilities.
• D igital Imaging and Communications in Medicine
(DICOM) slices of adequate thickness (s::l mm) should
be postprocessed on a digital workstation using a multi­
planar reformatting (MPR) tool to visualize a scan which
angulation matches that of the aorta or the vessel under
investigation. Postprocessing may be performed on a
dedicated workstation (AquariusNet®, TeraRecon, Inc)
or desktop computer with open source software ( O siriX
and others ) in a user-friendly and time/resources-efficient
way ( FIG 2 ) .
• Beyond analysis o f aortic diameter and the extent o f patho­
logic involvement, reformatted images are particularly
useful for evaluating the presence, extension, and charac­
teristics of dissection and thrombus, particularly at pro­
posed sites of clamp placement and the infradiaphragmatic
aorta when direct aneurysm cannulation is considered for
distal aortic perfusion. The exact location and geometry
of aortic branches is obtained to reveal possible anatomic
variations or anomalies, which are particularly common
at the level of the renal arteries and arch vessels. Vessel
patency is also routinely evaluated; in particular, obstruc­
tion of the superior and inferior mesenteric artery and the
hypogastric arteries and dominance of one vertebral artery
are assessed.
• Three-dimensional rendering tools such as maximum inten­
sity projection (MIP ) , volume rendering, surface rendering,
and so forth produce realistic imaging of the anatomic struc­
tures that may expand anatomic understanding, including,
for instance, the most appropriate intercostal space to per­
form thoracotomy ( FIG 3 ) .
• Perioperative SC ischemia may precipitate paraparesis or
paraplegia. Prior knowledge of the SC arterial supply in­
forms both procedural planning and risk stratification.
FIG 2 • M P R tools a l l ow the sag itta l reco nstruction to properly
fo l l ow the major axis of the t h o racic a o rta. I n this refo rmatted
i m a ge, the e n t i re t h o racic a o rta is i n c l uded despite s i g n ificant
tortuosity.
 C h a p t e r 1 2 EXPO S U R E A N D OPEN S U R G I CAL RECON STRUCT I O N I N T H E C H E S T
FIG 3 • B e y o n d a o rtic i m a g i ng, the C T provides extensive
a n ato m i c information to g u i d e exposu re and surgical decision
making.
Recent advances i n imaging techniques, especially nonin­
vasive techniques, increased the likelihood that patient­
specific risk criteria may soon be recognized and be widely
available4 ( FIG 4).
SURGICAL MANAGEMENT
Preoperative Workup and Patient Optimization
• Preoperative transthoracic echocardiography is a satisfac­
tory noninvasive screening method to evaluate both valvular
and biventricular function. Stress testing identifies patients
who require coronary catheterization and possible interven­
tion.5 Electrocardiographically (EKG) gated CT has recently
emerged as a less invasive method of visualizing coronary
anatomy. For severe, symptomatic coronary disease requir­
ing percutaneous transluminal angioplasty prior to aneu­
rysm repair, use of drug-eluting stems requiring prolonged
double antiplatelet therapy should be avoided to reduce sub­
sequent perioperative bleeding.
• The use of estimated glomerular filtration rate (eGFR) ,
rather than serum creatinine levels alone, is recommended
to assess renal function. 6 Based on the eGFR metric, chronic
kidney disease has been shown to be a strong predictor of
death following open or endovascular thoracic aneurysm re­
pair, even in patients without other clinical evidence of pre­
operative renal disease?
FIG 4 • U s i n g a custo m ized c u rve p l a n , the w h o l e path of the
a rteri a l feeder to the spi n a l cord (a rte ria ra d i c u l a ris m a g na) can
be visu a l i zed from the a o rta to the a nterior spi n a l a rte ry.
1 903
FIG 5 • O n ce t h e d u ra h a s b e e n p u nctured w i t h t h e i ntrod u c e r
n e e d l e , a d r a i n a g e c a t h e t e r i s i n se rted 8 to 1 0 e m a l o n g t h e
i nt ra d u ra l s p a c e . T h e catheter i s t h e n co n n ected to a press u re
t r a n s d u c e r, a n d t h e fl u i d is d r a i n e d to keep t h e p ressure
b e l ow 10 e m H 2 0. Autom ated syste m s a re a va i l a b l e for t h i s
p u rpose.
Pulmonary function evaluation with arterial blood gases
and spirometry is used to evaluate the respiratory reserve
of all patients undergoing open surgery of the descend­
ing aorta. In patients with a forced expiratory volume in
1 second ( FEV ) of less than 1 L and a partial pressure
1
of carbon dioxide (PC0 ) greater than 45 mmHg, opera­
2
tive risk may be improved by cessation of cigarette smok­
ing, treatment of chronic bronchitis (if present) , weight
loss, and participation in a supervised exercise program
for a period of up to 6 months prior to surgery. How­
ever, in patients with aneurysm-related symptoms, this
type of respiratory rehabilitation may not be practical or
possible.
Positioning
• After inserting a cerebrospinal fluid drainage ( CSFD ) 8 cath­
eter into the subarachnoid space between L2 and L3 or L3
and L4 ( FIG 5), the patient is turned to a right lateral decu­
bitus position, with the shoulders at 60 degrees and the hips
flexed back to 30 degrees.
• Preparation should allow for access to the entire left tho­
rax, abdomen, and both inguinal regions. Patient position
is maintained with a moldable beanbag attached to a suc­
tion line for vacuum creation. A circulating water mattress
is placed between the beanbag and the patient in order to
modify body temperature as necessary ( FIG 6 ) .
FIG 6 • Pre p p i n g a n d d r a p i n g for TAAA. Poste rol atera l a spect of
the l eft t h o rax, the a bd o m e n , a n d l eft g r o i n a re i n c l uded in the
ste r i l e ope rato ry f i e l d . P l ease n ote the gentle cu rvatu re of the
line i n d icat i n g the s k i n i n c i s i o n to avoid f l a p necrosis.
1 904 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

THORACO-PHRENO-LAPAROTOMY
• The thoracic i n c i s i o n varies i n l e n gt h a n d l eve l , d e p e n d ­
i n g o n exposure req u i re m e nts. U s u a l ly, t h e 5 t h , 6 t h , o r
7 t h i nte rcost a l space is e m p l oyed accord i n g to t h e a n e u ­
rysm a n atomy. The poste r i o r sect i o n of t h e r i b s i s gently
s p read to reduce thoracic wa l l t r a u m a a n d fractu res;
a nterol atera l ly, the i n c i s i o n c u rves gently as it crosses
the cost a l m a r g i n to m i n i m i ze su bse q u e n t tissue n ecro­
sis. The p l e u r a l space i s e ntered after s i n g l e r i g ht l u n g
venti l a t i o n i s i n itiate d . M o n o p u l m o n a ry vent i l at i o n
i s m a i nta i n ed t h ro u g h o ut t h o r a c i c a o rta r e p l a c e m e n t
(FIG 7) .
• P a r a lysis of t h e l eft h e m i d i a p h ra g m cont r i b utes s i g n ifi­ FIG 8 • The d i a p h r a g m is ci rcumferentia l ly d ivided (arrows)
cantly to posto pe rative res p i ratory fa i l u re; t h e refore, for seve ral ce ntimeters n e a r its p e r i p h e r a l atta c h m ent to the
a l i m ited c i rc u mfere n t i a l rather t h a n rad i a l sect i o n a nterior ch est wa l l sparing the p h r e n i c center (asterisk).
of t h e d i a p h ra g m i s routi n e l y p e rformed, s p a r i n g
t h e p h re n i c center. U n d e r favora b l e a n a to m i c co n d i ­
t i o n s, t h i s a p p ro a c h reduces res p i ratory wea n i n g t i m e 9
(FIG 8) .
• Speci a l ca re m ust be taken when iso l a t i n g the p roxi m a l
a n e u rysm n e c k . The i nsertion o f a l a rg e ca l i be r eso p h ­
agea l p robe m a kes it easier to d i sti n g u is h the eso p h a ­
g u s at t h i s leve l . The va g u s n e rve a n d the o r i g i n of the
recu rrent l a ry n g e a l n e rve m ust a l so be identified because
they can a lso be damaged d u r i n g isolation and c l a m p i n g
m a n euvers (FIG 9) . I d e ntification a n d c l i p p i n g o f some
" h i g h " i ntercosta l a rteries can sometimes fac i l itate t h e
prepa rati o n for the proxi m a l a n asto mosis, t h u s red u c i n g
a o rtic bleed i n g .
• T h e u p pe r a b d o m i n a l a o rt i c seg m e n t is exposed v i a a
t r a n s pe rito n e a l a p p ro a c h ; after e n te r i n g t h e p e r i to­
FIG 9 • The va g u s n e rve (bla ck a rro w) a n d the ongm of
n e u m , m e d i a l vi scera l rotat i o n i s p e rformed to retract the recu rrent l a ry n g e a l n e rve a re m o b i l ized a n d i d e ntified
t h e l eft c o l o n , s p l e e n , a n d l eft k i d ney a nt e r i o r l y a n d to with vessel loops to p revent i nj u ry d u r i n g a o rt i c c l a m p i n g
t h e right (FIG 1 0) . Use of a t r a n s p e r i to n e a l a p p r o a c h m a n euvers o r suture p l acement. When a n a o rtic cross­
a l l ows d i rect assess m e n t of t h e a b d o m i n a l o r g a n s c l a m p i n g between l eft carotid and subclavian a rtery is
at t h e e n d of p roced u re . Extra c a r e m u st be t a k e n req u i red, these vesse l s a re a l so i d e ntified and contro l led with
to avo i d d a m a g e to t h e s p l e e n , w h i c h i s p a rt i c u l a r l y vesse l loops (white arrows).
p r o n e to b l e ed i n g aft e r c a p s u l a r i n j u r i e s reg a r d l ess
of s i z e .

FIG 10 • M ed i a l viscera l rotat i o n : The left colon, the s p l een,

a n d t h e l eft kid ney a re retracted a nteriorly a n d to the r i g h t
FIG 7 • Thoraco-p h re n o - l a p a rotomy i n the 6 t h i ntercosta l to v i s u a l ize the viscera l a n d i nfra renal a o rta. Tra nsperito n e a l
space. A ci rcumferent i a l i ncision of the d i a p h ra g m is carried a p proach a l l ows d i rect eva l u at i o n of the a b d o m i n a l o rg a n s
out (d otted l i ne). t h rou g h out the p roced u re .
 C h a p t e r 1 2 EXPO S U R E A N D OPEN S U R G I CAL RECON STRUCT I O N I N T H E C H E S T 1 90 5

DISTAL AORTIC PERFUSION

• Cross-c l a m p i n g of the desce n d i n g thoracic a o rta pro­
d u ces i m med iate and s i g n ificant i n c reases in left ven­
tricu l a r afterload, myocard i a l oxygen co nsu m ption, a n d
viscera l a n d r e n a l isch e m i a . Tec h n i q ues i n co rporat i n g d is­
ta l a o rtic perfus i o n with l eft h e a rt bypass (LH B P) have s i g ­
n ificantly i m p roved outcomes i n t h o r a c i c a o rt i c s u rg e ry. 1 0
I n preparation for L H B P a n d a o rtic cross-cl a m p i n g , l ow­
dose i ntrave n o u s h e p a r i n is a d m i n istered. If cessati o n of
p u m p s u p port i s a ntici pated d u ri n g the case, a d d i t i o n a l
h e p a r i n s h o u l d be a d m i n istered at that t i m e to p rovide
fu l l a nticoa g u lati o n .
• The u p p e r l eft p u l m o n a ry ve i n is usua l ly ca n n u l ated for
i nflow of oxyg e n ated b l ood, w h i c h i s routed t h r o u g h a
centrifu g a l p u m p ( B i o - M e d icus®) i nto the l eft fe moral
a rtery (FIG 1 1 ) . A " Y " c o n nector i n c l uded i n the c i rc u i t
provides t w o occl usion/perfusion catheters (9 F r) for
sel ective viscera l perfu s i o n when necessa ry.

FIG 11 • S c h e m a t i c view of d ista l a o rtic perfu s i o n . A 20-Fr

ca n n u l a is i n serted i n l eft s u pe r i o r p u l m o n a ry ve i n fo r the
a rte r i a l b l ood drainage (up) . N o n occlusive fem o r a l ca n n u l a
(1 4 t o 1 8 F r) a l l ows synchronous p roxi m a l a n d d ista l perfus i o n
f r o m the fe moral axis (down).

AORTIC REPAIR
• Once the neck of the TAAA is isolated and control led be­
tween clam ps, the descending thoracic aorta is tra nsected
and sepa rated from the esophagus (FIG 1 2). The g raft is su­
tu red proxi m a l ly to the descending thoracic aorta using 2-0
polypropylene sutu re in a r u n n i n g fashion. The a nastomosis
is rei nforced with Teflon felt (individual pledgets or single
strip) (FIG 1 3). An additional aortic clamp is appl ied onto
the abdom i n a l aorta above the celiac axis before the proxi­
mal aortic c l a m p is rem oved (seq uential cross-c l a m p i ng).
• I ntercostal a rtery re i m p l a ntation i nto the aortic g raft p l ays
a critica l role in SC p rotect i o n . Patent i ntercosta l a rteries
from T7 to L2 a re temporarily occluded to p reve nt back­
bleed i n g/max i m ize cord perfusion p ress u re 1 1 then sel ec­
tively reattached to the g raft by means of aortic patch or
FIG 13 • The p roxi m a l a n astomosis routi n e l y rei nforced with
g raft i nterposition (FIG 14). When ready, the d i stal c l a m p a Tef l o n str i p .

FIG 14 • Critica l i ntercosta l a rteries reatta c h m e nt . H e re

FIG 1 2 • The p roxi m a l desce n d i n g t h o r a c i c a o rta is contro l led
a n d co m p l etely tra n sected to avo i d accidenta l i n j u ry to the
adjacent eso p h a g u s .
visua l i zed a re two d iffe rent tec h n i q ues: On the left, an aortic
i s l a n d i n c l u d i n g t h e orig i n of seve ral i ntercosta l a rteries is
reattached to a fen estrati o n created o n the a o rtic g raft; o n
the right, i n te rcosta l a rteries a re reattached sel ectively to t h e
g raft via 6/8-m m i nterpos ition g rafts.
1 906 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

FIG 1 7 • A mod ified tech n i q u e to s e p a rate ly reatta ch

t h e l eft re n a l a rt e ry i s deta i l ed h e r e : T h e use of a hybrid
t u b e g raft t h a t i n c l u d e s a s e l f-expa n d a b l e covered ste n t
a l lows for a s u t u r e l ess a n a st o m o s i s . T h e a d v a n t a g e s a re t h e
FIG 1 5 • Visce ral a rteries perfusion with b l ood, renal red uced isc h e m i a t i m e of t h e k i d n ey a n d k i n k p reve n t i o n o f
perfus i o n with co ld Custod i a l ® solution during branch a rtery t h e g raft after v i scera l d e rotat i o n at t h e e n d of t h e a o rt i c
re i m p l a ntat i o n . repa i r.

is m oved below t h e ren a l a rteri es, a n d t h e a n e u rysm is

opened across the d i a p h ra g m . The centrifu g a l p u m p
m a i nta ins visce ral perfusion (400 m l p e r m i n ute) fo l l ow­
i n g i n se rtion of the 9-Fr i rrigation-pe rfusion cath eters
(Le M a itre Vasc u l a r) i nto the ce l i a c tru n k and the superior
mesenteric a rtery. Cold perfusion of Custod iol1 2 (histid i ne­
tryptophane-ketogl uta rate) is d i rected i nto the ren a l
a rteries (FIG 1 5) . F o r visce ral a rtery re i m p l a ntation, a fen­
estration is created i n the g raft and the viscera l vessels a re
reattached as a s i n g l e patc h . Usual ly, the left ren a l a rtery
is reco n nected with an 8-mm polyester i nterposition g raft.
If viscera l a rtery orifi c i a l stenosis is encou ntered, before
placing the i rrigation perfusion catheter, the stenosis may
FIG 1 8 • Visce ral vessels a n d ren a l a rteries a re reattached
be resolved by d i rect p l acement of an a ppropriate-sized
sepa rate ly i n this patient with M a rfan syn d ro m e to red u ce a s
b a l l oo n-expa n d a b l e ste nt with i n the a rtery1 3 (FIGS 16 and m u c h a s poss i b l e the a o rtic native t i s s u e a n d p reve nt recu rrent
1 7). If creation of the viscera l patch req u i res reta i n i n g a a o rtic a n e u rysm format i o n .
l a rge seg ment of n ative aorta, we p refer to p l ace a m u l­
t i b ra nched g raft i nstead. This p rosthesis, although some­
what more time cons u m i ng, s i g n ificantly red uces the risk
of recurrent aortic patch a n e u rysm (FIG 1 8) . F i n a l ly, the
d i sta l end-to-end a n astomosis with the d i stal aorta is per­
formed, the g raft fl ushed, a n d c l a m ps rem oved (FIG 1 9) .

FIG 1 9 • End-to-end d ista l anastomosis at t h e aortic b ifu rcation.

FIG 1 6 • From left t o rig ht. I n case o f orifi c i a l stenosis,

intra l u m i n a l stents a re p l aced under d i rect visu a l ization before
i nsertion of the perfusion catheter and u ltimate re i m p l a ntati o n .
 C h a p t e r 1 2 EXPO S U R E A N D OPEN S U R G I CAL RECON STRUCT I O N I N T H E C H E S T 1 907

CLOSURE
• The entire a o rt i c repa i r (FIG 20) is i n s pected . A l l exposed
a o rtic branch p u lses a re p a l pated after derotati o n a n d
re p l acement o f the a b d o m i n a l viscera. A n y bleed i n g o r
k i n k i n g of the a o rtic b r a n c h e s i s add ressed at t h i s j u n c­
t u re . The atri a l a n d fe m o ra l ca n n u lae a re removed; the
pu rse-st r i n g sutu res a re tied a n d rei nforced. Antico­
a g u lation is reversed with p rota m i n e . The crus of the
d i a p h ra g m is rea p p roxi m ated to restore the a o rtic h i a­
tus (FIG 2 1 ) a n d the l eft h e m i d i a p h ra g m loosely sutu red
with a r u n n i n g polypropy l e n e suture. The l eft l u n g is
tempora r i ly i nfl ated to check for a i r leakage.
• A c l osed-suct i o n a b d o m i n a l d r a i n is p l aced n ext to the
a o rtic g raft i n the l eft retro perito n e a l spa ce, a n d two FIG 21 • The p i l l a rs of the d i a p h ra g m (arrows) a re approximated

ch est tu bes a re p l aced in the posteroa pical a n d basal with a bsorba ble sutu res to reshape the aortic hiatus.
pleural space. Absorba b l e pericosta l sutu res a re p l aced
to a p prox i m ate the ribs (FIG 22), and two stee l wi res a re
used to sta b i l i ze the costa l m a rg i n . The l u n g is i nflated,
and the correct expa n s i o n of a l l the segm ents is ca refu l ly
ch ecked; the pericosta l a n d d i a p h ra g matic sutu res a re
tig htened a n d l i gated . The steel wi res a re twisted a n d
bu ried i n the carti l a g i n o u s costa l m a rg i n . T h e a b d o m i ­
n a l fascia is cl osed w i t h a ru n n i n g suture. The a b d o m i n a l
a n d t h o ra c i c d r a i n s a re c o n nected t o suct i o n . T h e serra­
tus and latissi m u s dorsi m u scles a re a p p roxi m ated with
sepa rate a bsorba b l e sutu res. S u b d e r m a l l ayer is sutu red,
and the skin is cl osed with sta ples (FIG 23) .

FIG 22 • The thoracic wa l l i s repai red with pericosta l sutu res.

The l eft l u n g is i nfl ated and checked for a i r leakage; two ch est
tu bes a re positioned to d r a i n the u p p e r a n d lower thoracic
space.

FIG 23 • The a b d o m i n a l a n d thoracic wa l ls a re sutu red; skin

is closed with sta ples.

B
FIG 20 • F i n a l repa i r of a type I I TAAA. A. Sta n d a rd i n c l u s i o n
tec h n i q u e . B. Sel ective rei m p l a ntation w i t h m u ltibranched
g raft.
1 908 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

PEARLS AND PITFALLS

I n d i cations
Preoperative p l a n n i n g
S u r g i c a l access
Tec h n ical adj u n cts fo r organ
p rotect i o n
• Aortic d i a m eter a n d a n e u rysm m o r p h o l ogy
• Signs a n d sym ptoms of acute a o rtic syn d ro m e
• Leve l o f i ntercosta l i n c i s i o n
• G raft sel ection
• I d e ntification of accessory ren a l a rteries a n d other viscera l a n o m a l ies (e . g . , h o rseshoe k i d n ey)
• Pote nti a l need for m u ltibranch g raft vs. Carrel patch
• Avo i d s k i n f l a p necrosis.
• R i b sect i o n
• L i m ited p h re n otomy (circumferent i a l d i a p h ra g matic i n cision)
• Tra nsperito n e a l a p p roach
• Careful a n d l i m ited lung m a n i p u lation
• N o n occlusive fe moral ca n n u l at i o n
• Spinal cord drainage
• Left h e a rt bypass
• Sequenti a l a o rtic c l a m p i n g
• Critica l i ntercosta l a rtery reattachment
• Viscera l perfus i o n from l eft h e a rt bypass ca n n u las
• Re n a l perfus i o n with cold Custo d i a l ® o r s i m i l a r sol ution
• D i rect stenti n g of ren a l and visce ral orifi c i a l lesions a s needed

POSTOPERATIVE CARE
• The main focus of immediate postoperative management is
the early detection of neurologic or cardiovascular compli­
cation as prompt intervention may prevent substantial long­
term morbidity. As soon as baseline blood pressure and body
temperature are restored, sedation is lightened regardless of
ventilatory status. When SC or cerebral neurologic inj ury is
suspected, CT imaging is performed immediately to address
the possibility of intracranial or intradural SC hematoma.
In case of paraparesis or paraplegia, mean arterial pressure
is chemically maintained above 80 mmHg, CSFD is drained
in order to lower the cerebrospinal fluid pressure below
10 mmHg, and methylprednisolone ( 1 g bolus followed by
4 g per 24 hours continuous infusion) and 1 8 % mannitol
(5 mg/kg, four times a day) are administrated.
• If malperfusion develops in the lower limbs, renal or visceral
circulation, efforts should be made to restore normal cir­
culation immediately. For a precise visualization of visceral
organ perfusion, emergency arteriography (catheter-based
or CT) is required.
• Blood pressure fluctuations, including recalcitrant hyperten­
sion, is common in the early postoperative period, especially
in the chronically hypertensive patient; prompt attention
should be paid to regulating the mean arterial pressure in a
physiologic range. Immediate intervention may be required
to reduce the risk of anastomotic bleeding, especially in the
setting of dissection.
• In uncomplicated cases, drainage tubes are removed at 3 6
t o 4 8 hours postoperatively, whereas the intrathecal CSFD
catheter is removed usually after 72 hours. A prolonged re­
quirement for ventilatory support is not unusual, especially
after emergency operations, in patients with significant blood
loss and after longer periods of circulatory arrest (if neces­
sary for concurrent arch or ascending aortic reconstruction ) .
I n case o f severe chronic kidney disease, transient temporary
renal replacement therapy may also be necessary in the early
postoperative period.
COMPLICATIONS
• Bleeding
• Multiorgan failure
• Dialysis
• Paraplegia
• Stroke
• Death
• Aneurysm recurrence
REFERENCES
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coabdominal aortic aneurysms. Ann Thorae Surg. 2007;83:S862-S864.
3. MacArthur RG, Carter SA, Coselli JS, et al. Organ protection dur­
ing thoracoabdominal aortic surgery: rationale for a multimodality
approach. Semin Cardiothorae Vase Anesth . 2005;9: 143-149.
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spinal cord vascularisation: a pictorial essay. Eur J Vase Endovase
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5 . Kieffer E, Chiche L, Baron JF, et al. Coronary and carotid artery dis­
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mortality. Ann Vase Surg. 2002; 1 6 : 679-6 84.
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measured and estimated glomerular filtration rate. N Eng/ J Med.
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7. Mills JL Sr, Duong ST, Leon L R Jr, e t a l . Comparison of the effects
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8 . Cina C S , Abouzahr L, Arena G O , e t a l . Cerebrospinal fluid drainage
to prevent paraplegia during thoracic and thoracoabdominal aortic
aneurysm surgery: a systematic review and meta-analysis. J Vase Surg.
2004;40: 3 6-44.
9. Engle J, Safi HJ, Miller CC III, et al. The impact of diaphragm manage­
ment on prolonged ventilator support after thoracoabdominal aortic
repair. J Vase Surg. 1999;29 ( 1 ) : 1 50-1 56.
1 0 . Caselli JS. The use of left heart bypass in the repair of thoracoabdomi­
nal aortic aneurysms: current techniques and results. Semin Thorae
Cardiovase Surg. 2003 ; 1 5 : 326-332.
1 909
1 1 . Etz CD, Homann TM, Plestis KA, et al. Spinal cord perfusion after
extensive segmental artery sacrifice: can paraplegia be prevented?
Eur J Cardiothorae Surg. 2007;3 1 (4 ) : 643-648 .
12. Schmitto J D , Fatehpur S, Tezval H , e t a l . Hypothermic renal protec­
tion using cold histidine-tryptophan-ketoglutarate solution perfusion
in suprarenal aortic surgery. Ann Vase Surg. 2008;22(4 ) :520-524.
1 3 . LeMaire SA, Jamison AL, Carter SA, et al. Deployment of balloon
expandable stents during open repair of thoracoabdominal aortic
aneurysms: a new strategy for managing renal and mesenteric artery
lesions. Eur J Cardiothorae Surg. 2004;26:599-607.

Chapter 13 Thoracic Aortic Stent Graft
Repair for Aneurysm, Dissection,
I
and Traumatic Transection
- ----------------------------------- � -----------------------------------------------------
Bra n t W Ullery
DEFINITION
• In 1 994, Dake and colleagues/ at Stanford University, were
the first to report the use of custom-designed thoracic aortic
stem grafts for the treatment of descending thoracic aortic
aneurysms in patients deemed high risk for conventional
open surgery. Each of these devices was deployed through
peripheral arterial access, successfully excluding the aneu­
rysm from systemic pressurization. This groundbreaking
minimally invasive technique thereby avoided many of the
physiologic insults associated with open surgery, including
the need for thoracotomy, aortic cross-clamping, reperfusion
inj ury, and acute hemodynamic changes.
• Results from the first multicenter U . S . Food and Drug
Administration-sponsored trial for thoracic aortic stem
grafts demonstrated significantly less perioperative mortal­
ity, respiratory failure, renal insufficiency, and spinal cord
ischemia in patients after thoracic endovascular aortic re­
pair (TEVAR) compared to a matched cohort of patients
undergoing open descending thoracic aortic aneurysm
repair.2
• After two decades of surgeon experience and endovascu­
lar technologic advancement, TEVAR has evolved to serve
as a primary treatment strategy for an increasingly diverse
group of acute and chronic aortic pathologies including
thoracic aortic aneurysms, dissections, and traumatic tran­
sections .
DIFFERENTIAL DIAGNOSIS
• Depending on the type and extent of pathology, TEVAR
may include the use of fenestrated or branched stent
grafts, advanced snorkel/chimney/periscope techniques,
or the need for hybrid debranching procedures . The deci­
sion to treat thoracic aortic pathology with stent grafts
is based on individual patient comorbidity burden, de­
tailed analysis of thoracic aortic anatomy, and physician
experience.
• Acute thoracic aortic pathologies often present with chest
pain and therefore must be considered in the workup for
acute coronary syndrome. The ubiquitous use of computed
tomography ( CT) scanning for pain, shortness of breath,
trauma, and to " rule out" many pathologies has led to an
increase in the recognition of thoracic aortic pathology po­
tentially benefitting from TEVAR technology.
PATIENT HISTORY AND PHYSICAL FINDINGS
• Thoracic aortic aneurysms (TAAs ) are defined as local­
ized or diffuse dilation of 50% or more relative to the
diameter of the adj acent normal-sized aorta. Common
risk factors for aneurysmal degeneration include smok­
ing, hypertension, chronic obstructive pulmonary disease,
1910
-
�
Jason T. Lee
atherosclerosis, and connective tissue diseases. Indica­
tions for repair of descending TAAs are similar to those
for conventional open repair: maximum aortic diameter
greater than 6 em, rapid aneurysmal growth ( > 5 mm of
growth over 6 months ) , or symptoms such as persistent
chest or back pain, rupture, or dissection. In most patients
with TAA, the aneurysms were diagnosed following rou­
tine imaging ordered for other reasons and are therefore
most commonly asymptomatic.
• Aortic dissection occurs when an intimal tear in the aorta
causes blood to flow between the layers of the wall of the
aorta and most often presents as tearing chest pain that
radiates to the back. Potential etiologic factors leading to
aortic dissection include poorly controlled hypertension,
connective tissue disorders, trauma, or vasculitis. Medi­
cal management of uncomplicated type B thoracic aortic
dissection serves as the current standard of care. These
practice guidelines stem from the results of the INvestiga­
tion of STEm grafts in patients with type B Aortic Dis­
section (INSTEAD ) trial, the first prospective, multicenter
randomized trial comparing optimal medical therapy ( e . g . ,
b l o o d pressure control) to TEVAR for uncomplicated type
B dissection.3 This trial demonstrated no significant im­
provement in 2-year survival or adverse event rates with
TEVAR despite favorable aortic remodeling, although re­
cently reported 5-year data suggest improved long-term
survival in patients undergoing TEVAR. In contrast, for
patients with complicated type B dissections involving
rupture, malperfusion ( e . g . , visceral or limb ischemi a ) , or
refractory back pain despite optimal medical management,
TEVAR is indicated. The goal of TEVAR in this setting is
to cover, or exclude, the primary entry tear and reexpand
the true lumen while promoting thrombosis of the false
lumen.
• Traumatic aortic transection results from a high-velocity or
deceleration injury to the aorta. The tethering of the aorta
by the ligamentum arteriosum makes this site most suscep­
tible to shearing forces during sudden deceleration. A high
index of suspicion is necessary to help make the diagnosis.
Trauma workups most often involve whole-body CT scan­
ning, which allows rapid triage for possible treatment. CT-A
commonly demonstrates an irregular outpouching beyond
the takeoff of the left subclavian artery at the aortic isthmus,
which corresponds to the presence of an aortic pseudoan­
eurysm caused by the traumatic event. Extent of blunt trau­
matic aortic injury and the corresponding physiologic insult
may range from clinically occult intimal inj ury to life-threat­
ening complete transection and rupture ( FIG 1 ) .4 Early diag­
nosis and endovascular treatment is generally recommended
for those presenting with a traumatic aortic transection, par­
ticularly when there is a contour abnormality visualized on
cross-sectional imaging.
 C h a p t e r 1 3 THORACIC AORT I C STENT G RAFT REPA I R
GRADEl GRADE II
GRADE Ill GRADE V
I
Pseudoaneurysm Rupture
IMAGING AND OTHER DIAGNOSTIC STUDIES
• Transesophageal echocardiography (TEE) may serve as
a useful imaging tool, particularly in the setting of acute
thoracic aortic pathology. TEE can confirm the presence of
aortic dissection, distinguish between types A and B dissec­
tions, identify involvement of supra-aortic vessels, and as­
sess for contained rupture.
• High-resolution computed tomography angiography ( CT-A)
with three-dimensional reconstructive software allows for the
most complete anatomic analysis, including details regarding
aneurysm morphology, diameter, dissection flap characteriza­
tion, thrombus burden, calcification, angulation, and branch
vessel orientation.
• Familiarity and routine usage of three-dimensional worksta­
tions and the ability to customize measurements provide an
accurate road map to guide endovascular strategy, device se­
lection, and stent graft sizing.
SURGICAL MANAGEMENT
Preoperative Planning
• Patients scheduled for elective TEVAR undergo routine pre­
operative cardiac evaluation. Based on cardiovascular risk
1 91 1
FIG 1 • Society for Vasc u l a r S u rgery cl assification
of b l u nt tra u m atic a o rtic i nj u ry. (Ada pted from Lee
WA, M atsu m u ra J S, M itch e l l RS, et a l . E n d ovasc u l a r
repa i r o f tra u m atic t h o racic a o rt i c i nj u ry: c l i n ical
p ractice g u i d e l i n es of the Soci ety for Vasc u l a r
S u rg e ry. J Vase Surg. 2 0 1 1 ; 5 3 : 1 87-1 92.)
profile, symptomatology, and presence of electrocardiogram
abnormalities, selected patients undergo further evaluation
in the form of an exercise stress test, dobutamine stress echo­
cardiography, or Persantine thallium stress testing. Coro­
nary angiography is pursued in cases involving extensive or
symptomatic coronary artery disease.
• Aortic transections or symptomatic dissections and an­
eurysms should have early and aggressive blood pressure
control using intravenous beta-blocker or calcium channel
blocker medications. After obtaining a reliable clinical ex­
amination, refractory chest, back, or abdominal pain should
be treated with narcotic analgesics.
• Renal protective strategies should be employed preopera­
tively to minimize the risk of contrast-induced nephropathy.
Intravenous hydration is initiated preoperatively and, in the
setting of baseline renal insufficiency, may warrant early
hospital preadmission and concomitant administration of
Mucomyst and bicarbonate infusion.
• Suspected blunt aortic injury should prompt a referral to a
level I trauma center in order to facilitate early evaluation
by a vascular specialist and other pertinent members of a
multidisciplinary trauma team.
• General anesthesia is routinely performed in TEVAR cases.
Prophylactic lumbar cerebrospinal fluid (CSF) drainage is
1 912 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY
considered in every case based on the relative risk of spinal
cord ischemia, hemodynamic status, and acuity of clinical
presentation. Arterial monitoring is performed via a right
radial artery approach. Peripheral intravenous lines are
typically adequate; however, more intensive central venous
monitoring may be required in cases involving unstable trau­
matic transections, patients with significant baseline cardio­
vascular comorbidities, or any case involving hemodynamic
instability.
• Preoperative imaging should be heavily scrutinized for the
adequacy of iliofemoral access anatomy. An iliac conduit
may be required in cases involving small-caliber, tortuous, or
heavily calcified access vessels. Anticipated use of a conduit
should prompt consideration of an autotransfusion or cell
saver machine to be available during the procedure.
• Numerous variables have been identified as risk factors
for the development of spinal cord ischemia after TEVAR.
Given that hypoperfusion represents the primary etiol­
ogy of spinal cord inj ury following TEVAR, commonly
cited risk factors involve those relating to the extent of
impairment or exclusion of the collateral perfusion to the
spinal cord. The European Collaborators on Stent/Graft
Techniques for Aortic Aneurysm Repair ( EUROSTAR)
investigators reported results from the largest multicenter
registry to date (N = 6 0 6 ) . 5 In the EURO STAR registry,
the incidence of spinal cord ischemia was 2 . 5 % and inde­
pendent risk factors included left subclavian artery cover­
age without revascularization (odds ratio [OR], 3 . 9 ; p =
. 0 3 7 ) , concomitant open abdominal aortic surgery (OR,
5.5; p = .037), and the use of three or more stent grafts
(OR, 3 . 5 ; p = .043 ) .
•
Based o n the principle that spinal cord perfusion pressure
is approximated by the difference between the mean arte­
rial pressure (MAP) and CSF pressure, placement of a pro­
phylactic lumbar drain has the potential to increase spinal
cord perfusion pressure by decreasing CSF pressure and may
be beneficial in select patients at high risk for spinal cord
ischemia. Percutaneous drainage of CSF is performed by in­
serting a silastic catheter 10 to 15 em into the subarachnoid
space through a 1 4-gauge Tuohy needle at the L3-L4 verte­
bral interspace. The open end of the catheter is attached to a
sterile closed circuit reservoir and the lumbar CSF pressure
is measured with a pressure transducer zero-referenced to
the midline of the brain. Lumbar CSF can be drained con­
tinuously or intermittently in the operating room to achieve
target CSF pressures of 10 to 12 mmHg. Postoperatively,
intermittent or continuous CSF drainage can be contin­
ued in the intensive care unit for CSF pressures exceeding
10 mmHg or at the first sign of lower extremity weakness. In
the absence of neurologic deficits, the lumbar CSF drainage
catheter can be clamped 24 hours postprocedure followed
by continued monitoring of CSF pressure together with se­
rial neurologic assessments. The CSF drain can then be re­
moved at 4 8 hours after operation. Although prophylactic
or therapeutic lumbar CSF drainage has an established re­
cord of safety, complications have been reported to occur
in approximately 1 % of patients, which may include neur­
axial hematoma, subdural hematoma, catheter fracture,
meningitis, intracranial hypotension, chronic CSF leak, and
spinal headache.
Selection and Sizing of Thoracic Stent Graft
Landing zones
• Proximal and distal landing zones must be of sufficient
length (usually at least 2 em) to enable safe and accurate
deployment bracketing the area of thoracic aortic pathology,
which often includes the subclavian artery proximally or the
celiac artery distally.
• Intentional coverage of the left subclavian artery is some­
times required due to a very proximal extent of aortic pa­
thology, especially transections. Left subclavian artery
revascularization may be required in select cases. The celiac
artery rarely requires intentional coverage.
• Significant tortuosity, circumferential mural thrombus, and
extensive calcification can compromise the proximal or dis­
tal landing zone, thereby predisposing to inadequate fixa­
tion and subsequent development of endoleak or migration.
Site of proximal and distal landing zones should be selected
in order to minimize the impact of these anatomic features,
even if it requires extending the length of aortic coverage.
• A variety of anatomic measurements are taken from preop­
erative CT-A imaging to assist in the sizing and selection of
the thoracic stent graft ( FIG 2 ) . Interventionalists should be
proficient in accurate sizing and measuring of key thoracic
aortic locations that influence device selection and ultimately
determine patient outcomes.
Sizing of stent grafts
• The degree of stent graft oversizing can vary based on the in­
dication for intervention. Stent grafts are generally oversized
by 1 0 % to 2 0 % based on the aortic diameter at the proximal
and distal fixation sites for aneurysmal disease. Insufficient
oversizing for the treatment of TAAs may predispose to in­
adequate exclusion and the potential for endoleak or migra­
tion. Aggressive oversizing, on the other hand, increases the
risk for stent graft collapse, graft thrombosis, access arterial
injury, and potential for peri- or postprocedural iatrogenic
retrograde type A dissection.
• Chronic type B dissections are frequently characterized by a
thick, nonmobile dissection flap, or septum, that separates
true and false lumens into concave or convex discs of flow
lumen. Such dissection flaps have limited compliance; there­
fore, minimal or no oversizing may be required in order to
achieve a suitable proximal or distal seal.
• Aortic transections frequently occur in young trauma pa­
tients with normal or minimally diseased aortas. As such,
minimal oversizing is needed to achieve an adequate seal
and only recently did device manufacturers create devices
meant for smaller diameter aortas. Note also that under­
rescucitated patients on admission will have smaller aortic
diameters on their CT-A.
• Currently available stent grafts range in diameter from 22 to
46 mm. Given the traditional 1 0 % to 20% rule of device over­
sizing, these devices are designed to safely treat aortas with
landing zones ranging from 19 to 43 mm in diameter.
Access vessel anatomy
• Current thoracic aortic stent grafts require large-caliber deliv­
ery systems, ranging from 1 8 to 26 Fr in outer diameter. Small,
 Ch a pt e r 1 3 THORACIC AORT I C STENT G RAFT REPA I R 1 913

Measu rements t o b e taken during the pretreatment

assessment of isolated lesions are described below:

A, B, C. Proximal aortic neck diameter (minimum of 1 em

apart)
D. Maximum lesion d i ameter
E, F, G. Distal aortic neck d i ameter (min imum of 1 em apart)
H. R ight common i l i ac artery d i ameter
I . Left common iliac artery diameter
J. Right external i l i ac/femoral artery d i ameter
K. Left external i l i ac/femoral artery d i ameter
L. Distance between the left subclavian/left common carotid
artery and the proximal end of the lesion (mi n imum of 2 em)
M. Length of the lesion measu red along the g reater
cu rvature of the flow l umen
N. Distance between the d i stal end of the lesion and the
cel i ac axis (min imum of 2 em)
0. Total treatment length

Measu rements to be taken d u ring the pretreatment

assessment of dissections are described below:

01. Diameter a t proximal extent o f proximal landing zone

(must be i n nondissected aorta)
02. Maximum transverse aortic diameter (combined true
A and false l umen)
T1. Maximum true l umen diameter i n DTA
T2. Min imum true l umen diameter in DTA
F. Maximum false lumen d i ameter in DTA
A1. Right access vessel diameter (common iliac, external
i l i ac, femoral)
A2. Left access vessel d i amter (common i l i ac, external i l i ac,
femoral)
L1. Proximal landing zone length from proximal end of
primary entry tear to left subclavian or left common carotid
L2. Distal neck length from distal end of primary entry tear
to cel i ac
TTL. Total treatment length from left subclavian or left
common carotid

B
FIG 2 • Anatomic measurements to assist i n tho racic stent graft device siz i ng and selectio n f o r the treatment of aneu rysms (A) a n d
d issect i o ns (B) . DTA, descen ding tho racic ao rta.
1 914 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

tortuous, and heavily calcified iliofemoral arteries may prohibit

sheath advancement and predispose to access site-related com­
plications, including groin hematoma, dissection, or rupture.
• Careful evaluation of access vessel anatomy on preopera­
tive imaging should be performed in order to assess the cali­
ber, tortuosity, thrombus burden, and extent of calcification
of the iliofemoral arteries. Such anatomic information will
A
serve as the basis for deciding laterality of femoral access as
well as to determine the need for an iliac conduit.
• Serial dilation may be attempted for patients with small il­
iofemoral vessels. Iliac atherosclerotic lesions may be pre­
treated with balloon angioplasty and/or stent grafting in
order to facilitate sheath advancement and introduction of
the thoracic stent graft components.
• Iliac conduits serve as a safe and reliable technique to circum­
vent issues related to suboptimal access vessel anatomy. From B
either flank incision, a retroperitoneal exposure provides visu­ FIG 3 • A. 1 0- m m Dacron c o n d u i t b isected l o n g itu d i n a l ly to
alization of the common iliac artery or distal abdominal aorta. create a sew i n g patc h . B. Dacron i l i a c co n d u it sewn to native i l i a c
A 10- or 1 2-mm Dacron graft is commonly used as the conduit a rtery a l l ows easy m o b i l ity of the c o n d u i t at m u lt i p l e a n g les o f
of choice. The conduit can be modified by creating a patch at entry for l a rge-ca l i be r device o r sheath. ( F r o m L e e JT, L e e G K,
the distal end in order to further facilitate the delivery of large­ C h a n d ra V, et a l . Compa rison of fen estrated endog rafts a n d the
caliber sheath and enable additional degrees of torqueability s n o rkel/ch i m ney tec h n i q u e [ p u b l ished o n l i n e a h e a d of p r i n t Apri l
27, 2 0 1 4 ] . J Vase Surg. doi:1 0 . 1 0 1 6/j .jvs . 2 0 1 4.03.255.)
( FIG 3) . This modification involves creating a patch by cutting
the Dacron graft along its long access, thereby enlarging the
transition zone from the graft to artery.

• The fe m o r a l a rtery is p u nctured u s i n g a sta n d a rd m i cro­

EARLY PROCEDURAL CONSIDERATIONS
Positioning
• The C-a rm is typica l l y confi g u red i n the " h ead " posit i o n .
The left a r m may be a b d u cted to 75 to 90 deg rees a n d c i r­
cu mferenti a l l y prepped i nto the field if an e m b o l izat i o n
o r s n o rkel/c h i m ney p roced u re involvi n g the l eft s u b c l a ­
v i a n a rtery is a ntici pated. The chest, a bdomen, a n d b i ­
l atera l g r o i n s s h o u l d be prepped . A s freq uently o n ly one
g r o i n access i s req u i red for the perfo rmance of a rout i n e
TEVAR, latera l ity of the o perator p o s i t i o n may vary based
o n su rgeon p reference o r a ntici pated access site l ocat i o n .
Establishing Vascular Access
• The i psi l ateral fe moral a rtery is accessed either percuta ne­
• O v e r the stiff Lu n d e rq u ist w i re p l atfo rm, the 7-Fr s h eath
ously o r from a n open exposure. Seco n d a ry access may
be o bta i n ed from the contra l atera l femoral a rtery o r bra­
c h i a l a rtery as needed fo r a 5-Fr sh eath a n d flush catheter.
S u rg i c a l exposure is obta i ned from a s m a l l o b l i q u e i nci­
sion at the level of the i n g u i n a l l i g a ment. The common
femoral a rtery is exposed, with p roxi m a l control o bta i ned
• After p l acement of the l a rg e r sheath, syste m i c h e p a r i n
at the l eve l of the exte r n a l i l iac a rtery and d ista l control
at the l eve l of the fe moral bifu rcation o r prox i m a l su perfi­
cial femora l and p rofu nda fe moral a rteries. Heavy calcifi­
cation may req u i re preem ptive e n d a rterectomy and patch
a n g i o p l asty i n order to fac i l itate safe sheath p l acement.
p u n ct u re set, and if a rte r i a l access is obta i ned percuta ne­
ously, a s h eath ogram is performed to confirm a d e q u ate
p u n ct u re site location ( m i d-co m m o n fe m o ra l a rte ry) . A
sta n d a rd l e n gth B e ntson w i re is i n se rted i nto the a o rta
t h r o u g h m icropu ncture sheath a n d exc h a n g e for a 7-Fr
sh eath is then performed u s i n g S e l d i n g e r tech n i q u e .
W i re exc h a n g e is t h e n d o n e f o r a 260-cm stiff L u n d e r­
q u i st wire. The L u n d e rq u i st w i re s h o u l d h ave a flexi b l e,
cu rved prox i m a l e n d that s h o u l d be adva nced u n d e r
f l u o roscopy across the a o rtic a rch to a b ut t h e a o rt i c
va l u e . The l o c a t i o n of t h e d ista l end of t h e Lunderqu ist
w i re s h o u l d be m a rked o n the operat i n g ta b l e and t h i s
w i re position s h o u l d be m a i ntained t h ro u g hout t h e
p roced u re .
is removed and seri a l d i lators are adva n ced to g ra d u a l l y
e n l a rg e the su bcuta neous tract a n d a rteriotomy site i n
order t o acco m m o d ate either t h e ste nt g raft device itse lf
o r a l a rg e r 1 8- to 26-Fr i ntrod ucer s h eath req u i red for
device d e l ive ry.
is a d m i n istered at a d o s e of 1 00 u n its/kg (g o a l activated
c l ott i n g t i m e of >2 50 seco nds). Concom itant t ra u matic
i nj u ri es, p a rticu l a r l y i n t racra n i a l h e m o rrhage, may a lter
the dose o r decision to a d m i n ister h e p a ri n .

INITIAL AORTOGRAM T h i s catheter m a y b e advanced v i a a contra latera l 5-Fr

sheath o r it may be i nserted i nto a n a d d i t i o n a l i p s i l atera l
• A 5-Fr 1 00-cm O m n iflush or p i gta i l catheter is i n se rted 5-Fr sheath p l a ced d i st a l to the a rteriotomy for t h e m a i n
i nto a o rta and adva n ced to the level of the a o rtic a rch . body del ivery sheath.
 C h a p t e r 1 3 THORACIC AORT I C STENT G RAFT REPA I R 1 91 5

• If satisfied w i t h ste nt g raft s i z i n g based o n ava i l a b l e pre­ Device Deployment

operative i m a g i ng, the thoracic a o rtic ste nt g raft may be
• Precise prox i m a l positi o n i n g of the ste nt g raft is fa­
adva nced over the L u n d e rq u i st w i re and be positioned i n
t h e p roxi m a l t o m i d portion o f t h e t h o racic a o rta p r i o r to c i l itated by either m a r k i n g the location of the l eft sub­
i n it i a l a o rtog ra m . clavian a rtery o n the view i n g screen a n d/or u s i n g the
• O pti m a l a n g i o g ra p h i c i m a g i n g o f t h e a o rtic a rch is ob­ road-m a p p i n g feature. The d ista l rad i o p a q u e line of the
t a i n e d by placing the f l u o rosco p i c C-a rm i n a l eft a nte­ e n d otrach e a l t u b e seen o n f l u o roscopy at a bout 45 de­
rior o b l i q u e o r i e ntation, often 3 5 to 6 5 deg rees, and can g rees l eft a nterior o b l i q u e can sometimes corre l ate to
be optim ized by refere n c i n g the preoperative CT-A. The the position of the l eft c o m m o n ca rotid a rte ry, t h ereby
l ocat i o n of the s u p ra-aortic vessels, p a rticu l a rly the left servi n g as a conve n i e n t l a n d m a r k in cases req u i r i n g l eft
s u bclavian a rte ry, s h o u l d be n oted a n d m a rked on view­ s u bclavian a rtery cove rage.
• I m m ed iately prior to ste nt g raft d e p l oyme nt, syste m i c
i n g m o n itors (FIG 4A) .
• I ntravasc u l a r u ltraso u n d ( I V U S ) may be u s e d a n adju nct a rte r i a l b l ood pressu re is red uced below 1 00 m m H g to
i n cases i nvo l v i n g d i ssection to assist i n the i d e ntification reduce risk of ca u d a l m i g rati o n .
• T h e stent g rafts a re g e n e ra l ly d e p l oyed i n a p roxi m a l -to­
of true a n d false l u m e n s, a s we l l as to gain a d d i t i o n a l
i nfo rmation o n a o rtic d i a m eter, branch vessel location, d ista l sequence. H owever, a d i stal-to-prox i m a l sequence
a n d m o r p h o l ogy of prox i m a l a n d d ista l l a n d i n g zones. may be p refe rred i n cases i nvolvi n g precise d e p l oyment
IVUS a l so a i d s i n l i m it i n g i ntrave n o u s contrast exposure n e a r the ce l i a c a rtery o r i n a o rtas with s i g n ificant d i a m ­
in t h ose patie nts with base l i n e i m p a i red re n a l f u n ct i o n . eter t a p e r a n d a l a rg e r p roxi m a l l a n d i n g z o n e compa red
• If n ecessa ry to g u ide d ista l exte nt of ste nt g raft p l ace­ to the d ista l l a n d i n g zone (wh e re devices of d i ffe rent d i ­
m ent, the ce l i a c a rtery is best i m a g e d from a fu l l latera l a m eter may n e e d t o be sta cked u p o n e a c h other).
• D e p l oyed endog rafts w i l l natu ra l ly exte n d toward the
p roj ect i o n . Ad d iti o n a l structu res to n ote a re l a rge, pa­
tent i ntercosta l a rteries at the level of the a o rtic h i atus. outer cu rvature of the a o rta and p recision d e p l oyment
Efforts should be m a d e to avoid cove r i n g t h ese if at a l l is fac i l itated by gently p rovi d i n g forwa rd tract i o n o n the
poss i b l e d u r i n g t h e cou rse o f t h e repa i r. w i re toward the outer cu rve during d e p l oyment. This

A B

FIG 4 • A. I n it i a l thoracic a o rtogram performed with C-a rm i n a

45-deg ree l eft a nterior o b l i q u e orientation i n a case i nvolvi n g a type B
a o rtic d issect i o n . N ote h ow clearly the o r i g i n of the subclavi a n (arrow)
is seen to accu rate ly decide if there is a d e q u ate p roxi m a l neck l e n g t h .
B. Ao rtogram fo l l ow i n g d e p l oyment of t h o r a c i c ste nt g raft w i t h
cove rage of the ost i u m of the l eft subclavian a rte ry. C. Posto perative
th ree-d i m e n s i o n a l i m a g i n g d e m o n strat i n g successf u l exc l u s i o n of the
c p roxi m a l entry d i ssection tea r.
1 916 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY
m a n euver a l so fac i l itates stra i g hte n i n g out of the tra ns­
verse a rch, w h i c h can be h e l pf u l in m i n i m i z i n g the " b i rd­
bea k i n g " effect at the p roxi m a l g raft m a r g i n , where the
device may not fully o ppose to the " i n n er" a o rtic wa l l .
B i rd bea k i ng, when p resent, c a n predispose t o prox i m a l
type I e n d o l e a ks, endog raft co l l a pse, a n d potenti a l a o rt i c
occ l u s i o n .
• Ad d i t i o n a l g raft co m p o n e nts a re added, w h e n n eces-
sa ry, by exch a n g i n g the fi rst device over the L u n d e rq u i st
wire. A m i n i m u m ove r l a p of 5 em between p i eces i s
reco m m e nded to e n s u re a d e q u ate a p position a n d m i n i-
m ize risk of j u n ct i o n a l (type I l l) e n d o l e a k .
Balloon Molding
• B a l loon m o l d i n g is often req u i red in cases i nvolvi n g TAAs.
U n der f l u o rosco p i c g u i d a n ce, a n o n co m p l i a n t m o l d i n g
COMPLETION AORTOGRAM
• After stent g raft d e p l oy m e nt, t h e p i g ta i l catheter is
w i t h d rawn a l o n g t h e outside of t h e d e p l oyed devi ce(s)
over a w i re to b e l ow the level of the stent g raft. T h e
c a t h e t e r i s t h e n readva nced over a w i r e with i n t h e
REMOVAL OF SHEATH AND
ARTERIOTOMY CLOSURE
• I n cases i nvolvi n g pe rcuta n e o u s access, t h e two p revi­
ously p l aced Percl ose Pro G i i d e devices a re used to c l ose
the a rteriotomy site(s) (see Pa rt 6, C h a pter 23 for de­
t a i ls). If open s u r g i c a l exposure was o bta i n ed, prox i m a l
LEFT SUBCLAVIAN ARTERY
REVASCULARIZATION
• E n d ovasc u l a r p roced u res that req u i re cove rage of the
l eft subclavi a n a rte ry h ave the pote n t i a l to i n crease the
risk of spinal cord i nj u ry by co m p ro m i s i n g b l ood flow to
the i p s i l atera l vertebral a rte ry, a n i m portant co l l atera l
pathway for a rte r i a l flow to t h e a nterior s p i n a l a rte ry.
S u bc l a v i a n a rtery revascu l a rization the refore se rves as
a n a d d iti o n a l strategy to decrease the risk of s p i n a l cord
isch e m i a i n sel ect patie nts deemed high risk.
• Tec h n i q ues to revasc u l a rize the l eft subclavian a rtery
i n c l u d e transposition of the subclavian onto the l eft ca­
rotid a rtery o r l eft ca rotid-subclavian bypass g raft i n g
w i t h su bseq uent e m b o l i zation o f the l eft subclavian a r­
tery proxi m a l to the bypass g raft (FIG 5) . These revas­
c u l a rization p roced u res may be pe rfo rmed a s p a rt of a
sta ged repa i r or at the t i m e of TEVAR.
• The existi n g c l i n ica l evidence to s u p p o rt the efficacy of
ro utine l eft subclavian a rtery revasc u l a rization re m a i n s
controvers i a l ; t h e r e a re advocates fo r rout i n e revascu­
l a rization, sel ective reva sc u l a rization, o r n o revasc u l a r­
izat i o n . A m eta-a n a lysis of p u b l ished stud ies showed a
balloon (Coda [Cook Medical, B l o o m i n gton, IN, U SA]
o r Tri-Lobe [W. L. G o re, F l a g staff, AZ, U SA]) is adva nced
u p to the p roxi m a l edge of the ste nt g raft and b a l loon
m o l d i n g is performed in a p roxi m a l -to-d ista l seq uence.
B a l loon m o l d i n g should be pe rfo rmed at the p roxi m a l
a n d d i sta l fixati o n sites, a s we l l as at a reas o f ste nt g raft
ove r l a p in those cases req u i ri n g m u lt i p l e ste nt g rafts.
• Agg ressive b a l l o o n i n g can cause component fract u re
a n d a o rtic i n j u ry, a n d ca re m ust be taken d u r i n g i nfla­
t i o n with consta nt v i s u a l ization a n d knowledge of the
tension a p p l i ed to the b a l l o o n .
• B a l loon m o l d i n g is n ot typica l ly req u i red i n cases i nvo lving
aortic d i ssection o r transection, p a rticu l a rly i n cases where
no obvious endoleak is visu a l i zed. B a l loon m o l d i n g may
i ncrease risk for iatrog e n i c retrograde type A convers i o n
if perfo rmed i n a reg ion o f fri a b l e o r fra g i l e a o rta a n d is
genera l ly not recom mended during d i ssection cases.
stent g raft l u m e n a n d p o s i t i o n e d at the level of t h e
aortic a rc h .
• Ad d i t i o n a l a o rtograms may be pe rfo rmed at t h i s t i m e a s
necess a ry i n order t o e n s u re a d e q u ate stent g raft posi­
tion a n d pate n cy of the s u p ra-aortic a n d ce l i a c a rteries
and to assess for the presence of e n d o l e a ks.
a n d d i sta l vasc u l a r control is obta i n e d i n t h e respective
g r o i n . All wi res and s h eaths a re rem oved . The a rteriot­
omy is cl osed tra n sverse ly u s i n g a polypropyl e n e sutu re
in either a r u n n i n g cont i n u o u s or i nterru pted fas h i o n .
Anteg rade a n d retro g ra d e f l u s h i n g m a n e uvers s h o u l d
be perfo rmed p r i o r t o co m p l et i o n o f t h e a rteriotomy
c l o s u re .
t r e n d towa rd i n creased risk of s p i n a l c o r d isch e m i a w h e n
the l eft subclavian a rtery was covered, s u g g esti n g a po­
tent i a l benefit for l eft subclavian a rtery revasc u l a riza­
tion, but the f i n d i n g was not statistica l ly s i g n ifica nt.4-6
FIG 5 • Left su bclavi a n a rtery transposition is performed by
l i g at i n g the l eft s u bclavian a rtery p roxi m a l to the verte bral
a rtery a n d m ovi n g it ce p h a l a d i n order to perform a n end­
to-side a n a stomosis between the l eft subclavian a n d l eft
c o m m o n ca rotid a rteries. Alternative ly, a Dacron g raft can be
used as a l eft ca rotid-subclavian bypass.
 C h a p t e r 1 3 THORACIC AORT I C STENT G RAFT REPA I R 1 91 7

• I V U S se rves as a u sefu l a dj u n ct i n d i ssect i o n ca ses,

SPECIAL CONSIDERATIONS BASED ON
both in terms of i n it i a l i d e ntificat i o n of true and fa l s e
AORTIC PATHOLOG Y
l u m e n , a s we l l a s a s s i st i n g i n precise positi o n i n g of t h e
Aortic Dissection device.

• The p r i m a ry g o a l of TEVAR for the treatment of d i ssec- Aortic Transection

t i o n is cove rage of the p roxi m a l entry tea r (FIG 6A,B) .
• Tra u m atic a o rtic i n j u ries a re typica l ly l ocated a l o n g the
Stent g raft s i z i n g is based o n the d i a m eter o f the adjacent
inner cu rve of the p roxi m a l desce n d i n g t h o ra c i c a o rta
n o n d i ssected t h o racic a o rta. M i n i m a l o r n o ove rs i z i n g of
the ste nt g raft is reco m m e n d e d .
(FIG 7). G i ve n the p roxi m a l locat i o n , l eft subclavian
•
a rtery cove rage i s sometimes needed.4
I n acute type B d i ssectio ns, the sept u m is relatively mo­
• I n the a bsence of concom itant hemorrhage o r b ra i n
bile a n d com p l i a nt. Therefore, the d i a m eter of the sma l l
i n j u ry, rout i n e h e p a r i n i s reco m m e n d e d .
true l u m e n i n t h e d i ssected port i o n often ret u r n s to
• Tra u m a patie nts a re freq uently hypovo l e m i c a n d , a s a re­
n o r m a l d i a m eter fo l l owi n g successf u l exc l u s i o n of the
su lt, may have an u n d e rd i ste nded a o rta o n p reope rative
prox i m a l entry tea r.
•
cross-sect i o n a l i m a g i n g . I n it i a l cross-sect i o n a l i m a g i n g
C h r o n i c d i ssect i o n s have t h icker, less co m p l i a n t septa,
can u n d e rest i m ate t r u e a o rtic m o r p h o l ogy at t h e reg i o n
w h i c h may l i m it expa n s i o n of the true l u m e n desp ite ad­
of the s u b c l a v i a n by as m u c h a s 1 0 % to 2 0 % . I n such set­
e q u ate entry tea r coverage. Ofte n, these patie nts h ave
t i n gs, IVUS may assist in more accu rate ste nt g raft s i z i n g
c h r o n i c false l u m e n a n e u rysm a l d i lation, a n d entry tea r
pe rfo rmed i n vivo.7
a n d fe n estrati o n cove r i n g se rve s i m p l y to decrease fa lse
l u m e n pressu rization and prom ote t h ro m bosis.

A B
FIG 6 • A. CTA reco nstruct i o n d e m o n strat i n g co m p l ex t h o racoa bdom i n a l a o rtic d i ssection with p roxi m a l entry tea r l ocated i n
t h e proxi m a l desce n d i n g thoracic a o rta. B. I n it i a l a o rtogram docu m e n t i n g positi o n o f t h e s u p ra-aortic a rteries. N ote t h e ste nt
g raft h a s been adva nced i nto a p p roxi m ate positi o n but is not yet d e p l oyed .
1 918 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

c
FIG 7 • A. Th ree-d i m e n s i o n a l reco nstructed i m ages s h ow i n g the presence of t ra u matic a o rtic tra nsect i o n at the level of the
l i g a m entum a rteriosum (arrow). B. Aortogram s h ow i n g foca l outpo u c h i n g (arro w) along the inner cu rve of the p roxi m a l
desce n d i n g thoracic a o rta, corre l a t i n g to the t ra u m atic transect i o n observed o n p reoperative i m a g i n g . N ote t h a t the ste nt g raft
has been advanced i nto the proxi m a l desce n d i n g thoracic a o rta but is not yet dep l oyed . C. Aortogram fo l l owi n g t h o racic ste nt
g raft d e p l oyment with successful exc l u s i o n of the transect i o n site.
 C h a p t e r 1 3 THORACIC AORT I C STENT G RAFT REPA I R 1 919

PEARLS AND PITFALLS

I n d icat i o n s • TEVAR fo l l ows g e n e ra l reco m m e ndations for e l ective repa i r o f desce n d i n g t h o racic a n d thoracoa b d o m i -
n a l a o rtic a n e u rysms a n d s h o u l d be offered to good a n ato m i c risk patie nts with a n e u rysms > 6 e m .
• Patient select ion s h o u l d t a k e i nto acco u n t t h e n eed f o r reg u l a r i nte rva l c l i n ica l a n d ra d i o l o g i c fo l l ow-u p
i n order t o m o n itor f o r ste nt g raft-re lated co m p l icat i o n s a n d e n d o l e a ks .

Preope rative w o r k u p
• H i g h-qua l ity i m a g i n g a n d a b i l ity to confi g u re th ree-d i m e n s i o n a l reco nstructive softwa re a re essenti a l
f o r successf u l p reope rative p l a n n i n g a n d device select i o n .
• Pre- a n d perio perative hyd rat i o n is a centra l p a rt i n the p rotect i o n f r o m contrast- i n d uced n e p h ropathy.
• Pati e nts s h o u l d be stratified accord i n g to base l i n e risk of s p i n a l cord isch e m i a . A prophylact i c l u m ba r
d r a i n s h o u l d b e considered i n those a t h i g h risk.

Patient set u p • A h y b r i d e n d ovascu l a r su ite p rovides o pt i m a l opport u n ity f o r accu rate i m a g i n g a n d ca pa b i l ity t o
perfo rm n ecessa ry o p e n s u r g i ca l exposure o r repa i r o f access-rel ated co m p l i cations.
• Antici pated adju nct procedu res, i n c l u d i n g l eft subclavian a rtery e m b o l ization o r revasc u l a rization, may
req u i re p re p p i n g the l eft neck a n d/o r a r m i nto the s u r g i ca l f i e l d .

T h o r a c i c a n e u rysms • Overs i z i n g of ste nt g rafts by 1 0 % to 20% a n d ba l l oo n m o l d i n g is g e n e ra l ly reco m m e n d ed i n order to

maxim ize proxi m a l a n d d i sta l fixat i o n .
• Proxi m a l a n d d i stal l a n d i n g z o n e s s h o u l d be relatively free o f ste n osis, cal cification, a n d t h r o m b u s t o
maxim ize d u ra b i l ity of t h i s m i n i m a l ly i nvasive tech n o l ogy.

Type B d i ssect i o n
• Accu rate i d entificat i o n of true a n d f a l s e l u m e n is essenti a l p r i o r to d e p l oyment of the ste nt g raft.
IV U S may be a usefu l adj u n ct in t h i s sett i n g to confi rm true o r false l u m e n posi t i o n .
• Agg ressive ove rs i z i n g of stent g rafts is not reco m m e n d ed i n patie nts with a o rt i c d issect i o n . B a l loon
molding is g e n e ra l ly rese rved o n ly for t h ose with type I o r Ill e n d o l e a k o n co m p l et i o n a n g iography and
not a g a i n st the reg i o n w h e re t h e re i s a mobile septu m .

Tra u m atic tra n sect i o n • Rout i n e h e p a r i n i s reco m m e n d ed u n l ess contra i n d i cated by conco m ita nt i ntracra n i a l o r s o l i d organ
i n j u ry.
• S i m i l a r to d i ssections, a g g ressive overs i z i n g a n d b a l loon m o l d i n g is n ot routi n e l y performed d u r i n g the
treatment of transections.

POSTOPERATIVE CARE motic aneurysm ( n = 13 ). 8 Technical success was achieved in

• Patients are typically extubated immediately following the
procedure unless prohibited by concomitant physiologic in­
sults (e.g., hemodynamic instability, trauma patient) .
• Intensive care unit monitoring i s required for patients who
require a lumbar drain for 24 to 48 hours. Immediate and
frequent neurologic assessments are critical in the early peri­
operative period to assess for spinal cord ischemia. Raising
MAP goals are an additional way to minimize risk of cord
ischemia.
• Durability of TEVAR is reliant on routine imaging to evalu­
ate for stent graft-specific complications postoperation.
Follow-up chest CT-A and plain x-rays are typically ob­
tained at 1, 6, and 12 months and at intervals thereafter.
Consideration should be made between balancing risks for
cumulative lifetime iodinated contrast and radiation expo­
sure versus the necessity for serial graft monitoring. In stable
patients, chest x-rays may suffice to confirm device position,
with CT scanning reserved for those with migration sug­
gested by CT or evidence of progressive aortic enlargement
or onset of recurrent symptoms such as chest pain.
OUTCOMES
• The largest published series, which has reported 1 -year
follow-up, included 443 patients treated with TEVAR for
a variety of indications, both emergent and elective, as
follows: TAA ( n = 249 ) , thoracic aortic dissection ( n =
1 3 1 ) , traumatic aortic inj ury ( n 5 0 ) , and false anasto-
= events are related to instrumentation of the aortic arch in
nearly 9 0 % of patients, with an all-cause mortality among
patients treated for aortic aneurysm and aortic dissection of
20% and 1 0 % , respectively.
• No randomized trials comparing TEVAR to open surgery
have been published to date. However, multiple nonran­
domized comparisons suggest equivalent or better outcomes
with TEVAR. In a single-center, retrospective study of
over 700 patients who underwent either TEVAR or open
surgery, mortality was not significantly different at 3 0-day
( 5 . 7 % vs. 8 . 3 % , respectively) or 1 -year ( 1 5 . 6 % vs. 1 5 . 9 % ,
respectively) follow-up. 9 Two smaller studies demonstrated
a reduction in 3 0-day perioperative mortality with TEVAR
compared with open surgery ( 1 . 9 % vs. 5 . 7 % ) . 1 0• 1 1
COMPLICATIONS
• Stroke continues to be a common complication following
TEVAR and is associated with significant in-hospital mor­
tality. Recent clinical series have reported an incidence of
stroke after TEVAR to range from 2% to 8 % . 12•13 The un­
derlying mechanisms contributing to acute ischemic stroke
after TEVAR and the temporal relationship of stroke to the
procedure are not completely understood. However, the
constellation of preoperative risk factors, neurologic exami­
nations, and patterns of brain infarction observed in these
patients has led most investigators to conclude that cerebral
embolization and ischemic events are the primary mecha­
nisms for perioperative stroke in TEVAR.5•13•14 Embolic
1 920 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY
patients with severe atheromatous disease, whereas ischemia
is a result of the planned or inadvertent endovascular cover­
age of supra-aortic vessels.
• Spinal cord ischemia and subsequent acute or delayed
paraplegia represents the most devastating complication
of TEVAR. The pathogenesis of spinal cord injury after
TEVAR is likely multifactorial but still poorly understood.
The deployment of thoracic stem grafts results in rapid com­
plete exclusion of varying lengths of segmental collateral
vessels without the ability to surgically reimplant or revas­
cularize the intercostal arteries. Stent deployment and cath­
eter manipulation can predispose patients to dislodgement
of thrombotic or atheromatous debris from the aortic wall
into segmental vessels, with subsequent distal embolization
and occlusion of arteries supplying the spinal cord. More­
over, endovascular coverage of the left subclavian artery
may compromise spinal cord perfusion in patients with a
dominant left vertebral artery, solitary vertebral artery, ca­
rotid artery disease, or an incomplete circle of Willis. Access
site injuries to the iliofemoral vessels may further increase
the risk of spinal cord ischemia by compromising collateral
flow to the anterior spinal artery through the hypogastric
and pelvic vascular plexus. Lastly, pharmacologic measures
aimed at decreasing arterial blood pressure to enhance accu­
racy of device deployment in cases involving difficult aortic
anatomy may lead to hypotension similar to that observed in
open surgery.
• Due to the large sheath sizes required for the delivery of
thoracic stent grafts, small-diameter, tortuous, or heavily
calcified access vessels can predispose to iliofemoral arte­
rial injury. Postoperative CT-A often documents arterial dis­
sections and injury that can be followed with noninvasive
duplex and managed expectantly until patients have claudi­
cation-like symptoms.
• Endoleaks are a relatively common finding after TEVAR,
affecting nearly 1 5 % of patients in the early or late post­
operative periods. Type I or III endoleaks typically require
additional stent placement or balloon molding in order to
improve proximal, distal, or j unctional fixation. Most type
II endoleaks observed on completion angiogram or early fol­
low-up cross-sectional imaging will resolve spontaneously.
Persistent type II endoleaks, especially those with aneurysm
sac expansion or failure to adequately seal a proximal entry
tear or transection, warrant additional intervention. Retro­
grade flow from intercostal or left subclavian arteries can be
treated using coil embolization or vascular plug placement.
REFERENCES
1. Dake MD, Miller DC, Semba CP, et al. Transluminal placement of en·
dovascular stent·grafts for the treatment of descending thoracic aortic
aneurysms. N Engl ] Med. 1 9 94;3 3 1 : 1 729-1 734.
2. Bavaria JE, Appoo JJ, Makaroun MS, et al. Endovascular stent graft·
ing versus open surgical repair of descending thoracic aortic aneu­
rysms in low-risk patients: a multicenter comparative trial. J Thorac
Cardiovasc Surg. 2007; 1 3 3 : 3 69-3 77.
3. Nienaber CA, Rousseau H, Eggebrecht H, et al. Randomized com­
parison of strategies for type B aortic dissection: the INvestigation
of STEm Grafts in Aortic Dissection (INSTEAD ) trial. Circulation.
2009; 120:25 1 9-252 8 .
4. Lee WA, Matsumura J S , Mitchell R S , e t a l . Endovascular repair o f
traumatic aortic injury: clinical practice guidelines o f the Society for
Vascular Surgery. ] Vase Surg. 2 0 1 1 ; 5 3 : 1 8 7-1 92.
5. Buth ], Harris PL, Hobo R, et al. Neurologic complications associated
with endovascular repair of thoracic aortic pathology: incidence and
risk factors. A study from the European Collaborators on Stem/Graft
Techniques for Aortic Aneurysm Repair (EUROSTAR) registry. J Vase
Surg. 2007;46 : 1 1 03-1 1 1 0 .
6. Rizvi A Z , Murad M H , Fairman RM, et a l . The effect of left subcla­
vian artery coverage on morbidity and mortality in patients undergo­
ing endovascular thoracic aortic interventions: a systematic review and
meta-analysis. J Vase Surg. 2009;50 : 1 1 59-1 1 69 .
7. Pearce BJ, Jordan W. Using IVUS during EVAR a n d TEVAR: improv­
ing patient outcomes. Semin Vase Surg. 2009;22 : 1 72-1 80.
8. Leurs LJ, Bell R, Degrieck Y, et al. Endovascular treatment of tho·
racic aortic diseases: combined experience from the EUROSTAR and
United Kingdom Thoracic Endograft registries. J Vase Surg. 2004;40:
670-679.
9. Greenberg RK, Lu Q, Roselli EE, et al. Contemporary analysis
of descending thoracic and thoracoabdominal aneurysm repair:
a comparison of endovascular and open techniques. Circulation.
2008; 1 1 8 : 8 08-8 17.
10. Matsumura ]S, Cambria RP, Dake MD, et al. International controlled
clinical trial of thoracic endovascular aneurysm repair with the Zenith
TX2 endovascular graft: 1 -year results. J Vase Surg. 2008;4 7(2):
247-257.
11. Bavaria JE, Appoo ]], Makaroun MS, et al. Endovascular stent graft­
ing versus open surgical repair of descending thoracic aortic aneu­
rysms in low-risk patients: a multicenter comparative trial. J Thorac
Cardiovasc Surg. 2007; 1 3 3 : 3 69-377.
12. Feezor RJ, Martin TO, Hess PJ, et al. Risk factors for perioperative
stroke during thoracic endovascular aortic repairs (TEVAR) . J Endo·
vase Ther. 2007; 1 4 : 5 6 8-573.
13. Gutsche ]T, Cheung AT, McGarvey ML, et al. Risk factors for periop·
erative stroke after thoracic endovascular aortic repair. Ann Thorac
Surg. 2007;84 : 1 1 95-1 200.
14. Fattori R, Nienaber CA, Rousseau H, et al. Results of endovascular
repair of the thoracic aorta with the Talent Thoracic stent graft: the
Talent Thoracic Retrospective Registry. J Thorac Cardiovasc Surg.
2006; 1 3 2 : 3 32-3 3 9 .

Chapter 14
. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 1 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Peter H. U. Lee
DEFINITION
• Thoracoabdominal aneurysms and complicated descending
aortic dissections are the two most likely reasons for requir­
ing surgical exposure of the diaphragm in vascular surgery.
The need to expose the aorta both above and below the
diaphragm requires an extended incision spanning the left
thorax to the abdomen, the length and exact location of
which depends on the location of the targeted aortic pathol­
ogy. Often, the diaphragm must be divided, necessitating an
awareness of the regional anatomy as well as various surgi­
cal management considerations.
DIFFERENTIAL DIAGNOSIS
• Thoracoabdominal aneurysm: The Crawford classifica­
tion categorizes thoracoabdominal aneurysms accord­
ing to the extent of the aneurysm and is the most widely
used 1 ( FIG 1 ) . The classification is as follows : type I, from
the left subclavian artery to j ust above the renal arteries;
type II, from the left subclavian artery to the infrarenal
aorta; type III, from the mid-descending thoracic aorta
to below the renal arteries; type IV, from the diaphrag­
matic aorta to the iliac bifurcation; and type V (modified
classification by Safi et aJ.2 ) : from the mid-descending
thoracic aorta.
• Descending (type B) aortic dissection: Two classifications
systems are commonly used to describe the extent of aortic
dissections ( FIG 2 ) . Stanford type A dissections involve the
ascending aorta with or without involving the descending
aorta, whereas type B dissections only involve the descend­
ing aorta beyond the left subclavian artery. The DeBakey
classification includes type I, which involves both the
ascending and descending aortas; type II, which involves
only the ascending aorta; and type III, which involves only
the descending aorta.
II
FIG 1
I
Exposure and Open Surgical
Management at the Diaphragm
�
Ra m in E. Beygui
PATIENT HISTORY AND PHYSICAL
FINDINGS
• Most patients who are referred for surgery for a thoracoab­
dominal aneurysm present with no symptoms. However, when
they do have signs and/or symptoms, they may present with
pain in the chest, abdomen, or lower back; a mass in the abdo­
men, which may be pulsatile, or rigid abdomen; and evidence of
atheroembolism distally. The aforementioned symptoms, with
signs of hypovolemic shock, may indicate a ruptured aneurysm.
• Uncomplicated descending aortic dissections are generally
managed medically. However, if the dissection is compli­
cated, such as when it is associated with significant symp­
toms or leads to visceral or distal malperfusion, rapid
surgical intervention is warranted.
• A more complete discussion regarding indications for interven­
tion in aortic dissections and thoracoabdominal aortic aneu­
rysm can be found in a number of relevant reference textbooks.
IMAGING AND OTHER DIAGNOSTIC STUDIES
• Imaging is used to determine the proximal and distal extent
of repair required. It impacts the type of exposure required
(i.e., thoracotomy vs. laparotomy vs. thoracoabdominal
incision) as well as the level of incision.
• If the exposure is for the repair of thoracoabdominal aortic
pathology, all patients require adequate preoperative imag­
ing, ideally consisting of a computed tomography aortography
(CTA) with or without 3-D reconstruction. Magnetic resonance
aortography (MRA) may also provide the necessary informa­
tion, but this generally requires more time, is more expensive,
and requires more extensive postprocessing. However, MRA
is the study of choice when CTA is contraindicated or unsafe,
such as in patients with a contrast allergy or renal insufficiency.
Catheter-based invasive aortography has generally been sup­
planted by CTA and MRA as the primary preoperative imaging
Ill V
I v
• Mod ified Crawford c l a ssificati o n .
192 1
1 922 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY
DeBakey II
Stanford A B
FIG 2 • Stanfo rd/DeBa key cl assificat i o n .
modality o f choice, as i t i s more cumbersome and does not pro­
vide a complete assessment of the aneurysm, including throm­
bus volume and adjacent anatomic structures.
• If the surgery is elective, as in the case of an incidentally
found aneurysm, extensive preoperative evaluations are nec­
essary to minimize postoperative morbidity and mortality.
• Thorough evaluations of the cardiac, pulmonary, and renal sys­
tems are necessary, especially because these systems are most
commonly affected when there are complications. Depending
on the risk factors and prior history, further testing may be re­
quired and patients should be referred to appropriate specialists
for proper evaluation. A good neurologic evaluation is also war­
ranted, particularly if the patient has a prior history or symp­
toms suggestive of a lower extremity weakness or spinal injury.
SURGICAL MANAGEMENT
Preoperative Planning
• Determine the possible need for adj uncts such as cardiopul­
monary bypass and neurophysiologic monitoring. In some
instances, pulmonary artery catheters may be warranted for
monitoring cardiovascular hemodynamics.
PLANNING THE INCISION
• T h i s c h a pt e r d e a l s w i t h d i sta l t h o r a c i c a o rt i c p a t h o l ­
ogy req u i r i n g e x p o s u r e of t h e d i a p h ra g m w h e re a s i m ­
p l e t h o ra coto m y i n c i s i o n wo u l d n ot b e a d e q u at e . S u c h
m o re l i m ited p a t h o l o g i e s a re d e s c r i b e d e l se w h e r e .
• Assess the need for spinal cord protection, including the use
of lumbar drainage of cerebrospinal fluid ( CSF), distal aortic
perfusion, epidural cooling, and distal aortic perfusion.
• Given the expected amount of blood loss, a Cell Saver and
rapid infuser should be available.
• Double lumen endotracheal tube should be used for single­
lung ventilation of the right lung. Bronchial blockers are not
reliable adjuncts for this purpose.
Positioning
• Initially, place the patient supine on a deflated beanbag (FIG 3).
Roll the left chest upward and toward the right and place a
shoulder roll under the right axilla and a bump under the left
scapula while also gently pulling and securing the right arm over
to the right side. Ideally, the upper back should be rotated about
60 degrees to the table with the pelvis remaining flat, such that
the trunk is twisted to the right. Position the patient with the
break located halfway between the left costal margin and the left
iliac crest. Jackknife the table and then inflate the beanbag. Be
sure to support and secure the arms ( "airplane" splint for the left
Ill arm) and pad all pressure points on the body and extremities.
• Prep the left chest with the following boundaries: the axilla
superiorly, the spine posteriorly, and the sternum and abdo­
men beyond the right of midline anteriorly. Keep the groins
in the field for surgical access to the femoral vessels for pos­
sible cannulation if necessary.
FIG 3 • Positi o n i n g .
• The p roxi m a l extent of the path o l ogy a n d the a ntici­
pated location of the p roxi m a l clamp determ i n e t h e l evel
of the t h o ra c i c port i o n of the i n c i s i o n .
• If the p roxi m a l c l a m p is to be p l aced between the
a o rtic a rch a n d j u st beyond the l eft s u bclavian a rte ry,
the ch est is e ntered through the 4th or 5th i ntercos­
tal spaces (e . g . , Crawford types I l l and V a n e u rysms) .
 C h a p t e r 1 4 EXPO S U R E A N D O P E N S U R G I CAL MANAG E M E N T AT T H E D I A P H RA G M 1 923

• If t h e p rox i m a l c l a m p is to be p l aced j u st a b ove or at

the d i a p h ra g m , the 8th or 9th i nterspace s h o u l d be
ente red (e . g . , Crawford type IV a n e u rysms).
• Consider the possi b l e use of p a ra l l e l or " d o u b l e " t h o ra­
coto my i n cisions if expos u re of both the proxi m a l a n d
d ista l extent o f the thoracic a o rta i s needed. I n t h i s case, External
Serratus
the s k i n i n c i s i o n i s p l aced between the l evels of the two oblique
anterior
i nterspaces a ntici pated to be e ntered . muscle
muscle
• The l e n gt h a n d locat i o n of a b d o m i n a l i n c i s i o n is deter­ I nternal
m i ned by d i sta l extent of the a o rtic pathol ogy. oblique Costal
• A mod ified t h o racoa bdom i n a l i n c i s i o n that does n ot muscle margin
exte n d to m i d l i n e is a d e q u ate if l i m ited exposu re of
the a b d o m i n a l a o rta to the level of the ce l i ac a rtery
is req u i red.
• Exte n d the i n c i s i o n to the m i d l i n e for exposure of
the viscera l a o rt a .
• The i n c i s i o n s h o u l d be exte nded down the a b d o m i ­
n a l m i d l i n e f o r m o re extensive exposu re of the i n ­
fra re n a l a bdom i n a l a o rta (types I I , I l l, a n d IV) to t h e
a o rtic b ifu rcation o r com m o n i l i a c a rteries (FIG 4).

FIG 4 • Thoracoabd o m i n a l i n c i s i o n .

• S p l it the exte r n a l a b d o m i n a l o b l i q u e m uscle i n the d i rec­

THE INITIAL INCISION AND EXPOSURE
• M a rk w h e re t h e i n ci s i o n is to be m a d e i n c l u d i n g f i n d i n g
the a p p ro p r i ate i nterspace a n d the extent o f the a b d o m ­
i n a l i n c i s i o n a s described e a r l i e r.
• Sta rt with the t h o racic i n c i s i o n ove r the a p p ropriate
i nterspace and then exte nd it across the costa l m a rg i n .
Depe n d i n g o n t h e deg ree o f t h e a b d o m i n a l exposu re re­
q u i red, exte nd this i n c i s i o n o b l i q u ely to the m i d l i n e of
the a b d o m e n . The m i d l i n e i n c i s i o n can t h e n be extended
to the l evel of the symphysis p u b is, if n ecessa ry.
• The a b d o m i n a l i n c i s i o n is carried t h r o u g h the su bcutane­
ous tissu es, the exte r n a l a b d o m i n a l o b l i q u e a p o n e u rosis,
and t h e a nterior rectus sheath.
t i o n of its fi bers.
• Divide t h e u n d erlyi n g i nternal o b l i q u e a n d t ra n sversus
a b d o m i n u s m u scles between the cost a l m a r g i n and lat­
e ra l edge of the rectus sheath.
• Divide l eft rectus m uscle .
• The t h o racic i n c i s i o n s h o u l d p rovi de a d e q u ate exposu re
posteriorly and s h o u l d be exte nded to the e rector s p i n a e
fasc i a .
• Expose the i ntercosta l m u scles by i nc i s i n g t h r o u g h the
su bcuta neous tissues a n d the exte r n a l o b l i q u e fasc i a .

ABDOMINAL EXPOSURE Sepa rate the perito n e u m f r o m the l atera l a n d

• Deve l o p the a b d o m i n a l port i o n of the i n c i s i o n before
entry i nto the l eft p l e u r a l cavity
• The a o rta may be exposed by an extra perito n e a l or trans­
perito n e a l a p proa c h .
• Extra perito n ea l : T h i s a p p roach is i d e a l for repa i r i n g
t h o racoa bdom i n a l a n e u rysms, especia l ly t h ose i n -
volvi n g the u p p e r a b d o m i n a l a o rta (FIG S) .
Deve l o p the p l a n e between the tra n sversa l i s
fasc i a a n d the pariet a l perito n e u m .
poste r i o r a b d o m i n a l wa l l s as we l l as from t h e
d ia p h ra g m superio rly.
• Tra nsperito n e a l : T h i s a p proach provides better expo­
s u re for visce r a l a rtery revascu l a rization when req u i red,
espec i a l l y when bypass i s req u i red to t h e right ren a l
a rte ry.
• Ad d i t i o n a l deta i l s of these a p p roaches can be fo u n d e lse­
w h e re and a re beyo n d the scope of t h i s cha pter.
1 924 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

FIG S • Abdom i n a l a o rtic exposu re via extra perito n e a l

a p p roach.

• Ad d it i o n a l exposure can be o bta i n ed from " n otch i n g "

THORACIC EXPOSURE
• Deve l o p a p l a n e su perfi c i a l to the r i bs a n d i ntercosta l
m uscles.
• H o l d venti lation to the l eft l u n g a n d a l low it to co l l a pse.
• E nter the l eft ch est by open i n g the i ntercost a l space
a l o n g the s u p e r i o r edge of the lower r i b, m a k i n g s u re
not to i n j u re the l u ngs.
• To maxi m i ze t h e exposu re, it may be n ecessa ry to per­
form a s u b p e r i oste a l resect i o n of t h e r i b a bove o r
below the i nterspace entered, depen d i n g o n t h e target
l ocat i o n .
a n adjacent r i b . T h i s is acco m p l ished b y exc i s i n g a 2-cm
seg ment of t h e rib poste r i o r l y
• If t w o i nterspaces a re b e i n g entered, deve l o p a n ad­
e q u ate plane a nterior to the ribs. The s k i n a n d ove r l y i n g
m uscles ca n be retracted to acco m m odate b o t h thoracic
i nterspace exposures.
• Use a self-reta i n i n g retractor to m a i nta i n exposu re .
• Be awa re that there ca n be extensive adhesions with i n
t h e p l e u ra that m a y pred ispose t o l u n g i n j u ry. U s u a l ly,
these ad hesions can be m o b i l ized b l u ntly if t h i n but may
need bovie ca ute ry o r scissors if m o re su bsta nti a l .

EXPOSURE AND DIVISION OF THE

DIAPHRAGM
• Release a n y ad hesions that may be p rese nt, m o b i l ize the
lung by dividing the i nfe r i o r p u l m o n a ry l i g a m e nt, and
retract the lung ce p h a l a d to expose t h e d i a p h r a g m .
• N ext, j o i n the l eft t h o racic cavity a n d the retro perito­
n e u m o r a b d o m e n by d ivid i n g the d i a p h ra g m .
• The diaphragm can be i ncised partia l ly or completely (FIG 6).
• Part i a l i n c i s i o n : I ncise the m uscu l a r portion of the d i ­
a p h ra g m a n d p rese rve the centra l te n d i n o u s port i o n .
T h i s a p p roach m i n i m izes respi ratory co m p l ications.
• Co m p l ete d i v i s i o n : T h i s a p p roach p rovides the best
exposu re of the a o rta. T h i s exte nds the i n c i s i o n from
the d ivided costa l m a r g i n to the a o rtic h i atus. Divi­
s i o n ca n be acco m p l ished either rad i a l l y o r c i rcu mfer­
enti a l ly. B e s u re to leave a p p roxi m ately 2 to 3 em of FIG 6 • Division o f t h e d i a p h ra g m .
d i a p h ra g m from the i ntern a l costa l m a rg i n to a i d i n
t h e l ater c l o s u re o f d ia p h ra g m . T h e c i rcu mferenti a l
a p p roach a lso theo retica l l y m i n i m izes d i s r u pt i o n of
the p h re n i c n e rve a n d is g e n e ra l ly p refe rred .
 C h a p t e r 1 4 EXPO S U R E A N D O P E N S U R G I CAL MANAG E M E N T AT T H E D I A P H RA G M 1 92 5

• P l a ce ch est tu bes .
CLOSURE
• Rea p p roxi m ate the i nterspace with m u lt i p l e s i m p l e o r
• After co m p l et i o n of the core s u r g i ca l p roced u re, close fig u re-of-e i g h t heavy (no. 1 ) n o n a bsorba b l e suture.
the d i a p h ra g m . • C l ose t h e incision i n l ayers, i n c l u d i n g the m u scle with
• Ta ke patient o u t o f fl exed position a n d c l ose t h e d i a­ ru n n i n g Vicryl as we l l as the deep dermal layer. Close the
p h r a g m with heavy ru n n i n g suture. skin with su bcutic u l a r sutu res o r sta ples.

PEARLS AND PITFALLS

I n d icat i o n s • Preo perative CTA or M RA is m a n d atory to dete r m i n e the suita b i l ity of the a o rtic pathol ogy for
s u r g i ca l repa i r.
P l a cement of i n c i s i o n • The p l acement of the i n ci s i o n s h o u l d be ca refu l ly considered preoperatively based o n i m a g i n g
a n d the exte nt o f the pathol ogy. A s i n g l e thoractomy i n c i s i o n can b e p l aced even if two i ntercos­
tal spaces need to be entered . To m i n i m ize morbid ity, beg i n with a s m a l l e r i n c i s i o n because it can
a l ways be exte nded w h e n n ecessa ry.
I nj u ry to p h r e n i c • A c i rc u m fe renti a l d ivision of the d i a p h ra g m can p rovi de the best exposure w h i l e a l so m i n i m i z i n g
the risk o f i n j u ry to the p h re n i c n e rve.
C l o s u re • When carryi n g out a c i rcu mfrent i a l d ivision of the d i a p h ra g m , leave 2 to 3 em of d i a p h r a g m
f r o m the i ntern a l costa l m a rg i n for t h e repa i r of the d i a p h ra g m when closi n g .

POSTOPERATIVE CARE COMPLICATIONS

• Monitor in the surgical intensive care unit as necessary for
the extent of the aortic reconstruction required.
• Remove chest tubes when drainage is adequately low.
• Continuous spinal cord protection and neurologic monitor­
ing immediately postoperatively; continue CSF drainage for
-3 days.
• Follow-up imaging with CTA to establish a baseline
• Standard postoperative incision and wound care
OUTCOMES
• It is proposed that pulmonary dysfunction associated with
thoracoabdominal aortic surgery is to a large part associated
with diaphragmatic dysfunction. Stickley and Giglia3 recom­
mend a new technique using a gastrointestinal stapler to di­
vide the diaphragm. This technique is proposed to be "rapid,
hemostatic, and aids with reapproximation at the completion
of the case" and that "this method of diaphragm division is
quicker and less traumatic and has the potential to decrease
the incidence of postoperative pulmonary dysfunction. "
• Huynh et al.4 conclude that renal failure, spinal cord deficit,
and pulmonary complication were the major determinants
of length of stay (LOS) in patients for thoracoabdominal
aortic aneurysm (TAAA) repair. Their study has shown that
the preservation of diaphragmatic function and the use of
the adj unct distal aortic perfusion and CSF drainage may
reduce hospital LOS.
• Bleeding; take back
• Phrenic nerve palsy or paralysis
• Diaphragmatic hernia
• Pulmonary complications, respiratory failure
• Wound complications
• Paralysis; spinal cord ischemic inj ury, associated with thora­
coabdominal aortic surgery
• Stroke/transient ischemic attack (TIA), associated with tho­
racoabdominal aortic surgery
• Multiorgan failure, associated with thoracoabdominal aor­
tic surgery
• Death, associated with thoracoabdominal aortic surgery
REFERENCES
1. Crawford ES, Crawford JL, Safi HJ, et a!. Thoracoabdominal aortic
aneurysms: preoperative and intraoperative factors determining imme­
diate and long-term results of operations in 605 patients. J Vase Surg.
1 9 8 6 ; 3 ( 3 ) : 3 8 9-404.
2. Safi HJ, Winnerkvist A, Miller CC III, et a!. Effect of extended cross­
clamp time during thoracoabdominal aortic aneurysm repair. Ann
Thorac Surg. 1 9 9 8 ;66(4): 1204-1209.
3 . Stickley SM, Giglia JS. Novel use of a gastrointestinal stapler for dia­
phragm division during thoracoabdominal aortic exposure. Ann Vase
Surg. 2 0 1 3 ;2 7 ( 5 ) : 6 8 9-69 1 . doi: 1 0 . 1 0 1 6/j . avsg.20 1 2. 1 1 .005.
4. Huynh TT, Miller CC III, Estrera AL, et a!. Determinants of hospital
length of stay after thoracoabdominal aortic aneurysm repair. J Vase
Surg. 2002;35 ( 4 ) : 648-653.

Chapter 15
r
r
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - · - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
t
IMAGING AND OTHER DIAGNOSTIC
STUDIES
General Considerations
•
Retroperitoneal aortic exposure may be desirable for a
variety of vascular conditions, including abdominal aortic
aneurysms, aortoiliac occlusive disease, and mesenteric or
left renal artery occlusive disease.
•
Retroperitoneal exposure may be preferred for patients with
a hostile abdomen from previous intraabdominal infection,
surgery, or radiation.
•
Compared with transabdominal aortic exposure, retroperi­
toneal exposure may be associated with shorter postopera­
tive ileus, decreased pulmonary complications, decreased
pain, and lower incidence of late complications including
small bowel obstruction or aortoenteric fistulae. 1
•
Retroperitoneal aortic exposure can be converted, when
necessary, to thoracoabdominal exposure with excellent
visualization of the superior mesenteric artery (SMA), left
renal artery, celiac axis, and descending thoracic aorta.2
• Examination of intraabdominal contents is possible through
a retroperitoneal approach by simply opening a peritoneal
window as necessary.
Preoperative Imaging
• Prior to aortic reconstruction, detailed anatomic imaging
derived from modern, multirow detector computed tomo­
graphic arteriography ( CTA) will greatly facilitate surgical
planning. Image acquisition should extend from the normal
proximal aorta to the common femoral artery bifurcations
bilaterally. Runoff imaging may also aid decision making
depending on clinical circumstances.
• Data derived from submillimeter imaging slices may be read­
ily reformatted into multiplanar and 3-D reconstructions,
with excellent resolution of the peripheral mesenteric and
renal vasculature.
• Noncontrast images should also be obtained to help assess
the degree of mural calcification present in diseased proxi­
mal aorta. Recognition of extensive mural calcification may
modify the location chosen for clamp placement, or prohibit
safe clamping entirely in diseased segments.
• CTA may require larger contrast dose than that required for
catheter-based contrast aortography. Contrast volumes re­
quired for CTA may be reduced significantly by modifying
the field of view or imaging parameters required for the pro­
cedure. Consultation with the responsible radiologist will
ensure optimal imaging of the necessary arterial anatomy
with minimal contrast and radiation exposure.
• Contrast-based aortography, either CT or catheter-based, may
be contraindicated for patients with reduced creatinine clear­
ance or an anaphylactic reaction to contrast. Milder allergic
1926
-
Retroperitoneal Aortic
Exposure
�
Ma tth e w Mel/
responses (hives, rash) may be successfully tempered by pre­
medication with steroids and antihistamines, depending on the
relative indication for contrast administration and the patient's
overall medical condition. Adverse effects of intravenous or
intraarterial contrast administration on creatinine clearance
may be partially ameliorated by preprocedural oral or in­
travenous hydration and administration of N-acetylcysteine
(Mucomyst) . Although sometimes considered a reasonable
alternative under these circumstances, gadolinium-based con­
trast administration for magnetic resonance arteriographic in­
dications is also contraindicated in patients with a creatinine
clearance less than 60 mL per minute. When contrast admin­
istration is absolutely out of the question, CT images acquired
without contrast may provide adequate anatomic imaging to
proceed with surgery, with the caveat that anomalies such as
a retroaortic left renal vein may be present and unrecognized
until exposed at surgery.
SURGICAL MANAGEMENT
Instrumentation
• In addition to standard vascular instrumentation, additional
equipment may aid in exposure of the aorta and its visceral
branches from the retroperitoneal approach:
Beanbag and airplane for positioning
A fully articulated operative table, capable of flex and
reflex at the level of the umbilicus
Self-retaining, table-mounted retractor (e.g., Bookwalter,
Omni, or other)
Finochietto chest retractor
Nos. 3, 4, and 5 Fogarty occlusion balloons
Cold renal perfusion
Arterial cannulas for renal perfusion
Positioning
• The patient is placed supine on a beanbag and all lines and
tubes are placed. For exposure of the infrarenal aorta and
iliac arteries, the left shoulder is lifted and protected with the
beanbag and padding. The left arm can be abducted or ro­
tated to the patient's right with a padded airplane retractor
for support. The table break and the kidney bar are used to
open up the retroperitoneal space between the 1 2th rib and
the iliac crest as the incision is developed. For this reason,
it is essential that the patient be positioned with the umbi­
licus on the table break. An oblique incision is made from
below the umbilicus to the tip of the 1 1th rib. With this loca­
tion, the incision can be extended into the 1 Oth intercostal
space and the chest entered if additional proximal exposure
is required ( FIG 1 ) . When additional iliac artery or pelvic ex­
posure is anticipated, the incision should be initiated distal
to the umbilicus. Either way, in patients with considerable
 C h a p t e r 1 5 RETROPERITONEAL AORT I C EXPOS U R E
, ,
I
I
I
I
• The i n c i s i o n is carried t h r o u g h the exte r n a l o b l i q ue,
i ntern a l o b l i q ue, and tra n sversus a b d o m i n i s m uscles. The
retroperito n e a l space is then entered l atera l ly near the
tip of the 1 1 th rib by identifyi n g the cha racte ristic yel­
l ow p reperito n e a l fat. The retroperito n e a l space is then
deve loped from l atera l to m ed i a l using a sponge stick
o r h a n d s for blunt d issect i o n . Ante r i o rly, the perito n e u m
t e n d s to be m o r e ad h e rent at the level o f the rectus
sheath; ca re s h o u l d be taken to avo i d enteri n g the peri­
tonea l cavity i n t h i s a re a . The psoas fascia i s encou ntered
as the d issect i o n is deve loped posteriorly in the cou rse of
t h i s d i ssection, w h i c h leads d i rectly to t h e l eft i l iac vesse l s
a n d u reter. D i ssect i o n is conti n u e d p roxi m a l ly a nterior to
the u reter; the u reter is either l eft in situ to l i m it i n j u ry
or gently retracted m ed i a l ly with s i l astic s l i n g s as the ret­
roperito n e a l space is deve l o ped.
• S u pe r i o rly, the kid ney is identified as the d issect i o n i s
cont i n ued a nterior to G e rota's fasci a-a potenti a l space
exists between desce n d i n g co l o n and G e rota's fascia in
the retro perito n e u m , which is p rog ressive ly deve loped in
a ce p h a l a d d i rect i o n from the psoas m uscle, adjacent to
t h e a o rta. O n ce the re n a l ve i n is visu a l i zed i n this spa ce,
the superior m a r g i n of the d issect i o n is co m p l ete. If
su prare n a l a o rtic control a n d exposu re is req u i red, t h i s
same d i ssect i o n p l a n e s h o u l d be deve l oped poster i o r to
the k i d n ey, e l evat i n g the kid ney a n d u reters a l o n g with
the perito n e a l contents and retract i n g all to t h e right to
expose the s u bd i a p h ra g matic visce ral a o rta.
• Se lf-reta i n i n g retracto r syste m s a re best d e p l oyed ei­
t h e r afte r t h e psoas m u scle i s i d e ntified o r fo l l owi n g
exposure o f t h e re n a l ve i n o r e l evat i o n of t h e l eft k i d -
1 92 7
abdominal girth and redundant pannus, landmarks should
be confirmed to ensure that the incision is not placed too far
distally on the abdomen, as j uxtarenal aortic control can be
extremely difficult when the incision is placed too far distally
on the abdomen.
• For thoracoabdominal exposure, the patient is placed in the
right lateral decubitus position using a beanbag and axillary
role for support. The left arm is protected with adequate
padding and an airplane-type retractor. It is important to
secure the left arm such that the scapula rolls anteriorly,
providing exposure of the posterior lateral chest. The inci­
sion will be made overlying the 8th intercostal space and
extended toward the umbilicus.
FIG 1 • Patient position fo r t h o racoabd o m i n a l exposure with
i n c i s i o n i n the 8th i ntercosta l space (dotted l i ne). Positi o n i n g is
s u p p o rted with a bea n b a g and r i g h t axi l l a ry ro l l .
n ey. D e p loyi n g t h e retracto r system e a r l i e r w i l l i nterfere
with the d i ssect i o n n ecessa ry to access the a p p ro p r i ate
retroco l i c space. F o l l o w i n g p l a c e m e n t of the i n it i a l pad­
ded retractor blade along t h e m ed i a l m a rg i n of t h e
w o u n d , ci rcu mfere n t i a l retract i o n i s secu red by p l a ce­
ment of a d d i t i o n a l b l a d es, typica l ly o p posite each oth e r
to p revent u n d u e t e n s i o n o n t h e retract i o n system, with
seq uenti a l replacement with deeper b l a d e s and a d d i ­
t i o n a l retract i o n u n t i l t h e e n t i re p e r i a o rt i c retro pe rito­
neum i s exposed .
• The a o rta a n d i l i a c a rteries a re then d i ssected free of
su rrou n d i n g tissue. C i rcu mferenti a l a o rtic control is a n
essenti a l safety element o f a l l a o rtic procedu res, a n d care
s h o u l d be taken to gently and patiently create a space
betwee n the i nfe r i o r ve n a cava (IVC), a o rta, and verte­
bra l bodies poste riorly to pass an u m b i l ical tape a r o u n d
the a o rta with a rig ht-a n g l e c l a m p . C i rcu mferenti a l c o n ­
trol of the co m m o n i l iac a rteri es, o n the o t h e r h a n d , is
not n ecessary i n all circumstances. S uffi cient m ed i a l a n d
l atera l d issect i o n to a l low f o r p l acement o f a Wyl i e hy­
pogastric c l a m p a r o u n d the co m m o n i l iac a rtery w i l l usu­
a l ly suffice. Avo i d a n ce of atte m pts at c i rcu mfere n t i a l i l i ac
control will reduce the risk of r i g h t i l i a c ve i n i n j u ry. When
c i rcumferenti a l control is req u i red, patience is n eces­
sa ry to g ra d u a l l y sepa rate the r i g h t co m m o n i l i a c a rtery
from the d i sta l IVC a n d l eft common i l iac ve i n . When a
ve n o u s i n j u ry is encou ntered d u r i n g t h i s m a n e u ver, d ivi­
s i o n of the co m m o n i l i ac a rte ry may be n ecessary to g a i n
a d e q u ate exposu re f o r contro l . Alternative ly, a n occ l u ­
s i o n ba l l oo n may be i ntrod uced f r o m the right c o m m o n
fe m o ra l o r exte r n a l i l i ac ve i n s w i l l t a m p o n a d e the ve n o u s
1 928 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

b l eed i n g u n t i l sufficient expos u re is g a i ned to repa i r

t h e wo u n d . F i n a l ly, a cove red se lf-expa n d i n g endog raft
may a lso be d e p l oyed over a w i re to g a i n contro l . Ag a i n,
readj ustment of the retractor syste m with each consecu­
tive sta g e of exposure w i l l o pt i m ize o perative effi ciency.
Freq uently, to opti m i ze d ista l exposu re, the p roxi m a l re­
tractor b l a d es need to be tempora r i l y rel axed a n d vice
versa.
• T h i s exposu re provides a d e q u ate exposu re to the i nfrare­
nal a o rta (and i nfe r i o r mesenteric a rtery if re i m p l a ntat ion
is a ntici pated), r i g ht a n d l eft co m m o n a n d l eft exte r n a l
i l i ac a rteries. The r i g ht exte r n a l i l iac a rtery is n ot we l l
visua l i zed from t h i s a p p roach, a l t h o u g h tu n n e l i n g t o the
right fem o r a l a rtery is read i l y a c h i eved for a o rtofe m o r a l
bypass g raft i n g when n ecessa ry. Ca re s h o u l d be t a k e n
to deve l o p the t u n n e l i m med iately a nterior to t h e i l i a c
a rteries to a v o i d i nj u ry to the r i g h t u rete r o r tra p p i n g the
u reter betwee n the g raft limb a n d adjacent a rte ry. When
right exte r n a l i l i a c a rtery exposure i s req u i red d u ri n g a
l eft retrope riton e a l exposu re, a cou nteri ncision may a lso
be p l aced in the r i g h t lower q u a d ra nt, a lt h o u g h patient
positi o n i n g a n d retractor syste m p l a cement may l i m it the
potenti a l use of t h i s m a n e uver.
• For p roced u res req u i ri n g m o re proxi m a l , viscera l a o rt i c FIG 2 • The d i a p h ra g m is i n cised c i rcu mferenti a l ly (d otted
exposu re, the latiss i m u s dorsi i s identified a n d d i ssected l i ne) to p rotect the p h re n i c n e rve a n d t h e reby preserve
from su rrou n d i n g s u p e rfi c i a l and deep tissues and re­ d i a p h ra g matic f u n ct i o n . A o n e-to two cent i m eter cuff of
tracted l atera l ly. The 8th i ntercosta l space is opened pos­ d i a p h ra g m is l eft attached to the ch est was to a i d e in closure.
teriorly to the parasp i n a l m uscles and a nteriorly to the
costa l m a r g i n , w h i c h is d ivided. As the retroperitoneal
space is deve loped, the perito n e u m is b l u ntly sepa rated • D i ssect i o n of t h e p l a n e poste r i o r t h e G e rota's fascia
from the i nfe r i o r su rface of the d i a p h r a g m . The d i a­ a l l ows for expos u re of t h e l eft renal a rte ry, which i s
phragm is d ivided i n a ci rcumferenti a l m a n n e r 1 to 2 em a n i m p o rt a n t l a n d m a r k i n f u rt h e r d i ssect i o n of t h e vis­
from its atta c h m e nts to the ch est wa l l to avo i d i n j u ry to cera l a o rt a . O n ce t h e o r i g i n of t h e l eft renal a rtery i s
the p h r e n i c n e rve (FIG 2) . The m e d i a n a rcuate l i g a ment i d e ntified a n d t h e m e d i a n a rcuate l i g a m e n t h a s b e e n
is i d e ntified a n d d ivided. Prox i m a l a o rtic control can n ow d iv i d e d , t h e v i scera l a o rta a n d o r i g i n s of t h e c e l i a c a x i s
be obta i n e d u n d e r d i rect vision, a g a i n fo l l ow i n g strate­ a n d S M A ca n be i s o l ated with s h a r p d i ssect i o n . W i t h
g i c p l a cement of self-reta i n i n g retractor b l a des, t a k i n g t h e l eft k i d n ey rotated a nt e r i o r ly, t h e S M A c a n be
ca re to identify a n d a v o i d i n j u ry to the eso p h a g us. exposed over a d i st a n ce of a p p ro x i m a t e l y 5 em (FIG 3) .

FIG 3 • Exposu re o f the viscera l a o rta

with the l eft k i d n ey l i fted to expose the
l eft renal a rtery a n d the entire poste r i o r-
latera l a o rta. N ote that the l eft re n a l ve i n
ro l ls off t h e a o rta.
 C h a p t e r 1 5 RETROPERITONEAL AORT I C EXPOS U R E 1 929

A d d i ti o n a l exposu re c a n be o bta i n e d by rotat i n g t h e

k i d n ey poste r i o r to expose t h e S M A a s it cou rses b e h i n d
t h e p a n c reas (FIG 4).
• Fol lowing vascu l a r repa i r, the retro perito n e a l space
s h o u l d be i n spected fo r hem ostasis. The u reter s h o u l d be
i n s pected, and any suspected i n j u ry o r leak ca n be i n ves­
tig ated with i ntrave n o u s methyl e n e b l u e . If needed, the
perito n e u m can be opened for i nspect i o n of a b d o m i n a l
contents.
• Remov i n g t h e ta b l e break or lowe r i n g the k i d n ey bar
if used will a i d i n a p p roxi m a t i n g tissue l ayers without
tension.
• If d ivided, the d i a p h ra g m can be rea p p roxim ated with
a cont i n u o u s ru n n i n g a bsorba b l e suture. The suture can
be secu red at t h e a nterior costa l m a r g i n and w i l l h e l p
a p p roxi m ate these structu res a s we l l .
• If t h e t h o rax was entered, a l a rge-bore ch est tube i s
p l aced dependently a n d secured w i t h U stitches.
• A l a rg e B l a ke or Jackson-Pratt d r a i n can be p l aced in the
retroperito n e a l space to avo id early posto perative f l u i d
co l l ections.
• The m uscu l a r l ayers a re cl osed with cont i n u o u s a bsorb­
able sutu res and the s u bcuta neous tissue and skin c l osed FIG 4 • Exposu re of the viscera l a o rta with the l eft k i d n ey

with sta n d a rd tec h n i q ues. l eft in situ. T h i s a p p roach a l l ows for a d d i t i o n a l exposu re of
the p roxi m a l s u p e r i o r mesente ric a rtery.

PEARLS AND PITFALLS

• Choosi n g the m ost a p p ro p r i ate p roced u re for a n y g iven patient with m esenteric or re n a l a rtery occ l u sive d i sease is dependent o n
a m u ltitude of factors, especia l ly w i t h the w i despread ava i l a b i l ity of percuta neous i nterventions. Open surgical p roced u res c o n ­
t i n u e to rem a i n a n exce l lent a ltern ative f o r patie nts with m u ltivessel d i sease, with coexist i n g a o rto i l i ac occ l u sive o r a n e u rysm a l
d i sease, a n d with d isease too extensive t o b e adeq uately treated with wi re-based tec h n i q ues. When select i n g from t h e va riety of
open p roced u res, patient comorbid ity, body h a b itus a n d its i m pact on a d e q u ate exposu re, q u a l ity of the i nflow a n d outflow ves­
sels, a n d a b i l ity to safely c l a m p vessels s h o u l d a l l be taken i nto co n s i d e rat i o n . Havi n g a work i n g knowledge of a l l a lternatives is
i m porta nt, as occa s i o n a l ly, i ntraoperative fi n d i ngs d i ctate a deviation from the preoperative p l a n .
• I ntraoperative m a n a g e m e n t is s i m i l a r to t h a t f o r other abdom i n a l vascu l a r p roced u res. When the d issect i o n i s co m p l ete, patie nts
a re g iven h e p a r i n at a dose of 1 00 u n its/kg prior to c l a m p i n g vessels, a c h i evi n g a ta rget activated clott i n g t i m e (ACT) of 200 to
250 secon d s . For cases where renal perfus i o n is i nterrupted, 0 . 2 5 to 0.5 g/kg of m a n n itol is g iven p r i o r to cross-c l a m p i n g . As soon
as poss i b l e, the k i d n ey i s perfused with 300 to 400 m l of sa l i n e cooled to 4"C. T h i s may be d o n e at the ren a l a rtery ost i u m i m me­
d i ately after a renal e n d a rte recto my, o r d i rectly i nto t h e renal a rtery at the level of the d i stal a n a stomosis. Renal a rtery ca n n u l as,
w h i c h come in a variety of si zes, a re used for perfu s i o n . U s i n g a size that m ost closely matches the d i a meter of the ren a l vessel
assu res that the perfusate w i l l g o i nto the k i d n ey and not s p i l l onto the operative f i e l d .
• When revasc u l a rization is co m p l ete, h e p a r i n is reversed w i t h p rota m i n e w h i l e checking for h e m ostasis. The patency of revascu­
l a rization may be checked with i ntraoperative d u p lex i m a g i n g . Confi rmation of a n a d e q u ate e n d p o i nt is especi a l ly i m porta nt
w h e n e n d a rterectomy h a s been perfo rmed, as i n t i m a l f l a ps may p resent a s a d e l ayed vessel occ l u s i o n a n d end-organ l oss.

POSTOPERATIVE CARE
• In addition to the standard postoperative strategies for
patients undergoing aortic surgery, including serial hema­
tocrit and hemoglobin, electrolytes, creatinine, and lactic
acid, it is important to monitor renal and intestinal func­
tion. Patients undergoing renal revascularization commonly
have an obligatory diuresis for the first 12 hours after sur­
gery. This phenomenon may be due to residual effects of
operative mannitol as well as a response to transient renal
ischemia. During this time, urine output is not reflective of
the patient's overall volume status, and crystalloid should
be given at rates sufficient to maintain central filling pres­
sures. Also, serum creatinine should be serially measured.
It is common for the serum creatinine to increase slightly
in the first 1 or 2 postoperative days, but increases of more
than 20% or 3 0 % warrant further investigation, especially
if associated with oliguria. Sudden changes in renal function
that are unexplained or unresponsive to corrective measures
warrant duplex imaging to determine renal perfusion.
1 930 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

• Patients after mesenteric revascularization often develop
hyperactive peristalsis, sometimes while the incision is still
open. Under these circumstances, serial examination for
bowel sounds in the first 24 hours can provide clues to the
continued patency of the revascularization. Serial lactate
levels are also checked. Although immediate postoperative
lactate levels are elevated, they should return to normal as
the patient is warmed and resuscitated. Coagulation param­
eters may also be elevated initially in response to blood loss
and transient hepatic ischemia. These parameters should be
monitored and corrected for active bleeding; normal values
are usually present by the first postoperative day.
COMPLICATIONS
General Considerations
• As with all aortic surgery, potential complications after vis­
ceral artery revascularization include myocardial infarction,
respiratory failure, and postoperative bleeding. Addition­
ally, renal failure is always a potential complication during
visceral revascularization, although its incidence is low.3-5
Potential causes of renal failure include generalized hypo­
perfusion from cardiac dysfunction or hypovolemia, pro­
longed intraoperative ischemia, or thrombosis of the repair.
Progressive or unexpected renal failure should initiate a
prompt workup including duplex imaging of the kidneys
to identify potentially treatable causes. Thrombosis with
absence of flow to the kidney is generally irreversible unless
identified immediately.
• Intestinal ischemia is the major concern after mesenteric
revascularization. Signs and symptoms may include severe
abdominal pain, continued acidosis, and hematochezia.
Ischemia may be secondary to vessel or graft thrombosis
or may result from distal embolization during or follow­
ing the repair. Patients with evidence of peritonitis should
be promptly reexplored, and those treated initially for acute
mesenteric ischemia should have a planned second look at
12 to 24 hours if there was any question of intestinal viabil­
ity at the time of the original operation. Arterial duplex may
confirm the viability of the repair but cannot rule out embo­
lization as a cause for postoperative intestinal ischemia. At
exploration, nonviable intestine can be resected, and issues
with the revascularization can be addressed.
Graft or Vessel Twisting or Kinking
the anastomosis. Additionally, the anastomotic site should
be chosen in a similar coronal plane to prevent kinking once
the end organs assume their natural position.
Injury during Endarterectomy
• Identifying the appropriate endarterectomy plane is usually
straightforward in the aorta, renal arteries, and SMA. The
celiac artery can be challenging, as it may be thin-walled,
and plaque removal may injure the arterial wall. Limited
injuries can be repaired with interrupted 4-0 or 5-0 Prolene
sutures supported with Teflon pledgers, but larger injuries or
those with severely attenuated vessel walls may not be suc­
cessfully repaired with this technique. If the integrity of the
artery is in doubt, it may be safer to transect it and perform a
bypass from the aorta to the transected celiac artery using an
8 -mm or 1 0-mm graft. The celiac artery stump can be over­
sewn with pledgeted 3-0 Prolene suture placed into healthy
aorta. Unacceptable endpoints after renal endarterectomy
are best treated with conversion to a bypass.
Inadequate Distal Endarterectomy Endpoint
• Plaque extending to the infrapancreatic SMA may be dif­
ficult to entirely remove with standard thoracoabdominal
exposure. Intraoperative duplex can confirm an adequate
endpoint, and if there is any uncertainty, the abdominal cav­
ity can be entered and the SMA exposed by dividing the liga­
ment of Treitz. This maneuver will provide exposure of the
SMA as it emerges from behind the pancreas, usually at a
place distal to the diseased segment. Inspection by palpation
or with duplex ultrasound can evaluate the repair. Incomplete
endarterectomy or intimal flaps can be managed through an
arteriotomy at this location. A reasonably sized SMA can be
transected and the retained plaque removed; reapproxima­
tion with interrupted sutures will secure the intima distal to
the endarterectomy. Exposing the endpoint in a smaller ves­
sel is most safely performed with a lateral arteriotomy and
subsequent patch angioplasty closure to prevent narrowing.
• Problematic endarterectomy endpoints in the celiac artery
or renal arteries may be best managed with placement of a
bypass graft. Conversion to bypass will require enough ex­
posure of the target vessel to allow for revascularization dis­
tal to the diseased segment. Either end-to-end or end-to-side
reconstruction is acceptable and should be performed, mak­
ing certain that the intima is secured with the suture line.

• When performing a bypass to the SMA, it is important to re­

REFERENCES
tract the mesentery in a caudal direction to adequately assess
graft length. Inadequate positioning will result in excessive
graft length and potential kinking and thrombosis once the
peritoneal contents are reduced to the abdomen and the inci­
2.
sion is closed. Additionally, for retrograde bypass, the graft
should be placed with enough slack to allow the distal end­
point to be in-line with the SMA with caudal retraction of
the intestines. This positioning will prevent both kinking
1. Leather RP, Shah DM, Kaufman JL, et al. Comparative analysis of
retroperitoneal and transperitoneal aortic replacement for aneurysm.
Surg Gyneeol Obstet. 9 8 9; 1 6 8 ( 5 ) : 3 8 7-39 3 .
Mell MW, Acher CW, Hoch J R , et a l . Outcomes after endarterectomy
for chronic mesenteric ischemia. ] Vase Surg. 2008;48 ( 5 ) : 1 1 32-1 1 3 8 .
3. Kasirajan K , O'Hara PJ, Gray BH, e t al. Chronic mesenteric ischemia:
open surgery versus percutaneous angioplasty and scenting. J Vase
Surg. 200 1 ; 33 ( 1 ) :63-7 1 .

of the graft and tenting and narrowing of the anastomosis.
Bypass to the renal arteries should similarly be constructed
with appropriate graft length as it will lay in the retroperi­
toneum after retraction is released. For cases of arterial
reimplantation, it is important to maintain orientation of
the target vessel to prevent twisting during construction of
4. Rapp JH, Reilly LM, Qvarfordt PG, e t a l . Durability of endarterectomy
and antegrade grafts in the treatment of chronic visceral ischemia.
J Vase Surg. 1 9 8 6 ; 3 ( 5 ) : 799-806.
5. Wei bull H, Bergqvist D, Bergentz SE, et al. Percutaneous transluminal
renal angioplasty versus surgical reconstruction of atherosclerotic renal
artery stenosis: a prospective randomized study. J Vase Surg. 1 9 9 3 ;
1 8 (5 ) : 84 1-850; discussion 850-842.
- I
Chapter 16
. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - , _ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
DEFINITION
• The term " hybrid" in vascular surgery traditionally refers to
the use of both traditional open surgical and endovascular
techniques for remedy of the vascular condition ( FIG 1 ) .
• Two hybrid approaches are described i n this chapter.
Complete visceral debranching and endovascular tube
graft repair
Partial visceral debranching and physician-modified fenes­
trated endovascular repair
DIFFERENTIAL DIAGNOSIS
• Paravisceral aortic aneurysms may develop due to the fol-
lowing conditions:
Degenerative aneurysm
Aortic dissection
Mycotic aneurysm
Paraanastomotic j uxtarenal aneurysm
Connective tissue disorders (Marfan's syndrome)
Beh<;et syndrome
PATIENT lll STORY AND PHYSICAL FINDINGS
• The maj ority of patients are asymptomatic and the diagnosis
is made with imaging done for other reasons. Some patients
will complain of mild to moderate abdominal and low back
pain. Severe and unrelenting pain should raise the index of
suspicion for a mycotic process which, if confirmed, would
make hybrid approaches prohibitive.
Hybrid Revascul arization
Strategies for Visceral/Renal
Arteries
�
Benja m in W Sta rn es
IMAGING AND OTHER DIAGNOSTIC
STUDIES
• Contrast-enhanced, axial thin-slice computed tomography
arteriography ( CTA) is the current standard for imaging
paravisceral aneurysms. Detailed information can be gath­
ered regarding the precise origin of the celiac, superior mes­
enteric artery (SMA), and renal arteries ( FIG 2 ) .
• Other important findings o n CTA should be a s follows:
Size and quality of access vessels for delivery of endovas­
cular devices ( > 7 mm)
Location of left renal vein
Aberrant anatomy (e.g., replaced right hepatic artery)
Quality of gastroduodenal artery for possible celiac artery
ligation or sacrifice
Renal cortical thickness
SURGICAL MANAGEMENT
• Indications for repair include aortic aneurysms of more than
5 . 5 em, symptoms, or evidence of rapid expansion ( > 0 . 5 em
per 6 months) .
Preoperative Planning
• As formal open repair would often include a bicavitary incision
(chest and abdomen, as in a formal thoracoabdominal repair),
the standard preoperative assessment should focus on the pa­
tient's fitness to undergo major vascular surgery. This includes
assessment of heart, lung, and kidney function and reserve.
FIG 1 • " Hybrid repa i r " refers to the use of both
trad iti o n a l open s u r g i ca l and e n d ovascu l a r tech n i q u es
to m a n a g e the same p ro b l e m . S M A, superior m esenteric
a rtery. A. I ntraoperative p h oto. B. Post operative CTA
after co m p l eted repa i r.
193 1
1 932 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY
FIG 2 • CTA axial i m ages d e p i ct i n g (A) a 7 .4-cm paraan asto motic
j uxta rena l a o rtic a n e u rysm a n d (B) a hea lthy a o rtic seg ment in
the reg i o n of the SMA.
Positioning
• I
Proper and precise positioning should be as follows ( FIG 3 ) :
Patient supine o n standard operating room table o r imaging
table
Hair properly clipped over entire abdomen and both
groins
Both arms tucked ( option to have right arm at 90 degrees
if planning brachial access)
Foley under one leg and padded
FIG 3
m i d l i ne.
COMPLETE VISCERAL DEBRANCHING AND
ENDOVASCULAR TUBE GRAFT REPAIR­
STAGE 1
First Step-Exposure
• Sta n d a rd m i d l i ne l a pa rotomy a n d positi o n i n g of retractor
system
• U po n e ntry i nto the a bdomen, the fa l ciform l i g a m ent is
d ivided between c l a m ps a n d l i g ated . The tria n g u l a r l i ga-
me nts a bove the l iver a re d ivided to fac i l itate a d e q u ate
exposu re/retract i o n w h i l e m i n i m i z i n g risk of hepatic cap­
s u l a r i n j u ry, a ntici pati n g syste m i c a nticoa g u l at i o n l ater in
the p roced u re .
• A nasogastric tube is positi oned in the sto mach to provide
temporary deco m p ress i o n . The common hepatic a rtery
is identified fo l l owi n g d ivision of the gastrohepatic l iga­
ment a n d traced back to origin of celiac a rtery. Once iden­
tifi ed, the ta rget a rtery is e n c i rcled with a si lastic vessel
loop. Space is created a l o n g the l eft side of the a o rta with
b l u nt/fi nger d i ssection, beg i n n i n g at the level of the ce l i a c
a rtery, to create the retrograde bypass t u n n e l posterior t o
the pancreas (FIG 4).
• The colon a n d omentum a re l ifted i n a ce p h a l a d d i rec­
tion, the s m a l l bowel swept to the patie nt's right a n d
packed i n m o i st towe ls. Self-reta i n i n g retractors (Om n i
o r Bookwalter) s h o u l d b e positioned a t t h i s j u n ct u re to
m a i nta i n exposu re, with ca re taken to a p propriately pad
the retractor b l ades as n ecessa ry.
I
I
I
I
I
I
...
I
r "'
I
I
I
I
I
I
I
• Depict i o n of positi o n i n g a n d i ntended i n c i s i o n in the
• The t h i rd a n d fo u rt h port i o n s of the d u o d e n u m a re mo­
b i l ized to the right fo l l owi n g d ivision of the l i g a m ent of
Tre itz, expos i n g the a nterior su rface of t h e a o rta. The in­
ferior m esenteric ve i n is l i g ated and d ivided a s we l l and
the d i ssect i o n conti n u e d along the prox i m a l a o rta u n t i l
the l eft renal ve i n is clearly identified (FIG S) .
• Widely m o b i l ize t h e l eft r e n a l ve i n s h a r p l y a n d e n c i rc l e
w i t h a m o i st u m b i l i cal tape. The self-reta i n i n g re n a l ve i n
retractor b l a d e is used t o retract t h e l eft re n a l vei n ce p h ­
a l a d a s necess a ry to fac i l itate f u rther exposure.
• The origin of the re n a l a rteries is identified by ca refu l
posterol atera l d i ssection a ro u n d the aorta, j ust cep h a l a d
o f the overlyi n g re n a l vei n . Exposure o n the r i g ht is com­
p l i cated somewhat by the overlyi n g i nfe rior ve n a cava/
l eft ren a l ve i n confl uence. At l east 2 em of re n a l a rtery
s h o u l d be exposed b i l atera l ly. E n c i rcle the ren a l a rteries
with s i l astic vessel loops. O n the l eft, finger d issect b l u ntly
along the aorta i n a cep h a l a d fas h i o n to com p l ete the ret­
ropa ncreati c t u n n e l for the ce l i a c l i m b of the bypass g raft.
• The SMA is i d e ntified n ext by pa l pation with i n the base
of the sma l l bowe l mesente ry, d i rectly a nterior to the
pancreas. D o p p l e r u ltrasonography may assist identifi­
cation when the pu lse is fa i nt. O n ce id entified, a 3-cm
seg ment of SMA is isol ated as p roxi m a l as possi ble to the
root of the m esentery. B eg i n n i n g with the m i d d l e co l i c
a rte ry, m u lt i p l e mesenteric a rteries q u ickly branch from
the S M A as it e m e rges from the pancreas, u n dersco r i n g
the n e e d for proxi m a l identification a n d isolat i o n . T h e
S M A is contro l led w i t h vessel loops.
 C h a pt e r 1 6 H Y B R I D REVAS C U LARIZAT I O N STRATEG I ES FOR V I S C E RAL/RENAL ARTE R I E S
• T h e n ext step is t o prepare t h e d o n o r a rtery f o r hybrid by­
pass. The specific a rtery-m ost com m o n l y the com m o n or
exte r n a l i l iac a rteri es-s h o u l d be sel ected from the p re­
ope rative i m a g i n g study. The retroperito n e u m is opened
d i rectly over the sel ected d o n o r a rte ry, w h i c h is exposed
w h i l e p rotect i n g the adjacent u reter. Alternatively, d o n o r
�----
_..-L---'---
-"'�-..,--..:.;"-..,�--.:,..=-7---
1 933
FIG 4 • D rawi n g of exposu re of the ce l i ac
a rtery t h r o u g h the lesser sac. N ote the b l u nt
f i n g e r d issect i o n a l o n g the l eft side of the
a o rta a n d b e h i n d the pancreas.
a rtery exposu re may be a c h i eved via m e d i a l-visce ral rota­
tion, deve l o p i n g the entire retro perito n e a l p l a n e o n the
l eft. The l atte r a p p roach provides the added ben efit of
exc l u s i o n of the g raft from the viscera a n d abdom i n a l
contents o n c e the viscera a re retu rned to t h e i r orig i n a l
posit i o n . T h i s m a neuver a d d s s i g n ificantly m o re t i m e to
Left renal vein
I nferior
mesenteric
vein
I nferior
mesenteric
artery
FIG S • D rawi n g of exposu re of t h e l eft
re n a l ve i n a n d a nterior su rface of the a o rtic
a n e u rysm . Dashed line d e p i cts i ntended
incision line to avo i d n ervi e r i g e ntes.
1 934 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

the case, h oweve r, a n d contri b utes to i ncreased b l ood

loss. G raft cove rage can a l so be obta i n ed without deve l ­
o p i n g the e n t i re retroperito n e a l p l a ne, e i t h e r via d i rect
t u n n e l i n g a l o n g the p refe rred cou rse of the g raft or cre­
ation of an omental tongue affixed d i rectly to the g raft .

Second Step-Anticoagulation

• System i c a nticoa g u lation is achieved with a bolus i njec­

tion of u nfractionated heparin, 50 u n its/kg . M o n itori n g
activated clott i n g t i m e is a usefu l method of m a i nta i n i ng
adequate a nticoa g u lation d u ri n g the p roced ure.

Third Step-Multivisceral Bypass

• Trifu rcated g rafts exist for the pu rpose of fa c i l itati n g

m u ltivessel hybrid revasc u l a r ization, b u t the u s e o f these
a re l i m ited by the tende n cy of the m i d d l e l i m b to occ l u d e
w h e n "squeezed " betwee n the outside l i m bs d u r i n g g raft
rout i n g a n d a bdom i n a l closure. In m ost circumstan ces, a
sta n d a rd 1 2 x 7 bifu rcated, co l l a g e n - i m preg n ated kn it­
ted po lyester g raft provides exce l lent condu its for b i l at­
e ra l renal revasc u l a rization, with a sepa rate 8-mm l i m b
c o n n ected t o t h e ce l i a c a n d S M A . Exa m ples o f bypass
g raft confi g u rations a re s h own in FIGS 6 and 7.
• The prox i m a l ( i l i ac/i nfl ow) a n a stomosis is co m p l eted fi rst FIG 7 • Aortob i i l i ac a n d su bseq uent d e b ra n c h i n g for a

with ru n n i n g 4-0 or 5-0 polypropy l e n e suture.
• The n ext a nasto mosis to be completed should be o n e an­
tici pated to be the tec h n ica l ly m ost d iffi cu lt, g iven expo­
s u re and g raft routi n g issues. M ost co m m o n ly, this is the
right re n a l a rte ry. This is d ivided fo l l owing p l a cement of
a l a rg e c l i p at the orig i n . The a p p ropriate g raft l i m b is
FIG 6 • D rawi n g of a fou r-vesse l debra n ch i n g based off of
the l eft co m m o n i l i a c a rte ry. N ote that the l eft renal ve i n was
d ivided in t h i s case, a n d su bseq uently repai red, for bette r
exposure of the r e n a l a rteries.
patient with a sol itary l eft kid ney a n d i nfra renal a n e u rysm .
p u l led t o l e n gth a n d a n a stomosed end-to-e nd with 5-0
polypropylene suture. The l i m b and a rtery a re flushed j u st
prior to co m p l etion of the g raft, after which the c l a m ps
are released to reperfuse the kid ney. Following t h i s se­
q u e nce, warm re n a l isch e m i a t i m e is g e n e ra l ly l ess t h a n
1 2 m i n utes. The stu m p o f the r i g ht re n a l a rtery is then
suture l i g ated; avo i d c l i p d islodgement. Note: Excessive
tract i o n o n the confl uence of the l eft re n a l ve i n and vena
cava may cause cava l i n j u ry and massive hemorrhage d u r­
i n g preparation a n d co m p letion of the right re n a l a rtery
a nastomosis. Retractor posit i o n i n g needs to acco u nt for
potentia l ve nous i n j u ry d u r i n g exposure and s i g n ificantly
relaxed fo l l owi n g comp leti o n of the a n asto mosis.
• The left ren a l anastomosis is com p l eted in nearly identica l
fashion, m i n u s m a ny of the exposure l i m itations present
o n the rig ht.
• The S M A g raft is ca refu l ly sized to length so that it fol­
l ows a " ( " -sha ped confi g u ration without k i n k i n g . I nflow
can be obta i n e d either from the m a n y bodies of the g raft
or either of the co m p l eted r e n a l l i m bs . The S M A-g raft
a n asto mosis is co m p l eted e n d-to-s ide with i nterru pted
o r ru n n i n g 5-0 polypropylene suture. The e n d-to-s ide
a rteri otomy l e n gt h is 1 . 5 to 2 t i m e s the width of the
bypass g raft ( 1 2 to 16 m m ) . Alternatively, end-to-e nd
a n asto motic co nfi g u ration may reduce the l i ke l i h ood of
g raft k i n k i n g depen d i n g o n final confi g u rati o n . Fol l ow­
i n g com p l et i o n of the a n asto m osis, the proxi m a l SMA is
l i g ated with a l a rg e c l i p o r c i rcu mference suture. Ag a i n ,
isc h e m i a t i m e s h o u l d be u n d e r 1 0 to 1 2 m i n utes.
• Typical ly, fo l l owi n g S M A a n d ren a l g raft co m p letion, repo­
siti o n i n g of the retraction system is n ecessa ry to reobta i n
a n d opt i m ize celiac a rtery expos u re . Prior t o reexposi n g
 C h a pt e r 1 6 H Y B R I D REVAS C U LARIZAT I O N STRATEG I ES FOR V I S C E RAL/RENAL ARTE R I E S
the celi ac, a vascu l a r c l a m p is repassed through t h e ret­
ropancreatic t u n n e l l eft of the a o rta. This position is then
m a i nta i n ed u n t i l the tra nsverse colon a n d mesoco l o n
a re reduced to t h e i r usual locati o n . T h i s reexposes the
" l ooped " ce l i a c a n d co m m o n h e patic a rteries previously
isol ated i n the Jesser s a c . T h e c l a m p t i p exit i n g the retro-
h e patic tunnel is identified, a n d a m o i st u m b i l ical tape is
p u l led through the tunnel. Following t h i s, the ce l i a c l i m b
COMPLETE VISCERAL DEBRANCHING AND
ENDOVASCULAR TUBE GRAFT REPAIR­
STAGE 2
First Step-Percutaneous Access
• F o l l o w i n g the "debranch i n g " p roced u re descri bed i n
sta g e 1 , e n d ovascu l a r a n e u rysm repa i r (EVAR) m a y be
pe rfo rmed either at the same sett i n g o r with i n seve ra l
weeks of the i n it i a l p roced u re . The risk of potential a n ­
e u rysm r u pt u re associ ated w i t h a sta ged a p p roach needs
to be b a l a n ced with the a d d i t i o n a l operative risk i n h e r­
ent i n t h e l o n g e r a n esthetic t i m e req u i red to co m p l ete
both sta ges in one sitt i n g . For the EVAR p roced u re itself,
sta n d a rd percuta neous access to an a p p ro p r i ately sized
access vessel is obta i n e d using S e l d i n g e r tech n i q u e and
a w i re adva nced i nto the a o rta under f l u o rosco p i c g u id­
a n ce. I n o u r p racti ce, t h i s i s m ost co m m o n ly o bta i n e d
percuta neous ly, u s i n g u ltraso u n d g u i d a n ce a n d preplace­
ment of polypropy l e n e suture p r i o r to d i lation of the
access sites (a lso known a s the " p reclose" Perc l ose® tech­
n i q u e (Abbott Vascu l a r I n c, Redwood C ity, CA) . 1 An 1 1 -F r
sta n d a rd s h eath is p l aced i nto the com m o n fe moral a r­
tery a n d fl ushed with hepa r i n ized sa l i n e . W i re adva nce­
ment from the fe moral a rtery to the a o rtic a rch m u st be
visu a l i zed ra d i o g ra p h ica l ly t h roug hout its cou rse, as the
w i re may p referenti a l ly enter the debra n c h i n g g raft a n d
c a u s e end-organ i nj u ry o r hemorrhage without rea l -t i m e
position m o n ito r i n g a n d g u i d a nce.
Second Step-Stiff Wire Exchange
• After w i re advancement to the transverse a o rtic a rch,
sta n d a rd w i re exc h a n g e tec h n i q u e is used to position a
PARTIAL VISCERAL DEBRANCHING AND
PHYSICIAN-MODIFIED ENDOVASCULAR
REPAIR-STAGE 1
First Step-Exposure
• Sta n d a rd m i d l i ne l a p a rotomy a n d positi o n i n g of retractor
syste m .
• U po n entry i nto the a bdomen, the fa lciform l i g a ment is
d ivided between c l a m ps a n d ligated . The tria n g u l a r l iga­
ments above the l iver a re d ivided to fac i l itate adequate ex­
posu re/retraction w h i l e m i n i m izing risk of hepatic caps u l a r
1 93 5
is tied to the u m b i l ical tape, w h i c h is then p u l led cepha­
lad beh i n d the p a ncreas a n d i nto position for either end­
to-end o r end-to-side a n astomosis. Care a g a i n needs to
be taken to o pt i m ize limb rout i n g a n d length to m i n i m ize
risk for k i n k i n g .
• After coverage of rem a i n i n g exposed g raft l i m bs with
omentum o r parieta l perito n e u m as a p p ropriate, sta n d a rd
abdom i n a l closure is performed.
0.035-in stiff (e . g . , L u n d e rq u i st®, C o o k M e d i c a l , B l oom­
i n gton, I N) w i re t h rou g h t h e a bdom i n a l a n d thoracic
a o rta. O pt i m a l f i n a l w i re positi o n i n g i s at/j u st d i sta l to
the l eft subclavian a rtery orifice.
Third Step-Intravascular Ultrasound
• An 8.2-Fr Visions® catheter (Volcano Therapeutics, I rv i n e,
CA) is used to confirm a p p ropriate p roxi m a l a n d d ista l
l a n d i n g zones for endovascu l a r g raft placement. The opti­
mal g raft size a n d config u ration is dete r m i ned by a n a lysis
of CTA i m ages reformatted and visu a l i zed o n a dedicated
3-D i m a g e workstation (Aq uariusNet®, Te raRecon, I nc,
S a n M ateo, CA) . G raft d i a m eter s h o u l d be ove rsized by
1 0 % to 1 5 % for t h i s a p p l icat i o n .
• D u r i n g adva ncement of the device, the orig i n of the
debra n c h i n g g raft ca n a l so be visua l i zed either t h rou g h
f l u o rosco p i c confi rmation o f a meta l l ic c l i p p l aced d u r i n g
the debra n c h i n g p roced u re o r u n d e r i ntravasc u l a r u ltra­
sound (JVUS) rea l-t i m e g u i d a nce. Using IVUS, the posi­
tion of the IVUS catheter is m a rked o n the f l u o roscopic
m o n itor when the cath ete r itself reco g n i zes the orifice
of the debranched g raft. Alternative ly, a contrast powe r
i nject i o n can be performed t h ro u g h an a p p ro p r i ately po­
sitioned a rte r i o g ra p h i c catheter with 30 m l of contrast
i nj ected at 1 5 ml per seco n d to confirm the proxi m a l a n d
d i sta l l a n d i n g zones.
Fourth Step-Endograft Deployment
• The e n d ovascu l a r g raft is d e p l oyed fo l l ow i n g device­
specific i nstruct i o n s for use ( J F U ), cove r i n g the native
o r i g i n s of the viscera l vesse l s a n d exc l u d i n g the a o rtic a n ­
e u rysm . The fem o ra l a rteriotomy i s t h e n closed.
inju ry, a nticipating syste m i c a nticoagu lation later i n the
proced u re.
• A nasogastric tube is positioned i n the stomach to provide
temporary decompression. The com mon hepatic a rtery is
identified fol lowi n g d ivision of the gastrohepatic l i g a ment
and traced back to origin of celiac a rtery. Once identified,
the target artery is encircled with a sil astic vessel loop. Space
is created along the left side of the aorta with blu nt/finger
dissection, beg i n n i n g at the leve l of the celiac a rtery, to cre­
ate the retrograde bypass tunnel posterior to the pa ncreas.
• The colon and omentum a re l i fted in a cep h a l a d d i rec­
tion, the s m a l l bowel swept to the patie nt's r i g ht a n d
1 93 6 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY
packed i n moist towe ls. Self-reta i n i n g retractors (O m n i
o r Bookwalter) s h o u l d b e positioned a t t h i s j u n ct u re to
m a i nta i n exposu re, with care taken to a p p ropriately pad
the retractor b l ades as necessa ry.
• The t h i rd a n d fo u rt h portions of the d u o d e n u m a re mo­
b i l ized to the r i g h t fo l l owi n g d ivision of the l i g a m ent of
Tre itz, expos i n g the a nte r i o r s u rface of t h e a o rta. The in­
ferior m esenteric ve i n is l i g ated a n d d ivided a s we l l and
the d i ssect i o n cont i n ued along the prox i m a l a o rta until
t h e l eft re n a l ve i n is clearly identifi e d .
• Widely m o b i l ize the l eft r e n a l ve i n s h a r p l y a n d e n c i rcle
with a m o i st u m b i l i ca l tape. The self-reta i n i n g re n a l ve i n
retractor b l a d e is used t o retract t h e l eft re n a l ve i n ce p h ­
a l a d a s necess a ry to fac i l itate f u rther exposure.
• The orig i n of the ren a l a rteries is identified by ca refu l pos­
terol atera l d i ssection a ro u n d the a o rta, j u st ce p h a l a d of
the overlyi n g re n a l vei n . Exposu re on the right is com p l i ­
cated somewhat b y the overlying i nferior v e n a cava/l eft
re n a l vei n confluence. At least 2 em of ren a l a rtery s h o u l d
be exposed b i l atera l l y. E n c i rcle the re n a l a rteries w i t h si­
l astic vessel loops. O n the l eft, f i n g e r d i ssect b l u ntly along
the a o rta i n a cep h a l a d fash ion to com p l ete the retro pan­
creatic t u n n e l for the ce l i ac limb of the bypass g raft.
• The SMA is i d e ntified n ext by pa l pation with i n the base
of the sma l l bowe l mesente ry, d i rectly a nterior to the
pancreas. D o p p l e r u ltrasonography may assist i d e ntifi­
cat i o n when the pu lse is fa int. Once i d entifi ed, a 3-cm
seg ment of S M A is isol ated as p rox i m a l as possi ble to the
root of the mesentery. B eg i n n i n g with the middle co l i c
a rte ry, m u lt i p l e mesenteric a rteries q u ickly branch from
the S M A as it e m e rges from the pancreas, u n dersco r i n g
the n e e d f o r proxi m a l identification a n d isolat i o n . T h e
S M A is contro l led w i t h vessel loops.
• The n ext ste p is to p re p a re the d o n o r a rtery fo r hybrid by­
pass. The specific a rtery-most com m o n ly the co m m o n or
exte r n a l i l iac a rteries-s h o u l d be sel ected from the p re­
operative i m a g i n g study. The retro perito n e u m is opened
d i rectly over the sel ected d o n o r a rte ry, w h i c h i s exposed
w h i l e p rotect i n g the adjacent u reter. Alternatively, d o n o r
a rtery exposu re may be a c h i eved via m e d i a l-visceral rota­
tion, deve l o p i n g the entire retroperito n e a l p l a n e o n the
l eft. The l atte r a p p roach provides the added benefit of
exc l u s i o n of the g raft from the viscera a n d abdom i n a l
contents once the viscera a re returned to t h e i r orig i n a l
posit i o n . This m a n euver adds s i g n ificantly more time to
the case, h oweve r, and cont r i b utes to i ncreased b l ood
PARTIAL VISCERAL DEBRANCHING AND
PH YSICIAN-MODIFIED ENDOVASCULAR
REPAIR-STAGE 22
First Step-Creation o f a Fenestrated Graft for the
Celiac and Superior Mesenteric Artery
• The a p p ro p r i ate e n d ovascu l a r device is chosen accord i n g
t o sta n d a rd I F U s i z i n g g u i d e l i nes, typ i ca l ly i ncorporat i n g
1 0 % to 1 5 % oversi z i n g . The ste r i l e g raft is u n s heathed
loss. G raft cove rage c a n a l so be obta i n ed without deve l ­
o p i n g the e n t i re retroperitoneal p l a ne, e i t h e r via d i rect
t u n n e l i n g a l o n g the p referred cou rse of the g raft or cre­
ation of a n omental tongue affixed d i rectly to the g raft .
Second Step-Anticoagulation
• System i c a nticoagu lation is achieved with a bolus i njec­
tion of u nfractionated heparin, 50 u n its/kg . M o n itoring
activated clott i n g t i m e is a usefu l method of m a i nta i n i n g
adequate a nticoa g u lation d u r i n g the p roced u re.
Third Step-Multivisceral Bypass
• Trifu rcated g rafts exist for the pu rpose of fac i l itati n g
m u ltivessel hybrid reva sc u l a r ization, b u t the u s e o f these
a re l i m ited by the tende n cy of the m i d d l e l i m b to occ l u d e
w h e n squ eezed betwee n the outside l i m bs d u ri n g g raft
rout i n g a n d a bdom i n a l closure. In m ost circumstances, a
sta n d a rd 1 2 x 7 bifu rcated, co l l agen-i m p re g n ated kn it­
ted polyester g raft provides exce l l ent co n d u its for b i lat­
e ra l renal revasc u l a r i zation, with a sepa rate 8-mm l i m b
c o n n ected t o t h e ce l i a c a n d S M A . Exa m ples o f bypass
g raft confi g u rations a re s h own in FIGS 6 and 7.
• The prox i m a l (i l i ac/i nfl ow) a n a stomosis is co m p l eted fi rst
with ru n n i n g 4-0 or 5-0 polypropy l e n e suture.
• The n ext a n asto mosis to be completed s h o u l d be o n e a n ­
tici pated to be the tec h n i c a l l y m ost d iffi cu lt, g iven expo­
s u re and g raft routi n g issues. M ost co m m o n ly, this is the
right re n a l a rte ry. This is d ivided fo l l owi n g p l a cement of
a l a rg e c l i p at the orig i n . The a p p ropriate g raft l i m b is
p u l led to length a n d a n asto mosed end-to-end with 5-0
polypropylene suture. The l i m b a n d a rtery a re fl ushed j u st
prior to c o m p letion of the g raft, after w h i c h the c l a m ps
a re released to reperfuse the k i d n ey. F o l l o w i n g t h i s se­
q u e n ce, warm ren a l isch e m i a t i m e is genera l ly less t h a n
1 2 m i n utes. The stu m p of the r i g ht ren a l a rtery is then
suture l i g ated; avoid clip d islodgement. N ote: Excessive
traction o n the confl uence of the l eft ren a l vei n and vena
cava may cause cava l i nj u ry a n d massive hemorrhage d u r­
i n g preparation a n d comp letion of the r i g ht ren a l a rtery
a n astomosis. Retractor positi o n i n g needs to account for
potential venous i n j u ry d u r i n g exposure and s i g n ifica ntly
rel axed fo l l owi n g co m p l etion of the a n astomosis.
• The renal a n a sto m osis is co m p l eted i n nearly identical
fash ion, minus m a n y of the exposu re l i m itat i o n s p resent
o n the r i g ht.
o n a ded icated ste r i l e table in t h e operat i n g room and
m a rked with t h e relat ive l ocat i o n s ( l e n gth from p roxi­
mal e n d and c l ockface measurements) of the ce l i a c a n d
S M A fen estrati o n s a s p revi ously d ete r m i ned via Ter­
a Reco n ® workstation a n a lysis. M i n o r adj u st m e nts a re
a l l owed to m i n i m i ze strut ove r l a p of p l a n ned fen estra­
tion l ocat i o n s . Fen estrat i o n s in the po lyester e n d o g raft
fa b r i c a re created with a d isposa b l e ophth a l m i c ca utery
to m i n i m i ze fray i n g . The fen estrations a re o u t l i ned
a n d rei nfo rced with 1 5- m m g o l d A m p l atz Gooseneck®
 C h a pt e r 1 6 H Y B R I D REVAS C U LARIZAT I O N STRATEG I ES FOR V I S C E RAL/RENAL ARTE R I E S 1 93 7

FIG 8 • Photog raph o f a t h o racic endog raft w i t h two

fenestrations created for the ce l i ac (struts p rese nt) a n d S M A
(strut free), p r i o r to resheat h i n g a n d d e p l oyment.

s n a res (ev3 E n d ovasc u l a r, I n c, Plymouth, M N) . These a re

h a n d sewn i nto p l ace u s i n g 4-0 Prolene sutu re in a d o u ­
b l e r o w ci rcumferent i a l l y (FIG 8) . D i a m eter-red u c i n g t i e s
w e r e t h e n u s e d to constra i n t h e device a l o n g i t s poste­
rior border (op posite the SMA and o r ce l i a c fen estrati o n
at 6 o'clock) by rerouti n g t h e exist i n g p roxi m a l t r i g g e r
w i re t h r o u g h a n d t h r o u g h t h e g raft mate r i a l at t h e m i d ­
FIG 9 • N ote the d o u b l e densities dep icti n g the o r i g i n s of
port i o n of each of t h e top t w o Z ste nts. The constra i n i n g
the c e l i a c a n d S M A on t h i s f l u s h a o rtog ra m .
ties a re t h e n t i e d down i nto p l a ce over t h e t r i g g e r w i re .
The enti re g raft is t h e n wetted with h e p a r i n ized sa l i n e
a n d t h e n reloaded i nto t h e exist i n g sheath . 7 - F r Raa be® s h eaths (Cook M e d i c a l , B l o o m i n g t o n , I N )
a re adva nced toget h e r t h r o u g h t h e 1 8- F r s h e a t h . Work­
Second Step-Percutaneous Access ing t h ro u g h t h ese s h eaths, t h e SMA and ce l i a c vesse l s
• Sta n d a rd percuta n e o u s access to an a p p ro p r i ately s i zed a re s e l ected t h r o u g h t h e fen estrat i o n s u s i n g sta n d a rd
access vesse l i s obta i n ed u s i n g S e l d i n g e r tech n i q u e . The catheter a n d g u i d e w i re tec h n i q u es, with t h e s h e a t h s
i n it i a l g u i d e w i re i s adva n ced i nto the a o rta u n d e r fluo­ u l t i m ately adva nced i nto t h e ta rget vesse l s over stiff
w i res.
rosco p i c g u i d a n ce . I n o u r p racti ce, this i s m ost co m m o n ly
• After sheath adva ncement a n d confirmation of target
o bta i n ed percuta n e o u s ly, u s i n g u ltraso u n d g u i d a n ce
vesse l acqu isition, the m a i n body is d iste nded flush with
a n d p r e p l a c e m e n t of polypropy l e n e sutu re p r i o r to d i ­
the su rrou n d i n g a o rta with a m o u l d i n g ba l l oo n (e . g . ,
l a t i o n of t h e access s ites ( a l s o k n own a s t h e " p reclose"
Coda®, C o o k M e d i c a l , B l o o m i ngton, I N ) . T h i s i nflation
Percl ose® tech n i q u e (A bbott Vasc u l a r I n c, Redwood
represents the final o p po rtu n ity to d iste n d the endo­
C ity, CA) . 1 A n 1 1 - F r sta n d a rd s h eath i s p l aced i nto the
g raft i n the reg i o n of the viscera l ste nts. Late ra l posit i o n ­
co m m o n fe m o r a l a rtery and f l u s h e d with h e p a r i n ized
i n g of the i m a g e i n t e n s i f i e r g u ides ste nt p l acement i nto
sa l i n e . W i re advancement from t h e fe m o r a l a rtery to
the SMA and ce l i ac a rteries (typica l ly 8- to 9-mm stents;
t h e a o rt i c a rc h m u st be v i s u a l ized rad i o g ra p h i ca l ly
t h ro u g h o ut its cou rse, as t h e w i re may p refe re n ti a l l y
FIG 1 0) . FIG 11 s h ows fo l l ow-u p computed tomography
(CT) i m a g i n g of a patient 1 yea r after successf u l treat­
enter t h e d e b ra n c h i n g g raft a n d cause e n d - o rg a n re n a l
ment with t h i s tec h n i q u e .
i n j u ry, r u pt u re o f G e rota's fa scia, a n d retro perito n e a l
h e m o r r h a g e w i t h o u t rea l -t i m e p o s i t i o n m o n ito r i n g a n d
Sixth Step-Access Site Closure
g u i d a n ce.
• The access sites a re closed with the p revi ously p l aced
Third Step-Stiff Wire Exchange sutu res.
• A sta n d a rd 4- or 5-Fr catheter is used to pe rfo rm a w i re
exc h a n g e to a stiff 0.035-in L u n d e rq u i st® w i re (Cook
Medical, B l o o m i ngton, IN). The w i re is positioned so that
its tip is j ust d i stal to the l eft subclavian a rtery.

Fourth Step-Marking of the Target Vessels and

Graft Deployment

• A contrast power i njection can be pe rfo rmed with 1 0 mL of

contrast i njected at 25 mL per second to m a rk the precise
orig ins of the ce l iac and SMA (FIG 9). The mod ified g raft is
positioned over the target vessels, oriented, and dep loyed .

Fifth Step-Cannulation of the Target Vessels

• An 1 8- F r s h eath is a d va n ced from t h e contra latera l FIG 1 0 • Latera l i m a g e d e p i ct i n g p l acement of a covered

g ro i n a n d i nto the d i sta l g raft over a stiff w i re . Two b a l l o o n-expa n d a b l e ste nt i nto the S M A prior to d e p l oyment.
1 938 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

FIG 1 1 • A.B. F o l l ow-up CT i m ages of a

patient successfu l ly treated with p a rti a l
viscera l debra n c h i n g a n d physi c i a n -mod ified
e n d ovascu l a r fen estrated repa i r.

PEARLS AND PITFALLS

C h o i ce of operati n g room
(OR) ta b l e
Exposu re of co m m o n i l i a c
a rtery
P l a cement of wi res after
d e b ra n c h i n g p roced u re
Ti m i n g of ste nt g raft
ba l l oo n m o u l d i n g d u r i n g
fe n estrated EVAR
• Use sta n d a rd O R ta b l es f o r open s u r g i c a l p roced u res a n d i m a g i n g ta b l es f o r i m a g e- g u i ded o r
h y b r i d p roced u res. Adva nced p l a n n i n g is essenti a l to o pt i m i ze outco m e . N ever sacrifice exposu re !
• I d e ntify a n d p rotect the u rete r.
• Pass g u idewi res u n d e r cont i n u o u s f l u o rosco p i c g u i d a nce fo l l ow i n g d e b ra n c h i n g . An adva n c i n g
a o rtic w i re may p refe renti a l l y e n t e r a n d trave rse the debra n c h i n g g raft, c a u s i n g end-org a n i n j u ry,
d i so r i e ntation, a n d possi b l e endog raft m a l d e p l oyment if n ot recog n i ze d .
• A lways seat the endog raft with ba l l oo n i nflation p r i o r to p l acement of viscera l bridg i n g ste nts.
I n st r u m e ntat i o n o r d iste ntion of the fen estrated endog raft fo l l owi n g branch vesse l ste n t i n g may
compromise ste nt positi o n i ng, i nteg rity, and paten cy.

POSTOPERATIVE CARE COMPLICATIONS

• Open aortic debranching procedures are not benign; almost • Access-related complications
all patients will require intensive care postprocedure. Spi­ • Hemorrhage requiring transfusion
nal drainage is used selectively for aortic coverage extending • Paraplegia
more than 10 em cephalad to the celiac artery. Postoperative • Stroke
anuria or persistent acidosis/rising lactate require immediate • Renal failure
investigation to prove branch vessel patency. • Death

OUTCOMES
• Contemporary hybrid debranching procedures for complex
abdominal aortic aneurysmal disease are associated with a
1 3 % operative mortality rate, 2 % permanent paraplegia
rate, and 1 % stroke rate.3
• Hybrid approaches offer the advantage of versatility, avoid­
ance of extensive operative exposures, and potentially offer
a broader range of therapies to a patient population that
would not otherwise be considered for aortic surgical repair.
REFERENCES
1. Starnes BW, Andersen CA, Ronsivalle JA, et al. Totally percutaneous
aortic aneurysm repair: experience and prudence. J Vase Surg.
2006;43 (2) :270-276.
2. Starnes BW, Quiroga E. Hybrid-fenestrated aortic aneurysm repair: a
novel technique for treating patients with para-anastomotic juxtarenal
aneurysms. Ann Vase Surg. 2 0 1 0;24( 8 ) : 1 1 50-1 1 5 3 .
3 . Starnes BW, Tran NT, McDonald J M . Hybrid approaches to
repair of complex aortic aneurysmal disease. Surg Clin North Am.
2007;8 7(5 ) : 1 0 8 7-1098, ix.
- I

Chapter 17 Snorkel/Chimney and Periscope

Visceral Revascul arization
during Compl ex Endovascul ar
Aneurysm Repair
1
I
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ·

Jason T. Lee Ronald L. Dalm a n

DEFINITION treatment. Careful attention during the history and physi­

• Although routine endovascular aneurysm repair (EVAR) has
gained widespread acceptance as the procedure of choice for
patients with suitable aortic neck anatomy, the optimal ap­
proach to the j uxtarenal aortic aneurysm (JAA), often with
challenging anatomy at the visceral neck, remains contro­
versial. 1 Although open repair is an effective and durable
option for patients with JAA, particularly in centers of excel­
lence for low physiologic risk patients,2 endovascular tech­
niques including fenestrated and branched EVAR (FBE) have
emerged as effective, potentially less invasive alternatives.3
• In the United States, however, lack of widespread availabil­
ity of FBE has allowed other techniques to emerge, and in
this chapter, we describe the increasingly popular " snorkel "
or " chimney" technique, defined as a parallel stent graft ad­
j acent to the endograft main body to maintain perfusion to
renal and visceral branches during EVAR and placed from a
cranial direction, and the "periscope" technique, where the
parallel stent graft is placed from the caudal direction.
• First described by Greenberg and associates,4 the snorkel
strategy can be employed either as a bailout from accidental
coverage of vital side branches during deployments requir­
ing close approximation of the main body to the branch ar­
tery in question, or the intentional cranial relocation of the
EVAR seal zone for JAAs.5-8
DIFFERENTIAL DIAGNOSIS
• The challenge for the vascular specialist in treating JAAs
revolves around an increasing number of choices for inter­
vention, including traditional suprarenal repair, hybrid type
debranching procedures, fenestrated and branched devices
in clinical trials or certain centers, and snorkel/chimney/
periscope techniques. The choice is most often based on pa­
tient physiologic parameters, physician experience with the
multitude of techniques, and a very individualized approach
to complex aortic anatomy.
cal examination to cardiac and renal comorbidities aids in
risk-stratifying the patient for potential repair of their JAA.
Because most patients are asymptomatic and aneurysms are
repaired to prevent future rupture, some reasonable quality
of life must be present for the patient to enjoy the survival
advantage.
IMAGING AND OTHER DIAGNOSTIC
STUDIES
• High-quality computed tomography angiography ( CT-A) on
a modern 64-slice scanner able to produce at least 2-mm-thin
cuts is a requirement for treatment with snorkel techniques.
These imaging algorithms allow the creation of virtual mod­
els of the aneurysm for the surgeon to better appreciate the
relationship of branches and potential areas of technical
challenge ( FIG 1 ) . Patients with compromised kidney func­
tion who cannot undertake iodinated contrast are poor can­
didates for snorkel procedures, as noncontrast scans fail to
elucidate thrombus volume, branch artery patency, and lumi­
nal diameter in the preoperative planning that is paramount
to success.
• Access to a three-dimensional ( 3 -D ) workstation/program
and familiarity with reconstruction software by the implant­
ing surgeon for manipulation of the images and creating cen­
terline pathways should be mandatory to most accurately
plan device orientation, selection, and sizing ( FIG 2) .
• Because the snorkel technique usually involves access of
the brachial artery for delivery of the parallel visceral stent
grafts, visualization of the arch and proximal subclavian is

PATIENT HISTORY AND PHYSICAL

FINDINGS
• Most patients present electively and essentially without
symptoms for consideration of repair of their JAA, as it
is most often discovered during radiographic workup for
vague abdominal discomfort, back pain, or as part of a
screening program. A pulsatile, nontender abdominal mass
can be elicited on careful abdominal exam. Any signs of per­
sistent abdominal or back pain or hemodynamic instabil­
ity or compromise should suggest the possibility of an acute FIG 1 • 3-D reco nstruct i o n of j uxta renal a n e u rysm with i nfra­
aortic pathology and prompt more urgent workup and renal neck l e n gt h of 5 m m .

1939
1 940 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY
FIG 2 • Te raRecon workstation view h i g h l i g ht i n g a b i l ity to
m a n i p u l ate i m ages in m u lt i p l e user-defi ned p l a nes.
most conveniently obtained by including the chest in the
standard CT-A of the abdomen and pelvis. The presence of a
challenging type III arch, where the subclavian inserts below
the inner curve of the aortic arch, makes the procedure more
challenging and many times prohibitive due to concerns
about arch manipulation, cerebral emboli, and deliverability
of stent grafts ( FIG 3 ) . If the patient has already undergone
an adequate CT-A abdomen and pelvis and one wishes to
avoid the additional contrast load of repeating the study, a
noncontrast chest computed tomography ( CT) can be per­
formed to visualize the arch but then should be combined
with arterial duplex and waveforms of the upper extremities
to ensure patency of the axillosubclavian arterial system.
• For patients with chronic kidney disease, high-grade renal
stenosis, atretic kidneys, or multiple visceral and renal ves­
sels involved in the endovascular plan for snorkeling, nu­
clear medicine split renal function tests can help determine if
it is reasonable to sacrifice one of the renal arteries. This can
be done in order to simplify the snorkel strategy and keep
the number of cranially oriented stent grafts to two, which
may have an influence on overall morbidity and mortality
from the procedure. 1 •7•8
FIG 3 • Type I l l a o rtic a rch with o r i g i n of subclavian a rtery b e i n g
l ower t h a n i n n e r cu rve of a o rtic a r c h . The a b i l ity to adva n ce a
snorkel s h eath from the l eft a r m is seve rely comprom ised i n t h i s
confi g u ration a n d g e n e ra l ly n ot reco m m e n d ed if a ltern ative
repa i r methods a re ava i l a b l e .
SURGICAL MANAGEMENT
Preoperative Planning
• All patients considered for snorkel/chimney or periscope tech­
niques should have undergone an extensive informed consent
discussion related to off-label use of endograft components for
treatment of their complex aneurysm. Alternatives often dis­
cussed include open surgery with suprarenal clamping, hybrid
de branching, referral to a center with access to fenestrated or
branched devices, or no surgery at all. Once the decision is
made to proceed with the snorkel strategy, we prefer a two­
surgeon approach with one performing the femoral access
portion and one the brachial access portion. Both surgeons
should have reviewed on the 3-D workstation the anatomy,
the endovascular plan, and the sequence for deployment.
• Access to a hybrid endovascular suite is highly recommended,
although not mandatory, for successful completion of these pro­
cedures. Fixed imaging provides improved accuracy, reliability,
and reproducibility of the anatomy throughout the sequence
of the snorkel procedure. Knowledgeable operating room and
cath-angio staff should be assigned to these cases and available
endografts and wires/catheters as well as backups should all be
arranged ahead of time to provide the safest working environ­
ment for the patient as well as the operative team.
• Choosing the main body endograft, its configuration, and
size has been described by numerous authors who all report
excellent results overall with a wide variety of devices and
formulas. 9 In general, we often " oversized" to about 2 5 % to
3 0 % instead of the typical 1 5 % to 2 0 % for standard EVAR
to account for the additional fabric infolding to accommo­
date the snorkel stent ( s ) .
• Given the amount of dye often used as well as renal artery
manipulation during the most complex of snorkel cases,
we prefer to admit the patient the evening before or several
hours prior to surgery for additional intravenous hydration
when possible.
• General anesthesia is preferred, with consideration for pre­
operative lumbar drainage based on risk of spinal cord ische­
mia. Arterial monitoring, when necessary, is achieved via the
right arm. Adequate venous access can consist of either large­
bore peripheral intravenous lines (IVs) or a central line. There
is usually not a need for autotransfusion or cell saver setups
unless an iliac or axillary conduit is planned where there is
more potential for early blood loss during the procedure.
Positioning
• The hybrid room can be set up as either "head" position ( FIG 4)
or "right side, table rotated" depending on the type of imaging
equipment. With the right arm tucked, the left arm is prepped
circumferentially and placed on an armboard at about 75 to
90 degrees while the chest and abdomen down to the groins
are prepped. Surgeon A, who will stand at the patient's right
hip, has control of the C-arm and imaging functions and is
in charge of obtaining femoral access and delivery of devices
from the groins. Surgeon B stands above the outstretched left
arm, with an additional sterile table extending off the left hand
to allow for wires and catheters to remain sterile and available
for arm access during the procedure. The monitor is placed
at a slight angle toward the foot of the bed to allow both sur­
geons to visualize, or a slave monitor can be employed.
 C h a p t e r 1 7 S N O R K E L/CH I M N EY A N D P E R I SCOPE EVAR
SNORKEUCHIMNE Y ENDOVASCULAR
ANEURYSM REPAIR
Arm Access
• A 5-cm tra nsverse i n c i s i o n s l i g htly b e l ow t h e l eft axi l l a
over t h e p a l p a b l e brach i a l p u lse affo rds seve ra l centi­
m eters of l o n g i tu d i n a l expos ure of t h e h i g h brach i a l
a rtery (FIG SA) . Stay i n g p roxi m a l to t h e d e e p brach i a l
a rtery takeoff a l l ows a l a rg e e n o u g h ca l i be r o f bra­
c h i a l a rtery for typ i c a l d e l ivery of two 7-Fr sheaths for
a d o u b l e re n a l snorkel p roced u re . At l e a st 7 to 8 em
of h e a lthy bra c h i a l a rtery s h o u l d be d i ssected free a n d
s l u n g w i t h vessel l o o p s to a l low accu rate p u n ct u re o f
t h e vesse l . The t w o p u n ctu res s h o u l d be p l a ced at least
2 em a p a rt, a n d n ot n ext to each other, to fa c i l itate later
s i m p l e r, i n d iv i d u a l p r i m a ry c l o s u r e .
• For cases w h e n l a rg e r d e l ivery s h e a t h s may n e e d to b e
i n se rted o r i n cases w h e re potent i a l l y u p to th ree o r
fo u r snorkel stents n eed d e l ive ry, then a n i nfra c l avicu­
lar incision a n d exposu re of the axi l l a ry a rtery for pos­
s i b l e 1 0- m m Dacron c o n d u i t p l acement is reco m m ended
(FIG SB) . When t h i s is p l a n ned, a 20-Fr o r 22-Fr s h eath
can be i nserted to get around the a rch and then th ree
6-Fr o r 7-Fr sheaths can be used to ca n n u l ate the visce ral
vesse ls.
1 941
FIG 4 • E n d ovasc u l a r su ite set u p for
s n o rkel/ch i m ney EVAR with l eft arm
p repped and outstretched, C-a rm at
rig ht-si d ed/ta b l e rotated posit i o n to
a l l ow for latera l i m a g i n g, and m o n itors
at foot of bed. S u rgeon A sta nds at
patient's right h i p and controls C-a r m .
S u rgeon B sta nds a b ove patie nt's l eft
a r m to d e l iver wi res a n d catheters
from side table.
• For the s i m p l est of all snorkel cases, when j u st o n e renal
a rtery n eeds stenting, a l ower brach i a l i n ci s i o n can be
m a d e to a l low i nsert i o n of a single 7-Fr sheath (FIG SC) .
Renal/Visceral Cannulation and Sheath
Advancement
• A 5-Fr m i cropu ncture access is o bta i n e d u n d e r d i rect
visua l i zation i nto the brach i a l a rte ry. A B e ntson w i re is
advanced, u n d e r f l u o rosco p i c g u i d a n ce, m ost often i nto
the ascend i n g a o rta. The use of an O m n iflush catheter
and g l idewire (either a 260-cm Rosen o r A m p l atz [Cook
Medical, B l oom i n gton, I N ] ) co m b i nation, to d i rect the
w i re toward the viscera l a o rta, a l l ows a w i re exc h a n g e
fo r a stiffe r p l atfo r m . Ove r t h i s stiffer p l atfo rm, two
7-Fr 90-cm P i n n a c l e Desti nation sheaths (Te r u m o M e d i ­
cal, Some rset, NJ) a re positioned n e a r the visce ral target
branches to fa c i l itate ca n n u lation attem pts (FIG 6A) .
• T h ro u g h t h e 7 - F r sheaths, t h e targeted re n a l a n d vis­
cera l branches a re ca n n u l ated using 260-cm-l ength hy­
d r o p h i l i c g u idewi res and a 1 2 5-cm J B 1 catheter (Cook
M e d i c a l , B l o o m i ngton, I N) . An a n g i o g ra p h i c run ca n be
pe rfo rmed from a flush catheter a d v a n ced from fe m ­
o r a l access to a i d i n re n a l ca n n u l a t i o n (FIG 68) . T h o r­
o u g h k n o w l e d g e of t h e preope rative a n atomy, d e r ived
from refo rmatt i n g from the 3-D workstati o n fa c i l itates
FIG S • A. Skin i n c i s i o n via a h i g h brach i a l i n c i s i o n
n e a r the axi l l a exposes the p rox i m a l b rach i a l a rte ry,
often g i v i n g a d e q u ate size for d o u b l e pu nctu re.
B. I nfracl avicu l a r i n c i s i o n to expose the axi l l a ry a rtery
n ecessa ry w h e n t h ree or fo u r sno rkel/c h i m ney sheaths
needed. A 1 0- m m o r 1 2- m m Dacron conduit can be
sewn i nto the axi l l a ry a rtery i n t h i s posit i o n . C. S m a l l
i n c i s i o n over p a l p a b l e brach i a l a rtery n e a r a ntecubital
crease ca n be used w h e n o n ly single s n o rkel/c h i m ney
sheath n ecessa ry.
1 942 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY
t h i s p o rt i o n of t h e p roced u re, g u i d i n g opti m a l a n g u l a ­
t i o n o f t h e C-a r m .
• O n ce ca n n u l ated, the sheaths a re adva n ced coaxi a l ly
i nto the ta rget a rtery orifice. When n ecessa ry, or i n cases
w h e re t h e re is a s l i g ht turn to the h o rizonta l rath e r
t h a n downward a n g led, the soft hydro p h i l i c g u idewire
needs to be exc h a n g e d for a 260-cm J-t i p Rosen w i re
(Cook Medical, B l o o m i n gton, I N) or A m p l atz S u p e rstiff
(1 -cm t i p) to fa c i l itate s h eath advancement i nto the ta r-
g et renal a rte ry. Confi rmation a n g iog raphy, t h r o u g h the
sheath, i s performed to e n s u re patency of t h e renal a r­
teri es, ca n n u lation of the m a i n renal a rte ry, a n d avo i d ­
a nce of a c c i d e n t a l s i d e branch ca n n u lati o n .
Positioning o f Main Body Endograft and Snorkel
Stent Grafts
• Sta n d a rd fe m o ra l access for EVAR is e m p l oyed for s n o r­
kel tech n i q u e . T h i s is we l l descri bed i n other cha pters.
B r i efly, a s m a l l transverse i ncision, below the i n g u i n a l
l i g a m e nt, ca n be used to expose the c o m m o n femo-
ra l a rtery to the b ifu rcat i o n for del ivery of endog raft
components. The percuta neous a p p roach i n vo lves the
" p reclose" tech n i q u e a n d e m p l oys two Perclose ProG i i d e
FIG 6 • A. Two 7 - F r Te r u m o sheaths p l aced from
a r m access down desce n d i n g t h o racic aorta ready
to be positioned near vi scera l a o rtic reg i o n . B. R i g h t
ren a l a rtery ca n n u l ated w i t h g l idew i re a n d J B 1
catheter. O m n if l u s h catheter from below reve a l s i n
a n a n g iogram t h e position o f t h e l eft renal a rtery to
be ca n n u lated n ext.
devices (Abbott Va sc u l a r, Sa nta C l a ra, CA) orie nted at
10 o'clock and 2 o'clock posit i o n s 1 0
• The m a i n body endog raft ca n then be del ivered up the
chosen fe moral side to the pa ravisceral a o rta at the same
t i m e as the i CAST (Atri u m Medical, H u dson, NJ) o r Via­
bahn (Gore Medical, Flagstaff, AZ) stents a re adva n ced
through the snorkel sheaths out to the ta rget re n a l a rter­
ies (FIG 7A} . The typical length of the i CAST is 59 m m ,
w i t h the d i a m eter si zed a p p ropriately to sea l i n the ta rget
ren a l a rte ry, m ost often 5, 6, o r 7 m m . For Viaba h n stents,
s i m i l a r d i a m eters a re used in 50- o r 1 00- m m l e n gths as
a p p ro p riate. To p reve nt th eoretica l com p ress i o n of the
Viaba h n stent by the main body of the endog raft, the
Viaba h n can be reinforced from the inside with a ba re­
m eta l, b a l l oon-expa n d a b l e stent a l o n g the a reas of over­
lap with the m a i n body. The positi o n i n g of the snorkel
stent req u i res that at least 10 m m of fixation i nto the
ren a l a rtery be p resent a n d that the p roxi m a l exte nt of
the g raft is a bove the fa bric of the main body endog raft.
• In a latera l p roj ect i o n a n g i o g ra phy, the superior mes­
enteric a rtery (SMA) is visua l i zed (wh e n perfo r m i n g the
typica l d o u b l e renal s n o rkel) a n d the main body fa bric
edge p l aced i m m ed iately below the origin of the S M A
(FIG 7B) .
FIG 7 • A. I n t h e a nterior-posterior view,
both snorkel iCAST stents in position from arm
a p p roach a l o n g with m a i n body endog raft being
put i nto position. B. Lateral view a n g iogram
shows ta keoff of SMA (red arrow) a n d positi o n i n g
o f the m a i n body endog raft fa bric e d g e (white
arrow) immediately below SMA.
 C h a p t e r 1 7 S N O R K E L/CH I M N EY A N D P E R I SCOPE EVAR 1 943

FIG 8 • A. M a i n body endog raft d e p l oyed in a ntero poste r i o r (AP) view with snorkel stents in posit i o n . B. After ca n n u lation
of contra l atera l gate a n d adva ncement of p roxi m a l m o l d i n g balloon i nto a o rtic stent, the two snorkel stents a re f u l l y i nflated .
C. The m o l d i n g b a l l o o n is then maxi m a l ly infl ated to p rofi l e a n d to m i n i m ize g utters. D. The m o l d i n g b a l loon is co m p l etely
defl ated prior to snorkel ste nt ba l l oo n defl ati o n .

• At t h i s poi nt, f i n a l s m a l l adj u stme nts can be m a d e as the re n a l snorkel bal loons a re deflated to a l l ow perfu­
we l l a s further a n g i o g r a p h y to e n s u re that t h e s n o rkel sion of the k i d n eys.
stents a re i n good posit i o n . To avo i d the issue of the
i CAST ste nt b e i n g u n sta b l e off its b a l loon, we often Completion of Distal Components
l eave t h e 7-Fr sheaths i n p l ace to p rotect them until f i n a l
• Prior to losi n g w i re a ccess to the re n a l vesse ls, a p roxi­
d e p l oyment.
mal a o rtog ram is pe rfo rmed to look for a l a rg e type I
e n d o l e a k or poor perfus i o n of either targeted k i d n ey. If
Sequence of Stent Graft Deployment and Balloon this is satisfactory, the d i st a l compon ents of the e n d o­
Molding g raft can be adva n ced a n d d e p l oyed i n the u s u a l fas h i o n .
• Repa i r of the access sites, p a rticu l a r l y the brach i a l site,
• The m a i n body endog raft is d e p l oyed at the ta rget l oca·
req u i res ca refu l i nterru pted 6-0 o r 7-0 P ro l e n e sutu res,
tion with its fa bric edge being i m med iately below the
and a d e q u ate h a n d and foot perfus i o n is verified prior
S M A edge (FIG SA) . Depe n d i n g o n the endog raft system
to co m p letion of t h e case.
used, d e p l oyment p roceeds down to the contra latera l
• Postope rative CTA d e m o n strates the typ i c a l a p pearance
gate open i n g . From the contra l atera l fe m o r a l access,
of the snorkel stents adjacent to the m a i n body e n d o­
ca n n u l at i o n of the gate is confirmed and a noncom p l i ·
g raft with m i n i m a l g utters (FIG 9A), a n d the 3-D reco n­
a n t m o l d i n g ba l l oo n (32- o r 40- m m C o d a b a l loon; Cook
struct i o n s h ows exce l lent a l i g n m ent a n d confi g u ration
Medical, B l o o m i n gton, I N ) is p l a ced u p to the level of the
of the snorkel EVAR components (FIG 9B).
re n a l vesse ls.
• The 7-Fr sheaths a re s l owly withd rawn from the brach i a l
a p proach s o the t i p i s j u st p rox i m a l t o t h e e d g e o f t h e
re n a l snorkel stents a n d d e p l oyment o f the i CAST occu rs,
most often s i m u lta neously a n d to a n o m i n a l pressure of
e i g h t atmos p h e res (FIG SB ) . At the same t i m e that the
i CAST stents a re b e i n g d e p l oyed by b a l loon i nflation,
s l ower i nflation of the Coda occu rs to slowly m o l d the
main body fa bric a r o u n d the snorkel stents to m i n i m ize
g utte r formati o n .
• O n ly w h e n the renal snorkel stents a re maxi m a l l y i nfl ated
can the Coda bal loon g o up to fu l l m a i n body endog raft
d i a m eter (FIG SC). T h i s step ca n n ot be ove re m p h a s i zed,
as defl ation of the snorkel stents w h i l e the Coda is i n ­
flated is l i kely to c r u s h the b a l l oo n-expa n d a b l e cove red
ste nts.
• With the renal snorkel stents sti l l maxi m a l ly i nfl ated, the FIG 9 • A. Postoperative CTA axial v i e w s h ow i n g m o l d i n g o f
Coda b a l loon can finally be l et down after a few seco nds m a i n b o d y endog raft a r o u n d t w o widely patent snorkel ste nts.
of ba l l oo n molding to co m p l ete the sequence (FIG SD) . B. 3-D reco nstruct i o n demo nstrat i n g exce l l ent perfus i o n of
Afte r t h e p roxi m a l m o l d i n g bal loon i s co m p l etely defl ated, both k i d n eys a n d no evidence of e n d o l e a k .
1 944 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY
PERISCOPE ENDOVASCULAR ANEURYSM
REPAIR/THORACIC ENDOVASCULAR
AORTIC REPAIR
Femoral Access for Introduction of Main Body
Endograft
• Periscope EVAR/t h o racic e n d ovascu l a r a o rtic repa i r
(TEVAR) b u i lds o n t h e concept a bove o f p a ra l l e l e n ­
dog rafts but p l a ces the visce ral stents f r o m a fe moral
a p p roach, req u i r i n g b l ood flow to g o t h r o u g h the m a i n
body ste nt g raft, t h e n t u r n a r o u n d a n d retu rn cra n i a l ly
to the vi scera l or re n a l vesse l . "
• T h e fe m o ra l access f o r periscope, i n contra d i sti n ct i o n
to sno rkel/c h i m n ey strate g i es, often i nvolves the use o f
l a rg e r ca l i be r t h o r a c i c o r fen estrated m a i n b o d y compo­
n ents (often 22 F r to 2 6 F r), lea d i n g to a s l i g htly h i g h e r
u s a g e o f o p e n o r e n d ovascu l a r i l i a c c o n d u its.
• One usefu l mod ification to a n i l iac con d u it that can be
helpful i n del ivering and torq u i n g l a rge-ca l i ber main body
com ponents or sheaths d u r i n g periscope EVARITEVAR i n ­
volves creating a patch at the d ista l end (FIG 1 0). This patch
reg ion is created by cutting a 1 0- o r 1 2-mm Dacron g raft
a l o n g its long access, creating a sewing patch that e n l a rges
the tra nsition from g raft to vessel, and not l i m iting the
flexi b i l ity of the branch to the i n itial a n g l e it is sewn i nto.
Contralateral Access and Cannulation of Target
Visceral Branch(es)
• After the femora l access side has been chosen and p re­
pa red for m a i n body endog raft del ivery, the contra latera l
femoral site is used to ca n n u l ate the p l a n ned viscera l or
ren a l branches from the bottom . I n the periscope confi gu­
ration, the para l le l stent g raft is often req u i red to make a
U-turn, so the more flexible covered stent, the self-expand­
i n g Viaba h n (G o re Medical, Flagstaff, AZ), is preferred. This
FIG 1 0 • A. 1 0- m m Dacron con d u it b isected l o n g itud i n a l ly to
create a sew i n g patc h . B. Dacron i l iac co n d u it sewn to native
i l iac a rtery a l l ows easy m o b i l ity of the co n d u it at m u lt i p l e
a n g les of entry f o r l a rge-ca l i be r device o r sheat h . ( F r o m L e e JT,
Lee G K, C h a n d ra V, et a l . Compa rison of fenestrated endog rafts
a n d the snorkel/ch i m ney tec h n i q u e [ p u b l ished o n l i n e a head of
p r i nt Apri l 27, 2 0 1 4 ] . J Vase Surg. do i : 1 0 . 1 0 1 6/j .jvs.201 4.03 .255.)
FIG 11 • 22-Fr sheath with m u lt i p l e p u n ctu res a l l ows th ree
sepa rate 6-Fr sheaths to be i n se rted without leakage.
req u i res l a rger sheath access (up to 1 2 Fr) than the i CAST
described earlier; however, for a double periscope config u ­
ration, a l a rger 20-Fr or 2 2 - F r sheath is usua l l y necessa ry t o
perform m u ltiple pu nctu res i nto (FIG 1 1 ).
• The typical periscope EVARITEVAR i nvolves the need for a
d ista l landing zone (FIG 1 2). In this particu lar case, the celiac
and one renal artery were a l ready occluded, so the periscope
tech nique was used to revascu la rize the SMA and rem a i n i n g
renal a rtery, with a n 1 1 -mm Via bahn i n the SMA req u i ring a
1 2-Fr sheath (blue arrow) and an 8-m m Via bah n as the renal
periscope req u i ring a n 8-Fr sheath (orange arrow) (FIG 1 3).
Sheath Advancement and Periscope Stent Graft
Positioning
• S i m i l a r to the s n o rkel/c h i m ney EVAR p roced u re e a r l i e r,
the g e n e ra l p r i n c i p les of adva n c i n g the s h eath i nto the
target vi scera l vesse l a re repeated, but i n periscope EVAR/
TEVAR, a l l is performed from the fem o r a l a p p roach. The
S M A a n d renal periscopes a re positioned seve ral centi­
meters i nto the target vessel o r i g i n , with the d ista l end
(blue a rro w) below the bottom end of the m a i n body
ste nt g raft (white a rrow) (FIG 14) .
Sequence o f Deployment and Balloon Molding
• The m a i n body endog raft is d e p l oyed with the periscope
sheaths sti l l i n posit i o n (FIG 1 5A) . The sheaths a re t h e n
s l o w l y withdrawn to a l l ow the periscope ste nt g rafts
(Vi a b a h n s) to d e p l oy a g a i n st the m a i n body endog raft
(FIG 1 5 8) . Because there is often some co m p ress i o n of
the self-exp a n d i n g periscope ste nts, an a d d i t i o n a l b a l ­
loo n-exp a n d a b l e b a re ste nt is p l aced a l o n g w h e re there
is contact with the main body endog raft a n d a s i m i l a r
seq uence as e a r l i e r o f b a l loon m o l d i n g is pe rfo rmed to
m i n i m ize g utte r fo rmation (FIG 1 6) .
• The re m a i n d e r o f the p roxi m a l aspect o f the a n e u rysm
is visua l i zed and a p p ropriately ste nt g rafted with proxi­
mal exte n s i o n s and b a l looned (FIG 1 7), and posto pera­
tive CT-A confi rms a n e u rysm exc l u s i o n with wide patency
of the periscope ste nt g rafts a n d n o r m a l target vessel
perfusion (FIG 1 8) .
 C h a p t e r 1 7 S N O R K E L/CH I M N EY A N D P E R I SCOPE EVAR 1 945

FIG 1 3 • 22-Fr s h eath (white a rro w) h o u ses 1 2-Fr periscope

sheath (blue a rro w) i nto S M A as we l l as 8-Fr s h eath (orange
a rro w) positioned to try to ca n n u late renal a rte ry.

FIG 14 • Bottom of both periscope stents (SMA and right renal)

FIG 12 • Thoracoa bdom i n a l a n e u rysm formed a bove prior
are at blue arrow position and therefore lower than bottom of
open repa i r with occl uded r i g h t r e n a l a n d ce l i a c a rteries.
plan ned dista l component of m a i n body endog raft (white arrow).
Periscope confi g u ration to keep S M A a n d right renal a rtery
perfu sed .

FIG 1 6 • B a l loon m o l d i n g of m a i n body endog raft with

FIG 1 5 • A. M a i n body endog raft deployed while periscope co m p l i a n t a o rtic b a l loon a g a i n st ba l l oo n -expa n d a b l e bare
sheaths sti l l i n place. B. After withd rawa l of sheaths, periscope ste nts p l aced with i n periscope stents at l evel of contact a n d
stents (Viabah ns) a re deployed . d i sta l sea l .
1 946 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

FIG 1 8 • C o m p l et i o n CTA show i n g exc l u ­

FIG 1 7 • A. Prox i m a l a n g i og ra p h y s h ows reg ion of proxi m a l a n e u rysm to s i o n of a n e u rysm a n d periscope stents i n
treat. B. Proxi m a l m a i n body endog raft is del ivered a n d ove r l a p is m o l d e d with exce l lent position, perfu s i n g S M A a n d
co m p l i a n t a o rt i c b a l l o o n . r i g h t re n a l a rte ry.

PEARLS AND PITFALLS

I n d i cations • Fol l ow g e n e ra l reco m m e n d at i o n s for e l ective repa i r of a bdom i n a l a o rtic a n e u rys ms (AAAs) and
co n s i d e r ra i s i n g criteria w h e n a p p ly i n g com p l ex s n o rkel/c h i m n ey/periscope p roced u res to these
often comprom ised patients.
• M ost of these p roced u res use a p p roved devices in an off- l a b e l m a n n e r so i nformed consent to
d iscuss a l l ava i l a b l e options i s i m po rtant.
Preoperative workup • H i g h - q u a l ity i m a g i n g a n d the a b i l ity to m a n i p u l ate i m ages on a 3-D workstati o n a re m a n d atory
for successf u l p reope rative p l a n n i n g a n d device choices.
• Ad e q u ate preoperative and peri operative hydrat i o n is i m porta nt, g iven the a m o u nt of renal a rtery
m a n i p u l ation that occurs d u r i n g these cases.
Patient set u p • The adva nced i m a g i n g affo rded b y a dedicated h y b r i d e n d ovascu l a r su ite a l l ows i m p roved v i s u a l -
i z a t i o n d u r i n g t h e s e ve ry tec h n ica l ly d e m a n d i n g p roced u res.
• A we l l -tra i n e d staff and two-s u rgeon a p p roach a re i m portant to e n s u re safe d e l ivery of endog raft
co m p o n e nts from both the fe m o ra l a n d brach i a l positions.
Arm access • Two 7-Fr sheaths can be p l a ced in the h i g h brach i a l position from a transverse i ncision, and the
p u ncture sites need to be at least 2 to 3 em away from each other to a l l ow safe a n d i n d e pendent
a rteriotomy c l o s u re .
Ren a l ca n n u lations • A coaxi a l system with sheath a n d cove red ste nt i nto the target ren a l o r viscera l vessel from the
brach i a l a p p roach opti m i zes safe a n d accu rate d e p l oyment of snorkel ste nts.
• Ca refu l w i re m a n i p u l ation i n d i sta l renal and u s i n g less stiff wi res with J-ti ps, if poss i b l e, m i n i m izes
l i ke l i h ood of re n a l parenchym a l i nj u ry and theoretica l possi b i l ity of re n a l m icroem bol i .
B a l loon m o l d i n g seq u e n ce • Ca refu l atte ntion to seq u e n ce of s n o rkel/c h i m n ey/periscope ba l l oo n seq uence m i n i m izes g utter
formation, promotes g ood neck a p position, and p revents c o m p ress i o n of vita l viscera l and ren a l
branches.

POSTOPERATIVE CARE OUTCOMES

• At the conclusion of the procedure, patients are usually ex­
tubated, observed for 2 to 3 days in a monitored setting (in
the intensive care unit overnight if lumbar drain present) ,
a n d discharged home when ambulating, tolerating a normal
diet, and with stable renal function. Clopidogrel and aspirin
are given if the patients are not already taking these medica­
tions for at least 6 weeks postoperatively.
• Multiple reviews of the worldwide experience with snorkel/
chimney and periscope techniques continue to find it to be
technically successful with target revascularization rates in
the 95% to 1 0 0 % , mortality in the 2 % to 5% range, mor­
bidity up to 1 0 % , and midterm renal and branch patency
rates of 92% to 9 6 % . 12•13
• Rupture-free survival after snorkel/chimney or periscope
EVAR is excellent in the small amount of literature published
 C h a p t e r 1 7 S N O R K E L/CH I M N EY A N D P E R I SCOPE EVAR
on this new approach but will be important to observe in
the mid- and long-term to ensure that this technique is
durable as a strategy for endovascular repair of complex
aneurysms.
COMPLICATIONS
• Perioperative complications related to complex EVAR in
general include cardiac ischemia, arrhythmias or exacerba­
tion of heart failure, groin wound seroma and infection,
early thrombosis of endograft components, and bleeding is­
sues related to access site. Reported rates of these issues are
not particularly different than the wealth of literature for
routine EVAR.
• Particular to snorkel/chimney techniques involve the use of
the arm access, which has the potential of leading to arm
ischemia, nerve injury/irritation of the brachial plexus, and
axillary seromas.
• Wire and catheter manipulation and poor wire hygiene can
lead to inadvertent renal parenchymal inj ury that can lead
to hematomas and excessive bleeding requiring transfusion.
The rate of renal function decline is certainly more than in
standard EVAR, although we do not believe it to be worse
than open suprarenal surgery, fenestrated, or branched
devices.
•
Right arm access for multiple snorkel/chimney stems has
been reported to lead to higher rates of cerebrovascular
complications. 1 •8 This is likely due to moderate amounts of
time that sheaths are across the aortic arch and the possibil­
ity of thrombus formation that can lead to cerebral emboli.
• Gutter leaks are a unique consequence of the parallel stent
graft strategy and are poorly understood. Some general
guidelines involve placing as long of stems as possible in
parallel configuration to force gutter leaks to thrombose,
and careful long-term imaging follow-up to ensure that the
aneurysm is excluded.
1 947
REFERENCES
1. Lee JT, Greenberg Jl, Dalman RL. Early experience with the snorkel
technique for juxtarenal aneurysms. J Vase Surg. 2012;55:935-946.
2. Knott AW, Klara M, Duncan AA, et al. Open repair of juxtarenal aor­
tic aneurysms (JAA) remains a safe option in the era of fenestrated
endografts. J Vase Surg. 2008;47:695-70 1 .
3. Greenberg RK , Sternbergh WC ill, Makaroun M , et al. Intermediate re­
sults of a United States multicenter trial of fenestrated endograft repair for
juxtarenal abdominal aortic aneurysms. J Vase Surg. 2009;50:730-737.
4. Greenberg RK, Clair D, Srivastava S, et al. Should patients with chal­
lenging anatomy be offered endovascular aneurysm repair? J Vase
Surg. 2003 ; 3 8 : 990-996.
5. Ohrlander T, Sonesson B, lvancev K, et al. The chimney graft: a tech­
nique for preserving or rescuing aortic branch vessels in stent-graft
sealing zones. J Endovase Ther. 200 8 ; 1 5 :427-432.
6. Donas KP, Torsello G, Austermann M, et al. Use of abdominal chim­
ney grafts is feasible and safe: short-term results. J Endovase Ther.
2 0 1 0 ; 1 7 : 5 8 9-59 3 .
7. Bruen KJ, Feezor RJ, Daniels MJ, et a l . Endovascular chimney tech­
nique versus open repair of juxtarenal and suprarenal aneurysms.
J Vase Surg. 2 0 1 1 ;5 3 : 895-905.
8. Coscas R, Kobeiter H, Desgranges P, et al. Technical aspects, current
indications, and results of chimney graft for juxtarenal aortic aneu­
rysms. J Vase Surg. 2 0 1 1 ; 5 3 : 1 520-1527.
9. Moulakakis KG, Mylonas SN, Avgerinos E, et al. The chimney graft
technique for preserving visceral vessels during endovascular treat­
ment of aortic pathologies. J Vase Surg. 2012;55: 1497- 1 5 0 3 .
10. Al-Khatib WK, Dua M M , Zayed MA, e t a l . Percutaneous EVAR
in females leads to fewer wound complications. Ann Vase Surg.
2 0 12;26:476-482.
11. Rancic Z, Pfammatter T, Lachat M, et al. Periscope graft to extend dis­
tal landing zone in ruptured thoracoabdominal aneurysms with short
distal necks. 1 Vase Surg. 2 0 1 0 ;5 1 : 1 293-1296.
12. Katsargyris A, Oikonomou K, Klonaris C, et al. Comparison of out­
comes with open, fenestrated, and chimney graft repair of j uxtare­
nal aneurysms: are we ready for a paradigm shift? 1 Endovasc Ther.
2 0 1 3;20:1 59-1 69.
13. Donas KP, Pecoraro F, Bisdas T, et al. CT angiography at 24 months
demonstrates durability of EVAR with the use of chimney grafts for
pararenal aortic pathologies. J Endovase Ther. 2 0 1 3;20: 1-6.

Chapter 18
�
I
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
• Anatomic constraints for endovascular management of
abdominal aortic aneurysms include the presence of short
or angulated surgical necks and aneurysmal degenera­
tion of the origins of the visceral arteries. Fenestrated and
branched endografts were introduced to enable minimally
invasive repair of complex j uxta- and suprarenal aortic
aneurysms. 1 These devices incorporate reinforced fenes­
trations or directional branches, permitting incorporation
of visceral artery origins into the proximal endograft seal
zone without compromising end-organ perfusion or an­
eurysm exclusion.2 This chapter summarizes the technical
features of endovascular aneurysm repair using fenestrated
and branched stent grafts for pararenal and thoracoab­
dominal aortic aneurysms.
DEFINITION
• The term fenestrated repair refers to deployment of an en do­
graft featuring custom orifices created and reinforced at pre­
cise locations around the aortic perimeter to enable branch
artery access, cannulation, and placement of a bridging stent
graft in the course of aneurysm exclusion. Fenestration sites
are created from patient-specific cross-sectional image data
to enable exclusion of aneurysms with short or angled in­
frarenal necks. In most circumstances, the target arteries
(e.g., renal or mesenteric) must arise from normal aorta to
enable fenestrated repair. As a rule, fenestrations must be
able to deploy flush with the aortic wall to ensure adequate
aneurysm exclusion. "Alignment" stents (covered or un­
covered, depending on individual patient circumstance) are
deployed as needed to prevent target artery malperfusion as
a consequence of misalignment between the fenestration and
target artery orifice.
• Branched repair refers to endovascular aneurysm exclu­
sion employing covered stents to directly connect the
main lumen of the endograft to the target visceral artery.
These devices enable repair of aneurysms involving or ex­
tending proximal to the origins of the renal or visceral
vessels ( e . g . , type IV thoracoabdominal aortic aneurysms
[TAAAs] ) . Of necessity, some distance must be present
between the main body of the endograft at full deploy­
ment and the aortic wall at the target visceral artery ori­
fice. Branched stent grafts are currently available in two
distinct configurations:
Fenestrated branches arise from reinforced fenestrations
bridged by balloon-expandable covered stents.
Directional or cuffed branch devices feature appended
fabric cuffs, precisely located to enable straight, helical,
down- or up-going guidewire egress, target vessel can­
nulation, and deployment of bridging covered stents.
Self-expanding flexible nitinol stents are usually employed
for this purpose.
1948
-
Branched and Fenestrated
Endovascul ar Stent Graft
Techniques
·
Gusta vo 5. Oderich Ka rina 5. Ka n a m ori
DIFFERENTIAL DIAGNOSIS
• Most aneurysms are degenerative (previously characterized
as " atherosclerotic, " based on a similar, although not identi­
cal, causal risk factor profile) .
• Other relevant etiologies include infection (e.g., mycotic
aneurysms), inflammation (e.g., inflammatory aneurysm or
aortitis), development of penetrating ulcers or asymmetric
saccular enlargement, and related aortic pathologies (dissec­
tion or intramural hematoma) .
PATIENT HISTORY AND PHYSICAL
FINDINGS
• Most patients' aneurysms do not prompt symptoms prior
to catastrophic rupture and are diagnosed incidentally or
during screening. Indications for repair are size greater
than 5 . 5 em for males and greater than 5 em for females or
enlargement greater than 5 mm in 6 months.3
• In approximately 5% to 10% of patients, aneurysms in­
duce periaortic inflammation and resultant retroperitoneal
fibrosis involving adjacent structures, including the duode­
nal and ureters.4 These patients may present with abdomi­
nal or back pain, fatigue, malaise, or low-grade fever even
at relatively small diameters. Commonly, these aneurysms
also enlarge at accelerated and unpredictable rates. Other
uncommon presentations of abdominal aortic aneurysm
disease include the presence of distal embolization with
" blue toe syndrome, " congestive heart failure from aor­
tocaval fistulae, or gastrointestinal bleeding from primary
aortoenteric fistulae.
• A comprehensive history should be obtained to fully appre­
ciate the potential natural history of each patient's disease,
including a comprehensive assessment of cardiovascular
risk factors, current smoking habits, and a family history of
aneurysmal disease or connective tissue disorders.
• Evaluation of perioperative clinical risk emphasizes cardiac,
pulmonary, and renal functional status and reserve, includ­
ing baseline laboratory testing, noninvasive cardiac stress
testing, pulmonary function assessment, and carotid duplex
ultrasonography when indicated.
DIAGNOSTIC IMAGING
• Preprocedural aortic imaging studies provide fundamental
and necessary guidance for endovascular repair strategies of
all types. Aneurysm morphology is best analyzed through
acquisition of high-resolution computed tomography an­
giography ( CTA) datasets.5 CTA with submillimeter slice
acquisition is recommended for optimal acquisition, allow­
ing three-dimensional reformatting techniques, maximum
intensity projections, and volume rendering.
 C h a p t e r 1 8 BRAN C H E D A N D F E N E STRAT E D E N DOVASCULAR STENT G RAFT TECH N I Q U E S
• Stent grafts are currently custom-made to conform to patient
anatomy, based on estimates of longitudinal distance, axial
clock position, arc lengths, and angles derived from center­
line of flow measurements.
• Anatomic limitations to be considered include difficult iliac
access, excessive aortic tortuosity, visceral artery occlusive
disease, and anatomic variants including multiple accessory
renal arteries or early renal branch bifurcation.
STENT GRAFT DESIGN
• Device planning starts with selection of the proximal landing
zone based on "healthy" aorta. The proximal landing zone
should include at least a 2-cm length of "normal , " noncalci­
fied, parallel aortic wall. The outer-to-outer aortic diameter
should be more than 1 8 mm and less than 32 mm for para­
renal aneurysms and more than 18 mm and less than 38 mm
for TAAAs. 6 Landing zone diameter should be no larger than
the diameter of the next most proximal aortic segment.
• Fenestrated stent grafts are currently manufactured with
three fenestration options: small and large circles and more
proximal scallops ( FIG 1 A) . Small fenestrations are 6 X 6 mm
or 6 X 8 mm, created without crossing struts and reinforced
by circumferential nitinol rings. Large fenestrations' diam­
eters are 8, 1 0 , or 12 mm and may incorporate stent struts
crossing the edge or middle of the circular defect, limiting
space available for alignment stents. Scallops are contoured
indentations along the upper edge of the main body endograft
fabric, 1 0 mm wide and ranging in height from 6 to 12 mm,
depending on individual patient anatomy.5
• Device designs vary with aneurysm extent. For pararenal
aneurysms, 70% of patients are adequately treated with two
small fenestrations for the renal arteries and a scallop for the
superior mesenteric artery ( SMA).5 Suprarenal and type IV
A B
6 mm wide
6 or 8 mm high
> 1S mm from
edge
'
8 ·12 mm diameter
No nitinolring
> 10 mm from edge
FIG 1 • A. There a re th ree types of fen estrati o n s that can be m a n ufact u red: s m a l l , l a rge, a n d sca l l o p fe n estrations. The fen estrated
ste nt g raft consists of a p roxi m a l fen estrated t u b u l a r component, a d ista l bifu rcated u n ive rsa l component, and a contra l atera l i l iac l i m b
exte n s i o n . B. T h e Cook Zenith® stent g raft l i neage. C . Newer d e s i g n with two stra i g h t down-g o i n g branches a n d two fen estrations.
1 949
TAAAs typically require four fenestrations (no scallops).
Extensive TAAAs (types I to III) need directional branches,
particularly if the aortic diameter is relatively large or aneu­
rysmal at the level of the visceral arteries. The combination
of directional branches for celiac and SMA management with
fenestrations for the renal arteries is increasingly popular.
SURGICAL MANAGEMENT
Ancillary Tools
• These procedures require advanced endovascular skills and
a comprehensive inventory of applicable catheters, balloons,
and stents (Table 1 ) . Dedicated training in fenestrated and
branched techniques is highly recommended for physicians
already experienced in endovascular disease management
and ancillary procedures including renal and visceral artery
disease management.
Perioperative Measures
• Patients with difficult aneurysm anatomy, chronic kidney
disease, or advanced age are preadmitted for bowel prepara­
tion and intravenous hydration with bicarbonate infusion.
Oral acetylcysteine is administered to minimize risk of peri­
procedural renal dysfunction following administration of
iodinated contrast.
• Hybrid, fixed imaging platforms are essential for optimal
results of these complex procedures. Most are performed
using general endotracheal anesthesia; local or regional an­
esthesia may be sufficient in select cases.
• Intraoperative blood salvage systems ( " cell saver" ) are recom­
mended for difficult cases and all TAAAs. The creation of large,
impermeable pockets within dependent portions of the surgical
drapes will facilitate pooling and collection via the cell saver.
c
.. .
1 9 50 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

Table 1 : List of Anci l lary Tools Recommended for Physicians Perform ing Fenestrated Stent G raft Procedures

Category Manufacturer Appl ication

Sheaths
20- to 24-Fr Check-Flo sheath (30 em) Cook Medical, Bloomington, IN Femoral access for m u ltivessel catheterization
7 -Fr Ansel sheath ( 5 5 em, flexible d i l ator) Cook Medical, Bloomington, IN Femoral access for branch a rtery stenting
7- or 8-Fr Raabe sheath (90 em long) Cook Medical, Bloomington, IN B rach ial access for branch a rtery stenting
1 2-Fr Ansel sheath ( 5 5 em, flexible d i l ator) Cook Medical, Bloomington, IN B rach ial access for tortuous aortic arch to facil itate branch a rtery stenting
5-Fr S h uttle sheath (90 em) C o o k Medical, Bloomington, IN Branch a rtery access during difficult a rch
Catheters
Kumpe catheter 5 Fr (65 em) M u ltiple Selective vessel catheterization
Ku mpe catheter 5 Fr (1 00 em) M u ltiple Selective vessel catheterization
C1 catheter 5 Fr ( 1 00 em) M u ltiple Selective vessel catheterization
M PA catheter 5 Fr ( 1 2 5 em) M u ltiple Selective vessel catheterization
MPB catheter 5 Fr ( 1 00 em) M u ltiple Selective vessel catheterization
Van Schie 3 catheter 5 Fr (65 em) Cook Medical, Bloomington, IN Selective vessel catheterization
Vertebra l catheter 4 Fr ( 1 2 5 em) M u ltiple Selective vessel catheterization
VS 1 catheter 5 Fr (80 em) M u ltiple Selective vessel catheterization
Simmons I catheter 5 Fr ( 1 00 em) M u ltiple Selective vessel catheterization
Diagnostic fl ush catheter 5 Fr ( 1 00 em) M u ltiple Diag nostic ang iography
Diagnostic pigtail catheter 5 Fr ( 1 00 em) M u ltiple Diagnostic angiogra phy, selective vessel catheterization
Quick-cross catheter 0.0 1 4 in to 0.035 in ( 1 50 em) Spectra-Medics Selective vessel catheterization
Renegade catheter ( 1 50 em) Boston Scientific, M i n neapol is, M N Selective vessel catheterization
Guide catheters
L I M A guide 7 Fr ( 5 5 em) Cordis Corporation, Bridgewater, NJ Precatheterization
Internal m a m m a ry (IM) guide 7 Fr ( 1 00 em) M u ltiple Selective vessel catheterization
M PA guide 7 Fr ( 1 00 em) M u ltiple Selective vessel catheterization
Balloons
1 0-mm x 2-cm angioplasty balloon M u ltiple Proximal stent fla re
1 2- m m x 2-cm angioplasty balloon M u ltiple Proxi m a l stent fla re
5-mm x 2-cm angioplasty balloon M u ltiple Adva nce sheath over balloon
Wires
Bentson wire 0 . 0 3 5 in ( 1 50 em) M u ltiple I n itial access
Soft g l idewire 0 . 0 3 5 i n (260 em) M u ltiple Ta rget vessel catheterization
Stiff g l idewire 0.035 i n (260 em) M u ltiple Ta rget vessel catheterization
Rosen wire 0.035 i n (260 em) M u ltiple Branch a rtery stenting
1 -cm tip Amplatzer wire 0.035 i n (260 em) M u ltiple Branch a rtery stenting
Lunderqu ist wire 0 . 0 3 5 i n (260 em) M u ltiple Aortic stent graft
G lidegold wire 0 .0 1 8 i n ( 1 80 em) M u ltiple Target vessel catherization
Stents
iCAST stent grafts 5 to 1 0 m m Atri u m , H udson, NH Branch a rtery stenting
B a l l oon -expandable stents 0 . 0 3 5 i n M u ltiple Branch a rtery stenting or rei nforcement
Self-expandable stents 0 . 0 3 5 i n M u ltiple Distal branch a rtery stenti ng
Self-expandable stents 0 .0 1 4 i n M u ltiple Distal branch a rtery stenting

MPA, main pulmonary catheter; VS 1, Van Schie 1; LIMA, left internal mammary artery

• The use of iodinated contrast is minimized by avoidance
of power injector digital substraction angiography (DSA)
runs during device implantation and side stent placement.
Whenever possible, hand injections of dilute contrast (70%
saline) are used to locate the side branches. Completion aor­
tography is obtained only after all stents are positioned and
postdilated, again using diluted contrast ( 50 % ) .
• To minimize contrast, precatheterization o f targeted visceral
arteries or use of onlay computed tomography ( CT) images,
when available, is recommended. In experienced hands,
precatheterization adds little to the overall procedure time.
Positioning
• Patients are positioned supine with the imaging unit oriented
from the head of the table. Both arms are tucked for repair
of pararenal aneurysms requiring up to three fenestrations.
• Brachial artery access is used in patients treated by directional
branches or those who need four fenestrations. The left arm
is abducted and prepped in the surgical field up to the axilla.
A working sterile side table is oriented in the same axis of
the abducted arm for optimal support of necessary wires and
catheters.
• Electrocardiogram (EKG) leads, urinary catheter, and other
monitoring cables and lines should be taped or secured so that
they are not in the path of the x-ray beam of the fluoroscopic
unit and do not impede movement of the C-arm gantry.
Arterial Access
• Access is established in the femoral arteries. Patients with
small, calcified, or stenotic iliac arteries may require creation
of an iliac conduit for safe device delivery.
• Total percutaneous femoral access is the preferred approach
in patients with noncalcified arteries or mild posterior
plaque. The standard "preclose " technique enables complete
hemostasis in more than 9 5 % of patients irrespective of
sheath diameter. 7 When femoral arteries are small, calcified,
 C h a p t e r 1 8 BRAN C H E D A N D F E N E STRAT E D E N DOVASCULAR STENT G RAFT TECH N I Q U E S 1 95 1

o r bifurcate close t o the inguinal ligament, standard surgical
exposure and access is obtained. Proximal and distal control
is obtained using vessel loops.
• The left brachial artery is surgically exposed via small longi­
tudinal incision in the upper arm, j ust proximal to the origin
of the deep brachial artery.
• Intravenous heparin ( 8 0 to 1 0 0 units/kg) is administered
immediately after femoral and brachial access is established.
An activated clotting time longer than 250 seconds is main­
tained throughout the procedure with frequent rechecks every
3 0 minutes. Prior to deployment of the stent graft, diuresis is
induced with intravenous mannitol and/or furosemide.

ENDOVASCULAR REPAIR USING
FENESTRATED STENT GRAFTS
• Fenestrated-branched repa i r is cu rrently performed using
the Cook Zenith® stent g raft l i neage. N ewer designs by
E n d o l og i x (Venta n a). Te r u m o (Anaconda). a n d Cook
Medical (p-Branch) a re under c l i n ical i nvestigation.
• The Cook Zenith® fenestrated stent g raft consists of a proxi-
mal fenestrated tubular com ponent, a d ista l bifu rcated uni­
versa l com ponent, and a contra l atera l i l iac l i m b extension
(FIG 1A). The fenestrated tubular component is custom­
made to fit the patient's anatomy. Four to 6 weeks a re re­
q u i red for man ufacturing and del ivery in the U n ited States.
• B i l atera l percuta neous fem o r a l access is esta b l ished
u n d e r u ltraso u n d g u i d a nce; each fe m o r a l p u n ct u re
is precl osed u s i n g two Percl ose devices. B i latera l 8-Fr
sheaths a re i ntroduced to the exte r n a l i l i ac a rteries over
B e nson g u i d ewi res (Cook Medical, B l o o m i n gton, IN). The
g u i d ew i res a re exch a n g e d to 0.035-in soft g l i dewi res
and K u m pe cath ete rs, w h i c h a re adva n ced to the asce nd­
i n g a o rta a n d exc h a n g e d for stiff 0.035-in L u n d e rq u i st
g u i d ewi res (Cook M e d i c a l , B l o o m i ngton, I N ) .
• Cho ice o f access site is dependent on tortuosity a n d ves­
sel d i a m eter. Provided there a re no issues with both i l iac
a rteries, the branches a re performed via the r i g ht femoral
a p p roach, whereas the fen estrated a n d bifu rcated de­
vices a re i ntrod uced via the left femora l a p proach. A 20-Fr
(two fen estrations) o r 22-Fr (th ree fenestrations) Check­
Flo sheath (Cook Medical, B loom i n gton, I N) is i ntroduced
via the r i g ht fe moral a p p roach (FIG 2A) . The va lve of the

FIG 2 • A. A 20-Fr (two fenestrations) o r 22-Fr (th ree fen estrati o n s) Check- F l o sheath (Cook Medical, B l o o m i ngton, IN) is
i ntrod u ced via the r i g h t fem o ra l a p proa c h . B. Precathete rization of the ren a l a rteries. C. Seq uenti a l ly reg a i n access i nto the
fen estrated co m po n e nt, fen estration, a n d ta rget vess e l . D. An a l i g n ment stent i s adva nced u n d e r p rotect i o n of the sheat h .
1 9 52 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY
Check-Flo sheath has fou r leaflets, wh ich a re accessed by
two short 7-Fr sheaths at 2 o'clock a n d 7 o'clock positions.
• Precathete rization of the re n a l a rteries is performed
u s i n g 0.035-in soft g l i dewi res a n d 5-Fr K u m pe or C 1
catheters (Cook Medical, B l oom i n gton, I N), w h i c h a re
s u p p o rted by 7-Fr l eft i nternal m a m m a ry a rtery (LIMA)
g u i de catheters (FIG 28) . Altern ative ly, on lay fusion CTA
is recom m e n d ed to m i n i m ize contra st use.
• O nce the ta rget vesse ls a re cathete rized, the fen estrated
stent g raft is oriented extracorporea l l y, i ntrod uced via the
left femoral a p p roach, a n d deployed with opt i m a l a p posi­
tion between the fenestrations a n d the ta rget catheters.
• Proper device orientation, using the a nterior and posterior
markers, is essentia l . It is usefu l to deploy the fi rst two or
th ree stents and then rotate the imaging u n it latera l ly, con-
firm i n g a l i g n ment between the catheter and its respective
fenestration. The device should be deployed s l i g htly h i g h e r
than w h a t is a ntici pated, w i t h the catheter matc h i n g t h e
lowest o f the fou r rad iopaque ma rkers i n the fen estrati o n .
The d i a m eter-reducing wire on the fe nestrated component
a l l ows for some rotational a n d cra n i a l-<:a udal m ovement
to opt i m i ze a l i g n ment fol l owing i n itial deployment.
• After d e p l oyment of the fen estrated co m p o n e nt, each
catheter is removed from its target a rtery and used to
seq uent i a l l y reg a i n ta rget vesse l access t h r o u g h the re­
spective fen estrati o n . (FIG 2C) . In m ost cases, w h e n
a l i g n m ent i s ca refu l ly confi rmed p r i o r to attem pted ca n-
n u l ation, the target vesse l is accessed without d ifficu lty.
• After the ta rget vesse l is cathete rized, soft g l idewire is re­
m oved and h a n d i nject i o n is used to confirm locat i o n . The
g l idewire is exchanged for a 0.035-in Rosen g u idewire
(Cook Medical, B l o o m i ngton, I N ) . The Rosen g u idewire
has a floppy J t i p, red u c i n g the risk of branch re n a l
a rtery perforations. W h e n add itio n a l s u p po rt is req u i red,
FIG 3 • A. The top cap of the device is adva n c i n g forwa rd a l lowing d e p l oyment of the u n covered fixati o n ste nt. B. The
proxi m a l l a n d i n g zone i s gently d i lated using a co m p l i a b l e b a l l o o n . Stent d e p l oyed 3 to 5 m m i nto the a o rta (C) a n d f l a red
u s i n g a 1 0- m m x 2-cm b a l loon (D).
the A m p l atz g u idewire (Cook Medical, B l o o m i ngton, I N )
w i t h 1 -cm soft t i p ca n be used.
• After the Rosen o r stiff g u i dewire of choice is positioned,
a 7-Fr Ansel sheath with flexi b l e d i lator is advanced.
If there is d ifficu lty to advance the sheath, a n u ndersized
ba l l oo n may be used as a d i lator to fac i l itate adva ncement.
• O n ce the sheath is i n position, a n a l i g n m e n t ste nt i s posi­
tioned under p rotect i o n of the sheath with the t i p of the
ste nt j u st beyo nd the t i p of the sheath (FIG 20) .
• F o r repa i rs requiring two or three vessel fenestrations, the
ta rget vessels a re accessed seq uenti a l ly using femoral a p­
proach. For those req u i ring fou r fenestrations, the celiac axis
is accessed via brach ial approach using a preloaded catheter,
which is placed through the celiac fenestration and exits the
stent g raft via a n access sca llop at the top of the device.
• The d i a m eter-red u c i n g tie o n the fe n estrated seg m e nt
is rem oved after a l l the target a rteries a re accessed a n d
secu red b y 7 - F r hyd ro p h i l ic sheaths.
• The top cap of the device is adva n ced forward to d e p l oy
the u n covered fixat i o n ste nt (FIG 3A) . The top cap is re­
trieved p r i o r to d e p l oyment of the a l i g n m ent ste nts.
• After the top cap and d i l ator a re removed, the proxi m a l
l a n d i n g z o n e is gently d i lated u s i n g a com p l i a b l e bal loon
such as the Coda bal loon (Cook Medical, B l oom i n gton IN,
FIG 38). It is critica l that the ba l l oon d i latation is performed
prior to pl acement of a l i g n ment stents, o r a lternatively,
each stent has to be protected by sepa rate bal loons.
• The a l i g n m ent stents a re seq uenti a l l y d e p l oyed fo l l ow i n g
rem ova l of the d i a m eter-red u c i n g t i e , retrieva l of the t o p
ca p, a n d b a l loon d i l atation of the n e c k . T h e sequence of
stent deployment is ren a l a rteries fol l owed by SMA and
celiac axis. Prior to each ste nt d e p l oy m e nt, the posit i o n
o f the stent is c o n f i r m e d by h a n d i nject i o n . The ste nt is
d e p l oyed 3 to 5 m m i nto the a o rta (FIG 3C) a n d f l a red
 C h a p t e r 1 8 BRAN C H E D A N D F E N E STRAT E D E N DOVASCULAR STENT G RAFT TECH N I Q U E S
u s i n g a 1 0- m m x 2-cm b a l l o o n (FIG 3D) . A c o m p letion
a n g iography of each branch is pe rformed using h a n d
i nject i o n afte r d i rect i nject i o n o f 1 00 to 2 0 0 fi-g of n itro­
g lyce r i n to m i n i m ize spasm .
• F o l l o w i n g p l acement of t h e a l i g n m ent stents, a d ista l b i -
fu rcated ste nt g raft is oriented, advanced, a n d d e p l oyed
with p reservation of the i psi l atera l i nternal i l i ac a rte ry.
The d i lator of the bifu rcated device may encroach the
contra l atera l renal ste nt o r the S M A ste nt. I n these
cases, it is usefu l to leave a 1 0- m m ba l l oo n ready to be
i n f l ated in the renal ste nt to p reve nt d a m a g e (FIG 4A,
inset) . The m i n i m u m ove r l a p between the bifu rcated
a n d the fenestrated co m ponent is two f u l l - l e n gth stents
(1 7 mm each), but idea l ly, m o re t h a n t h ree fu l l stents is
FIG 4 • To avo i d the d i lator of the bifu rcated device en croa c h i n g the contra latera l re n a l ste nt o r the SMA stent, leave a
1 0- m m b a l loon ready to be i nfl ated i n t h e re n a l ste nt (A, inset). B. The m i n i m u m ove r l a p between the b ifu rcated a n d the
fen estrated component is m o re t h a n two f u l l - l e n gth ste nts. C. The contra latera l l i m b exte nsion is d e p l oyed with p reservati o n
of the i nternal i l iac a rte ry.
ENDOVASCULAR REPAIR USING
MULTIPLE DIRECTIONAL BRANCHES
{MULTIBRANCH T-BRANCH STENT GRAFT)
• D i rect i o n a l branches created with p resewn cuffs a re c u r­
rently ava i l a b l e from Cook Zenith® ste nt g raft l i neage
o n a n i nvestigationa l-use basis (FIG 1 B) . A fou r-vessel
m u ltibranch ste nt g raft design (T branch) i s a lso b e i n g
i nvestig ated f o r treatment of TAAAs 9
• T h e extent of repa i r v a r i e s d e pe n d i n g on t h e proxi­
mal exte n s i o n of a n e u rysm w i t h i n t h e thoracic a o rta .
T h e p roced u re is p e rformed u s i n g b i l at e r a l fe m o r a l
1 953
reco m m e n d ed to m i n i m ize risk of component separat i o n
(FIG 4B ).8 After d e p l oyment of t h e bifu rcated device,
the d i lator is rem oved with care to avo id d a m a g e o r d is­
lodgement of the re n a l ste nts.
• The contra l atera l gate is catheterized u s i n g a soft g l ide­
w i re a n d 5-Fr catheter (FIG 4B) . Access is confi rmed by
360-deg ree catheter rotati o n . The g l idewire is exc h a n g e d
fo r a 0.035-in Lunderqu ist g u idewire. L i m ited i l i a c a n g i ­
ography u s i n g contra l atera l o b l i q u e views w i t h h a n d i n ­
ject i o n . The contra latera l l i m b exte n s i o n is d e p l oyed with
preservati o n of the i ntern a l i l ia c a rtery (FIG 4C).
• A com p letion a n g iography o f the aorta and i l iac a rteries i s
obta ined using power i njection to demonstrate patency of
the viscera l a rteries, m a i n body, i l iac l i m bs, and i l iac a rteries.
a n d l eft b r a c h i a l a p proa c h . I n g e n e r a l , t h e repa i r sta rts
with d e p l oy m e n t of a p roxi m a l t h o ra c i c TX2 ste nt
g raft (Cook M e d i c a l , B l o o m i n g t o n , IN) fo l l owed by de­
p l oy m e n t of t h e T- b r a n c h ste nt g raft (Cook M e d i c a l ,
B r i s b a n e, Austra l i a) a n d d i sta l b i f u rcated c o m p o n e n t
a n d contra l a t e r a l l i m b exte n s i o n . T h e s e l f-expa n d a b l e
stents a re p l aced i nto t h e fo u r b r a n c hes fo l l o w i n g
d e p l o y m e n t of a l l a o rt i c c o m p o n ents. T h e c r i t i c a l ste ps
a re reviewed a s fo l l ows:
• B i l atera l fe m o ra l a n d l eft brach i a l a rte r i a l access i s
o bta i n e d (FIG SA) . A p roxi m a l t h o racic ste nt g raft i s
d e p l oyed if n e e d e d depe n d i n g o n a n e u rysm extent.
1 9 54 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

• Precath ete rization of t h e renal a rteries is not re­
q u i red, but it is critica l that the d i sta l edge of the
d i rect i o n a l branch i s d e p l oyed a b ove its i ntended
ta rget vesse l . To guide d e p l oyment of the T-branch
co m p o n e nt, the S M A is p recathete rized via the bra­
ch i a l a p p roach (FIG 58) .
• The T-branch ste nt g raft is orie nted extraco rporea l ly,
i ntrod u ced via the fem o ra l a p p roach, a n d d e p l oyed
with the d i rect i o n a l branches l ocated p roxi m a l to its
i ntended ta rget vesse l (FIG SC) .
• Deployment of the d ista l u n iversa l bifu rcated ste nt
g raft and contra l atera l i l i ac exte n s i o n a re identical

y
(

FIG 5 • A. E n d ovascu l a r repa i r u s i n g m u lt i p l e d i rect i o n a l branches i s pe rfo rmed u s i n g b i l atera l fe moral a n d l eft brach i a l
a p p roach. D e p l oyment o f p roxi m a l t h o racic TX2 ste nt g raft (Cook M e d i c a l , B l o o m i ngton, I N ) (B), fo l l owed b y d e p l oyment
of the T-branch ste nt g raft (Cook Medical, B risbane, Austra l i a) (C), a n d d ista l bifu rcated component a n d contra latera l l i m b
exte n s i o n (D) . T h e fe moral a rteries m a y be cl osed, resto r i n g flow i nto t h e l ower extre m ities; m a i nta i n access i nto o n e o f the
fe moral a rteries u s i n g a 5-Fr sheath (E, inset). F,G. 9-Fr 80-cm flexor sheath (Cook M e d i c a l , B l o o m i n gton, I N ) is adva n ced i nto
the ta rget vesse l, fo l l owed by p l a cement of a self-exp a n d a b l e ste nt g raft. H. Com p l ete p roced u re .
 C h a p t e r 1 8 BRAN C H E D A N D F E N E STRAT E D E N DOVASCULAR STENT G RAFT TECH N I Q U E S
to w h a t w a s described i n the fen estrated tech n i q u e
(FIG SO) .
• The fem o r a l a rteries a re cl osed at t h i s poi nt, resto r­
i n g flow i nto the l ower extre m ities. It is usefu l to
m a i nta i n access i nto o n e of the fe m o ra l a rteries
with a 5-Fr sheath (FIG SE, inset). This m a neuver
a l l ows passa g e of a 0 .0 1 4- i n g u idewire from the l eft
brac h i a l a rtery to fe m o ra l a rtery. The g u idewire is
c l a m ped i n both e n ds, w h i c h locks the 1 2-Fr sheath
i n p l ace and provides s u p p o rt fo r d e p l oyment of the
side branches.
• The 1 2-Fr Ansel I sheath (Cook M e d i c a l , B l o o m i n g ­
t o n , I N ) is adva n ced via t h e l eft brach i a l a p p roach
a n d positioned inside the T-branch component
i n the desce n d i n g thoracic a o rta (FIG SE) . At t h i s
poi nt, a 0.0 1 4- i n g u idewire is adva nced t h r o u g h a n d
t h r o u g h f r o m the l eft b rac h i a l to fe m o ra l a rte ry,
p reve n t i n g move m e nt of the 1 2-Fr sheath i n the
a o rtic a r c h .
• Each s i d e branch is i n d ivi d u a l ly cath ete ri zed in a
seq uentia l fas h i o n , sta rt i n g with the re n a l a rter­
ies (FIG SF) fo l l owed by the S M A a n d celiac axis.
A 5-Fr m a i n p u l m o n a ry a rtery (M PA) o r K u m pe
catheter (Cook Medical, B l o o m i ngton, I N ) is used
ENDOVASCULAR REPAIR USING TWO
DIRECTIONAL BRANCHES AND
TWO FENESTRATIONS (TWO BRANCH-
TWO FENESTRATED STENT GRAFT)
• A d e s i g n with d i rect i o n a l branches for the ce l iac a n d S M A
a n d fen estrations f o r the r e n a l a rteries has been widely
used at the C l eve l a n d C l i n i c . 1 0 M o re rece ntly, a newer
design with two stra i g h t down-g o i n g branches and two
fen estrat i o n s has been used (FIG 1 C) . The advantage of
the l atter is the a b i l ity to p rovide s h o rt, transversely ori-
ented branches for the re n a l a rteries.
• The same p r i n c i p les a l ready described for fen estrated
stent g rafts are a p p l ied with respect to device design,
p l a n n i n g , a n d a rteri a l access.
• B i latera l fe moral access a n d l eft brach i a l a rtery access
is needed (FIG 6A) . The right fe moral a ccess i s used for
p recathete rization of the renal a rteries. The l eft b rac h i a l
access i s used f o r the ce l i a c a x i s a n d S M A (FIG 68) .
• A p roxi m a l thoracic TX2 stent g raft (Cook Medical,
B l o o m i ngton, I N ) is d e p l oyed fi rst, depe n d i n g o n proxi-
mal exte n s i o n of the a n e u rysm (FIG 6A) .
• After the ren a l a rteries a n d SMA a re p recatheterized,
the fen estrated-b ranched ste nt g raft is o r i e nted extra-
corporea l l y, i ntrod uced via the fem o r a l a p p roach a n d
d e p l oyed w i t h pe rfect a p position between the renal fen-
estrations and the ta rget re n a l a rteries (FIG 68) .
1 95 5
to access the d i rect i o n a l branch a n d target vesse l .
O n ce t h e vessel i s cath ete ri zed, t h e soft g l i d ew i re i s
exc h a n g e d fo r a stiff g u idewire (Rosen o r s h o rt-t i p
A m p l atze r, C o o k M e d i c a l , B l o o m i ngton, I N), w h i c h
is positi o n ed i n the target vesse l .
• A 9-Fr 80-cm fl exor s h eath (Cook Medical, B l oom­
i n gton, I N) is adva n ced coaxi a l ly with i n the 1 2-Fr
sheath i nto the ta rget vesse l .
• Each target vessel is stented with a self-expa n d a b l e
ste nt g raft (FIG SF) . The ste nt g raft s h o u l d be over­
sized by 1 to 2 mm and s h o u l d p rovi de at least 2 em
of d i sta l l a n d i n g zone in the target vessel, exte n d ­
i n g 3 to 5 m m i nto the a o rtic l u m e n of the T-branch
device.
• To p revent k i n ks i n the transition of the stent g raft
to the ta rget a rte ry, each self-exp a n d a b l e ste nt
g raft is rei nfo rced by a seco n d self-expa n d a b l e
u n covered stent, w h i c h is d e p l oyed 1 em beyo n d
the d i sta l edge of t h e ste nt g raft (FIG SG) . Selec­
tive comp letion a n g i og ra p h y is o bta i n e d for each
seq u e n t i a l b ra n c h .
• A co m p l et i o n a n g i og ra p h y of the a rch a n d thora­
coabd o m i n a l a o rta is o bta i n e d after all matt i n g
ste nt g rafts a re d e p l oyed (FIG SH).
• The ce l i a c a n d S M A branch a re accessed u s i n g pre loaded
catheters a n d g l i dewi res, w h i c h a re s n a red via the l eft
brach i a l a p p roach (FIG 68) .
• E a c h catheter is sequenti a l ly rem oved from the r e n a l
a rteries a n d used to reg a i n access i nto the fe n estrated
component, re n a l fen estration, a n d target re n a l a rtery
(FIG 6C) . Hyd ro p h i l ic sheaths a n d a l i g n m ent re n a l stents
a re adva n ced a s previously described.
• The preloaded catheters i n the SMA and celiac branch a l low
adva ncement of a 0.035-in soft g l idewi re, which is snared via
the left brachial approach (FIG 68). A sheath and catheter
a re advanced i nto the celiac branch. Following access i nto
the celiac axis, a 0.035-i n Amplatz guidewire is placed.
• The SMA is accessed using s i m i l a r steps, and after access is es­
ta blished with Amplatz gu idewi re, a 9-Fr sheath is advanced
to a l low positioning of a self-expa ndable stent g raft.
• O n ce a l l fo u r vesse l s a re cath ete rized a n d sheaths a re
positioned i nto the re n a l a rteries a n d S M A, the d i a me­
ter-re d u c i n g tie is removed, a l lowing com p l ete expa n ­
s i o n of the fe nestrated-b ranched component (FIG 60).
• Sequential ta rget a rtery stenting is performed using b a l ­
loon-expa ndable covered stents f o r the ren a l fenestrated
branches (FIG 6E, inset) and self-expandable stent g rafts
for the SMA and cel iac axis (FIG 6E, inset). Selective branch
a n g iography is performed after each branch stent is placed .
• D e p l oyment of d ista l bifu rcated component a n d contra­
l atera l i l i a c l i m b exte n s i o n is identica l to what has been
described for fen estrated ste nt g rafts (FIG 6F) .
1 9 56 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

FIG 6 • A. B i latera l fe moral a ccess a n d l eft b rach i a l a rtery access is needed. B. After the renal a rteries a n d S M A a re
p recathete rized, the fen estrated-bra nched ste nt g raft is orie nted extraco rporea l l y, i ntrod u ced via the fe m o ra l a p proa c h . The
ce l i a c a n d S M A branch a re accessed u s i n g preloaded catheters a n d g l idewi res, w h i c h a re s n a red via the l eft brach i a l a p p roach.
C. Reg a i n access i nto the fenestrated com ponent, re n a l fen estration, a n d ta rget ren a l a rte ry. D. Co m p l ete expa n s i o n of the
fen estrated-b ra nched component. Seq uenti a l target a rtery stenti n g i s pe rfo rmed u s i n g b a l loo n-expa n d a b l e cove red stents for
the re n a l fen estrated branches a n d self-exp a n d a b l e ste nt g rafts for the S M A a n d ce l i a c axis (E, inset). F. D e p l oyment of d ista l
bifu rcated component a n d contra l atera l i l i a c l i m b exte n s i o n .
 C h a p t e r 1 8 BRAN C H E D A N D F E N E STRAT E D E N DOVASCULAR STENT G RAFT TECH N I Q U E S 1 957

PEARLS AND PITFALLS

Preope rative eva l u ation
Arte r i a l access
Stent g raft i m p l a ntation
M i s a l i g ned fen estrati o n s
B ra n c h perforat ion or
d i ssect i o n
Stent k i n ks
• Com p l ete h i story a n d physica l exa m i n at i o n with e m p hasis o n ca rd iovascu l a r risk factors, fa m i ly
h i story of a n e u rysm d isease, a n d c o n nective tissue d isorders
• Preope rative medical eva l uation focused on cardi ac, p u l m o n a ry, a n d renal perfo r m a n ce
• Aortic i m a g i n g with co m p uted tomography a n g iography a l l ows deta i l ed a n a lysis of a n e u rysm
m o r p h o l ogy for ste nt g raft d e s i g n and p roced u re p l a n n i n g .
• I l iac c o n d u its a re reco m m e n d ed in patie nts with s m a l l , d iseased, o r excess ively tortuous i l iac a rteries.
• Pelvic perfus i o n with m a i nte n a nce of i nt e r n a l i l iac a rtery flow decreases risk of s p i n a l cord i nj u ry.
• Precise ste nt g raft desig n and i m p l a ntat i o n a re critica l aspects of the proce d u re .
• M i n i m ize u s e of iod i n ated contra st by avo i d i n g contra st a o rtog raphy d u r i n g device i m p l a ntati o n .
• Precathete rization a n d/o r o n lay C T a l l ows p recise device i m p l a ntat i o n w i t h m i n i m a l n e e d of
a n g i o g ra p hy.
• Fen estrat i o n s a re typica l l y accessed via the fe moral a p p roach a n d ste nted u s i n g ba l l oon-expa n d a b l e
cove red ste nts.
• D i rect i o n a l branches a re accessed via the b rac h i a l a p p roach and stented u s i n g self-exp a n d a b l e ste nt
g rafts.
• Excessive tortuosity i n the i l i ac o r visce ral seg ment may c a u s e m i sa l i g n ment o f fenestrations a n d
d iffi cult target vesse l cath ete rizat i o n .
• Rotation of the device, w h i c h i s constra i n e d by a d i a m eter-red u c i n g t i e , a n d u s e of b a l loon
d is p l a cement o r c u rved catheters a l low successfu l catheterization i n m ost cases.
• S m a l l , d iseased, a n d tortuous visceral a rteries a re prone to perforation o r d issect i o n , p a rticu l a rly i f
a n A m p l atz g u idewire is n e e d e d to p rovide m o re s u p p o rt.
• Careful atte ntion to deta i l a n d m i n i m i z i n g g u idewire m a n i p u lation with cl ose attention to the t i p of
the g u idewire help p reve nt this com p l i cati o n .
• B ra n c h tortu osity may lead to k i n ks with i n the side stents.
• This s h o u l d be i m med iately recog n i zed and treated by p l acement of a seco nd self-expa n d a b l e ste nt
to p reve nt branch occl u s i o n .

POSTOPERATIVE CARE averages 1 . 8 % in a systematic review. 13 TAAAs are associated

• Length of stay averages 2 to 3 days for endovascular repair
of pararenal aneurysms and 4 to 5 days for TAAAs.
• Cerebrospinal fluid drainage is discontinued on postopera­
tive day 2, after a 6-hour clamp trial and documentation of
normal coagulation profile.
• Oral diet is resumed the day after the operation for uncom­
plicated cases requiring two to three fenestrations, but it is
typically withheld for 1 or 2 days for difficult cases or those
requiring four fenestrations or branches.
• A CTA and baseline duplex ultrasound of the visceral
branches is obtained prior to dismissal. Follow-up includes
clinical examination and imaging ( CTA and ultrasound) in
6 to 8 weeks, every 6 months during the first year, and yearly
1 year, and early thereafter.
• Patients are started on aspirin indefinitely. Clopidogrel is not
recommended unless there is a specific concern with one of
the side branches because of small size ( < 4 mm), occlusive
disease, or dissection. Clopidogrel should be avoided early
aft er extensive TAAA repair because of risk of delayed spinal
cord injury and paraplegia, which may necessitate replace­
ment of the spinal drain.
OUTCOMES
• Fenestrated and branched stent grafts have been widely applied
to treat pararenal and TAAAs. Early mortality rate is depen­
dent on the extent of repair. For pararenal aneurysms, mor­
tality ranges from 0% to 3 % in single-center reports1 1•12 and
with early mortality of 0% to 9% in single-center reports. 14•1 5
• Technical success is high for endovascular repair using fenes­
trated stent grafts ( 9 1 % to 1 0 0 % ) 16•17 and branched stent
grafts ( 9 3 % to 1 0 0 % ) Y · 1 8
• Endoleaks from the attachment sites (type I and type III)
are uncommon with fenestrated and branched stent grafts.
Type II endoleak is the most common type of endoleak and
occurs in 0 % to 20% of the patients. 1 9•2 0
• Branch vessel patency is excellent with fenestrated branches,
averaging 9 0 % to 1 0 0 % . 15•21 In a recent report by Mastracci
and associates,22 freedom from any branch-related compli­
cation ( occlusion, kink, reintervention) was 8 4 % at 5 years.
COMPLICATIONS
Intraprocedural Complications
• Fenestration misalignment
Neck angulation, tortuosity, and errors of design or im­
plantation can lead to misalignment between the fenestra­
tion and the target vessel. Several maneuvers can be used
to overcome misalignment between the fenestration and the
vessel. Initially, the catheter and guidewire are rotated to
"probe " the aortic wall in search for the vessel. To maintain
access into the fenestration, a 7-Fr Ansel sheath is advanced
into the fenestration and secured by a 0 . 0 1 8-in guidewire,
whereas a 5-Fr " buddy" catheter (e.g., Van Schie [VS] 3) is
used to locate the renal artery. In patients with down-going
or stenosed renal arteries, it may be difficult to advance the
1 9 58 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

catheter over a soft glidewire. The catheter and glidewire REFERENCES

may bounce up into the top cap, providing support for the
1.
catheter to be advanced deep into the renal artery.
• Diameter-reducing ties are located posteriorly, which may result
in the fenestrations being pulled slightly more posterior than its
intended location. A useful maneuver is to gently rotate each 2.
fenestration, usually anteriorly. Other maneuvers are rarely
needed but included use of curved catheters (e.g., VSl or SOS)
for down-going vessels or vessels that are originating from the
3.
lower part of the fenestration, microcatheters, and balloon dis­
placement of the main stent graft. The latter is rarely needed
but may provide more room for catheter manipulations.
• Branch perforation or dissection 4.
Branch vessel perforation and/or dissection can be prevented
5.
by meticulous technique, visualization of the tip of the wire,
and avoiding wire manipulations. The guidewire should not
be positioned in small terminal branches, which are prone
to perforate or dissect. It should be visualized and stabilized 6.
during exchanges manipulations, avoiding forward or retro­
grade movement. If perforation occurs, it should be immedi­ 7.
ately recognized and treated using a microcatheter and coil
embolization. Dissections within the main renal artery can
8.
be treated by placement of a self-expandable scent.
• Endoleaks
Type II and type IV endoleaks may occur and should be left 9.
untreated. Type I and type III endoleaks ( < 3 % ) are infre­
quent with proper selection of a healthy landing zone and
10.
adequate planning.23 In the U.S. fenestrated trial, there were
no type I or III endoleaks. 5 In the event of a type Ia endoleak, 11.
the proximal neck may be redilated, but all the alignment
scents need to be protected by separate balloons. Type III en­
doleaks may result from inadequate flare, lack of apposition, 12.
use of bare metal scent, or inadequate length into the aorta.
• Stent kinks or narrowing
13.
Kinks are highly preventable and can be anticipated from
careful review of vessel anatomy by CTA. These remain a
cause of reintervention or branch vessel loss if not recognized. 14.
Short scents ( < 2 em) tend to avoid bends and the mid- or
distal portion of the renal artery, which has greater respira­ 15.
tory motion. The right renal may have a posterior orienta­
tion from its course behind the inferior vena cava. If a kink is
16.
anticipated by CTA or is evident by completion angiography,
a self-expandable scent should be placed. Kinks or narrowing
may also result from inadequate flare, strut compression, and 17.
ostial disease. In these cases, angioplasty or scenting with a
second balloon-expandable scent may be recommended.
18.
Postoperative Complications
• Spinal cord injury 19.
•
Stroke
20.
• Cardiac events (myocardial infarction, arrhythmias, conges­
tive heart failure)
• Pulmonary complications (pneumonia, prolonged ventila­ 21.
tion, tracheostomy)
• Gastrointestinal complications (ileus, pancreatitis, cholecystitis)
• 22.
Systemic inflammatory response (fever, leukocytosis, throm­
bocytopenia )
• Renal function deterioration 23.
• Access-related problems ( bleeding, thrombosis, pseudoa­
neurysm)
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endovascular aortic aneurysm repair ( " Preclose" technique) . J Vase
Surg. 2007;45 ( 6 ) : 1 095-1 1 0 1 .
Dowdall JF, Greenberg RK , West K , et a!. Separation o f components i n fe­
nestrated and branched endovascular grafting-branch protection or a po­
tentially new mode of failure? Eur J Vase Endovasc Surg. 2008;3 6 ( 1 ) :2-9.
Sweet MP, Hiramoro JS, Park KH, et a!. A standardized multi­
branched thoracoabdominal stent-graft for endovascular aneurysm
repair. J Endovasc Ther. 2009; 1 6 ( 3 ) :359-364.
Greenberg RK, Qureshi M. Fenestrated and branched devices in the
pipeline. J Vase Surg. 2 0 1 0;52(suppl 4 ) : 1 5 S-2 1 S .
Beck AW, B o s WT, Vourliotakis G , et a ! . Fenestrated a n d branched
endograft repair of juxtarenal aneurysms after previous open aortic
reconstruction. J Vase Surg. 2009;49 ( 6 ) : 1 3 8 7- 1 3 94 .
Greenberg RK, Haulon S, O'Neill S, et a!. Primary endovascular repair
of juxtarenal aneurysms with fenestrated endovascular grafting. Eur J
Vase Endovasc Surg. 2004;27(5):484-49 1 .
Health Quality Ontario. Fenestrated endovascular grafts for the re­
pair of juxtarenal aortic aneurysms: an evidence-based analysis. Ont
Health Techno/ Assess Ser. 2009;9 ( 4 ) : 1 -5 1 .
Gilling-Smith GL, McWilliams RG, Scurr JR, et a!. Wholly endovascular
repair of thoracoabdominal aneurysm. Br j Surg. 2008;95 (6):703-708 .
Haul on S, D'Eiia P, O'Brien N , et a ! . Endovascular repair of tho­
racoabdominal aortic aneurysms. Eur J Vase Endovasc Surg.
2 0 1 0 ; 3 9 (2 ) : 1 71-1 7 8 .
O'Neill S, Greenberg R K , Haddad F, et a!. A prospective analysis o f
fenestrated endovascular grafting: intermediate-term outcomes. E u r J
Vase Endovasc Surg. 2006;32 (2 ) : 1 1 5-123.
Semmens JB, Lawrence-Brown MM, Hartley DE, et a!. Outcomes of
fenestrated endografts in the treatment of abdominal aortic aneurysm in
Western Australia ( 1 997-2004 ) . ] Endovasc Ther. 2006; 1 3 ( 3 ) :320-329.
Roselli EE, Greenberg RK, Pfaff K, et a!. Endovascular treatment of
thoracoabdominal aortic aneurysms. J Thorac Cardiovasc Surg. 2007;
1 3 3 ( 6 ) : 1474-1482.
Scurr JR, Brennan JA, Gilling-Smith GL, et a!. Fenestrated endovascular
repair for juxtarenal aortic aneurysm. Br J Surg. 2008;95 ( 3 ) :326-332.
Bicknell CD, Cheshire NJ, Riga CV, et a!. Treatment of complex aneu­
rysmal disease with fenestrated and branched stent grafts. Eur J Vase
Endovasc Surg. 2009;37(2 ) : 1 75-1 8 1 .
Verhoeven EL, Tielliu IF, Bos WT, et a!. Present and future o f branched
stent grafts in thoraco-abdominal aortic aneurysm repair: a single­
centre experience. Eur J Vase Endovasc Surg. 2009;3 8 ( 2 ) : 1 55-1 6 1 .
Mastracci TM, Greenberg RK, Eagleton MJ, e t a!. Durability of
branches in branched and fenestrated endografts. J Vase Surg. 2 0 1 3 ;
57(4):926-9 3 3 ; discussion 9 3 3 .
Dijkstra M L , Eagleton MJ, Greenberg R K , et a!. Intraoperative C-arm
cone-beam computed tomography in fenestrated/branched aortic
endografting. j Vase Surg. 2 0 1 1 ;5 3 ( 3 ) : 5 83-590.

Chapter 19
. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - , _ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
DEFINITION
• The content discussed in the following text presupposes fa­
miliarity with basic wire and catheter-based endovascular
techniques. For a summary of such techniques, the reader
may refer to excellent existing references. 1
• Various occlusive and/or aneurysmal disease processes in
renal and visceral arteries may necessitate endovascular
interventions (Table 1 ) .
• Progressive renal artery stenosis (RAS) o r occlusion may pre­
dispose to renovascular hypertension (RVH; most common
form of secondary hypertension) and ischemic nephropathy.2
Aortic atherosclerosis at the ostia or proximal renal artery
accounts for two-thirds of cases.3 Fibromuscular dysplasia
(FMD) also causes progressive serial stenoses throughout
the renal arteries and may also predispose to RVH. FMD
occurs most commonly in younger female patients.4
• Acute mesenteric ischemia (AMI) and chronic mesenteric
ischemia ( CMI) are life threatening but fortunately rare ( 1 in
1 ,000 and 1 in 1 00,000 hospital admissions, respectively)
conditions.5• 6 The infrequent nature of symptomatic mesen­
teric ischemia may be due to the rich collateral supply derived
from the celiac, superior, and inferior mesenteric arteries.
CMI most commonly develops following progressive athero­
sclerotic occlusion of two or more mesenteric arteries, with
the superior mesenteric artery (SMA) being the most critical
of the three. Arterial embolization, leading to acute occlusion
of the celiac artery or SMA, more commonly is associated
with AMI. 6 In rare circumstances, in critically ill patients,
impaired intestinal perfusion due to arterial vasospasm may
occur in the absence of thromboembolic occlusion.
• Extra- and intra parenchymal renal artery branch aneurysms
occur with a reported autopsy incidence between 0 .0 1 % and
Table 1 : Rena iNiscera l Arterial D i sease
Causes of rena l/visceral a rtery • Atherosclerosis
stenosis or occlusion • Fibromuscu lar dysplasia
Dissection
•
• Coa rctation syndromes
• Extri nsic compression
• Vascu l itis
• Hypercoagulable state
Causes of renal/visceral a rtery • Extension of aortic aneurysm a l disease
aneurysm Atherosclerotic degeneration
•
Blunt or penetrating tra u m a
•
• Fibromuscu lar dysplasia
• Connective tissue d isorder
• Iatrogenic injury
I
Stenting, Endografting, and
Embolization Techniques:
Celiac, Mesenteric, Spl enic,
Hepatic, and Renal Artery
Disease Management
�
Moha med A. Zayed Ronald L. Dalm a n
0. 7% and may arise from various disease etiologies? Overall,
the risk of acute clinical evolution (rupture or thrombosis)
is low but may be increased during pregnancy, with high re­
sultant maternal and fetal mortality. The risk of progression/
rupture, as is the case in most visceral artery aneurysms, is
presumed to decline significantly following menopause.
• Aneurysms of the celiac artery, SMA, and their branches are also
infrequent and associated with varying etiologic entities. Splenic
artery aneurysms are the most common (60%), followed by
aneurysms in the hepatic (20 % ) , superior mesenteric, and celiac
arteries, in that order. 8•9 Syndromes such as polyarteritis nodosa
or Kawasaki's disease may be associated with aneurysms in var­
ious segments of the mesenteric arterial circulation. Guidelines
for intervention vary, depending on aneurysm location, rate of
enlargement, symptom status, and demographic considerations:
age, gender, and menstruation status.
PATIENT HISTORY AND PHYSICAL
FINDINGS
• RVH, with or without concurrent evidence of ischemic
nephropathy, is seen in less than 5 0 % of individuals mani­
festing severe RAS.2•3 Hypertension in children, new onset
hypertension in individuals younger than 30 or older than
55 years old, or accelerated hypertension should prompt sus­
picion for the presence of RAS. Older patients with RVHIRAS
typically manifest other stigmata of systemic vascular disease,
including coronary and cerebrovascular disease, in addition
to peripheral vascular disease. In patients with severe bilateral
RAS, renal failure may be exacerbated with recent initiation
of an angiotensin-converting enzyme (ACE) inhibitor. 10 Acute
exacerbations of poorly controlled RVH may manifest with
"hypertensive crisis, " flash pulmonary edema, or neurologic
symptoms ranging from headache to seizure and stroke. Phys­
ical examination may reveal severe elevation of both systolic
and diastolic blood pressures, abdominal bruits, and other
manifestations of peripheral arterial occlusive disease.
• Patients with CMI are typically elderly and have a prior
history of symptomatic vascular disease. Like RAS/RVH
patients, CMI rarely is present without other signs and
symptoms of advanced vascular disease, including aortic and
mesenteric branch arterial calcification on plain x-ray films
of the abdomen. Symptoms produced by CMI are frequently
nonspecific and intermittent, leading to delayed diagnosis
and disease progression. Classical symptoms usually include
postprandial dull/crampy midepigastric abdominal pain,
progressive weight loss, and " food fear" with decreased ca­
loric intake. 1 1 Findings on physical examination are usually
noncontributory, save those related to advanced peripheral
1959
1 960 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY
vascular disease (e.g., absent pedal pulses); patients fre­
quently are malnourished and cachectic. Abdominal auscul­
tation frequently reveals hyperactive bowel sounds, and a
bruit may sometimes be auscultated.
• AMI presents more dramatically, with sudden onset of
abdominal pain, often in patients suffering acute embolic
occlusion of the SMA. Although pain may seem out of pro­
portion to obj ective physical examination findings initially,
progressive tenderness to palpation and ultimately perito­
neal signs develop in parallel with diminishing bowel viabil­
ity. Clinical status also rapidly deteriorates, with progressive
metabolic acidosis, shock, and multisystem organ failure.6
• Patients with renal artery aneurysms ( RAAs) may provide
a history of trauma, arterial dissection, syndromic vascular
conditions, connective tissue disorders, or RAS. The ma­
j ority of RAAs are asymptomatic at the time of diagnosis,
identified as incidental findings on cross-sectional imaging
studies ordered for unrelated indications. Specific associated
historical and physical findings are rare but may include
acute onset hypertension, abdominal distension, flank pain,
hematuria, syncope, and shock. Occasionally, an abdominal
pulsatile mass is present on physical examination.7 Although
not always fatal, RAA rupture, particularly those in segmen­
tal branches, frequently predisposes to renal infarction and
resultant decrease in glomerular filtration capacity.
• Patients with aneurysms of the celiac and SMAs and derived
branches may manifest with a history of arterial dissection,
trauma, pancreatitis, or other local inflammatory processes
or infections. One-third of patients may also have aneurys­
mal disease in other segments of their arterial anatomy. 8 As is
the case with RAAs, patients rarely present with symptoms
other than rupture, which itself is also rare. Free rupture may
result in hemoperitoneum, hematobilia, or life-threatening
gastrointestinal hemorrhage. The risk of rupture is highest
with hepatic (20% to 44% of mesenteric arterial aneurysm
ruptures) and splenic artery aneurysms, the latter notoriously
at risk during the third trimester of pregnancy. 12•13 Presence
of a splenic artery aneurysm recognized during pregnancy
should prompt consideration of immediate repair, regardless
of the status of the pregnancy. 14
IMAGING AND OTHER DIAGNOSTIC
STUDIES
• Renal artery disease assessment usually begins with duplex
ultrasonography, which has a reported sensitivity of 8 6 %
t o 9 3 % , specificity o f 9 8 % , and overall accuracy o f 9 6 % . 1 5
Duplex criteria used to diagnose more than 6 0 % RAS in­
clude an arterial peak systolic velocity of more than 1 8 0 to
200 em per second, a ratio of renal artery to aortic peak
systolic velocity of more than 3 . 5 , or acceleration time be­
tween onset and peak of systole of more than 1 0 0 m per
second. Kidney length and resistive indexes derived from
parenchymal insonation may also provide important insight
into the presence, nature, and severity of end-organ disease.
• Similarly, duplex ultrasound provides a useful, noninvasive
method of assessing for the presence of chronic mesenteric
occlusive disease. 1 6 In the celiac artery, peak systolic veloci­
ties of more than 200 em per second provides a sensitiv­
ity and accuracy for detecting a greater than 70 % stenosis
of 8 7 % and 8 2 % , respectively. In the SMA, peak systolic
velocities of more than 275 em per second provides a sensi­
tivity and accuracy for detecting a greater than 70% stenosis
of 92% and 9 6 % , respectively.
• Computed tomography angiography ( CTA) is the current
gold standard for confirming the presence, severity, and
extent of occlusive mesenteric vascular disease. CTA-derived
images also provide insights into the potential underlying
mechanism of occlusion, including FMD, associated dissec­
tion, evidence of inflammation/infection, or thromboembolic
occlusion. Moreover, three-dimensional reconstructions
generated from CTA datasets also provide valuable guidance
for preprocedural planning. In emergent circumstances, such
as those associated with suspected AMI, CTA usually repre­
sents the "go-to " diagnostic test.
• For patients with contrast allergies or other contraindica­
tions to computed tomography ( CT) scanning, magnetic
resonance angiography (MRA) may provide a suitable alter­
native, particularly for initial diagnosis and screening pur­
poses. Overall resolution of MRA is not equal to that of
CTA and in some circumstances may not provide sufficient
detail for the precise surgical or interventional planning.
SURGICAL MANAGEMENT
Patient Selection
• Appropriate patient selection for endovascular intervention is
paramount and dependent on therapeutic indication, anatomy,
patient comorbidities, and acuity of the disease process. In the
following text, we discuss considerations for patients with renal/
mesenteric arterial occlusive disease, followed by considerations
for patients with renal/mesenteric arterial aneurysmal disease.
• For RAS, the indication for endovascular intervention is con­
tingent on severity of stenosis, the presence and severity of
presumed resulting hypertension, and extent of residual glo­
merular filtration capacity. For RAS, there is no accepted indi­
cation currently for "prophylactic" intervention. Endovascular
intervention is considered only in patients with severe hyper­
tension, who have failed medical management with at least
three concurrent antihypertensive medications or have dem­
onstrated progressive loss of renal function due to ischemic
nephropathy in the setting of more than 60% RAS. The future
role for endovascular intervention in treating RVH has been
called into question by level I data demonstrating only modest
reductions in blood pressure following renal artery stentingY
• Patients with critical stenosis or occlusion of at least two
mesenteric arteries, in the setting of signs and symptoms
consistent with CMI, are also potential candidates for
endovascular management. Patients with atypical symptoms
who may meet anatomic criteria for mesenteric occlusive
disease often experience disappointing results following
endovascular intervention.
• Given the compromises inherent in management of AMI,
often in the setting of uncertain bowel viability, hybrid
open and endovascular approaches may represent the saf­
est and most expeditious option. Particularly in regard to
" acute-on-chronic " occlusion of the proximal SMA, with
a patent distal segment preserved by collateral flow, surgi­
cal exposure at celiotomy enables distal SMA cannulation
and sheath placement. Standard angiographic techniques are
 C h a p t e r 1 9 S T E N T I N G , E N D O G RAFT I N G , A N D E M B O L I ZATI O N TECH N I Q U E S
then employed t o cross the occlusive proximal lesion i n a
retrograde fashion, with subsequent angioplasty and stent­
ing performed to restore pulsatile antegrade flow. 1 8 We have
employed this technique reliably under a variety of challeng­
ing clinical conditions with consistently good results.
• In patients with disease in multiple mesenteric arterial segments
and symptoms concerning for mesenteric ischemia, SMA
revascularization, either via endovascular or open surgical
approaches, represents the most reliable and effective method
for resolving critical mid- and distal gut ischemia. Decompres­
sive laparotomy should always be considered as an essential
adjunct in these circumstances, regardless of revascularization
method used, to facilitate selective resection of nonviable bowel
if needed and limit the noxious effects of abdominal compart­
ment syndrome in these already compromised patients.
• In comparison, the safety and use of primary inferior mesen­
teric artery (IMA) endovascular intervention remains contro­
versial in patients with disease in multiple mesenteric arteries.
Recent series report relatively frequent procedure-related
complications and poor outcomes following attempted IMA
intervention.19 These results may in part be due to the pro­
gressive nature of occlusive vascular disease in the most distal
aortic segment at the level of the IMA and resulting difficulty
in resolving significant ostial stenoses with even high-pressure
angioplasty techniques.
• The criteria for elective repair of asymptomatic RAAs is
controversial. Recommendations vary for intervention based
on aneurysm diameter, also taking into account the size of
the parent artery, extent of mural calcification, and rate of
enlargement, if available. Consensus exists regarding treat­
ment for all aneurysms larger than 3 em in diameter.20•21 Simi­
larly, patients with intact but symptomatic true aneurysms,
recent-onset false (pseudo-) aneurysms, and aneurysms result­
ing from associated FMD are also typically repaired promptly,
given their presumed higher risk of rupture. RAAs in women
of childbearing age with plans for future pregnancies are usu­
ally repaired, when recognized, at almost any size. Less agree­
ment is present for RAAs larger than 2 em but smaller than
3 em in diameter, with treatment recommendations often cus­
tomized based on individual circumstances.
• There are no set size criteria for visceral artery aneurysm
repair. Although larger aneurysms are thought to have an
increased potential risk of rupture, small visceral artery
aneurysms are also known to rupture and manifest with
life-threatening hemorrhage. Therefore, most visceral aneu­
rysms larger than 2 em should be repaired when identified.
This recommendation does not necessarily apply to post­
stenotic arterial dilations (not true aneurysms) and distal
SMA aneurysms. The latter are generally best managed by
embolization and/or resection of the dependent loops of ad­
j acent small intestine. In most circumstances, ruptured vis­
ceral artery aneurysms are best managed by open or hybrid
approaches, allowing for assessment of bowel or end-organ
ischemia in conjunction with restoration of arterial flow.
Preoperative Planning
• Prior to attempted repair or exclusion, aneurysm location
and access issues should be precisely determined via cross­
sectional imaging studies. Luminal plaque, thrombus burden,
1 96 1
associated aneurysms, and preexisting dissections should
also be noted. Finally, target vessel diameter should be deter­
mined at several intervals before, within, and after the lesion
of interest to optimize coil, stent, and graft selection.
• The preferred method of critical renal artery ostial lesion
management is by balloon-expandable stent placement. In
rare circumstance, angioplasty predilation may be required
to advance the appropriate stent through the renal ostia and
across the stenotic lesion. Renal artery stents range from 1 0
t o 3 0 m m i n length and 4 t o 7 m m i n diameter. Transfemoral
approaches to the renal artery are generally preferred due
to the shorter distance to target, smaller imaging fields, and
abundant availability of purpose-specific instrumentation.
However, cephalad angulation of the renal artery origins
relative to the aorta, the presence of extensive infrarenal
aortoiliofemoral arterial occlusive disease, or significant iliac
artery tortuosity may favor consideration of the left brachial
artery and descending thoracic aorta as the preferred route
of access.
• For the treatment of mid- to distal RAS in the setting of
FMD, angioplasty alone is generally the preferred treatment
modality. Either transfemoral or transbrachial approaches
may be considered, depending on the considerations noted
earlier. Care must be taken to minimize procedural trauma
with precise determination of target artery diameter and
selection of appropriately sized instruments (sheaths, bal­
loons, and stents) . Poor planning or ill-considered procedural
technique may precipitate arterial dissection, thrombosis,
and renal infarction.
• Depending on the degree of lesional calcification, the ex­
tent of associated j uxtaostial aortic occlusive disease, lesion
length and associated target vessel tortuosity, balloon- or
self-expanding stent grafts may be chosen for luminal recon­
stitution and may provide improved long-term patency in the
proximal SMA.22 Cannulation of either the celiac or SMA
may be achieved from both femoral and brachial approaches.
However, in emergent or extenuating circumstances, left
brachial access often proves more expeditious and effective.
This is particularly true in the setting of high-grade ostial
stenosis or occlusion, where brachial access and antegrade
aortic sheath placement may provide improved guidewire,
sheath, and crossing catheter pushability and trackability.
• Successful wire cannulation of ostial SMA and celiac lesions
may require "telescoping" techniques with different sheath
and wire combinations ( see in the following text ) . This is
also true of attempts to deploy devices in the mid- and dis­
tal splenic artery, where a triaxial catheter and sheath com­
bination extending into the target lesion is frequently most
effective. Given the short and often tortuous nature of the
celiac artery, stable sheath placement is challenging, often
representing the most difficult aspect of the procedure.
• Similar principles are used when treating aneurysms of renal
and visceral arteries, including precise catheter positioning
and stable sheath support. Aneurysm size, location, neck
anatomy, and extent of tortuosity of feeding target vessels
impact the strategy of repair. For example, for large retro­
pancreatic splenic artery aneurysms, coil embolization of
the aneurysm sac (preferably with large-end-first or nesting
coils ) prior to covered stent placement across the ostium of
the aneurysm is necessary to ensure long-term procedural
1 962 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

success. For precise embolization of shallow or wide-necked Operating Room Setup

aneurysms, adj uncts such as distal balloon occlusion with
• Procedures may be performed in an angiography suite, or in
deployment of detachable coils may be necessary. For more
an operating room, equipped with a floating-point carbon
accessible aneurysms with a wide-based aneurysm neck,
fiber, radiolucent operating table; fluoroscopy platform;
bare metal stenting may be performed across the ostium of
and monitor-viewing bank. However, for precise visceral
the aneurysm first, followed by placement of coils through
artery interventions requiring steep oblique/lateral imag­
the open interstices of the stent to keep the coils localized to
ing and higher fluoroscopic kilovolt (kV), portable systems
the area of interest. Branch artery aneurysms usually occur
in the operating room setting may not provide sufficient
at bifurcation points and are accompanied by small, well­
image clarity and resolution. Under these circumstances
defined necks and are ideally suited for embolization with
microcoils ( 0 . 0 1 8-in catheter compatible) delivered through
use of a fixed-imaging system, either in an angiograph ;
suite or hybrid operating room, will maximize the likeli­
a triaxial delivery system.
•
hood of success.
The preferred size/shape of embolization devices or covered
• For the maj ority of elective renal and visceral artery inter­
stents may be either accurately estimated from a prepro­
ventions, conscious sedation with a combination of short­
cedural CT arteriogram or determined at the time of an­
acting analgesic and sedative agents will provide adequate
giographic imaging and sheath placement. Based on these
patient comfort, immobility, and optimal imaging param­
measurements, coil and plug diameters may be oversized by
eters. Standard patient safety measures for conscious seda­
20% of the target vessel diameter. The length of coils selected
tion, including supplemental oxygen, standard monitoring,
is derived from the anticipated arterial lumen surface area
and availability of resuscitation equipment should be em­
that requires embolization. Similarly, the length of vascular
ployed in compliance with local hospital policy. However,
plugs selected depends on the target artery to be embolized
general anesthesia is clearly indicated to facilitate treatment
and the estimated luminal flow. For example, higher flow
of AMI, urgent/emergent management of aneurysm rupture,
arteries, such as those proximal to arteriovenous fistulae,
and/or hemorrhage potentially requiring bowel resection or
usually need more extensive coverage to ensure definitive
open conversion.
occlusion. Both self-expanding and balloon-expandable
• For the most part, all renal and visceral artery endovascular
stent grafts are available. The former are also typically over­
interventions can be performed with the patient in the supine
sized by 2 0 % , and the latter are usually sized 1 mm greater
position. The left arm may be positioned out at 90 degrees
than the target artery diameter. Attention should be given to
to allow for transbrachial interventions. If a transfemoral
the sheath selection to ensure adequate diameter and length.
intervention is planned, the patient's arms may be extended
The device-specific instructions for use (IFU) should be con­
over the head to aid with image clarity; however, most pa­
sulted in all circumstances prior to use of occlusion devices,
tients can only tolerate this for certain time periods prior to
or more generally, any endovascular device with the poten­
fatigue. Placing the patient in a 30-degree rotation to the
tial risk for significant vascular inj ury.
•
right, on bolsters placed behind the left flank, at the time of
Depending on their specific location, some visceral artery
the procedure, will facilitate "true lateral " position to local­
aneurysms may be embolized without specific end-organ
ize and cannulate the origin of the SMA without requiring
ischemic injury. However, embolization of distal aneurysms,
the image intensifier and radiation source to be in full hori­
such as those located within the splenic hilum, may result
zontal position and limiting operator access to the patient as
in splenic infarction, further bleeding, or abscess formation.
a result.
Therefore, splenectomy remains a viable alternative method
• In addition to a full array of complementary wires, cath­
of splenic artery aneurysm management for many patients.
eters, and sheaths, premounted balloon-expandable stents
Appropriate vaccinations should be administered with suf­
and stent grafts should be available, including in low-profile
ficient lead time to allow for an appropriate immunization
platforms ( 0 . 0 1 4 in or 0. 0 1 8 in) . Appropriate sizes of coils
response prior to elective splenic artery embolization proce­
and plugs should also be identified and readily available.
dures or planned splenectomy.

RENAL ARTERY ANGIOPLAST Y fa c i l itate precise p l acement. O nce a n i nterventio n a l

sheath access is p l aced, i ntravenous u nfract i o n ated hep­
AND STENTING
arin is a d m i n i stered to m a i nta i n a n activated c l ott i n g
First Step t i m e (ACT) of m o r e t h a n 2 0 0 seconds.

• For a rte r i a l access, a retrog rade tra n sfe m o r a l a p p roach is

usu a l ly sel ected; h owever, antegrade tra nsbrach i a l a ccess
may i m p rove access i b i l ity and sheath sta b i l ity in the p res­
ence of s i g n ificant a b d o m i n a l/pelvic g i rth, s i g n ificantly
down-s l o p i n g ren a l a rteri es, o r tortuosity/o bstruct i o n of
the d ista l a o rta o r i l iac a rteries.
• Arte r i a l access is usua l ly obta i ned percuta neously u s i n g
sta n d a rd S e l d i n g e r tech n i q u e . B e d s i d e u ltraso u n d may
Second Step
• W i re access to the para r e n a l a o rta may be a c h i eved with
0.035-in g u i d ew i re . A 4- o r 5-French (Fr) flush cath ete r is
adva nced over the g u idewire to a p p roximately the level
of the 1 st l u m b a r verte bral body.
• If r e n a l f u n ction perm its, a co m p l ete a o rto i l iac a rterio­
g ra m i n a nterior-poste rior image i ntensifier o r i e ntat i o n
 C h a p t e r 1 9 S T E N T I N G , E N D O G RAFT I N G , A N D E M B O L I ZATI O N TECH N I Q U E S 1 963

s h o u l d be pe rfo rmed t o assess both the re n a l a rteries a n d
renal accessory a rteries. A power i njecto r s h o u l d be used
for the road map a o rtogram, u s i n g a h i g h i nject i o n rate
(e . g . , 1 5 to 20 m l per second) and low vo l u m e (e . g . , 1 0
to 1 5 m l) . B reath- h o l d i n g i nstruct i o n s s h o u l d be g iven to
the patient or the assist i n g a n esth es i o l o g i st to a l l ow for
a o rtogram acq u isition d u r i n g end expi rati o n . G l ucagon
(0 . 2 5 to 2 m g i n t rave n o u s; a p p roxi m ately 10 m i n utes pre­
p roced u re) ca n a l so be a d m i n istered to d i m i n ish i ntesti-
nal m ot i l ity and e n h a nce a rte r i a l visua l i za t i o n .
• A m a g n ified a n g i o g r a m can be repeated of a reas of
i nte rest a n d i ntended treatment. For bette r v i s u a l ization
of the renal a rte ry, the image i ntensifier should be ori­
ented with a few deg rees i n cra n i a l a n d latera l o b l i q u ity
i psi latera l to the renal a rtery of i nterest.
• I ntraoperative a n g i o g ra p h i c measu rements a re o bta i n e d
to co nfirm device select i o n . A m a rked flush catheter o r
rad i o p a q u e r u l e r may fac i l itate accu rate a n g i og r a p h i c
measu rements.
Third Step
• A stiff 0.035-in g u idewire (i.e., A m p l atz, Rosen) is p l aced
in the parare n a l a o rta to fa c i l itate adva ncement of a
45-cm 8-Fr re n a l d i lation g u ide catheter (RDC), or 6-Fr
RDC sheath (i.e., Te r u m o P i n n a c l e 1M destination o r Cook
Ansei1M F l exo r1M). The sheath d i lator tip s h o u l d not be
adva nced i nto the ta rget vessel to avoid compromise of
the res i d u a l vesse l l u m e n .
• Wi re ca n n u lation o f the r e n a l a rte ry is the essenti a l fi rst
ste p . Depend i n g on the a n g l e of entry at the o rifice, a
n u m be r of d iffe rent catheter t i p s h a pes may fac i l itate
successf u l renal ca n n u lation (Sos 1 o r 2, Cobra, Va nchi,
etc.). O n ce ca n n u l ated, the sheath t i p i s adva nced
i m m e d i ately adjacent to, but n ot across, the re n a l a rtery
orifice (FIG 1 ) . A 0. 0 1 4- i n or O . Q 1 8-in stiff g u i dewire with
a floppy o r hyd ro p h i l i c t i p is then e m p l oyed to probe
across a reas of severe sten osis, through a reverse cu rve
or a n g led catheter, depe n d i n g on the opti m a l a n g l e
f o r access. Alternatively, a 0.035-in g u idewi re, with
i m p roved h a n d l i n g and ra d i opacity, may p rovide suita b l e
tracka b i l ity for l e s s c r i t i c a l ste n oses.
• O n ce access is a c h i eved, the w i re s h o u l d be adva nced
to a seco n d a ry branch to o pt i m ize posit i o n a l sta b i l ity.
Ca re s h o u l d be taken to m a i nta i n w i re t i p visu a l ization
i n the f i e l d of vi ew, p a rt i c u l a rly when using hyd ro p h i l ic
g u i d ewi res, as they can easily perforate parenchym a l
a rterioles w h e n adva n ced too fa r i nto t h e seg mental
re n a l ci rcu lati o n . Parenchym a l pe rfo rati o n may prec i p i ­
tate i ntra- o r extraca psu l a r h e m atoma formation, r e n a l
h e m o rrhage, a n d c i r c u l atory co l l a pse u n less i m med iately
recog n i zed and corrected .

FIG 1 • A. Parare n a l a o rta d e m o nstrati n g h i g h-grade ste nosis at the r i g h t renal a rtery o rifice. B- Ca n n u lation of the r i g ht
ren a l a rtery with a 0.0 1 4- i n or 0 . 0 1 8-in g l idewire g u ided by a c u rved-t i p cath eter. Wi re a n d catheter ca n n u lation system a re
sta b i l ized by a 6-Fr sheath . The ca n n u l a t i n g w i re is adva n ced i nto the d i sta l right renal a rtery to p rovide a d d i t i o n a l sta b i l ity to
the system . C. The right ren a l a rtery orifice stenosis is p red i l ated with a low-p rofi l e, s m a l l-dia meter b a l l o o n . D. U s i n g sheath
s u p p o rt for sta b i l ity, a n a p p ro p r i ately sized b a l loon-expa n d a b l e ste nt is d e p l oyed across the ste nosis a n d is p rotru d i n g 1 mm
i nto the a o rtic l u m e n . E. While m a i nta i n i n g ca n n u lation syste m , p rotru d i n g edge of the ste nt is fla red i nto the a o rt i c l u m e n
w i t h a n a p p ro p r i ate com p l i a nt a n g i o p l asty b a l l o o n .
1 964 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

Fourth Step with d rawa l to avo i d move m e n t or d i s l o d g i n g of the

• Prior t o renal a rtery stenting, pred i lation m a y b e neces­
sary to provide sufficient l u m i n a l space for del ivery of the
crim ped stent/del ivery catheter (FIG 1 ). A 2- to 4-m m low­
profi le, semicom p l i a nt, or coronary bal loon com patible with
a 0.0 1 4-in or O.D1 8-i n system can be used for this pu rpose.
Care needs to be taken to m a i ntain wire position during
subseq uent stent exchange; loss of wire position here ca n
preclude stent del ivery or precipitate l u m i n a l throm bosis if
aortic and/or orificial atheroma is d isplaced by pred i lation.
• U s i n g a l ow-profi l e 0.0 1 4- i n o r 0 . 0 1 8-in syste m (ra p i d
exc h a n g e o r over-the-wire [OTW]), a ba l l oon-expa n d a b l e
ste nt (e . g . , Cord is Pa l m a z B l ue, Boston Scientific Exp ress
SD, Cook F o r m u l a ) is d e l ivered across the lesion (FIG 1 ) .
The low-prof i l e n a t u r e of th ese devices e n a b les fac­
ile placement, a s we l l a s contrast del ivery across the
lesion to confi rm a p p ropriate posit i o n . R a p i d exc h a n g e
o r m o n o ra i l systems a l l ow for s h o rter w i re l e n g t h , a i d-
i n g p roced u r a l effi c i e n cy vis-a-vis cath eter/wi re/device
exc h a n ges. I n contrast, OTW devices p rovide i m p roved
p u s h a b i l ity a n d tracka b i l ity across constrict i n g lesions.
• For m i d - or d i st a l RAS, the s h o rtest ba l l oon-expa n d a b l e
ste nt l e n gth p rovi d i n g co m p l ete cove rage s h o u l d b e
sel ected . For m i d - o r d i sta l RAAs, a p p ro p ri ate l e n gt h self-
expa n d i n g or b a l loo n -expa n d a b l e stent g rafts s h o u l d
be sel ected to provide a d e q u ate p r e - a n d posta n e u rysm
re n a l a rtery sea l i n g zones (FIG 2) .
• Fo l l ow i n g ste nt p l acement u n d e r f l u o rosco p i c g u i d ­
a n ce, t h e b a l l o o n s h o u l d be deflated f u l l y p r i o r to its
stent. Areas with s u bsta nti a l tortuos ity may prec i p i ­
tate a rte r i a l k i n k i n g at t h e transition p o i n t between
stented and n o n stented seg m e nts. Excessive overs i z i n g ,
o r overi nflation of stents m o u nted o n se m i co m p l i a nt
ba l l oo n s, may promote re n a l a rtery i nj u ry, d i ssect i o n , o r
t h r o m bosis. Te m ptati o n to opti m i ze t h e postp roced u r a l
a n g i o g ra p h i c i m a g e, pote nti a l ly at t h e expense o f vesse l
i nteg rity or a nt i c i pated l o n g -te rm paten cy, s h o u l d a l so
be avo i d e d .
• For ost i a l renal a rtery lesio ns, the ba l l oon-expa n d a b l e
ste nt s h o u l d be positioned so t h a t the a o rtic end i s d e ­
p l oyed a p p roximately 1 m m i nto the a o rtic f l o w stre a m .
The a o rtic e d g e o f t h e ste nt can be " f l a r e d " outward
with a repeat a n g i o p l asty u s i n g the d ista l edge of the
same ba l l oo n (FIG 1 ) .
Fifth Step
• After successfu l d e p l oym ent, the sheath s h o u l d o n ly be
withd rawn afte r the c o m p letion i m a g i n g encom passi n g
the enti re i p s i l atera l kid ney is pe rfo rmed to confi rm
u n iform perfus i o n a n d a bsence of p a renchym a l a n d/o r
capsu l a r i n j u ry.
• F o l l o w i n g withdrawa l of the sheath from the re n a l orifice,
wh i l e m a i nta i n i n g w i re access, co m p l et i o n paraorifi c i a l
a o rtog raphy is performed to co nfirm ste nt positi o n i n g
a n d ta rget l u m e n d i a m eter. Res i d u a l ste nosis, k i n k i n g,
o r d i ssect i o n should be confi rmed to be a bsent prior to
withd rawa l of the w i re .

FIG 2 • A. Left renal a rtery h a s a n associated saccu l a r a n e u rysm . Ca n n u lation of the l eft renal a rtery is fac i l itated w i t h a n
a n g led g u i dewire a n d c u rved-t i p catheter. T h e ca n n u lation system i s sta b i l ized b y a n a p p ro p r i ately sized sheath. B. A b a re
m eta l stent is d e p l oyed across the orig i n of the l eft RAA. C. A telesco p i n g tech n i q u e is used to ca n n u l ate the a n e u rysm sac
t h rou g h a n i nterstice of the b a re m eta l ste nt. Sheath tip is adva nced to the renal a rtery orifice and catheter i s adva n ced u p to
the i n n e r l u m i n a l wa l l of the bare m eta l ste nt to sta b i l i ze and fac i l itate ca n n u l at i o n of the a n e u rysm sac. D. Appropriately sized
co i l s a re d e p l oyed i nto the a n e u rysm sac through the ste nt i nterstices.
 C h a p t e r 1 9 S T E N T I N G , E N D O G RAFT I N G , A N D E M B O L I ZATI O N TECH N I Q U E S
VISCERAL ARTERY ANGIOPLAST Y AND
STENTING
First Step
• As p reviously n oted, access considerations need to
acco u n t for i n d ivid u a l patient a n atomy, operator experi­
ence and s k i l l , ava i l a b l e devices, pote n t i a l com p l i cations,
g o a l s of treatme nt, a n d a ntici pated t i m e of the p roce­
d u re . M ost i nternat i o n a l ists p refer the transfe m o r a l
a p proach for viscera l vascu l a r access. H owever, prox i m a l
l eft b rac h i a l a rtery expos u re a n d p u n ctu re often fac i l i ­
tates access t o s i g n ifica ntly down-s l o p i n g o r tortuous
mesenter i c a rteries.
• A 4- o r 5-Fr s h eath i s p l aced i n the a rte r i a l access site to
fa c i l itate advancement of a 4- o r 5-Fr m a rked flush cath ­
eter to the pa ravisce ral aorta .
• I ntrave n o u s u nfract i o n ated h e p a r i n is a d m i n i stered
after s h eath p l acement to ach ieve a n ACT of m o re t h a n
2 0 0 secon d s .
Second Step
• After a sta n d a rd a o rtogram, a m a g n ified pa ravisce ral
a o rtogram can be pe rfo rmed with the i m a g e i ntensifier
p l aced i n a stee p o b l i q u e o r true l atera l position to op­
t i m ize local ization a n d ca n n u lation of the ce l i a c a rtery
and SMA origins.
• Care s h o u l d a l so be taken here to visu a l ize the major
branches of the c e l i a c a rtery a n d/o r SMA. Attem pts
s h o u l d be m a d e to v i s u a l i z e the fi rst s i g n ificant branch
of the S MA, usua l ly the middle co l i c a rte ry, to avo i d inad­
verte nt cove rage a n d/o r comprom ise of co l o n i c a rteri a l
perfusion as a conseq uence o f p l a n ned p roced u res.
• Viscera l lesions of i nterest can be f u rther cha racte rized
at this time by opti m i z i n g i m a g e i ntensifier o b l i q u ity.
1 96 5
Accurate measu reme nts a re fa c i l itated by m a rked f l u s h
catheter o r rad i o p a q u e r u l e r p l acement.
Third Step
• After withdrawal of the flush catheter, a stiff g u ide­
w i re a n d a long (90 em), braided 6-Fr sheath (i.e.,
Te r u m o P i n nacle1M dest i n ation, Cook Ansei1M F l exor1M)
is adva nced to the p a raviscera l a o rta. Va rious a n g led
sheath t i p s (i.e., stra i g ht, a n g led hockey t i p, c u rved) can
be used depen d i n g o n the d e g ree of viscera l a rtery a n ­
g u lation, a o rt i c d i a m eter, a n d access a p p roach (fe m o r a l
o r brach i a l ) .
• A l o n g w i t h sel ected sheath, v a r i o u s g u i d e catheter types
(i.e., a n g led, ve rte bral, cobra, RDC, o r reverse cu rved S I M
o r S o s cath ete rs) c a n be used t o fac i l itate viscera l a rtery
ca n n u l at i o n .
Fourth Step
• An exc h a n g e- l e n gth, stiff 0. 0 1 4- i n or 0 . 0 1 8-in g u i d ewi re,
with a floppy t i p, is adva nced t h r o u g h the p resel ected
catheter and sheath co m b i n at i o n . H oweve r, w i re ca n ­
n u lation of a d i seased viscera l a rteries orifice may b e
cha l l e n g i n g . F r o m the b rach i a l a p p roach, successf u l
ca n n u lation may be fac i l itated with s h eath p l acement
d ista l to the a rtery of i nterest, fo l l owed by g rad u a l with­
d rawa l of the sheath with the sel ected a n g led catheter
i n s i d e the sheath p rotru d i n g s l i g htly outwa rd . When the
catheter " c l icks" i nto p l ace, a n exp l o ratory hyd ro p h i l ic
g u idewire is t h e n gently adva n ced to o bta i n l u m i n a l
access. O n c e t h e l u m e n is ca n n u l ated, t h e g u idewire i s
t h e n advanced t o a seco n d a ry visce ral branch to fac i l itate
catheter and s h eath adva ncement, as i n d i cated (FIG 3) .
Another ca n n u l at i o n strategy is to with d raw w i re a n d
catheter co m b i n ations from a sta b l e sheath posit i o n
FIG 3 • A . H i g h-grade ste nosis o f t h e
p roxi m a l ce l i a c a rtery orig i n . B. A cu rved­
tip g u ide catheter is used to fac i l itate ce l i a c
a rtery ca n n u l ated w i t h a 0.01 4-in o r 0 . 0 1 8-i n
g u i d ew i re. T h e ca n n u l ation system is sta b i l ized
with d ista l advancement of the g u i dewire i nto
a ce l i a c a rtery branch, as we l l as m a i nta i n i n g
a sheath i n t h e aortic l u m e n . C. A l ow­
prof i l e, com p l i a nt p red i lation bal loon may
be advanced over the g u i dewi re to d i l ate the
stenosis a n d provide a tract for future stent i n g .
D. An a p propri ately sized b a l l oon-expa n d a b l e
covered stent g raft is deployed across the
stenosis wh i l e s l i g htly p rotru d i n g i nto the
a o rtic lumen. E. Full stent a pposition fo l lowi n g
deployment a n d prox i m a l f l a r i n g o f the stent
g raft at the prior stenosis site.
1 966 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY
across the a ntici pated vesse l o rifice a rea at va rious
"clock" posit i o n s .
• For a " n o-to u c h " tec h n i q ue, a s h a ped catheter or s h eath
tip is positioned l u m i n a l ly i n d i rect p roxi m ity to the
orifice of i nte rest. A 0 .0 1 4- i n o r 0 . 0 1 8-in hyd ro p h i l i c
g u idewire i s then u s e d t o local ize a n d fac i l itate ca n n u -
lati o n . To i m p rove tracka b i l ity a n d push a b i l ity of the
system, a sta b i l i z i n g " b uddy" stiff g u idewire may a l so
be advanced, when n ecessa ry, to " p i n " the ca n n u l at i o n
s h e a t h to the o p posite wa l l .
• When s i n g l e-wire ca n n u l at i o n p roves i n adeq uate to s u p­
port catheter a n d sh eath adva ncement i n to the target
vesse l, p l acement of a seco nd, or even t h i rd 0. 0 1 4- i n o r
0 . 0 1 8-in w i re, across the a rea of ste nosis may fac i l itate
successf u l cath eter/sheath adva ncement.
Fifth Step
• An a p p ro p r i ately sized s e l f-exp a n d i n g or ba l l o o n ­
expa n d a b l e ste n t g raft i s p referred for t h e treatm e n t
of viscera l a rtery ste n oses. Pred i l a t i o n of t h e t ra ct m a y
be n ecessa ry w i t h a s m a l l , l ow-p rofi l e b a l l o o n to f a ­
c i l itate a d v a n c e m e n t of t h e b a l l o o n -expa n d a b l e stent
(FIG 3) .
H YBRID REPAIR OF PROXIMAL
MESENTERIC ARTERY STENOSIS/
OCCLUSION
First Step
•
I n the sett i n g of acute or acute-on-chro n i c mesenteric
isc h e m i a , where expl o ratory l a p a rotomy is otherwise
i n d i cated to assess bowe l v i a b i l ity, a hybrid retrog rade
cath ete rization a p p roach is g e n e ra l ly p refe rred . At l a pa­
roto my, s u r g i c a l expos u re of t h e superior mese nte ric o r
c e l i a c a rtery is o bta i n e d . To expose the ce l i ac a rte ry, the
l eft tria n g u l a r l i g a ment is i n cised, the l eft hepatic lobe
is retracted to the rig ht, a n d the g a stroeso p h a g e a l j u nc­
tion is retracted to the l eft. F u rt h e r ca u d a l d i ssect i o n
a l o n g the su rface of the a o rta may be u s e d to expose t h e
S M A o ri g i n .
• For p u r poses o f both e m b o lectomy a n d h y b r i d retro­
g ra d e cath ete rizat i o n , exposure of the prox i m a l sec­
t i o n/m i d sect i o n of the SMA i s p refe re n t i a l ly o bta i n ed at
t h e s u p e r i o r root of t h e s m a l l bowel mesentery (FIG 4) .
T h i s location g e n e ra l ly provides access 4 o r m o re cen­
t i m eters d i sta l to t h e S M A o r ifice, which a l l ows sta b l e
s h eath positi o n i n g to fa c i l itate retro g r a d e ca n n u l a t i o n
a n d ste nt i n g . D i sta l to t h e l o w e r m a r g i n of t h e p a n creas,
t h e l e n g t h of t h e SMA is l i m ited by early b ra n c h i n g of
the i l eoco l i c a rtery a n d i ntest i n a l cascade, so rel atively
p roxi m a l posit i o n i n g s h o u l d be a c h i eved to m i n i m i ze
excess ive d i l at i o n/tra u m a to t h e vessel by t h e s h eath . 1 8
• The a o rtic e n d of a b a l l oo n -expa n d a b l e ste nt used for
the treatment o f ost i a l o r p roxi m a l viscera l a rtery lesions
should be positioned 1 m m i nto a o rtic flow l u men, and
the stent edge should be fla red out with the edge of an
a n g i o p l asty b a l l o o n .
• Accu racy of d e p l oyment of se lf-expa n d i n g ste nt g rafts
can be i m p roved with p a rti a l d e p l oyment of the ste nt
wh i l e m a i nta i n i n g the ca n n u lation sheath in the ori­
fice of the viscera l a rte ry. O n ce the d i sta l portion of the
ste nt g raft i s accu rate ly d e p l oyed, the rem a i n d e r of the
prox i m a l ste nt g raft can be u n sheathed to a l l ow for fu l l
d e p l oyment. A n a p p ro p r i ately si zed co m p l i a nt b a l loon
may then be su bseq uently used to fu l ly m o l d the self­
expa n d i n g stent g raft to p rofi l e a n d/o r s l i g htly f l a re the
a ortic edge.
• F o r fr i a b l e l e s i o ns, or l e s i o n s t h a t m a y i n c l u d e fresh
t h ro m b u s, c o n s i d e r a t i o n s h o u l d be g iven to a d va n c i n g
a n d d e p l o y i n g b a l l o o n s a n d stents over a f i l t e r w i re
(0 . 0 1 4- i n eV3 S p i d e r FX e m b o l i c p rotect i o n syst e m ) .
A l th o u g h p l a c e m e n t of a d i sta l f i l t e r m a y n ot p r e ­
c l u d e a l l e m b o l i c seq u e l ae, it m a y reduce t h e seve rity
or s i g n ificance of associ ated pote n t i a l co m p l i c a t i o n s .
T h i s o p t i o n m a y be p a rt i c u l a r l y va l u a b l e i n S M A
i nt e rve n t i o n s .
Second Step
• When e m b o l i c occl usion is p resent, e m b o l ecto my is per­
formed gently t h roug h an a nte r i o r a rteri otomy. The
taperi n g nature of the S M A i n this a rea req u i res gentle
catheter withd rawa l with g ra d u a l b a l loon defl ation in
order to avo id iatrog e n i c a rte r i a l da mage, d issection, o r
t h ro m bosis.
• Retro g r a d e ca n n u l at i o n of a n exposed d i st a l seg m e n t
of t h e ta rget vesse l p r o v i d e s o p t i m a l access for de­
f i n itive e n d ovascu l a r i nt e rvent i o n . In e m e rg e n t c o n ­
d it i o n s w i t h co m p ro m ised i ntest i ne, t h i s a p p r o a c h
i s p refe r e n t i a l to o p e n reva scu l a r i z a t i o n strate g i es,
w h i c h may req u i re p ro st h e t i c g raft p l a c e m e n t fo l l ow­
i n g p r o l o n g ed, exte n s ive d i ssect i o n of the m e s e n te ry
a n d a o rt i c root.
• Retrog rade mesenteric ca n n u lation is fac i l itated by
p l acement of a l o n g itu d i n a l a rteriotomy i n the exposed
d ista l seg ment of the ta rget vesse l . To reduce the risk
of i n j u ry to the exposed a rtery during ca n n u lation, the
a rteriotomy site i s cl osed with a p rosthetic o r autogenous
patc h . The patch itse lf i s then ca n n u l ated to fac i l itate
sheath placement, a n g iogram, ste nt p l acement as we l l
as expedited p u n ct u re site c l o s u re a t t h e e n d o f the
p roced u re (FIG 4) .
• Relatively l o n g sheaths ( 2 0 em o r m o re) s h o u l d b e used
d u r i n g retrog rade ca n n u lation to e n s u re that the opera­
to r's h a n d s a re clear from the f l u o roscopy field and m i n i ­
m ize operator ra d i ation exposu re d u r i n g cath ete rization
m a n euvers . 1 8
 C h a p t e r 1 9 S T E N T I N G , E N D O G RAFT I N G , A N D E M B O L I ZATI O N TECH N I Q U E S 1 967

A B

c D

FIG 4 • A. Open exposu re of the p roxi m a l S M A at the ca u d a l

port i o n o f the m esenteric root. B. T h e proxi m a l S MA, - 3 to 4 e m
f r o m i t s a o rtic o r i g i n , is ci rcumferentia l ly exposed w h i l e p reserv i n g
i t s s i d e branches. A l o n g itu d i n a l a rteriotomy is created a n d
throm becto my is pe rfo rmed w i t h patch a n g i o p l asty. C . Sheath is
p l a ced t h r o u g h a p u n ct u re i n the a n g i o p l asty patch a n d a rteriogram
is pe rfo rmed to eva l u ate ste nosis i n the p roxi m a l S M A orig i n . D.
A ste nt is d e p l oyed u s i n g f l u o roscopic g u i d a nce at the S M A o r i g i n
across the identified h e m odyn a m i c ste nosis. The patch p u n ct u re
site is repai red to m a i nta i n h e m ostasis. Ei. Retro g rade access to
S MA, with i nflation of bal loon expa n d a b l e ste nt exte n d i n g i nto
a o rta p roxi m a l ly, spa n n i n g l e n gth of p rox i m a l occ l u s ive lesi o n . Eii.
Comp letion mesenteric a rteriogram from a o rtic i njection, s h ow i n g
co m p l ete resto rat i o n of m esenteric a rte r i a l l u m e n a n d n o r m a l d ista l
a rte r i a l perfu s i o n . Retro g rade mese nte ric w i re h a s been rem oved,
E and a rteriotomy cl osed at the patch site in d ista l SMA.

RENAL OR VISCERAL ARTERY Second Step

EMBOLIZATION • Angiogra p h i c cha racterization may req u i re a n g iograms

First Step
• Arte r i a l access can be secu red via either a l eft brach i a l
a rtery o r transfe m o r a l a p proach, depe n d i n g o n the
i ntended target vesse l a n d its a n g u lation relative to the
a o rta.
• For sta n d a rd co i l e m b o l ization, a 5- or 6-Fr s h eath a ccess
w i l l be a d e q u ate. H owever, if an occ l u s i o n device w i l l be
used, a l a rg e r sheath size may be req u i red depe n d i n g on
device specifications.
• System i c a nticoag u l at i o n with i ntrave n o u s u nfrac-
t i o n ated h e p a r i n is a l so co m m o n ly used d u r i n g these
p roced u res.
i n m u lt i p l e different o b l i q u ities to fu l ly a p p reci ate size,
extent, and a n g u l ation of the lesion of i nterest, particu­
l a rly th ose affect i n g seco n d a ry viscera l branches. I n the
a n g iogra p h i c parla nce, regard i n g the extent, severity, and
p rofi le of a l u m i n a l obstruction, " o n e view is no view. "
• O n e s h o u l d n ote t h e extent of vasc u l a r co l l atera l i za­
tion associated with the vasc u l a r segment that w i l l be
e m b o l ized.
Third Step
• A tel esco p i n g ca n n u l at i o n tech n i q u e is u s u a l l y used to
e n h a nce the positi o n i n g and sta b i l ity of the e m b o l i zation
1 968 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

Spleen

Splenic artery
aneurysm

c D Celiac trunk Splenic artery

E
FIG S • A. Ca n n u lation is attem pted of a saccu l a r visceral a rtery aneurysm . A sheath and ang led cathete r facil itate ca n n u lation of the
viscera l a rtery orig i n with a g u idewire. B. A 0.035-ln catheter and g u idewire negotiate proximal arterial tortuosity. C. A microcatheter
is telescoped through the 0.035-in catheter to fac i l itate wire ca n n u l ation of the aneurysm . D. Th ree-d i mensional a bdom i n a l CTA of a
female with a m i d-splenic a rtery saccu l a r a n e u rysm . E. Selective splenic a rtery aneurysm pre- and postselective coi l i n g .

syste m . To perform t h i s, a sheath is adva nced as cl ose to
the target lesion as poss i b l e . A catheter is t h e n exte nded
from beyo nd the t i p of the sheath a n d used to p rotrude
i nto target lesion (FIG 5) .
• E m b o l ization of rem ote ta rget l e s i o n s may req u i re
h i g h e r orders of tel esco p i n g . P l a c i n g a sheath i nto a n ­
oth e r l a rg e r s h eath, o r a 0 . 0 1 8 - i n m i c rocatheter ( i . e . ,
Cod m a n Prow l e rTM, Cook C X I T M , B S C I R e n e g a d eTM) i nto
a sta n d a rd 0 . 0 3 5 - i n g u i d e catheter, can h e l p access m o re
c h a l l e n g i n g l e s i o n s (FIG 5) . Alternat i n g w i re a n d m i c ro­
catheter advanceme nts m a y fa c i l itate ca n n u l a t i o n of
s m a l l e r a n d m o re tort u o u s a rteries (s u c h a s the s u pe r i o r
a n d i nferior g a strod u o d e n a l a rteries [FIG 6]) a n d d i sta l/
h i l a r s p l e n i c a rte ry.
• If poss i b l e, the ca n n u lation catheter/m i crocatheter
s h o u l d be adva n ced i nto the lesion s l i g htly f u rther t h a n
the i ntended e m b o l i zation s ite, beca use the system can
d raw back during d e p l oyment of co i l s o r p l ugs.
Fourth Step
• O nce the ca n n u lation catheter is positioned in the ta rget
lesion, 0 . 0 1 8-in or 0.035-in co i l s a re del ivered sequenti a l ly
i nto the target a rea through t h e i r respective catheters.
For detached co i l s, the meta l tube housing the co i l is
attached to the back end of the ca n n u l ation catheter, and
the stiff end of a g u i dewire is used to push the coil out of
its housing u n it a n d i nto the catheter shaft. The floppy t i p
o f the g u idewire is then replaced i nto the catheter t o push
the coi l along the entire shaft of the catheter a n d i nto the
lesion (FIG 5). The stiff end of the g u idewi re s h o u l d not be
used to push the coil i nto the lesion because it can change
the ca n n u l at i n g catheter t i p s h a pe a n d lead to i nsta b i l ity
in the ca n n u lation system a n d maldep loyment.
• Alternative ly, sma l l a n e u rysm may be occl uded with de­
tac h a b l e o r nondetac h a b l e m i c roco i l s o r ethylene vinyl a l ­
co h o l copolymer. I F U a re va r i a b l e a n d s h o u l d be referred
to for recom me n d ed deployment tech n i q ues.
• When co i l d e p l oyment ca n be accu rate ly local ized,
and p recise co i l positi o n i n g i s critical to the success of
the p roced u re, l a rge-to-sma l l tapered co i l s s h o u l d be
used . When a rteri a l b l ood flow is need ed/req u i red to
ca rry p a rt of the co i l i nto the p refe rred d e p l oyment
l ocation, s m a l l-to- l a rg e tapered co i l s a re p referred i n this
situat i o n . Newer " n esti n g " co i l s will refo rm i m m e d i ately
i nto l a rg e r, obstruct i n g p rofi les. Older t u b u l a r co i l s need
 C h a p t e r 1 9 S T E N T I N G , E N D O G RAFT I N G , A N D E M B O L I ZATI O N TECH N I Q U E S 1 969

t o be adva nced a s they a re b e i n g d e p l oyed t o avoid s i m ­

ply l i n i n g the ta rget a rtery without sufficient l u m i n a l
obstruct i o n . Atte ntion t o u n d e rsta n d i n g what co i l s a re i n
i nvento ry, a n d how respective co i l c h o i ces a re opti m a l ly
d e p l oyed, is essent i a l for p roced u r a l success.
• For l a rg e r a n e u rysms or p l a n ned occl usion of an e n ­
t i re vesse l l u men, a vascu l a r p l u g (i.e., A G A M e d i c a l
A m p l atzer1M I o r I I vascu l a r p l u g ) may be p refera b l e
a n d a m o re effective means f o r target e m b o l izati o n .
H owever, p l u g p l acement usua l l y req u i res sta b l e sheath
ta rget a rtery ca n n u l a t i o n . A m p l atzer1M I a n d II vascu­ A
lar plugs a re produced i n d i a m eters ra n g i n g betwee n 4
a n d 22 mm a n d l e n gths ra n g i n g betwee n 6 a n d 1 8 m m .
Reco m m e n d ed device I F U s h o u l d b e consu lted t o e n s u re
proper device sel ection a n d d e p l oyment. When sheath
access ca n n ot be withdrawn to e n a b l e plug d e p l oyme nt,
cath eter-d e l ivered co i l s s h o u l d be d e p l oyed i n stea d .
• Once a co i l or p l u g is del ivered i nto a lesion, its position
may be mod ified s l i g htly by catheter tip adva ncement. This
maneuver, when performed properly, maxi m i zes the ob­
structive su rface a rea a n d resu lti ng coil t h rombogenicity.
• When m u lt i p l e co i l s or p l u g s a re used, d e p l oyment
should a l so be strate g i zed a n d d e l i berate. For exa m p le,
the fi rst coil s h o u l d be p l aced in the dee pest p a rt of the
lesion (base of a n a n e u rysm). whereas the l a st co i l s h o u l d FIG 6 • A. B l e e d i n g gastrod uodenal a rtery with a n
be p l a ced i n the e ntry point of the l e s i o n ( n e c k of a n associated d u odenal u l cerati o n . B. Sheath ca n n u lation of
a n e u rysm). the com m o n hepatic a rtery branch of the ce l i a c a rtery,
fo l l owed by catheter ca n n u lation of the gastrod uode n a l
• For acutely b l eed i n g vesse l s (such as the g a strod u o d e n a l
a rte ry. C. Back-door d e p l oyment o f a n e m b o l ization co i l
a rteries i n the sett i n g of d u o d e n a l u l cerati o n s), a " back­
d ista l t o t h e a n g i og r a p h i ca l ly identified bleed i n g point i n
door "-"fro nt-d oor" a p p roach ensu res h e m ostasis. T h i s t h e gastrod uode n a l a rte ry. D. S u bsequent "fro nt-d oor"
i nvolves occ l u d i n g the c u l prit vesse l p re a n d post the e m b o l ization of the feed i n g seg ment of the gastrod uode n a l
a rea of bleed i n g (FIG 6) . Co i l i n g o n ly o n e side of the a rte ry.
b l eed i n g a rtery may p revent f u rther access atte m pts
w h i l e not provi d i n g sufficient vesse l occ l u s i o n and he­
mostasis. S m a l l b l eed i n g pelvic a rteries may s i m i l a r l y be
e m b o l i zed u s i n g a G e lfoam s l u rry s l u s h preparat i o n . 2 3 flow w i l l sti l l be evident in the rece ntly e m b o l ized
Reco m m e n d ed I F U s h o u l d be consu lted to e n s u re proper vesse l seg m e nt, beca use the patient g e n e ra l ly re m a i n s
preparation a n d a d m i n istrat i o n of th ese s l u rries. h e p a r i n ized d u r i n g t h i s period o f the p roced u re . If u n ­
certa i nty persists a s to the adequacy o f e m b o l ization,
a rteriog ra p h y may be repeated fo l l ow i n g reversa l of
Fifth Step
a nticoag u l ation, ta k i n g i nto acco u n t i n creased risks of
• It is custo m a ry to pe rfo rm poste m b o l i zation a rteriog­ throm bosis/e m b o l i zation around the d e l ive ry sheaths
raphy to confi rm final co i l/p l u g positi o n i n g . Res i d u a l a n d catheters proxi m a l to the ta rg eted lesi o n .

PEARLS AND PITFALLS

I n d icat i o n s
Vessel ca n n u l at i o n
• Preoperative i m a g i n g (d u p l ex a n d CTA) s h o u l d be reviewed i n deta i l to e n s u re p a t i e n t suita b i l ity
a n d h e l p p l a n out a p p ro p riate i nterventi o n .
• Com b i n i n g i nfo rmation gathered f r o m d u p lex a n d CTA is benefi c i a l , especi a l ly i n s i t u a t i o n s w h e n
the ste nosis is overest i m ated d u e to heavy l u m i n a l ca lcificat i o n .
• O n e s h o u l d n ote the a n g u lation o f the target vessel rel ative to the a o rta. Because t h i s a n g l e m a y
va ry w i t h res p i ration, a n g i og ra m s s h o u l d be o bta i n e d wh i l e the patient i s a p ne i c (if i ntu bated) o r
at e n d expi rati o n .
• G e n e r a l ly, re n a l a rteries a n d u p-s l o p i n g viscera l vesse ls may be e a s i e r to ca n n u l ate f r o m a
transfe m o ra l a rtery a p p roach . Down-s l o p i n g re n a l a n d vi scera l vesse l s may be easier to ca n n u late
from a p roxi m a l l eft brach i a l a rtery p u nct u re .
• U s i n g a n a n g u l ated, flexi b l e, l ow-profi l e sheath system a l so a i d s i n the ca n n u lation p rocess.
1 970 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

A n g i o p l a sty ba l l oo n • Ca re s h o u l d be taken in select i n g a p p ro p r i ate size and types of ba l l oons.

sel ection • G e n e ra l ly, o n l y l ow-prof i l e co m p l i a nt bal loons s h o u l d be used for a n g i o p l asty i nterventions i n the
re n a l a n d viscera l a rteries. I n ra re circumstances, a n o n co m p l i a n t ba l l oo n may be used to help mold
a stent g raft to fu l l p rofi l e .
• D i a m eter of a n g i o p l asty ba l l oo n s h o u l d be est i m ated rel ative to adjacent n o r m a l vessel l u m e n .
Overs i z i n g i s g e n e ra l l y n o t n ecessa ry, a n d a s m a l l e r d i a m eter b a l l o o n m a y be p referred w h e n
perfo r m i n g a n g i o p l asty across h i g h ly ca l cified lesions.
Stent select i o n • Ca re should a l s o be taken i n select i n g a p p ro p r i ately sized stents for desired i nterventions.
• Stent d i a meter should be est i m ated rel ative to normal vesse l lumen d i a m eter adjacent to ta rget
lesion to be treated a n d is g e n e ra l ly oversized by a p p roxi m ately 1 m m .
• Stent length s h o u l d be est i m ated relative t o t h e length o f t h e target lesion wh i l e p rovi d i n g e n o u g h
cove rage i nto the adjacent n o r m a l vessel l u m e n (area of needed cove rage i s va r i a b l e depe n d i n g o n
type o f l e s i o n a n d i ntervention).
• Ove rsized stents a re prone to kinking a n d may risk damaging the target vesse l . U n d e rsized stents
may lead to m a l d e p l oyme nt, m i g ration, and i n effective sea l with adjacent vesse l l u m e n .
• Someti m es, t h e a n g i o p l asty b a l loon o f a ba l l oon-exp a n d a b l e stent g ets stuck i n the ste nt d u r i n g
i t s rem ova l . I n t h i s situation, p u l l i n g t h e b a l loon risks m is p l a c i n g o r d i s l od g i n g the ste nt from
its desired l ocat i o n . I nstead, the operator s h o u l d e n s u re co m p l ete defl ation of the ba l l oo n a n d
attem pt slowly adva n c i n g the ba l l oo n w h i l e rotati n g i t s catheter.
Co i l/p l u g selecti o n • S i ze of co i l s a n d p l u g s s h o u l d be sel ected rel ative to lesion d i mensions. U n d ersized co i l s a n d p l u g s
risk m i g ration to u n i ntended vasc u l a r beds.
• Sta b i l ity of the e m b o l ization del ivery system s h o u l d be sel ected relative to the size of the e m b o l iza­
t i o n device. Larger e m b o l i zation devices may cause i n sta b i l ity i n low-p rofi l e d e l ivery syste ms.
Rena l/viscera l a rtery • Sheath a n d l a rg e catheter ca n n u l at i o n of re n a l a n d viscera l a rteries should be avoided to p reve nt
d i ssect i o n d a m a g e o r d i ssect i o n .
• If a d i ssection occu rs, a n g iogra p h i c eva l u ation is req u i red t o dete rm i n e whether it is f l o w l i m it i n g .
A l l flow- l i m it i n g d i ssections s h o u l d be stented w i t h a n a p propriately sized b a l l oon-expa n d a b l e stent.
Rena l/viscera l a rte r i a l • Arte r i a l spasms may be i n d uced with vessel ca n n u l ation, a n g i o p l a sty, o r stenti n g . Yo u n g e r patie nts
spasm a re typ i ca l ly m o re prone for t h i s . Arte r i a l vasod i l ato rs, such as n itrog lyce r i n o r pa paveri n e, may be
i nfused i nto the vesse l l u m e n by way of ca n n u l ation sheath o r catheter to h e l p re l i eve t h i s .
• The o pe rator s h o u l d be aware t h a t papaverine may precip itate out o f s o l u t i o n if m i xed w i t h hepari n .
Re n a l capsu l a r pe rfo rat i o n • T h i s m a y b e caused b y i n a dvertent advancement o f ca n n u l a t i n g w i re i nto t h e re n a l parenchym a .
o r h e m atoma To avo i d t h i s co m p l ication, a lways k e e p the end o f the w i re i n s i g h t d u r i n g sheath a n d device
adva ncements over the wi re. Al so, avo i d i n g the use of stra i g h t o r a n g l ed-t i p stiff g l i dewi res i n t h i s
c i rc u m stance ca n decrease the risk o f t h i s c o m p l icat i o n .
• Symptoms of re n a l caps u l a r h e m atoma o r perforati o n i n c l u d e a bdom i n a l pa i n a n d n a usea,
acco m p a n ied by a vasova g a l response, which freq uently req u i res a g g ressive resuscitation a n d
sta b i l ization m a n euvers b y the i nterventi o n a l tea m .
• If t h i s com p l icat i o n is encou ntered, m a i nt a i n w i re access ( d o n o t remove t h e offe n d i n g wi re) to
fac i l itate a cath ete r exch a n g e to provide access to c o i l p l acement and occ l u s i o n of the perforat i o n
s i t e . Loss of w i re access can f u r t h e r com p l i cate t h i s situation; h owever, as l o n g a s sh eath access
re m a i n s in the ren a l a rtery, the relevant seg mental branches can be reaccessed for co i l del ive ry.
Rem ova l of • A l l atte m pts s h o u l d be made to safe ly reposit i o n m a l posit i o n ed/m ispl aced stents, endog rafts,
m a l posit i o n ed/m i s p l a ced c o i l s, or p l ugs. T h i s may i nvolve seco n d a ry ca n n u latio ns, l a rg e r sheath placem e nt, a n d b a l loon
devices a n g i o p l asty with gentle d i rect i o n a l force .
• If e n d ovascu l a r retrieva l or reposit i o n i n g is u n s u ccessful, a n g i og r a p h i c flow across m a l positioned/
m i s p l aced devices s h o u l d be eva l u ated. If a rte r i a l flow is clearly obstructed to u n i ntended vita l
structures or may become a s i g n ificant n i d u s for t h ro m bosis or hemody n a m i c ste nosis, open
s u r g i ca l rem ova l may be i n d i cated o r atte m pted reposit i o n i n g of devices i n a reas of less critica l
h e m odyn a m i c s i g n ificance (e .g., i l i ac a rteri a l syste m).

POSTOPERATIVE CARE tus is monitored periodically, along with hydration status/urine

• At the conclusion of the procedure, hemostasis is achieved
with manual compression or, in cases requiring larger than
6-Fr sheath size, closure devices. Heparin reversal with prot­
amine administration is also helpful unless anticoagulation
is to be continued following the procedure.
• As is the case with all patients undergoing peripheral arterial
intervention in our practice, patients are observed for a 6- to
24-hour period following device placement. During this pe­
riod, access site hemostasis and ipsilateral pedal perfusion sta-
output and signs of unintended end-organ malperfusion.
• Patients treated with renal!visceral artery angioplasty or
stenting receive exaggerated antiplatelet therapy in the im­
mediate perioperative period. In our practice, we load pa­
tients with 300 mg of Plavix™ following the procedure,
therapy continuing at 75 mg daily for 6 additional weeks.
• Postoperative surveillance of patients with renal!visceral ar­
tery interventions is necessary. Duplex evaluation of renal/
visceral artery stents 1 to 3 months following intervention is
 C h a p t e r 1 9 S T E N T I N G , E N D O G RAFT I N G , A N D E M B O L I ZATI O N TECH N I Q U E S
usually recommended, followed b y repeat duplex evaluation
every 6 months for at least 1 to 2 years. Afterward, stents
with no evidence of in-stent restenosis or de novo disease
progression may be imaged at yearly intervals. Evidence of
restenosis, either by end-organ dysfunction or surveillance
imaging studies, should prompt reevaluation and reinterven­
tion as necessary to maintain luminal patency and long-term
success.
OUTCOMES
•
Endovascular treatment of RAS has a reported technical
success rate of 8 8 % to 1 0 0 % . Treatment effects on hyper­
tension alone are quantitatively modest and inconsistent be­
tween studies.24 •25 Improvement in renal function is reported
in approximately 2 5 % of patients.
• Treatment of mesenteric occlusive disease has a reported
technical success rate of 9 6 % . Postoperative symptom
improvement/resolution is reported in approximately 8 8 %
o f treated patients. Primary patency i s estimated at 6 5 % to
9 2 % , with primary assisted patency at 92% to 1 0 0 % , and
secondary patency at 9 9 % .2 6•27
• Embolization and stent graft techniques for repair of renal
and visceral artery aneurysms are limited to variably sized
retrospective series but with acceptable technical success
rates in appropriately selected patients.
COMPLICATIONS
• For renal artery interventions, complications most commonly
arise from access site complications, contrast-induced nephrop­
athy, or atheroembolization. Renal artery restenosis is reported
between 5% and 6 6 % , depending on duration of follow-up
and criteria used for continued surveillance. The perioperative
3 0-day mortality is estimated at 0% to 5% and survival at 3
years is estimated at 74 % .28 Other less frequent complications
include iatrogenic renal parenchymal perforation, capsular he­
matoma, arterial dissection, thrombosis, or distal plaque em­
bolization into branch or accessory arteries.
•
For mesenteric artery interventions, restenosis or occlusion
of treated visceral vessels is documented in 1 0 % to 27%
of patients,29 emphasizing the need for continued postpro­
cedural surveillance. Less common complications include
mesenteric artery perforation, dissection, or distal paren­
chymal embolization due to wire/catheter manipulation of
areas with fresh thrombus or friable plaque. While treating
branch artery aneurysms of the spleen, occasionally, portions
of the splenic parenchyma may be lost due to coiling and
branch occlusion, with attendant symptoms consistent with
segmental splenic infarction.
REFERENCES
1. Schneider PA. Endovascular Skills, Guidewire and Catheter Skills for
Endovascular Surgery. 3rd ed. New York, NY: Informa Healthcare; 2009.
2. Garovic VD, Textor SC. Renovascular hypertension and ischemic
nephropathy. Circulation. 2005; 1 12 : 1 3 62-1 3 74.
3 . Hansen KJ, Edwards MS, Craven TE, et al. Prevalence of renovas­
cular disease in the elderly: a population-based study. J Vase Surg.
2002;36:443-45 1 .
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4. Beregi JP, Louvegny S , Gautier C , e t al. Fibromuscular dysplasia
of the renal arteries: comparison of helical CT angiography and
arteriography. A]R Am J Roentgenol. 1 9 9 9 ; 1 72:27-34.
5. McMillan WD, McCarthy WJ, Bresticker MR, et al. Mesenteric artery
bypass: objective patency determination. J Vase Surg. 1995;2 1 : 729-740.
6. Stoney RJ, Cunningham CG. Acute mesenteric ischemia. Surgery.
1 9 9 3 ; 1 14:489-490.
7. Tham G, Ekelund L, Herrlin K, et al. Renal artery aneurysms. Natural
history and prognosis. Ann Surg. 1 9 8 3 ; 1 97:348-352.
8 . Messina LM, Shanley CJ. Visceral artery aneurysms. Surg Clin North
Am. 1 9 97;77:425-442.
9. Tessier DJ, Abbas MA, Fowl RJ, et al. Management of rare mesenteric
arterial branch aneurysms. Ann Vase Surg. 2002; 1 6 : 5 8 6-590.
1 0 . Hobbs SD, Thomas ME, Bradbury AW. Manipulation of the renin
angiotensin system in peripheral arterial disease. Eur J Vase Endovasc
Surg. 2004;28 : 5 73-5 82.
11. Chang JB, Stein TA. Mesenteric ischemia: acute and chronic. Ann Vase
Surg. 2003;1 7:323-3 2 8 .
12. Carr S C , Mahvi D M , Hoch J R , et a l . Visceral artery aneurysm rupture.
J Vase Surg. 200 1 ; 3 3 : 8 06-8 1 1 .
1 3 . Dave SP, Reis ED, Hossain A , e t al. Splenic artery aneurysm i n the
1 990s. Ann Vase Surg. 2000;1 4:223-229.
14. Selo-Ojeme DO, Welch CC. Review: spontaneous rupture of splenic
artery aneurysm in pregnancy. Eur J O bstet Gynecol Reprod Bioi.
2003; 1 0 9 : 1 24-127.
1 5 . House MK, Dowling RJ, King P, et al. Using Doppler sonography
to reveal renal artery stenosis: an evaluation of optimal imaging
parameters. AJR Am J Roentgenol. 1999;1 73:76 1-765.
1 6 . Moneta GL, Lee RW, Yeager RA, et al. Mesenteric duplex scanning:
a blinded prospective study. J Vase Surg. 1 9 9 3 ; 1 7:79-84.
17. Wheatley K, lves N, Gray R, et al. Revascularization versus medical
therapy for renal-artery stenosis. N Eng/] Med. 2009;3 6 1 : 1 953-1962.
18. Wyers MC, Powell RJ, Nolan BW, et al. Retrograde mesenteric scent­
ing during laparotomy for acute occlusive mesenteric ischemia. ] Vase
Surg. 2007;45:269-275.
19. Oderich GS. Current concepts in the management of chronic mes­
enteric ischemia. Curr Treat Options Cardiovasc Med. 2 0 1 0 ; 1 2 :
1 1 7-130.
20. Pfeiffer T, Reiher L, Grabitz K, et al. Reconstruction for renal artery
aneurysm: operative techniques and long-term results. ] Vase Surg.
2003;3 7:293-300.
21. Panayiotopoulos YP, Assadourian R, Taylor PR. Aneurysms of the vis­
ceral and renal arteries. Ann R Coli Surg Engl. 1 996;78 :412-4 1 9 .
2 2 . Tallarita T, Oderich G S , Macedo TA, e t a l . Reinterventions for stent
restenosis in patients treated for atherosclerotic mesenteric artery
disease. j Vase Surg. 20 1 1 ;54:1422-1429.
2 3 . Bauer JR, Ray CE. Transcatheter arterial embolization in the trauma
patient: a review. Semin lntervent Radial. 2004;2 1 : 1 1-22.
24. Carriere MA, Pearce JD, Edwards MS, et al. Endovascular manage­
ment of atherosclerotic renovascular disease: early results following
primary intervention. ] Vase Surg. 2008;4 8 : 5 8 0-5 87.
25. Tuttle KR, Chouinard RF, Webber JT, et al. Treatment of atheroscle­
rotic ostial renal artery stenosis with the intravascular stent. Am J
Kidney Dis. 1 9 9 8 ;32:61 1-622.
26. Sharafuddin MJ, Olson CH, Sun S, et al. Endovascular treatment of
celiac and mesenteric arteries stenoses: applications and results. J Vase
Surg. 2003;3 8 : 692-6 9 8 .
2 7 . Sivamurthy N , Rhodes JM, L e e D, et a l . Endovascular versus open
mesenteric revascularization: immediate benefits do not equate
with short-term functional outcomes. J Am Col/ Surg. 2006; 202:
8 59-867.
28. Yutan E, Glickerman DJ, Caps MT, et al. Percutaneous translu­
minal revascularization for renal artery stenosis: Veterans Affairs
Puget Sound Health Care System experience. J Vase Surg. 2001 ;34:
6 8 5-693.
29. Brown OJ, Schermerhorn ML, Powell RJ, et al. Mesenteric stenting for
chronic mesenteric ischemia. J Vase Surg. 2005;42:268-274.
 -

Chapter 20 Visceral Reconstruction to

Facilitate Cancer Management:
Celiac, Mesenteric, Spl enic,
Hepatic and Renal Artery
I
Disease Management
1
I
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ·

Mohamed A. Zayed E. John Ha rris, Jr.

DEFINITION Although most commonly arising from large vessels such as

the aorta and vena cava, primary vascular tumors may also
• This chapter assumes basic knowledge of surgical oncology originate from distal branches of the iliac, mesenteric, and
principles and the management of patients with intraab­ renal arteries . Classification systems (Wright/Salm classifica­
dominal tumor pathology. For further review of these topics, tion) have broadly categorized primary vascular tumors as
please refer to relevant background sources. 1•2 intimal (maj ority, 70 % ) and mural.3
• Advanced primary and recurrent abdominal malignant tu­
mors may frequently involve adj acent arterial and venous
structures. Surgical management may require curative en PATIENT HISTORY AND PHYSICAL
bloc tumor resection, with the goal of achieving negative FINDINGS
macroscopic and microscopic margins. Adjunct vascular re­
• Patients with complex intraabdominal oncologic pathol­
construction may be necessary to achieve complete tumor
ogy are best managed by a multidisciplinary care team at
removal.
a tertiary care center. If tumor extension to adj acent vascu­
• A wide variety of malignancies may develop in the perito­
lar structures is suspected, surgical planning should include
neal space and retroperitoneum. A representative range of
evaluation of potential revascularization options by a vascu­
pathologies involving intraabdominal arterial and venous
lar surgeon.
structures is summarized in Table 1 .
• The initial assessment should include a thorough evaluation
• Primary vascular tumors are exceedingly rare, frequently
of the patient's presenting symptoms. This may include focal
mimic other oncologic disease processes, and may evolve
or regional abdominal pain resulting in tumor parenchyma
slowly-leading to delay in diagnosis and treatment.
pressing against adj acent structures. Patients may also pres­
ent with gastrointestinal symptoms such as early satiety,
nausea, and vomiting. Erosive gastrointestinal lesions may
Table 1 : Range of l ntraabdo m i n a l Oncolog ical manifest with hematochezia, melena, or hematemesis. Con­
Pathologies that can Potent i a l l y I nvolve Arterial stitutional flu-like symptoms, fevers, malaise, fatigue, night
and Venous Structures sweats, and muscle aches may also rarely present in patients
with certain patients with rapidly expanding tumors.
Arterial • Depending on the primary site and tissue of origin, tumor­
Aorta Angiosarcoma.' paraga n g l ioma, pheoch romocy· associated physical findings may not be obvious until rela­
toma, leiomyosarcoma, rhabdomyosarcoma tively late in the disease process. Abdominal distension can
S u perior mesenteric a rtery Adenocarci noma, neuroendocrine carcinoma, result from increasing tumor volume or from serous ascites
adenosq uamous carci noma, cystadenocarci· due to portal venous compression. Tumor mass effect or
noma
infiltration of the inferior vena cava (IVC ) or iliac venous
Iliac a rtery Adenocarci noma, leiomyoma, endometrial stro·
mal carcinoma, fibrosarcoma, fibroma system may lead to unilateral or bilateral lower extremity
edema, dilated abdominal wall veins, evidence of deep ve­
Venous nous thrombosis (DVT), biliary symptoms, and renal insuf­
I nferior vena cava Ang iosarcoma.' adrenocortical carci noma, tera· ficiency. Accordingly, physical examination should not only
toma, Wilms' tumor, pheochromocytoma, neu· include a thorough abdominal exam with palpation of all
roendocrine carci noma, intestinal carcinoma, nodal basins but also a complete vascular exam with evalu­
hepatoce l l u l a r carcinoma ation of limb pulses, Doppler signals, and assessment of ex­
Renal vei n Renal cell carci noma, adrenocortical carcinoma,
pheochromocytoma tent/grade of limb edema.
Porta l vei n Adenoma, adenocarci noma, cholangiocarci· • Patient with primary vascular tumors, particularly ones with
noma, neuroendocrine carci noma, hepatocel· intimal expansion and growth, can present with evidence of
l u l a r carcinoma venous or arterial embolization. Manifestations of recurrent
I l i a c vein I ntestin a l carci noma, leiomyoma, endometrial
venous pulmonary emboli include shortness of breath, respi­
stromal carcinoma, fibrosa rcoma, fibroma,
transitional cel l carci noma, l i posarcoma. leio­ ratory distress, and hemodynamic changes including tachy­
myosarcoma cardia and right heart failure. Depending on the volume of
arterial emboli, symptoms can range from lower extremity
aPrimary vascular tumor pain to digital discoloration.

1972
 C h a p t e r 20 V I SCE RAL R E C O N STRUCT I O N TO FAC I L I TATE CANCER MANAG E M E N T
IMAGING AND OTIIER DIAGNOSTIC STUDIES
• Tumor staging and classification systems are beyond the
scope of this chapter. Please refer to other excellent references
for tumor-specific staging modalities and requirements.2•4
• Patients deemed candidates for surgical resection by a mul­
tidisciplinary team should receive a high-resolution, thin­
slice (at least 1 mm), multidetector computed tomography
(MDCT) scan with intravenous contrast injection to allow
for imaging during arterial and venous phases. Image ac­
quisition should allow for multiplanar sagittal, coronal, and
three-dimensional reconstructions. This type of detailed im­
aging provides valuable information regarding tumor mar­
gins, suspected histologic subtype, and grade and can also
help determine the morphology, patency, and extent of in­
volvement of adj acent vascular structures.
• In situations where mesenteric venous thrombosis is visu­
alized on MDCT, specific postprocessing protocols may be
further implemented to improve clarity regarding the extent
of thrombus burden and associated and/or resultant venous
congestion.
• Adjunct imaging studies may also include magnetic reso­
nance imaging (MRI), ultrasonography, and rarely, angi­
ography/venography. Particularly, in patients with concern
for osseous or neurogenic tumor involvement, MRI may be
particularly useful in defining tissue planes and tumor paren­
chyma boundaries. MRI also has a nearly 1 0 0 % sensitivity
for detecting intracaval tumor thrombus.
• Autogenous vascular conduit may be necessary for adequate
revascularization, particularly following bowel resection
and reconstruction. When anticipated, preoperative venous
duplex scanning of the lower extremities will help document
the presence and usage of superficial femoral vein as poten­
tial graft conduit. The presence of deep venous obstruction,
either acute or chronic, may preclude venous harvest from
that particular extremity. Similarly, the bilateral lower ex­
tremity greater saphenous veins should be evaluated for pa­
tency, diameter, and adequate length.
• Occasionally, preoperative or intraoperative transesophageal
echocardiography may be needed to confirm the proximal
extent of intracaval tumor thrombus visualized using other
cross-sectional imaging modalities and determine whether
the tumor thrombus is encroaching into the right atrium.5
SURGICAL MANAGEMENT
Patient Selection
• Whenever possible, the goal of surgical extirpation of ab­
dominal solid organ tumors should be oncologic cure. This
assumption presupposes tumor localization to a distinct
anatomic region that will allow for resection with negative
macroscopic and microscopic margins. Thus, the goals of
the procedure should be clearly defined by sufficient preop­
erative high-quality anatomic cross-sectional imaging, mul­
tidisciplinary consultation, and discussions with the patient
regarding the operative risks, benefits, expectant outcomes,
and overall prognosis. 2 • 6
• Abdominal solid organ tumors are traditionally considered
unresectable when they involve the arterial or venous vascu­
lature, are diffusely metastatic throughout the peritoneum
or at remote sites, or involve the root of the mesentery or
1 973
spinal cord to a significant extent. Patients with extensive
tumor burden precluding resection may still be offered in­
complete removal or debulking operations to potentially
prolong survival and improve symptom palliation.6
• Equally as important as the anatomic considerations, pre­
operative patient functional status is a significant determi­
nant of surgical eligibility. Performance assessments, such as
outlined by the Karnofsky or Eastern Cooperative Oncology
Group (ECOG) score, help predict patient-specific postop­
erative quality of life.2•7 At our institution, patients who are
bedridden at the time of initial assessment, severely disabled,
or unable to independently perform activities of self-care are
often not offered curative resection.
• Candidacy for intraabdominal vascular reconstruction is
also contingent on the extent of potential or preexisting
vascular compromise. As such, we have typically attempted
arterial reconstruction when tumors involve critical arterial
structures such as the aorta, celiac artery and its branches,
proximal superior mesenteric artery (SMA), common/exter­
nal iliac artery, and the internal iliac artery in the setting
of an embolized, occluded, or resected contralateral inter­
nal iliac artery. Similarly, venous reconstruction is also an­
ticipated when tumors margins appear to include the vena
cava, portal, superior mesenteric, common, and external
iliac veins.
Preoperative Planning
• Items to consider in preoperative multidisciplinary review
include the extent of planned gross surgical resection mar­
gins, the need for preoperative arterial or venous emboli­
zation, the need for other prophylactic procedures such as
placement of ureteral stems or nephrostomy tubes, and the
likelihood for intestinal resection and/or reconstruction.
• Ureteral stem placement should be considered in all patients
who demonstrate evidence of ureteral obstruction, renal
hydronephrosis, or urinary obstructive signs or symptoms
from either tumor mass effect or invasion of urologic struc­
tures. Moreover, ureteral stems should also be considered in
patients with pelvic tumors where there is potential concern
of ureteral injury during resection of the tumor or during
vascular reconstruction.
• A thorough review of detailed preoperative imaging will
greatly facilitate proper conduit selection and preparation
and, ultimately, a successful outcome. Particular attention
should be directed to the length of vascular segment in­
volved by adj acent tumor, the branch points and bifurca­
tions present along this length, and which segments, if any,
are circumferentially encased by tumor parenchyma.
• Attention should be paid as to whether planned resection
will include vessels which are already occluded with ad­
equate collateral circulation already in place, or whether
adj acent or contralateral vascular structures are capable of
supplying adequate inflow and outflow. Vascular segments
to be reconstructed should be patent and preserved to the
greatest extent possible during the planned tumor resection.
• Endovascular embolization is the preferred method of pre­
operative vascular occlusion prior to open surgical resection.
This strategy is commonly used for preoperative splenic ar­
tery/vein embolization prior to planned surgical splenectomy,
internal iliac artery embolization prior to planned pelvic
1 974 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY
tumor resection, and renal artery/vein embolization prior to
planned nephrectomy with or without the need for further
exposure of the retrohepatic IVC. For this purpose, the pre­
ferred size of coils/plugs is estimated based on the diameter
and length measurements of the target vessel on preopera­
tive cross-sectional imaging and is typically oversized by up
to 20% of the target vessel diameter. For additional details
regarding visceral embolization techniques, refer to Part 6,
Chapter 19 (Stenting, Endografting, and Embolization Tech­
niques: Celiac, Mesenteric, Splenic, Hepatic, and Renal Ar­
tery Disease Management) . For additional details regarding
internal iliac artery embolization techniques, refer to Part 6,
Chapter 24 (Advanced Aneurysm Management Techniques:
Management of Internal Iliac Aneurysm Disease) .
• Aortoiliac arterial involvement often requires resection fol­
lowed by reconstruction with patch angioplasty, interposi­
tion, or extraanatomic bypass. Type of reconstruction and
conduit type ( autogenous venous allograft, cryopreserved
homograft, or synthetic conduit) is contingent on the type of
tumor, extent of vascular segment involvement, and degree
to which intestinal reconstruction is also anticipated. In the
latter case, when contamination by succus entericus is likely,
autogenous femoral vein conduits for iliac artery reconstruc­
tions and IVC or spliced femoral vein conduits for aortic
reconstructions are preferred. Alternatively, when not avail­
able, rifampin-soaked, gel-sealed knitted D acron conduit
may serve as a potential substitute with acceptable results. 8
• Reconstruction of the celiac trunk, common hepatic artery,
SMA, portal vein, and superior mesenteric vein (SMV) are
similarly contingent on the extent of involvement of these
structures with tumor pathology. Unless the artery in ques­
tion is circumferentially involved, it is our preference to resect
only the portion of vessel wall directly involved with tumor
while preserving the remaining vessel architecture with patch
repair. Autogenous venous conduit (using superficial femoral
vein or greater saphenous vein or femoral vein) is preferred
for vessel segments requiring interposition grafting.
• The mainstay of treatment of primary and secondary tu­
mors of the IVC is surgical resection and reconstruction.
AORTIC RECONSTRUCTION
• For a d iscuss i o n of the tec h n ica l exposu re of the para­
viscera l , pararenal, and i nfra re n a l a o rta, p l ease refer to
Part 6, Cha pters 14 (Exposu re and Open S u r g i c a l M a n ­
a g e m e n t at the D i a p h ra g m), 1 5 (Retro perito n e a l Aort i c
Exposu re), a n d 22 (Adva nced A n e u rysm M a nagement
Tec h n i q ues: Open S u r g i c a l Anatomy Repa i r) .
First Step
• The s u r g i c a l exposu re of an i ntraabdo m i n a l t u m o r either
d i rectly adjacent o r i nvolvi n g the a o rta should aim to n ot
o n l y p rovide adeq uate exposu re of t u m o r resect i o n but
a lso fac i l itate a d e q u ate proxi m a l a n d d ista l a rte r i a l con­
tro l . A trad iti o n a l m i d l i n e abdom i n a l i ncision, exte n d i n g
f r o m the x i p h o i d p rocess to the p u b is, can fac i l itate t h i s
i n the majority of patients.
The extent of reconstruction is contingent on the type of
tumor, extent of caval involvement, and the anatomic seg­
ments involved. Adequate retrohepatic caval exposure is
challenging and may require total vascular isolation of the
liver to minimize blood loss during this maneuver. In circum­
stances where the IVC is chronically occluded with tolerable
lower extremity edema and adequate renal function, ligation
and resection without reconstruction should be considered.
On the other hand, patients with recent occlusion of the
IVC, few venous collaterals, notable lower extremity symp­
toms, or renal insufficiency should be considered for either
interposition grafting or patch venoplasty.
Operating Room Setup
• Preoperative endovascular embolization procedures should
be performed in an angiography suite or hybrid operating
room, equipped with a fixed-imaging apparatus, floating­
point carbon fiber operating table, fluoroscopy platform,
and monitor-viewing bank. A full complement of compat­
ible guidewires, catheters, sheaths, coils, and plugs should
also be available.
• Open tumor operative resection procedures are best per­
formed in an operating room setting with adequate space to
facilitate the maneuvering of multiple surgical subspecialty
teams and their necessary operative trays/equipment.
• Most intraabdominal operative tumor resection and recon­
struction procedures may be performed with the patient in
the supine position. In the surgical field, the patient's lower
extremities should be prepared for vein harvest if potentially
necessary.
• In patients who require retrohepatic IVC exposure and re­
construction, the left lateral decubitus position should be
employed to facilitate right thoracoabdominal exposure
through the 8th or 9th rib interspace.
• Placement of ureteral stems will require initial positioning of
the patient in lithotomy position and then subsequent repo­
sitioning of the patient to facilitate further planned surgical
intervention.
• I n patie nts with w i d e costa l m a r g i n s or an a ntici pated
need for wide parahepatic o r parasp l e n i c exposu re, a bi­
l atera l su bcosta l i n c i s i o n (also known as Michigan s m i le)
may a l so be usefu l .
• For l a rg e a b d o m i n a l t u m o rs, ren a l t u m o rs, o r t u m o rs
with ce p h a l a d i ntraabd o m i n a l exte n s i o n to the level of
the d i a p h ra g m , a latera l decu b itus t h o racoabdo m i n a l
a p p roach t o fa c i l itate both a d e q u ate t u m o r exposure a s
we l l a s vasc u l a r proxi m a l control a n d reco nstruct i o n i s
advised .
Second Step
• Prox i m a l a o rt i c control ca n often be o bta i n e d d i rect ly
above the a ntici pated ce p h a l a d m a rg i n of the t u m o r. In
this circumsta nce, via either retro perito n e a l o r transperi­
tonea l a p p roach es, the m ed i a l a n d l atera l a o rtic m a r g i n s
a re c l e a red f o r a d i stance of 2 to 3 em p roxi m a l to the
 C h a p t e r 20 V I SCE RAL R E C O N STRUCT I O N TO FAC I L I TATE CANCER MANAG E M E N T
t u m o r m a rg i n . The exposed seg ment is i n s pected for
l u m ba r vessel branches, which may be externa l ly l i g ated
as n ecessa ry to aid in exposu re and contro l . A l a rge,
s l i g htly c u rved vascu l a r a o rtic c l a m p (e . g ., DeBa key a o rtic
occ l u s i o n c l a m p) is best su ited to obta i n p roxi m a l a o rtic
contro l .
• Su prace l i a c o r s u p ra r e n a l a o rt i c exposure m a y b e n eces­
s a ry for opti m a l control (FIG 1 ) .
• F o r control o f the s u p race l i a c a o rta, the perito n e a l cavity
i s e ntered below the level of the x i p h o i d p rocess. With
ce p h a l a d retract i o n of the l eft lobe of the l iver, the l eft
tria n g u l a r l i g a m e n t of the l iver is d ivided a n d the lesser
sac i s entered via a l o n g itu d i n a l i n ci s i o n i n the g astro he­
patic l i g a ment. Care should be taken here to avo id i n j u ry
to the eso p h a g u s (identified by a i d of orogastric/naso­
gastric tube placement) o r a repl aced l eft hepatic a rte ry.
For a d d i t i o n a l exposu re, the m e d i a n a rcu ate l i g a ment
a n d t h e r i g h t crus may be d ivided (FIG 1 ) .
• S u p ra re n a l a o rtic control is obta i n e d fo l l owi n g circum­
ferenti a l d i ssect i o n a n d m o b i l i zation of the l eft renal
ve i n off the ventra l su rface of the a o rta. Left renal ve i n
i nfe r i o r l u m b a r branches s h o u l d b e l i g ated t o fa c i l itate
Right crus of d iaphragm
Posterior
peritoneum
of lesser sac
Gastrohepatic
omentum
/ Left g astric
A
Aortic clamp
c with vascu l a r c l a m p i n g .
1 97 5
m o b i l izat i o n . I n rare c i rc u m stan ces, the l eft ren a l ve i n
m a y need t o b e l i g ated d u r i n g t h i s m a neuve r. When t h i s
i s a ntici pated, exist i n g co l l atera l ve i n s s u c h a s t h e l eft
g o n a d a l , a d r e n a l , or l u m ba r s h o u l d be i ntentio n a l ly pre­
served p r i o r to d ivision of the l eft ren a l ve i n .
• l nfra re n a l a o rtic exposu re c a n be a c h i eved either via
transperito n e a l o r retro perito n e a l a p p roaches. If the
t u m o r has pelvic exte nsions o r if exposu re/control of the
right i l i ac syste m is a ntici pated, a transperito n e a l ap­
p roach may be p referable.
Third Step
• Depe n d i n g on the extent of a o rtic t u m o r i nvolve m e nt,
d u r a b l e repa i r may be a c h i eved u s i n g either patch a n g io­
p l a sty o r i nterposition g raft i n g .
• Patch repa i r i s co m m o n ly performed w i t h a woven D a ­
cron, bovi n e pericard i u m, o r a utog e n o u s fe moral ve i n .
T h e patch is fash ioned i n a m a n ne r t o fa c i l itate a w i d e
repa i r w i t h o u t n a rrowi n g the res i d u a l the a o rtic l u m e n .
T h e a n asto mosis is usua l ly performed w i t h 4-0 Pro l e n e
sutu res, i n a ru n n i n g fas h i o n , w i t h o n e suture sta rt i n g
Esophag us
T horacic
aorta
artery
B
FIG 1 • Tra nsabd o m i n a l exposu re of the su p race l i a c a o rta
for p roxi m a l a o rtic contro l . A. The l eft lobe of the l iver is
retracted superio rly and to the patie nt's r i g ht. The d ista l
eso p h a g u s is identified a n d gently retracted to the patie nt's
left. A l o n g itu d i n a l i n c i s i o n is m a d e in between th ese
structu res t h r o u g h the gastro hepatic l i g a m e nt to enter the
lesser sac. B. The poste rior perito n e u m a n d the r i g h t crus of
the d i a p h ra g m ca n t h e n be i n cised to expose the s u p race l i ac
a o rta. C. B l u nt d i g ital d i ssection can a i d with c i rcu mferenti a l
exposu re o f t h i s a o rtic seg m e nt t o a l l ow f o r prox i m a l control
1 97 6 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

A Right common B
il iac artery

c D
FIG 2 •Patch a n g i o p l a sty repa i r of i nfra re n a l a o rta. A. Tra nsa bdom i n a l exposu re of the i nfrare n a l abdom i n a l a o rta a n d
adjacent t u m o r mass. B. Fol lowing prox i m a l a n d d ista l a o rtic control, m a s s i s rem oved a l o n g w i t h associated a o rtic wa l l .
C,D. Aortotomy re p a i red with a a bovi n e perica r d i a I patc h .

from each end of the patch repa i r. Depen d i n g on the a g e
of the patie nt, presence a n d extent of retro peritonea I
so i l a g e by i ntest i n a l conte nts, a n d a m o u nt of retroperi­
tonea l i n f l a m mation p resent, po lyester pledgets may be
req u i red to m i n i m ize sutu re-re lated a o rtic i n j u ry a n d
need l e h o l e b l eed i n g (FIG 2) .
• Altern ative ly, w h e n m o re extensive a o rt i c seg m e nts a re
i nvolved or the t u m o r ca n n ot be safe ly m o b i l ized circum­
ferentia l ly a r o u n d the a o rta, i nterposition g raft i n g may
be m o re a p p ro p r i ate. After resection, the res i d u a l a o rta
s h o u l d be i n s pected for any i nti m a l defects, t u m o r i n f i l ­
tration, o r i ntra l u m i n a l thrombus. O n ce c l e a n e n d p o i nts
a re dete r m i ned, the i nterpos ition g raft of choice can be
brought to the f i e l d . Co n d u it c h o i ces i nc l u d e autogenous
vena cava o r s p l iced fe m o ra l ve i n s, cryo p reserved ho-
mogenous a rte r i a l condu it, or kn itted or woven po lyes-
ter and expa nded polytetraf l u o roethyl e n e (ePTF E). Once
sel ected, the proxi m a l e n d is fash ioned i n such as way as
to m i n i m ize d i a m eter d i fferences between the a o rta a n d
g raft. T h e a n asto mosis is usua l ly performed w i t h a r u n ­
n i n g 3 - 0 o r 4-0 polypropy l e n e suture. O n c e co m p l eted,
the proxi m a l c l a m p is tempora r i l y released to a l low the
cond u it to be routed in such a way to avoid red u n d a n cy,
k i n k i n g , o r twist i n g . After rec l a m p i n g of the g raft (to
avo id repeated a o rt i c c l a m p i ng), the d ista l a n a stomosis
is com p l eted i n a s i m i l a r fas h i o n after sufficient proxi m a l
a n d d i sta l f l u s h i n g m a n euvers (FIG 3) .
• Autoge n o u s tissue repa i rs o f the a o rta a re p refe rred i n
circumstances w h e re i ntest i n a l cont i n u ity has been i nter­
r u pted . H owever, if autogenous tissue is not ava i l a b l e o r
not adeq u ate for u s e , g e l - i m p re g n ated woven polyester
g raft mate r i a l i m m e rsed in rifa m p i n solution is the p ros­
thetic c o n d u i t of c h o i ce . To a c h i eve a d e q u ate cove rage,
the g raft is i m m e rsed i n 50 ml of n o r m a l sa l i n e conta i n ­
i n g 6 0 0 m g of rifa m p i n for at least 30 m i n utes.
• If the pa ravisceral o r parare n a l a o rta reconstruction is re­
q u i red, viscera l and ren a l vessels ca n be rei m p l a nted to
the i nterposition aortic g raft. Alternatively, a preman ufac­
tu red o r surgeon-mod ified branched aortic g raft can be
used to fac i l itate end-to-end a n asto moses to the viscera l
or ren a l vessels fol l owi n g aortic i nterposition g raft repa i r,
with side l i m bs typica l ly 6 to 8 mm i n d i a meter (FIG 3) .
 C h a p t e r 20 V I SCE RAL R E C O N STRUCT I O N TO FAC I L I TATE CANCER MANAG E M E N T 1 97 7

,, . '
..
. ..
.
-� . ....
�
,.
� ' .

FIG 3 • B ra n ched aortovisce ra l repa i r fo l l owi n g resect i o n of a l a rg e retroperito n e a l thoracoabd o m i n a l myxo i d sa rcoma
mass. A. Coro n a l abdom i n a l co m p uted tomography (CT) d e m o n strates l a rg e thoracoabd o m i n a l a n d m e d i a st i n a l mass d i rectly
adjacent to major organ structures a n d the pa ravisce ral a o rta. B. CT d e m o n st rates retroperito n e a l port i o n of t u m o r mass
d is p l a c i n g IVC toward the patie nt's rig ht. C. Sag itta l CT d e m o n strates ci rcu mferenti a l i nvolvement of the pa raviscera l a o rta
with the t u m o r mass. D. Left t h o racoa bdom i n a l exposu re reve a l s a l a rge retroperito n e a l mass exte n d i n g p roxi m a l ly d i rectly
u n derneath the d i a p h ra g m . The s u p ra d i a p h ra g matic a o rta (E), proxi m a l l eft re n a l a rtery (F), a n d proxi m a l S M A (G) were a l l
exposed t o fac i l itate t u m o r resect i o n a n d a o rtic branched repa i r. H. Aortic branch g raft was constructed o n t h e operative back
ta b l e by attach i n g a 1 4- m m bifu rcated Dacron g raft to the side of a 1 6- m m Dacron tube g raft. F o l l o w i n g e n bloc resect i o n of
the mass a l o n g with associated a o rtic seg ment (1), the resected a o rtic seg ment was then re pai red with the constructed g raft.
B ra n ches were used for e n d-to-e nd a n asto mosis to the l eft r e n a l a rtery and SMA.

SUPERIOR MESENTERIC ARTERY control s h o u l d o bta i n e d p r i o r to s i g n ificant d e b u l k i n g o r

RECONSTRUCTION
First Step
• Exposure of the S M A, in situations w h e re it is i nvolved
with the t u m o r, may be perfo rmed j o i ntly with the
s u r g i ca l oncology tea m . Particu l a rly in situat i o n s w h e re
the S M A is exte nsively i nvolved, suffi cient vascu l a r
resect i o n m a n e uvers.
• To expose the SMA at the base of the mesentery, the trans­
verse colon and omentum a re el evated w h i l e pack i n g the
sma l l bowe l to the right. The perito n e u m is then i n cised
at the base of the transverse mesocolon, taking care to
identify a n d p reserve the m i d d l e co l i c a n d jej u n a l a rte­
r i a l branches. J u d icious ce phalad retraction of the i nferior
border of the pancreas may a lso i m p rove exposure (FIG 4).
1 978 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

Middle Su perior
colic artery mesenteric
and vein artery

Su perior
mesenteric
artery ---+-'� Left renal
vein
Splenic
vein

B
A

Superior
mesenteric
artery

Su perior
mesenteric Aorta
Left artery
ureter

interposition graft
Aorta
Lumbar vein Left renal Left renal D
artery vein
c
FIG 4 • Tra nsabd o m i n a l exposure and reco nstruction of the SMA. A. The orig i n of the SMA may be exposed with m o b i l ization
a n d gentle retract i o n of the superior border of the p a n creas along with extended ce p h a l a d exposu re of the a o rta to the level
of the ce l i a c tru n k . B. Alternatively, the S M A can be exposed from a l atera l a p p roach with d ivision of the l i g a m e n t of Tre itz and
r i g h t latera l m o b i l i zation of the fo u rth port i o n of t h e d u od e n u m . C. Exposure can be e n h a nced with gentle cep h a l a d retract i o n
of the i nfe r i o r b o r d e r of the p a n creas a n d ventra l m o b i l ization o f the l eft k i d n ey. Ca re s h o u l d be t a k e n to n ot a v u l s e l eft re n a l
ve i n l u m b a r, g o n a d a l , o r a d r e n a l branches d u ri n g m o b i l ization o f the l eft k i d n ey. D. Tu m o r m ass resect i o n with associated
seg ment of SMA. The a rteri a l seg ment is repa i red with a n a utog e n o u s i nterposition g reater s a p h e n o u s ve i n g raft.
 C h a p t e r 20 V I SCE RAL R E C O N STRUCT I O N TO FAC I L I TATE CANCER MANAG E M E N T
• Altern ative ly, p roxi m a l S M A exposu re may be g a i ned l at­
eral ly, fo l l owi n g d ivision of the l i g a ment of Tre itz a n d
m o b i l ization o f the fo u rth port i o n o f the d u oden u m .
Visu a l i zation o f t h e u n derlyi n g S M A c a n be f u rther en­
h a nced with gentle retraction of the i nfe rior border of
the p a n creas to the level of the l eft re n a l ve i n (FIG 4) .
• The s p l a n c h n i c n e rves m u st be s h a rply exc ised to effec­
tively e l evate the S M A off the a nterior a o rt i c wa l l .
Second Step
• Reconstruct i o n a p p roach is d i ctated by t h e extent of
t u m o r i n g rowt h . S M A i nvolvement may be tangenti a l
o r req u i re seg mental resect i o n t o a c h i eve a p p ro p r i ate
tumor margins.
• Part i a l S M A i nvolvement may o n ly req u i re resect i o n a n d
reco nstruction o f o n e o f the S M A wa l ls . W i t h a rte r i a l
control esta b l ished, the t u m o r t i s s u e a n d i nvolved S M A
ca n be s h a r p l y resected e n bloc. Fol l ow i n g i n s pect i o n t o
e n s u re a d i sease-free patent l u men, the a rteriotomy is
repa i red with a patch a n g i o p l a sty tech n i q u e . Autoge­
nous ve i n is the p referred patch mate r i a l when ava i l a b l e,
espec i a l ly fo l l owi n g i nterruption of i ntest i n a l cont i n u ity.
When a l i m e nta ry tract cont i n u ity is not d i s r u pted, bo­
vine pericard i a ! tissue, polytetraf l u o roethy l e n e (PTFE),
o r polyester patch may be used for repa i r. 6-0 polypro­
pyl e n e m o n ofi l a m e n t suture i s a good cho ice for a rteri­
otomy c l o s u re and repa i r.
Third Step
• M o re extensive t u m o r i nvolvement with the S M A may
req u i re seg m e nta l resection a n d i nterposition g raft i n g .
Va r i a b l e s to co n s i d e r i n c l u d e the l e n gt h o f the defect,
wheth e r the SMA orig i n is a l s o i nvolved, a n d c o n d u i t ma­
teri a l ava i l a b l e for repa i r.
• For s h o rt seg ment replacement, reversed g reater sa­
p h e n o u s ve i n is the p refe rred cond u it for S M A g raft i n g .
Appropri ately sized s a p h e n o u s ve i n is usua l ly h a rvested
from the t h i g h , d istended, a n d p repa red for i nterpo­
siti o n . The t u m o r tissue is resected e n b l oc with the
SUPERIOR MESENTERIC VEIN OR PORTAL
VEIN RECONSTRUCTION
First Step
• Exposu re of the porta l ve i n is fa c i l itated via entry of the
perito n e a l cavity a n d i nterruption of the u m b i l i ca l ve i n
a n d fa lc iform l i g a ment. T h e po rta hepatis c a n b e bet­
ter visua l i zed with ce p h a l a d retract i o n of the right lobe
of the l iver, downwa rd retract i o n of the co l o n i c hepatic
fl exu re, a n d m ed i a l m o b i l ization of the fi rst and second
port i o n s of the d u oden u m . The port a l ve i n is then eas­
i ly i d e ntified in the right poste r i o r border of the hepa­
tod u o d e n a l l i g a m e nt. This exposu re ca n be exte nded
from the h i l u m of the l iver to the head of the pa ncreas
1 979
i nvolved seg ment of SMA. F o l l o w i n g co nfirmation of ad­
e q u ate m a r g i ns, seq uentia l e n d-to-e n d p roxi m a l a n a sto­
mosis is performed. The g raft is then brought to length
while avo i d i n g a n y twi st i n g o r k i n k i n g of the g raft.
The d ista l e n d -to-end a n asto mosis is then s i m i l a rly per­
fo rmed. Spatu lation of both the a rte r i a l e n d po i nts a n d
s a p h e n o u s c o n d u i t may o r may n ot be h e l pful, depend­
i n g o n size d iscre p a n cy.
• For l o n g segment resect i o n s or resect i o n s i nvolvi n g the
origin of the S MA, a l o n g retrog rade " q u estion mark"
g raft, so n a m ed for its a p pearance o n contrast a rteriog­
raphy fo l l ow i n g the p roced u re, is used to route a rte r i a l
b l o o d f r o m the r i g h t i l i a c a rtery a r o u n d the b a s e o f the
mese ntery to the d ista l SMA. Alternatively, a n a ntegrade
bypass from the s u p raceliac a o rta may be t u n n e led pos­
terior to the pa ncreas and brought out coaxi a l ly a l o n g
the cou rse o f the d ista l SMA. F i n a l ly, when the S M A
o r i g i n is i nvolved but sufficient d ista l S M A is present t o
a l low m o b i l ization, the S M A may be re i m p l a nted o n the
d i stal a o rta if a d isease-free seg ment can be i d e ntified by
p a l pation o r from assessment of p reope rative i m a g i n g
stu d i es. For bypass options u n d e r these c i rc u m stances,
cryop reserved a rte r i a l homog raft o r 6-mm po lyester or
externa l ly s u p p o rted PTFE are typica l l y p referred con­
d u its. Ca re i s once aga i n taken to avo i d co n d u it twist i n g
o r k i n k i n g d u r i n g p l acement o r t u n n e l i n g .
• A l t h o u g h a pote n t i a l o p t i o n , d i rect bypass f r o m t h e
reg i o n of t h e o r i g i n of t h e S M A to t h e d i sta l m es­
e n t e r i c a rt e ry i s p r o b l e m at i c in that fash i o n i n g the
bypass req u i res e l evat i o n of t h e mesentery, w i t h the
d i sta l a n asto m o s i s p o s i t i o n e d o n t h e poste r i o r a s pect
of the d i sta l mesenteric a rte ry. A l t h o u g h the g raft
m a y f u n ct i o n we l l w i t h t h e m esentery e l evated, re­
d u ct i o n of the i ntest i n e s i nto the a b d o m e n i nva r i a b l y
ca uses g raft c o n d u it, a u t o g e n o u s o r p rosthetic, to k i n k
a n d pote n t i a l l y t h r o m b o s e . I n t h i s c i rc u m st a n ce, it i s
a l m ost i m poss i b l e to fash i o n a n i nterpos i t i o n g raft o f
a p p ro p r i ate l e n gt h , so a p p ro a c h e s s u c h a s retro g r a d e
g raft i n g o r rei m p l a ntat i o n s h o u l d be c o n s i d e red a s
p refe rred a lt e r n atives.
i nfe riorly. I nferior ly, ca re should be taken to identify and
preserve the coro n a ry ve i n a n d s p l e n i c ve i n (FIG 5).
• I n m ost i n stan ces, the neck of the p a n creas is d ivided
a s p a rt of the tumor exposure a n d resection, which im­
p roves ca u d a l exposu re of the porta l ve i n , s p l e n i c ve i n ,
a n d SMV.
• Exposu re of the SMV can be a c h i eved via exposu re d i sta l
to the s p l e n i c ve i n confl u e n ce or via s i m i l a r tech n i q ues
used to expose the SMA. At the base of the transverse
mesoco lon, the SMV can be fo u n d l y i n g to the r i g h t of
the SMA n e a r the m i d l i n e . M u lt i p l e dense l y m p h atics
ove r l y i n g the vein often req u i re caref u l d issect i o n a n d
m etic u l o u s contro l . C a r e s h o u l d a lso be t a k e n to identify
a n d preserve the m i d d l e co l i c ve i n proxi m a l ly a n d ventra l
ve n o u s tributaries d ista l ly (FIG 5) .
1 980 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

I nferior
vena cava

Gall bladder
Portal
vein
( Free edge of
hepatod uodenal
ligament

Duodenum

Right kidney I
A
B

Portal vein

Bovine
pericardia!
patch

Portal
vein

Su perior mesenteric vein

Splenic vein
D
FIG S • Tra n sabd o m i n a l expos u re a n d reco nstruct i o n of the portal ve i n a n d SMV confl u e n ce . A. With ce p h a l a d retract i o n
of the r i g h t lobe of the l iver, the poste r i o r perito n e a l atta c h m e nts of the fi rst a n d seco n d portions of the d u oden u m may b e
visu a l ized. B. The po rta l ve i n a n d proxi m a l S M V may be exposed t h r o u g h a l o n g itu d i n a l i n cision a l o n g the l atera l f r e e a spect
of the h e patod uode n a l l i g a ment. C. Ven o u s tri butaries d ra i n i n g i nto the porta l vei n a n d S M V confl u e n ce may be l i g ated to
fac i l itate exposu re a n d reco nstruct i o n of t h i s venous seg ment. D. Tu m o r mass resect i o n with associ ated ventra l segment of the
portal vein a n d S M V confl u e n ce a n d repa i r with a patch ve n o p l a sty u s i n g a bovi n e pericard ia I patc h .
 C h a p t e r 20 V I SCE RAL R E C O N STRUCT I O N TO FAC I L I TATE CANCER MANAG E M E N T
Second Step
• The extent of t u m o r i nvolvement with the SMV a n d por­
t a l ve i n is va r i a b l e . Reconstruct i o n is often req u i red to
preserve mesente ric outfl ow.
• F o l l o w i n g esta b l i s h m e nt of vascu l a r control, en bloc re­
sect i o n of the t u m o r and associ ated ve n o u s structures
ca n be pe rfo rmed . Part i a l i nvolvement is best m a n a g e d
via p a t c h venoplasty. Prese rvation of a n i ntact back wa l l
o f t h e s p l e n i c S M V confl u e n ce is ofte n benefi c i a l i n
m a i nta i n i n g t h e structu ra l i nteg rity o f t h e bifu rcat i o n .
S M V a n d porta l ve i n patch ve n o p l asty repa i rs can b e
pe rfo rmed u s i n g a utog e n o u s s a p h e n o u s ve i n o r bov i n e
INFERIOR VENA CAVA RECONSTRUCTION
First Step
• I ntra hepatic IVC exposure can be fac i l itated either
t h r o u g h r i g h t retroperito n e a l o r transperito n e a l expo­
sure. Exposure is typica l ly d i ctated by the extent of other
p l a n ned i ntraabd o m i n a l procedu res and a ntici pated
t u m o r resect i o n m a rg i ns.
• For right retro perito n e a l exposu re, the fla n k is e l evated
to 1 5 to 20 deg rees with the patient posit i o n ed in the
supine posit i o n . A transverse i n c i s i o n can then be m a d e
exte n d i n g f r o m the rectus abdom i n i s to t h e t i p of the
1 1 t h o r 1 2th r i b . The exte r n a l o b l i q ue, i nternal o b l i q ue,
transversus abdom i n is m uscles, and transversa l i s fascia
a re d ivided to create the retro perito n e a l p l a n e via b l u nt
d i ssect i o n . With j u d iciously p l aced self-reta i n i n g retrac­
to rs, a 6-cm segment of the r i g h t l atera l aspect of the
parare n a l a n d i nfrare n a l ve n a cava may be easily ex­
posed (FIG 6) .
• For a transperito n e a l exposu re, either a m i d l i n e l a pa­
rotomy o r b i l atera l su bcosta l i n c i s i o n will fa c i l itate ad­
e q u ate exposure. Once the perito n e a l space is entered,
the s m a l l bowel is retracted to the l eft and the l atera l
perito n e a l attach m ents of the r i g h t colon a re d ivided.
T h i s fac i l itates medial m o b i l i zation of the r i g h t colon
a n d mesentery a n d p rovides access to the retro perito­
n e a l attach me nts of the seco n d and t h i rd port i o n s of
the d u oden u m . Once these atta c h m e nts a re d ivided, the
underlying ve n a cava can then be a d e q u ately exposed
from the s u p r a re n a l level to the c o m m o n i l i ac ve i n s . Li­
gation and d ivision of the ventra l p a ra re n a l l y m p h at i cs,
right latera l l u m ba r vei ns, a n d a nterior cross i n g l eft go­
nadal vei n will a i d i n cava l m o b i l ization d u ri n g p roxi m a l
a n d d ista l c i rcu mfere n t i a l d i ssect i o n . Vasc u l a r tapes may
be p l aced around the proxi m a l a n d d i sta l exposed seg­
m e nts of the vena cava to fac i l itate vasc u l a r contro l . Ca re
s h o u l d be taken to not avu l se m e d i a l l u m b a r ve i n s with
over a g g ressive m o b i l ization of the vena cava d u r i n g
these m a n e uvers (FIG 6) .
• For extended retro hepatic IVC exposu re, a r i g h t t h o ra­
coabd o m i n a l i n c i s i o n may be pe rfo rmed with the patient
positioned i n a l eft latera l decubitus posit i o n . Once the
perito n e a l cavity i s e ntered, the right tria n g u l a r l i g a ment
1 981
pericard i u m . A 6-0 polypropy l e n e suture repa i r is used to
close the vein, ru n n i n g or i nterru pted (FIG S) .
• Tu m o r i nvolvement req u i r i n g co m p l ete resect i o n of
the portal ve i n o r SMV w i l l req u i re i nterposit i o n g raft
reco nstruct i o n . I nterposition g rafti n g with a utogenous
su perfi c i a l fem o ra l vei n o r cryop rese rved ve n o u s homo­
g raft is p refe rred when i ntest i n a l resect i o n a n d reco n­
struct i o n i s a ntici pated . Alternatively, 6- o r 8-mm r i n g e d
P T F E w h e n ve n o u s co n d u it is u n ava i l a b l e o r i n a deq uate.
The d ista l e n d-to-e n d a na stomosis is co m p l eted fi rst, fo l­
l owed by the p roxi m a l end, with either i nterru pted o r
t ri a n g u l ated ru n n i n g sutu res to p reve nt p u rse-st ri n g i n g
a n d a n asto motic n a rrow i n g (FIG S) .
a n d latera l a n d poste r i o r perito n e a l atta c h m e nts to t h e
r i g h t h e patic l o b e can be d ivided. M ed i a l retract i o n of
the right hepatic lobe ca n then be pe rfo rmed to faci l i ­
tate v i s u a l ization of the latera l su rface of the retrohe­
patic IVC (FIG 6) . H e patic co m p ress i o n h ere, especi a l ly
fo l l owi n g p l acement of self-reta i n i n g retracto rs, can i n ­
crease hepatic co n g esti o n a n d isc h e m i a a n d s h o u l d b e
m i n i m ized to the g reatest extent poss i b l e . I n situat i o n s
where cava l visu a l ization is not a d e q u ate desp ite opti­
mal hepatic retraction, p roxi m a l exte n s i o n o r even d ivi­
sion of the ste r n u m may be necess a ry to fac i l itate safe
expos u re . O n ce a d e q u ate exposu re is a c h i eved, circum­
ferenti a l control can be ach ieved fo l l owi n g l i gation and
d ivision of small hepatic ve n o u s branches that cou rse
between the ca udate lobe of the l iver a n d the IVC in t h i s
reg i o n .
• T h e s u p r a h epatic I V C can be exposed fo l l ow i n g l i gation
a n d d ivision of the round l ig a m ent a n d wide d ivision of
the fa l ciform a n d coro n a ry l i g a m ents. C a u d a l retract i o n
of the b a r e d o m e of t h e l iver fac i l itates v i s u a l ization o f
t h e s u p ra h epatic v e n a cava a n d at least t w o of the th ree
m a i n hepatic veins. Ca ref u l d issection of the a re o l a r tis­
sue su rrou n d i n g these ve i n s a l l ows for ci rcumferenti a l
exposure o f each o f th ese veins as we l l as t h i s seg m e nt of
the vena cava.
Second Step
• O n ce the vena cava is contro l led both prox i m a l ly a n d d is­
ta l ly, the t u m o r m ass can be d i ssected off other perti nent
structures to fac i l itate e n bloc resect i o n . Syste m i c a ntico­
a g u l at i o n i s acco m p l ished with u nfract i o n ated h e p a r i n
su lfate ( 1 00 u n its/kg i ntrave n o u s i nfusion) a n d reve rsed
with p rota m i n e su lfate, 1 mg/1 00 u n its of h e p a r i n , w h e n
vasc u l a r reco nstruct i o n o r retraction is co m p l ete.
• Prior to remova l of the t u m o r mass, the patient is p l aced
in Tre n d e l e n b u rg position and vasc u l a r c l a m ps posi­
t i o n ed p roxi m a l and d ista l to t h e antici pated m a rg i n s of
resect i o n . If the i nvolved seg ment of the IVC is l i m ited to
o n ly a few ce ntimeters o r o n e side wa l l , a long Sati n sky
side-biti n g vasc u l a r c l a m p may be used fo r p a rt i a l cava l
occl usion (FIG 6) .
• Acute occl usion of t he s u p r a re n a l or retro h e patic IVC may
i n d uce p rofo u n d hypote n s i o n d u e to s i g n ificant preload
1 982 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

Duodenum H epatic flexure

H epatoduodenal
ligament

Vena cava

Gonadal artery U reter Right renal vein

and vein
A B

Inferior
FIG 6 • Tra nsabdom i n a l exposu re of t h e IVC to fa c i l itate operative
vena
cava reconstruct i o n . A. An exte nded right retro perito n e a l expos u re of
the IVC can be ach ieved with m o b i l ization of the sma l l bowel to
the patie nt's l eft, d ivision of the latera l perito n e a l atta c h m e nts
of the r i g h t co l o n to a l low its med i a l reflection, and d ivision of
the retro perito n e a l attac h m e nts of the seco n d a n d t h i rd port i o n s
of the d u oden u m . B. Poste rol atera l l u m ba r ve i n s can be l i g ated
to a l low for fu l l a nterior m o b i l ization of the IVC and fa c i l itate
c i rcu mferent i a l contro l . C. The retro h e patic vena cava is vis u a l i zed
with m ed i a l m o b i l ization of the r i g ht hepatic lobe. S m a l l hepatic
c vein branches e nter the IVC at this l evel a n d will req u i re ca refu l
Right renal vein d issection a n d d ivision to fa c i l itate t h i s seg ment of the IVC.

red u ct i o n . I n these c i rcu mstan ces, p reem ptive a g g ressive
f l u i d resuscitation, g rad u a l c l a m p i n g of the vena cava, or
p a rt i a l occl usion may be better tolerated . Altern ative ly,
venove n o u s bypass or atri ocava l s h u nt p l acement may be
necessa ry. P l ease refe r to p r i o r refe rences for f u rt h e r de­
ta i l s reg a r d i n g preparation and p l acement of atri ocava l
s h u nts.9•1 0
• Specific isolation of the retro hepatic vena cava req u i res
control of both the hepatic i n f l ow and outflow. I n f l ow
control is ach ieved with cross-cl a m p i n g of the i nfra­
hepatic vena cava a s we l l a s with a Pri n g l e m a neuver
(cl a m p i n g of the hepatic a rtery a n d portal vei n ) . Outflow
control is a c h i eved with s u p r a h epatic o r i nfrad i a p h rag­
matic clamping of the IVC.
Third Step
• The strategy for reco nstruct i o n is d i ctated by the extent
of the IVC defect and the concomitant need for other
vascu l a r reconstruct i o n s . Typica l ly, t h e vena cava i s re­
p a i red, when n ecessa ry, fo l l owi n g a rte r i a l reconstruc­
tions to decrease end-org a n isch e m i a . The d u ration of
cava l occ l u s i o n s h o u l d be l i m ited to less t h a n 30 m i n utes
to m i n i m i ze ven o u s congest i o n and resu ltant isch e m i a .
• F o r sma l l cava l defects, primary repa i r m a y suffice w h e n the
lumen d i a meter is reduced by less than 50 % . Otherwise, au­
togenous i nterna l jugular vei n or bovine pericard i a ! patch
repa i r may be incorporated i nto the repa i r. Lower extrem­
ity vei n ha rvest is not p referred for cava l reconstruction due
to increased risk for d ista l throm botic com p l ications.
 C h a p t e r 20 V I SCE RAL R E C O N STRUCT I O N TO FAC I L I TATE CANCER MANAG E M E N T 1 983

• For replacement of the IVC, when n ecessa ry, i nterposi­
t i o n g raft using externa l ly s u p p o rted ePTFE is the pre­
ferred condu it. Fol l ow i n g resect i o n of the i nvolved
seg m e nt, the transected ends of the ve n a cava a re i n -
spected for a n y res i d u a l d isease with i n the l u m e n . Con­
t ro l led seq uentia l flush i n g of the transected ends a lso
ensu res patency. The g raft d i a m eter is chosen to be de­
l i berately s m a l l e r t h a n the cava l seg ment b e i n g repl aced
to prom ote h i g h e r velocities with i n the g raft seg ment
fo l l ow i n g reco nstruct i o n . The p roxi m a l a n asto mosis i s
co m p l eted fi rst u s i n g e i t h e r a ru n n i n g 4 - 0 o r 5 - 0 P ro l e n e
s u t u r e . The d i stal a n asto mosis is then s i m i l a rly performed
with the patient i n Tre n d e l e n b u rg posit i o n . Prior to co m ­
p l et i o n of t h e d i sta l a n a stomosis, p roxi m a l a n d d ista l
c l a m ps a re seq u e nt i a l l y removed, a Va lsa lva m a n e uver i s
i n d uced by the a n esth es i o l o g ist, a n d the g raft i s f i l led
with h e pa r i n i zed sa l i n e wh i l e flushing i s performed to
m i n i m ize reta i n e d air a n d the risk for air e m b o l izat i o n .
• Exte r n a l s u p po rt r i n g s a re m a i nta i n ed to the g reatest ex­
tent possi b l e to avo i d c o m p ress i o n of the g raft, i n c l u d i n g
at m i d g raft seg m e nts w h e re e n d-to-s ide a n a stom oses
a re n ecessa ry for renal ve i n o r co m m o n i l i ac ve i n reim­
p l a ntat i o n . For repa i r of the confl u e n ce of the c o m m o n
i l i a c ve i n s, we h ave successf u l l y mod ified t h i s p roced u re
by i n corporati n g a s h o rt seg ment of n o n s u p p o rted b if u r­
cated ePTFE g raft i nto the repa i r. Externa l ly s u p ported
ePTFE g rafts a re then sutu red to the non ri nged seg ment
with ePTFE suture. The suture l i n es a re t h e n cove red
with B i o G i u e o r ste r i l e Dermabond to p revent suture l i n e
b l eed i n g a n d the g raft is t h e n p l a ced i n s i t u (FIG 7) .

FIG 7 • I V C a n d a o rtic reco nstruct i o n i n the sett i n g o f i ntraabdom i n a l resect i o n o f a l a rg e retroperito n e a l h i g h-grade
l e i o myosa rco m a . A. Operative exp l orat i o n d e m o n strated a l a rg e retroperito n e a l mass with c i rcu mferenti a l i nvolvement with
the i nfra re n a l a o rta and IVC. Proxi m a l i nfra re n a l a o rta and d i sta l b i l atera l common i l iac a rteries were c i rcu mferentia l ly exposed
and contro l l e d . The p rox i m a l i nfrare n a l IVC and d ista l l eft co m m o n i l iac ve i n were a l so contro l l e d . B. Back-ta b l e construct i o n
of a custom P T F E bifu rcated g raft for reconstruct i o n o f the I V C . T h i s was pe rfo rmed b y sutu r i n g a 1 6- m m r i n g ed PTF E g raft
to two 1 0- m m ri nged PTF E g rafts u s i n g a 6-0 G o re-Tex suture. The a n asto mosis was rei nforced with D e r m a b o n d . C. F o l l o w i n g
t u m o r m a s s resect i o n a l o n g w i t h associ ated IVC, i nfra renal a o rta, a n d p rox i m a l b i l atera l co m m o n i l i a c a rteri es, the ve n a cava
is reco nstructed u s i n g the custom-co nstructed bifu rcated PTF E g raft. The resected a o rto i l i ac seg ment was reco nstructed u s i n g
tra d i t i o n a l tec h n i q ues u s i n g a b ifu rcated D a c r o n g raft.

PEARLS AND PITFALLS

Preope rative workup • It is i m pe rative that a comprehensive plan for resect i o n a n d vasc u l a r reco nstruction be deve l oped
and a g reed upon by all pa rti cipating s u r g i c a l specia lties we l l i n advance of the proce d u re.
• Adeq u ate p reope rative eva l u at i o n will fac i l itate d iscussion of p l a n ned vascu l a r reconstruct i o n s a s
we l l a s t h e r i s k s a n d a nt i c i pated outcomes of the p roced u re .
I ntraoperative • The presence of a d e q u ate syste m i c a nticoa g u lation p r i o r to vascu l a r occl usion is esse n t i a l to the
a nticoa g u lation opti m a l outco m e of the p roced u re . Anticoa g u lation may be d e l ayed to m i n i m ize t u m o r bed b l eed­
ing d u r i n g resect i o n but s h o u l d be esta b l ished we l l i n advance of p l a n ned vasc u l a r reconstruct i o n .
• An a ctivated clott i n g t i m e (ACT) of g reater t h a n 250 seco nds i s reco m m e n d ed d u ri n g vascu l a r
rep a i rs to avoid t h ro m b ot i c co m p l ications. Reve rsa l o f a nticoa g u lation fo l l ow i n g completion of
a rte r i a l repa i rs is a lso sta n d a rd practice.
1 984 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

Arte r i a l repa i rs
Ve n o u s repa i rs
R e n a l vasc u l a r repa i rs
Posto pe rative b l eed i n g
M ethods to a v o i d l ower
extre m i ty edema
• If the a o rta is known to be i nvolved with t u m o r, it is i m perative that proxi m a l control be
esta b l ished we l l prox i m a l to the a ntici pated m a rg i n of resect i o n .
• To opti m i ze outcome, the p resence a n d extent of u n d e r l y i n g vasc u l a r a rte r i a l d isease s h o u l d
be f u l l y a p p reci ated . For exa m p l e, co m p l ete a o rto i l i ac o r a o rtofe m o ra l reco nstruct i o n may b e
necess a ry when s i g n ificant atherosc l e rotic d i sease is p resent i n the d ista l a o rta ( a s a n a ltern ative
to seg m e ntal patc h i n g o r replacement) . S i m i l a rly, e n d a rterectomy of resi d u a l SMA o r ce l i a c a rtery
d iseased l u m e n s may be necess a ry to o pt i m ize pate ncy of patch or i nterposition g raft repa i rs.
• Attem pts should be m a d e to preserve as m a n y S M A a n d ce l i a c a rte ry branches as poss i b l e d u r i n g
vasc u l a r reconstruct i o n to m a i nta i n a d e q u ate bowel perfu s i o n . T h i s is p a rti c u l a rly i m portant i f
concomitant bowe l resect i o n is a ntici pated.
• I n the sett i n g of co m p l ete com p ress i o n or occ l u s i o n of the IVC, the i n d i cations for reco nstruction
fo l l ow i n g resect i o n may be less compe l l i n g . Reco n struct i o n of c h r o n i ca l ly occl uded i l i ac ve i n s is
g e n e ra l ly n ot i n d i cated u n d e r a ny c i rc u m stances d u ri n g o n c o l o g i c resect i o n s-pa rti c u l a rly when
patie nts a re free preoperatively of s i g n ificant lower extrem ity edema.
• A i r e m b o l u s is a s i g n ificant potenti a l co m p l i cation of extensive venous reco nstruct i o n . The risk of
air e m b o l ization may be m i n i m ized when repa i rs a re pe rfo rmed with the patient i n Tre n d e l e n b u rg
position a n d with t i m e l y Va lsa lva i n d u ct i o n by the a nesthes i o l o g i st d u r i n g retro g rade f l u s h i n g
m a n e uvers p r i o r t o co m p l et i o n . If a l a rg e a i r e m b o l u s is suspected, b l ood can be aspi rated d i rectly
from the vena cava o r r i g h t atri u m w h i l e the patient is m a i ntained in Tre n d e l e n b u rg and left
l atera l decubitus posit i o n .
• R i g h t re n a l ve i n reconstruction a n d/o r re i m p l a ntation to t h e v e n a cava is n ecessa ry beca use there
is n o a d e q u ate co l l ateral venous outflow from the right k i d n ey. D u r i n g r i g ht renal vei n re i m p l a n ­
tation, the r i g h t ren a l a rtery s h o u l d a lso be contro l led a n d c l a m ped to avo i d ve n o u s congestion
i n j u ry to the k i d n ey.
• Left renal ve i n can be sacrificed a n d l i g ated if the l eft a d r e n a l a n d g o n a d a l ve i n s a re i ntact. H ow­
ever, if l eft k i d n ey ve n o u s outflow col l atera l s were l i g ated d u r i n g exposu re a n d reconstruct i o n , the
l eft re n a l ve i n should be p reserved o r reco n structed w h e n ever possi b l e .
• I n the i m med iate posto pe rative p e r i o d , sudden o r acute a n e m i a, a b d o m i n a l p a i n , a bdom i n a l
d istension, o r hem odyn a m ic i n sta b i l ity s h o u l d be a p p roached with h e i g htened awa re n ess for
poss i b l e i ntraabdo m i n a l bleed i n g .
• Particu l a rly i n patients with recent pa ncreatic reconstructio ns, bowe l-associ ated leaks may
comprom ise a rteria l/ven o u s repa i rs a n d can lead to acute catastro p h i c b l eed i n g req u i r i n g u rg e nt
i nterventi o n .
• Pati e nts a re prone t o i n c reased l ower extre m i ty edema fo l l ow i n g lower extrem ity ve n o u s h a rvest
o r i ntraabd o m i n a l vena cava reconstructions. For th ese patie nts, l ower extre m i ty e l evati o n in the
i m med iate posto perative period is reco m m en d e d .
• Early com p ress i o n t h e ra py of the l ower extrem ity can a l so s i g n ificantly m i n i m ize the extent o f
l ower extrem ity edema i n the perio perative period. Arte r i a l i n s ufficiency s h o u l d be r u l ed out p r i o r
to i n itiation of co m p ress i o n t h e ra py to avo id co m p ro m ise of a l ready l i m ited a rte r i a l i nfl ow.

POSTOPERATIVE CARE • Early mobilization and DVT mechanical and/or chemical

• Patients are typically managed in a monitored setting where
periodic vascular examination is available and vasoactive
agents are administered as necessary to maintain homeo­
static arterial perfusion pressure.
• Intravenous fluid resuscitation is maintained in the short­
term perioperative period until the patient resolves an antici­
pated course of intestinal ileus.
• All patients should be initiated and maintained on an anti­
platelet agent, typically 325 mg aspirin daily.
• In patients who preoperatively received therapeutic antico­
agulation, this should slowly be restarted 1 to 2 days fol­
lowing the patient's operation to minimize perioperative
bleeding complications.
• Patients with large PTFE interposition caval grafts are typi­
cally anticoagulated for at least 6 months postoperatively
and potentially lifelong depending on risk factors, history of
prior DVT, and extent of reconstruction required to restore
caval continuity.
prophylaxis should be initiated as soon as safely possible in
the postoperative period.
OUTCOMES
• Abdominal tumor resection with vascular reconstruction
is feasible for many malignancies previously deemed unre­
sectable.
• In a series of 47 patients who underwent IVC reconstruction
with en bloc tumor resection, there was an 80% 5-year patency
rate of the vascular reconstruction and a 45% 5-year survival.1 1
• I n a series o f 1 7 patients with SMA a n d portal vein recon­
structions with pancreatic mass resection, there was an 8 8 %
primary patency rate. Two patients returned t o the operating
room for vascular-related complications. Eighty-two percent
of patients were reported alive over follow-up period (4 to
48 months ) . 12
• In a series of 14 patients receiving retroperitoneal sarcoma re­
section and major arterial and venous reconstruction, primary
 C h a p t e r 20 V I SCE RAL R E C O N STRUCT I O N TO FAC I L I TATE CANCER MANAG E M E N T
arterial patency was 5 8 % and primary-assisted patency was
8 3 % . Venous patency was 78 % . Local recurrence occurred in
2 1 % of patients and 5-year disease-free survival was 5 2 % .1 3
• In a series of 1 4 1 patients who underwent resection of retro­
peritoneal soft tissue sarcomas with either major arterial or
venous structure involvement, arterial continuity was retained
in all patients and venous continuity was retained in 8 0 % .
Perioperative morbidity was 3 6 % and mortality was 4 % .
Midterm arterial patency was 8 8 . 9 % and venous patency was
93 . 8 % . The overall S-year patient survival was 6 6 . 7 % . 14
COMPLICATIONS
• Intraoperative bleeding
• Perioperative infection
• Thrombosis or occlusion of repair or graft site
• 1 0 . Klein SR, Baumgartner FJ, Bongard FS. Contemporary manage­
Venous air embolism
• Wound complications due to poor nutrition or possible ra­
diation to operative field
• DVT from hypercoagulable state
REFERENCES
1. De Vita VT, Lawrence TS, Rosenberg SA. D e Vita, Hellman, and
Rosenberg's Cancer Principles & Practice of Oncology. Philadelphia,
PA: Lippincott Williams & Wilkins; 20 1 1 .
2. Feig BW, C D Ching. The M D Anderson Surgical Oncology Hand­
book. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012.
1 985
3 . Wright EP, Glick AD, Virmani R, et al. Aortic intimal sarcoma with
embolic metastases. Am I Surg. 1 9 8 5 ; 9 : 890-8 97.
4. Edge SB, Byrd DR, Compton CC, et al. AICC Cancer Staging Manual.
7th ed. New York, NY: Springer; 2 0 1 0 .
5 . Sigman D B , Hasnain JU, D e l Pizzo ]], et a l . Real-time transesophageal
echocardiography for intraoperative surveillance of patients with renal
cell carcinoma and vena caval extension undergoing radical nephrec­
tomy. I Ural. 1 999; 1 6 1 : 3 6-3 8 .
6. Kilkenny ] W Ill, Bland KI, Copeland E M Ill. Retroperitoneal
sarcoma: the University of Florida experience. I Am Coli Surg. 1996;
1 82 ( 4 ) : 329-3 3 9 .
7. Ghosh J, Bhowmick A , Baguneid M. Oncovascular surgery. E u r J Surg
Oneal. 20 1 1 ; 3 7: 1 0 1 7-1 024.
8 . Bandyk DF, Novotney ML, Johnson BL, et al. Use of rifampin-soaked
gelatin-sealed polyester grafts for in situ treatment of primary aortic
and vascular prosthetic infections. I Surg Res. 2001;95:44-49.
9. Baumgartner F, Scudamore C, Nair C, et al. Venovenous bypass for
major hepatic and caval trauma. I Trauma. 1995;39:671-673 .
ment strategy for major inferior vena caval injuries. I Trauma. 1 994;
37:35-4 1 .
1 1 . Quinones-Baldrich W, Alktaifi A , Eilber F, e t al. Inferior vena cava
resection and reconstruction for retroperitoneal tumor excision. J Vase
Surg. 2012;55 : 1 3 8 6-1 3 9 3 .
12. Song TK, Harris E J Jr, Raghavan S, e t a l . Major blood vessel recon­
struction during sarcoma surgery. Arch Surg. 2009;144 : 8 1 7-822.
13. Tedesco MM, Norton JA, Cisco RM, et al. Pancreatic mass resection
and revascularization. I Vascular Surgery. 2 0 1 0;52(2):530.
14. Schwarzbach MH, Hormann Y, Hinz U, et al. Clinical results of sur­
gery for retroperitoneal sarcoma with major blood vessel involvement.
I Vase Surg. 2006;44:46-55.

Chapter 21
r
r
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -+ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
t
DEFINITION
• The hepatic and splenic arteries represent suitable alternative
inflow sources for renal artery revascularization. The most
common indications for basing bypass procedures from these
arteries include abdominal aortic occlusion or insufficiency or,
alternatively, a scarred or hostile periaortic retroperitoneum.
Hepatic- or splenic-based renal revascularization also mini­
mizes increases in cardiac afterload induced by aortic cross­
clamping, which may be of benefit in patients with congestive
heart failure. Alternative terms for hepatic- or splenic-based
renal revascularization include hepatorenal bypass, splenore­
nal bypass, splanchnorenal bypass, or extraanatomic renal
revascularization.
DIFFERENTIAL DIAGNOSIS
• Renal revascularization is most commonly performed to alle­
viate " resistant" renovascular hypertension. Resistant hyper­
tension is defined by a systolic blood pressure greater than
140 mmHg in patients taking at least three antihypertensive
medications, representing 5% to 1 0 % of all hypertensives.
A subsegment of these patients has secondary hypertension
due to renal artery pathology or endocrine tumors. Alterna­
tive causes of resistant hypertension include
Renal artery
Atherosclerosis
Aneurysm
Arteriovenous fistula
Fibromuscular dysplasia
Takayasu arteritis
Other vasculitides involving the renal artery (i.e., Behc;:et's
syndrome, polyarteritis nodosa)
Trauma
Endocrine tumors associated with hypertension
Pheochromocytoma
Primary aldosteronism
Cushing's syndrome
Primary adrenal hyperplasia
Hyperthyroidism
Acromegaly
PATIENT HISTORY AND PHYSICAL FINDINGS
• Patient age: In younger patients, renovascular hypertension
generally arises from nonatherosclerotic pathologies, such as
Takayasu's arteritis or fibromuscular dysplasia. In patients
older than 50 years of age, atherosclerosis is most common
etiology.
• Associated risk factors are those typical for all occlusive
arterial disease: tobacco use, diabetes, hyperlipidemia, and
hypertension.
• Length of the hypertensive diathesis: Was the hypertension
easily controlled for a period of time, with a recent increase
in the difficulty of control ? Is the hypertensive diathesis severe
1986
-
Hepatic- and Spl enic- Based
Renal Revascul arization
·
Fred Wea ver Sung Wa n Ham Gra ce Huang
and recent in onset? If either is true, the patient is more likely
to have a secondary hypertension.
• Recognition of the systemic burden of vascular disease
present provides important perspective on indications and
treatment options. Many vascular maladies involve multiple
vascular beds. Is there evidence of disease involving the ca­
rotid artery, lower extremity arterial tree, and/or thoracic
and abdominal aorta ?
• A history of postprandial pain, significant unintentional
weight loss, and food avoidance is suggestive of mesenteric
occlusive disease.
• Prior pancreatitis may complicate attempts at splenic-based
renal revascularization.
• Prior Hodgkin's disease or other neoplasms requiring mantle
or midline abdominal radiation
• For general operative risk considerations, recognition and
documentation of the presence of coronary artery disease,
previous coronary stents, or surgical coronary revascular­
ization as well as valvular disease and congestive failure is
fundamental to surgical planning.
• Documentation of renal function as evidenced by increased
serum creatinine, pedal edema, or recent requirement for
renal replacement therapy
• Recognition of prior aortic procedures, or intraabdominal
nonvascular procedures such as a retroperitoneal lymphad­
enectomy for testicular cancer, which may complicate retro­
peritoneal dissection and aortic exposure
• Family history of syndromic aortic diseases such as Marfan's,
Ehlers-Danlos, and Loeys-Dietz
• The specific antihypertensive regimen in place prior to sur­
gery needs to be verified and documented.
• To obtain the most accurate baseline measurement, the high­
est pressure obtained from either arm should be recorded
and retained.
• A complete vascular examination must be performed, with
particular attention paid to pulse deficits and bruits. In par­
ticular, diminished femoral pulses or an abdominal bruit
may indicate significant aortic or branch vessel occlusive dis­
ease, potentially complicating revascularization plans. The
presence of concomitant carotid bruits may suggest carotid
occlusive disease that should be assessed prior to renal revas­
cularization. The presence of an aortic aneurysm should be
excluded by abdominal palpation.
IMAGING AND OTHER DIAGNOSTIC STUDIES
• Laboratory assessment of renal function should include, at
a minimum, serum creatinine, blood urea nitrogen (BUN ) ,
a n d electrolytes. Baseline glomerular filtration rate c a n b e
estimated from the serum creatinine level a n d body mass
index using the Cockcroft-Gault equation.
• The co-occurrence of endocrine syndromes, such as pheo­
chromocytoma or functional adrenal tumors that potentially
contribute to resistant hypertension should be evaluated
with appropriate serologic studies.
 C h a pter 21
FIG 1 • Abdom i n a l a n g i o g r a m with l atera l v i e w sh ows a n o r m a l
c e l i a c a rte ry.
• Renal artery duplex ultrasonography is performed to docu­
ment existing renal artery disease, renal mass, and intraparen­
chymal renal flow indices. Hemodynamically significant renal
artery stenosis ( > 6 0 % ) are determined by duplex-derived
assessment of peak systolic velocity measurements across
lesions. Baseline characteristics (i.e., kidney size, velocity,
spectral waveforms, resistive indices) serve as reference points
for future surveillance imaging following revascularization.
• Selective visceral and renal arteriograms are obtained to
define normal and variant vascular anatomy, including
lateral imaging of both the celiac and superior mesenteric
arteries ( FIGS 1 and 2 ) .
• Computed tomography ( CT) arteriography o f the abdomen
and pelvis, with arterial and venous pelvis, may provide
additional useful information regarding the extent of aortic
disease an d other associated abdominal pathology ( FIGS 3
and 4) . Catheter-based arteriography alone may not identify
significant arterial wall disease or the presence of aneurys­
mal lesions. However, the expense, contrast load, and radia­
tion associated with complementary arteriographic imaging
modalities may not be justified or appropriate in every patient,
so anatomic information obtained from these examinations
FIG 2 • Abdom i n a l a n g iogram with latera l view s h ows a ste notic
ce l i ac a rte ry.
H E PATIC- A N D S P L E N I C-BAS E D R E N A L REVASCU LARIZAT I O N 1 987
I .
� . ,f- . ,:. Cl
0
Cellae a rte
,_. , . :,�
:ret-� 0
�
:
� ./
<:?
� 10::>
FIG 3 • Axi a l CT sca n i m a g e s h ows a n o r m a l c e l i a c a rtery o r i g i n .
should b e integrated into the operative plan o n a n iterative
basis. Preoperative, imaging-based planning is combine d with
direct intraoperative assessment to create the most effective
and durable revascularization possible for each patient.
• Documentation of celiac, hepatic, splenic, and superior mes­
enteric artery patency is a mandatory prerequisite for these
procedures. Significant stenosis of the celiac origin or hepatic
or splenic artery occlusive disease will prevent successful
renal revascularization from these arteries. Associated supe­
rior mesenteric artery disease also needs to be considered,
particularly when the gastroduodenal artery provides signifi­
cant collateral flow from the celiac plexus to the mesenteric
bed. Renal artery anatomy, including branch vessel involve­
ment and the presence of multiple renal arteries also needs to
be documented.
• Bilateral lower extremity vein mapping is also necessary to
identify potential graft conduit. Standard vein mapping tech­
niques, including imaging in a warm room with the patient
in reverse Trendelenburg position, should be employed to
ensure accuracy and reproducibility.
• For selected patients, a more extensive preoperative evalu­
ation for coronary artery or valvular disease should be
considered. This may include both a transthoracic echocar­
diogram and cardiac stress evaluation. Selective pulmonary
evaluation may be required in patients with chronic ob­
structive pulmonary disease ( COPD )-associated respiratory
FIG 4 • Axi a l CT sca n i m a g e s h ows a d i seased ce l i a c a rtery o ri g i n .
1 988 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY
compromise. Additional vascular assessments should be per­
formed as indicated, including carotid duplex ultrasonogra­
phy to assess the significance of carotid bruits identified on
physical examination.
SURGICAL MANAGEMENT
Preoperative Planning
• The indications for hepatic and splenic artery-based renal
revascularization are similar to those for aorta-renal revas­
cularization and are discussed elsewhere. 1 •4
• Although aorta-renal bypass is most direct and generally
most expeditious, extraanatomic renal revascularization may
be preferable in selected circumstances as previously noted.
• Review of preoperative imaging is performed to determine
variant vascular anatomy, if present. Anatomy of the exist­
ing renal artery disease is assessed.
HEPATORENAL B YPASS
Placement of Incision
• O pti m a l access is g a i ned through a right su bcosta l I nCI­
sion extending from the m i d l i n e to the tip of the 1 2th rib.
I n l a rge or obese patie nts, the med i a l extent of the incision
can be exte nded across the m i d l i n e as a chevron (FIG S).
• When n ecessa ry, an u p p e r m i d l i n e i n c i s i o n may a l so p ro­
vide sufficient exposure.
Hepatic Artery Exposure
• The h e patod uoden a l l i ga m e n t is exposed by retract i n g
the r i g h t l o be of the l iver ce p h a l a d .
t •
t
t a n d then d i sta l ly to the t h ree segm enta l renal a rtery
t
, branches. Each branch is identified a n d contro l led with
,..
. . ..
FIG S • R i g h t su bcosta l i n c i s i o n exte nded to the t i p of
1 2th r i b .
• The hepatic-right renal bypass requires a conduit, prefer­
ably autogenous vein.
• The spleno-left renal bypass may be performed with or
without graft conduit. The native splenic artery is sufficient
length, usually to extend directly to the left renal artery, when
fully mobilized. When necessary due to variant anatomy, or
prior inflammation or scarring around the pancreas, venous
conduit can also be employed.
• Planning for availability of duplex ultrasonography in
the operating room ( OR) will facilitate intraoperative
confirmation of adequate target revascularization and renal
perfusion.
Positioning
• Patient is placed in supine position with both arms tucked.
• A small bump is placed under the respective flank.
• The operative field is prepped from the nipples to the knees.
• The r i g h t colon a n d d u oden u m a re reflected a nteriorly
and to the l eft (Koc h e r m a n e uver) . The sma l l i ntest i n e is
packed toward the pelvis with m o ist l a p a roto my pads.
• The he patod u o d e n a l l i g a ment is i n cised l o n g itud i n a l ly.
The hepatic a rtery is l ocated i n the porta hepatis med i a l
t o the co m m o n b i l e d u ct (FIG 6) .
• T h e gastrod uodena l artery is identified as t h e fi rst large
branch cou rsing ca udad and encircled with a silastic loop.
The gastrod uodena l artery should be preserved i n the pres­
ence of superior mesenteric a rtery occlusive disease as it pro­
vides i m po rtant col l atera l circulation to the small i ntesti nes.
• The hepatic a rtery is contro l led proxi m a l ly and d i sta l ly
with s i l a st i c loops (FIG 7) .
Right Renal Artery Exposure
• The right co lon and duodenum are reflected as deta i led
earlier to expose the i nferior vena cava and right ren a l vei n .
• The r i g h t renal a rtery is l ocated poste r i o r a n d superior to
the m a i n ren a l ve i n . Depe n d i n g on its position, the renal
ve i n is retra cted either ce p h a l a d o r ca u d a d . To e n s u re
the m a i n renal a rtery is exposed, the d i ssect i o n s h o u l d be
carried to its a o rtic o ri g i n . T h i s req u i res m ed i a l retract i o n
of the i nfe r i o r vena cava a n d d ivision of l u m ba r ve i n s
when n ecessa ry.
• The r i g h t re n a l a rtery is contro l led u s i n g a s i l astic loop.
The main re n a l a rtery is exposed c i rcu mferent i a l ly
a s i l astic loop. This is a critica l operative m a n euver that
exc l udes the p resence of branch d isease and ensu res a
successf u l renal a rtery revascu l a rization (FIG 7) .
Distal Anastomosis
• The d i st a l a n asto mosis is pe rfo rmed fi rst to take adva n­
tage of the a d d iti o n a l deg rees of freedom provided by
the mobile g raft.
• An a p p ro p r i ate length of g reater s a p h e n o u s ve i n is
h a rvested from the t h i g h . The patient is h e p a r i n i zed
1 00 u n its/kg. The ve i n itse lf is reve rsed before p l acement.
 C h a pter 21 H E PATIC- A N D S P L E N I C-BAS E D R E N A L REVASCU LARIZAT I O N 1 989

I nferior vena cava

Gastrod uodenal
artery
Left gastric
Portal vein
artery
Right gastric
Gall bladder artery

Proper hepatic Splenic artery

artery

Liver

Right renal
artery

Right kidney

Right renal vein

U reter Duodenum

A B
FIG 6 • A,B. Koch e r m a n e uver with porta hepatis d i ssected . IVC, i nfe rior vena cava .

• The proxi m a l re n a l a rtery is m o b i l ized fo l l ow i n g its d ivi­
sion from the a o rta, at its o ri g i n . The proxi m a l stu m p i s
oversewn with 5-0 polypropy l e n e suture.
• Red u n d a nt ren a l a rtery is t r i m m e d d i sta l l y from its ori-
gin until the d i sease-free segment is rea ched. The m o b i l e
renal a rtery is then transposed a nterior to the i nfe r i o r
vena cava .
• The ve i n g raft a n d re n a l a rtery a re spatu l ated a n d
the e n d-to-en d a n astomosis created w i t h cont i n u o u s
6 - 0 polypropy l e n e sutu re, kn otted at o p posite ends o f

Proper hepatic
artery
Gastrod uodenal
artery

Right gastric
Right renal artery
artery
Proximal renal
artery stu m p
(behind the IVC}

Right kidney

Right renal vein

Duodenum
U reter

A
FIG 7 • A.B. R i g h t re n a l a rtery a n d d ista l branches e n c i rcled with s i l a st i c loops. D i stal a n asto mosis is perfo rmed fi rst.
IVC, i nfe rior vena cava . (contin ued)
1 990 P a r t 6 OPERATIVE TECH N IQUES I N VASCULAR SURGERY

m a g n ificati o n is n ecessa ry to e n s u re opti m a l results re­

g a r d l ess of w h i c h suture tech n i q u e is chosen (FIG 7) .
• O n ce the d i sta l a na stomosis is co m p l eted, the ve i n g raft
is o r i e nted l o n g itud i n a l l y to p revent twist i n g o r k i n k i n g
p r i o r to c o m p leti o n o f the proxi m a l a n asto mosis.

Proximal Anastomosis

Hepatic artery
• S m a l l vasc u l a r c l a m ps or remova b l e c l i ps a re used to con­
trol the p roxi m a l and d ista l hepatic a rtery.
• An a rteriotomy is m a d e on the hepatic a rtery a n d
exte nded u s i n g Potts scissors.
• The vei n is spatulated and an end-to-side a nastomosis is again
performed with ru nning polypropylene suture (FIG SA).
Gastroduodenal artery
• The gastrod uoden a l a rtery may be used as an a ltern ative
i nflow vesse l if sufficiently l a rg e (4 to 6 mm i n d i a m eter).
This a n a sto m osis may be perfo rmed either end-to-e nd o r
end-to-s ide, but p r i o r to d iv i s i o n o f the g a strod u o d e n a l
B a rte ry, consideration s h o u l d be g iven toward i t s contri­
FIG 7 • (con tinued) bution to the mesenter i c circulation (FIG 88) .

Intraoperative Duplex Ultrasonography

the a n a stomosis to p reve nt pu rse-stri n g i n g . Alternatively,
depen d i n g on re n a l a rtery d i a m eter, e i g ht interrupted
sutu res may be d istr i b uted c i rcu mferenti a l l y a r o u n d
the l u m e n . The s m a l l e r the re n a l a rtery d i a m eter, the
m o re advantageous the i nterru pted tec h n i q u e . Lo upe
• We reco m m e n d i nsonation of the g raft a n d both a n as­
tom oses u s i n g a ppropriately sized 7-M H z sca n heads to
e n s u re tec h n ica l p rofi ciency fo l l owi n g com p letion of the
bypass. I n recent yea rs, o u r practice h a s come to rely o n

Right Proper
renal hepatic
artery artery

Gastrod uodenal
artery

Proximal renal
Right artery stu m p
renal (behind the
vein inferior vena cava)

Right
kidney

U reter

A B

FIG 8 • A. The p roxi m a l a n asto mosis between the hepatic a rtery a n d ve i n g raft. B. Anter i o r-posterior a n g i o g ra p h i c i m a g e
demonstrates a h e pato-re n a l a rtery bypass.
 C h a pter 21 H E PATIC- A N D S P L E N I C-BAS E D R E N A L REVASCU LARIZAT I O N 1 99 1

d u p l ex u ltraso n o g ra p h y f o r i ntraoperative assessment
of all sma l l a n d m ed i u m size a utog e n o u s reconstruc­
tio ns, espec i a l l y in l i g ht of the red u ced freq u e n cy of
such p rocedu res i n the era of e n d ovascu l a r and hybrid
reco nstructions. Ren a l a rtery reco nstruct i o n is u nforg iv-
i n g in that fa i l u re in the perioperative period ca n n ot be
exped itiously add ressed after the a b d o m e n is cl osed,
a l m ost a lways p rec i p itat i n g kid ney i nfarct i o n and per­
m a n e n t red u ct i o n s in creati n i n e c l e a ra nce.
• S p ectra l wavefo r m s , v e l o c i t i es, a n d B - m o d e a re a l l
e m p l oyed t o d etect te c h n i c a l e r r o rs re q u i r i n g i m m e ­
d i ate r e p a i r.

SPLENIC-RENAL B YPASS
Placement of Incision

• Exposure is obta ined through a left su bcosta l i ncision

exte n d i n g from the m i d l i n e to the t i p of the 1 2th rib.
I n l a rge or obese patients, the medial extent of the i ncision
can be extended across the m i d l i n e as a chevron (FIG 9).
• As was the case on t h e right side, the u p p e r m i d l i n e
i n c i s i o n m a y a l so p rovi de suffi cient access depe n d i n g o n
b o d y h a b itus, p r i o r s u rgeries, a n d operator expe rience.

Splenic Artery Exposure

• The g reater omentum is e l evated expos i n g the tra n s­

verse mesoco l o n . The l i g a m e n t of Tre itz is taken down
and the i nferior m esenteric ve i n is l i g ated and d ivided .
The p l a n e betwee n the pancreas a n d k i d n ey is entered
and the pancreas e l evated. The s p l e n i c ve i n i s em bed­
ded in the body of the p a n c reas-avo i d i nj u ry d u ri n g
m o b i l ization o f the d ista l p a n creas. The s p l e n i c a rtery
s h o u l d be p a l p a b l e a l o n g t h e ce p h a l a d border of the
p a n creas. It is m o b i l ized free of s u r ro u n d i n g pa renchyma
movi n g m ed i a l ly a n d latera l ly until suffi cient length is
FIG 9 • Left su bcosta l i ncision extended to the t i p of 1 2th r i b .
obta i n e d to fa s h i o n either a p r i m a ry bypass o r s u p port
a n a utog e n o u s ve i n c o n d u i t (FIG 1 0).

Splenic artery

Splenic vein

adrenal vein

Left renal artery

Su perior (coursing posterior
mesenteric to renal vein)
artery ----�--tk��·

U reter

Lumbar vein I nferior mesenteric vein

(distal stu m p)

Left gonadal vein

FIG 10 • Left re n a l a rtery a n d ve i n exposu re .
Division of the i nfe r i o r mesenteric ve i n a l l ows
ce p h a l a d retract i o n of the retro pancreatic
p l a ne, which a l l ows visu a l ization of the
splenic a rte ry.
1 992 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

Splenic artery
(proximal end)
Splenic vein
Pancreas

Splenic artery
Left renal artery
(distal stu m p)
(proximal stu m p)

Left renal artery

(distal end)

Left adrenal vein

Su perior
(stump)
mesenteric
artery -----'-+:....

\
Left renal vein Ureter

Lumbar vein I nferior

mesenteric vein
(distal stu m p)
Left gonadal vein

Left colon
Duodenum

A B
FIG 1 1 • A.B. The splenic a rtery and l eft ren a l a rtery a re d ivided. The gonadal, adrenal, a n d l u m ba r veins a re l i g ated and d ivided,
a l lowing com p l ete mobil ization of the left ren a l vei n .

Left Renal Artery Exposure d ista l a n asto mosis is performed fi rst, fo l l owed by end-to­
end o r e n d -to-side a n a stomosis to the s p l e n i c a rte ry. The
• After m o b i l i z i n g the d ista l p a n creas, the l eft re n a l ve i n is ve i n g raft i s positioned poste rior and i nfer i o r to the body
l ocated j ust i nfe r i o r a n d s l i g htly ca u d a d . of the pancreas.
• The left ren a l vei n is circumferent i a l ly mobil ized. This
req u i res d ivision of its nonrenal tributaries: the gonadal,
adrenal, and lumbar ve ins. D ivid i n g these veins g reatly en­ Intraoperative Duplex Ultrasonography
hances ren a l vei n mobil ity, fac i l itating renal a rtery exposure • As descri bed e a r l i e r
from its position j ust cephalad and posterior to the vei n .
• As previously described on the rig ht, the l eft re n a l a rtery
is d i ssected to its a o rtic o r i g i n a n d contro l led with a s i lastic Splenic artery
loop. The d ista l a rtery and its th ree seg me nta l branches
are identified a n d encircled with s i l astic loops. The i m por­
tance of m o b i l i zation is a g a i n e m p h asized (FIG 1 1 ) .

Splenic-Renal Anastomosis

• The patient is h e pa r i n ized with 1 00 u n its/kg of u nfrac­

tionated h e p a r i n . The l eft rena l a rtery is c l a m ped at the
origin a n d d ivided. The ren a l stu m p is oversewn with a
5-0 polypropylene suture. The d ista l m a i n re n a l a rtery is
spatu l ated d i sta l to the exist i n g re n a l a rtery d isease.
• The m o b i l ized s p l e n i c a rtery is d ivided with sufficient
length to exte nd beh i n d the p a n creas to the l eft re n a l
a rtery without u n d u e tension. T h e d ista l s p l e n i c a rtery is
oversew n .
• The m o b i l ized s p l e n i c a rtery is spatu l ated a n d a n a sto­
mosed e n d-to-e n d to the l eft re n a l a rte ry, a g a i n with
either r u n n i n g o r i nterru pted polypropylene suture
depe n d i n g on the respective a rte r i a l d i a m eters (FIG 1 2).
• Alternatively, w h e n s p l e n i c a rtery l e ngth is i n sufficient,
reversed s a p h e n o u s ve i n may be e m p l oyed a s a bridge FIG 12 • Co m p l eted a n a stomosis betwee n the s p l e n i c a rtery
g raft. Ag a i n , to opti m i ze t h e deg rees of freed om, the a n d l eft ren a l a rte ry.
 C h a pter 21 H E PATIC- A N D S P L E N I C-BAS E D R E N A L REVASCU LARIZAT I O N 1 993

FINAL INSPECTION of the S M A at the base of the m esentery is performed

• With co m p l et i o n of the revasc u l a rization procedu res,
a l l a n a stomoses and oversewn re n a l a rtery orig i n s a re
i n s pected fo r h e m ostasis. H e p a r i n a nticoa g u l at i o n i s
reversed w i t h p rota m i n e, i n a q u a ntity suffi c i e nt to
n o r m a l ize the activated c l ott i n g t i m e (ACT) . Pa l pation
to confirm a pu lse. Operative tract i o n a n d/o r preexist­
i n g d i sease may compromise SMA flow or p rec i p itate
an occ u l t d i ssect i o n . If the SMA pu lse is a bsent, o r t h e
i ntest i n a l v i a b i l ity u n ce rta i n , m esenteric a rtery revascu­
J a rization may be n ecessa ry.

PEARLS AND PITFALLS

Preope rative i m a g i n g
Preope rative ve i n m a p p i n g
Exposure of the re n a l a rtery
G raft o r i e ntation
I ntraoperative d u p l ex
• S u rg i c a l p l a n n i n g may req u i re CT a n d catheter-based a rte r i o g ra p h y as c o m p l e m entary
refe rences for s u rg i ca l p l a n n i n g .
• Ce l i ac a rtery ste nosis is a n absol ute contra i n d i cation f o r he patic- a n d s p l e n ic-based re n a l
revasc u l a rizat i o n .
• Autog enous v e i n is the p refe rred cond u it for ren a l revasc u l a rizati o n .
• Lower extrem ity ve i n m a p p i n g a l l ows assessment f o r suitable cond u it .
• C i rcu mferent i a l exposure of the e n t i re m a i n r e n a l a rtery a n d the th ree seg m e nta l branches is
i m p e rative fo r p l acement of the re n a l a n asto mosis d i stal to exist i n g d isease
• Lo n g itu d i n a l orientation needs to be confi rmed repeated ly d u r i n g g raft tu n n e l i n g a n d
orientat i o n . Excessive re l i a nce o n g raft m a r k i n g o r "stri p i n g " as the s o l e method o f orientat i o n
may lead to i n a dvertent k i n k i n g o r twist i n g .
• C o m p letion d u p lex sca n n i n g is easy, q u ick, a n d i n va l u a b l e i n identifyi n g tec h n ical e rro rs, w h i c h
may comprom ise g raft patency a n d renal via b i l ity.
• U n l i ke l ower extrem ity bypass p roced u res, perio perative g raft occ l u s i o n ca n n ot typica l ly be
identified exped itiously to p reve nt end-org a n comprom ise.

POSTOPERATIVE CARE OUTCOMES

• Postoperative care typically involves central venous and
arterial pressure monitoring in an intensive care unit (ICU)
environment, at least for the first 24 to 4 8 hours.
• Serial monitoring of serum creatinine, urine output, and
acid-base status is essential in the early postoperative period.
Unexplained changes in acid-base or elevation of serum
creatinine could indicate occlusion of the revascularization
itself or progressive mesenteric ischemic.
• Blood pressure is maintained in a physiologic range with
vasoactive medications as necessary. Oral antihypertensives
are resumed on postoperative day 1 and adj usted depending
on the response to renal revascularization.
• Diet is resumed as bowel function returns; nasogastric suc­
tion is usually not required.
• Blood pressure and antihypertensive medication require­
ments may decrease after renal revascularization and should
be adjusted prior to discharge.
• Follow-up surveillance duplex ultrasonography is performed
at 6 and 12 months then annually thereafter. Detected
abnormalities suggesting stenosis of the renal reconstruction
may be addressed with remedial endovascular intervention
or surgical revision when indicated.
• Large case series documenting the outcomes following iso­
lated hepatorenal and splenorenal artery bypass are sparse.
Published results are derived from two relatively large series,
generally demonstrating acceptable perioperative morbidity
and mortality with improved renal function and blood pres­
sure and durable patency.
• Moncure et a!. reported 77 patients who underwent
79 procedures (29 hepatorenal, 50 splenorenal bypass)
for the treatment of renovascular hypertension and renal
preservation. The perioperative mortality was 6 % . Dete­
rioration in renal function occurred on three occasions but
only in patients with bilateral simultaneous repair. Cure
or improvement in hypertension was observed in 52 of
6 3 patients. Renal function was preserved or improved in
6 7 of 77 patients .2
• Another series by Geroulakos et a!. document similar out­
comes with extraanatomic renal artery revascularization
for atherosclerotic renal artery disease. Forty-five hepatore­
nal and/or splenorenal bypasses were performed in 38 pa­
tients for the treatment of renovascular hypertension, renal
preservation, or both. There was one postoperative death
from myocardial infarction and two cases of early graft
1 994 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY
thrombosis. There was a significant decrease in postoperative
mean serum creatinine as well as the average number of anti­
hypertensives. Over a median follow-up of 33 months, there
were 10 deaths all from cardiac issues. 3
COMPLICATIONS
• Bypass graft thrombosis
• Intestinal ischemia due to preex1stmg disease or traction
inj ury to SMA during operative procedure
• Bleeding from renal, hepatic, splenic anastomosis, ligated
renal artery stump, portal vein if injured
• Acute renal failure requiring temporary or permanent
dialysis
• Pancreatitis, splenic infarction, common duct injury
• Incisional hernia
REFERENCES
1.
Benjamin ME, Dean RH. Techniques in renal artery reconstruction:
part II. Ann Vase Surg. 1 9 9 6 ; 1 0 ( 4 ) :409-4 1 4 .
2. Moncure A C , Brewster DC, Darling R C , e t a l . U s e of the splenic and
hepatic arteries for renal revascularization. J Vase Surg. 1 9 8 6; 3 ( 2 ) :
1 96-203 .
3. Geroulakos G, Wright JG, Tober JC, et al. Use of the splenic and
hepatic artery for renal revascularization in patients with atheroscle­
rotic renal artery disease. Ann Vase Surg. 1 9 9 7; 1 1 ( 1 ) : 85-8 9.
4 . Weaver FA, Kumar SR, Yellin AE, et al. Renal revascularization
in Takayasu arteritis-induced renal artery stenosis. J Vase Surg.
2004;39:749-75 7.

Chapter 22 Advanced Aneurysm
Management Techniques: Open
Surgical Anatomy and Repai r
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - , - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Eliza b e th Blazick
DEFINITION
• An aneurysm is defined as a permanent, focal dilation of an
artery to a size that is greater than 5 0 % of the normal or
expected transverse diameter of the vessel. Although dimen­
sions differ slightly for men and women, practically speak­
ing the normal diameter for the abdominal aorta is 2 em;
therefore, the abdominal aorta is considered aneurysmal
when it reaches 3 em in transverse dimensions.
• Fusiform aneurysms are the most common configuration and
are a symmetric enlargement of the entire vessel, whereas a
saccular aneurysm is a focal outpouching that results in an
asymmetric bulge of the vessel wall.
• Aneurysms may occur in virtually any vessel in the body but
are most commonly seen in the infrarenal abdominal aortic
aneurysm (AAA). The neck is the length of normal aorta be­
tween the osteum of the lowest renal artery and the begin­
ning of the aneurysmal aorta. The term juxtarenal is used to
describe AAAs that do not involve the renal arteries but be­
cause of proximity ( < 1 em neck) require clamping above the
renal arteries to complete the proximal aortic anastomosis. In
a suprarenal aneurysm, at least one of the renal arteries arises
from aneurysmal aorta, implying the need not only for a prox­
imal clamp but also renal artery reconstruction at the time of
the repair (FIG 1 ) . This chapter will focus on the indications
and techniques for repair of infrarenal and juxtarenal AAA.
• AAA size and/or expansion rate is an important predictor of
rupture, and as such guides indication for repair in asymp­
tomatic patients. 1
• Other predictors for increased risk rupture include female
gender, positive family history of aneurysms, smoking status
(higher for current smokers versus never smokers and previ­
ous smokers ), hypertension, and chronic obstructive pulmo­
nary disease ( COPD ) .2-5
Pararenal/Juxtarenal
(less than 1 em neck) (including at least one renal artery)
• Potential cross-clamp sites
I
�
Ma rk F. Conra d
PATIENT HISTORY AND PHYSICAL FINDINGS
• A thorough history and physical exam is imperative in the
evaluation of a patient being considered for aneurysm repair.
• History of present illness: Determine how the aneurysm was
discovered. Often, AAAs are an incidental discovery on an
imaging test done for another purpose. Be sure to ask about
abdominal or back pain, which may indicate this is a symp­
tomatic aneurysm that would require more urgent repair.
• Past medical history: Patients with concomitant renal, car­
diac, or lung disease tend to have more complications peri­
operatively and should be medically optimized prior to
proceeding with elective repair. Although there is no benefit
to preoperative cardiac revascularization in asymptomatic
patients, those with known cardiac disease or risk factors
should be evaluated by a cardiologist. 6
• Family history: Close to 1 5 % of patients with AAA will have
a first-degree relative with aneurysmal disease. Patients with
AAA should be counseled to alert their siblings and children
to this condition, so they may be screened appropriately.3
• Social history: Smoking has been linked to increased risk of
aneurysm formation and rate of expansion. Patients should
be counseled on smoking cessation.
• Review of systems: In addition to the generalized systems re­
view appropriate for all patients undergoing maj or surgery,
particular attention should be directed to other vascular
comorbidities. In particular, query about previous cerebro­
vascular accident ( CVA) or transient ischemic attack (TIA)
symptoms, amaurosis fugax, mesenteric ischemia, lower ex­
tremity ischemic symptoms (claudication, rest pain, ulcers),
and work up positive symptoms as appropriate.
• On physical exam, perform a thorough abdominal exam,
although be aware that the positive predictive value for
localizing a small- to moderate-sized AAA on exam is poor.
FIG 1 • Anatomic differences between
Su prarenal a j uxta rena l AAA, where the neck of
normal aortic d i a meter is less than
1 em, and a s u p rarenal AAA, where
the ta keoff of at least one ren a l a rtery
a rises from the a n e u rysm .
1995
1 996 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY
A small proportion ( 1 % to 1 0 % ) of patients with AAA will
have a concomitant aneurysm elsewhere, so be cognizant
that those patients with known AAA and a prominent femo­
ral or popliteal pulse may need further imaging to exclude
an aneurysm in these locations.7
• Conversely, patients who initially present with peripheral
aneurysms such as femoral ( 8 5 % ) or popliteal aneurysms
( 6 0 % ) have a much higher rate of concomitant AAA and aor­
tic screening should be performed in these patients. 7•8
IMAGING AND OTHER DIAGNOSTIC
STUDIES
• Of all imaging techniques used for AAA surveillance, B-mode
ultrasonography is the least expensive and does not expose
the patient to radiation. Currently, the U.S. Preventative Ser­
vices Task Force (USPSTF) recommends an ultrasound as a
screening test for males between the ages of 65 and 7 5 years
who have ever smoked 1 0 0 or more cigarettes over a life­
time. There are no official recommendations for women. It
is generally accepted that a negative screening ultrasound
exonerates the patient from further screening or surveillance
imaging, as the likelihood of new aneurysm development of
clinical significance after the age of screening is extremely
low. If a screening ultrasound detects a small aneurysm,
yearly ultrasounds are indicated until the sac approaches a
size where repair may be indicated, at which time further im­
aging with computed tomography ( CT) is recommended.7•9
• Computed tomography angiography ( CTA) provides a more
accurate assessment of aneurysm size, extent, branch ves­
sel proximity and involvement (which may determine if the
aneurysm is amenable to endovascular or open repair, and if
open repair is to be done, where the proximal clamp should
be applied) and is the test that should be used for planning
open AAA repair. A thorough exam should include thin
( 1 .5 em or smaller) cuts of the chest, abdomen, and pelvis
with contrast administered in the arterial phase ( FIG 2 ) .
• I t i s important t o note the location o f the aneurysm and its
relationship to the renal arteries. Renal anatomy should be
noted as well, including any accessory renal arteries and the
presence of a pelvic or horseshoe kidney. The renal vein usu­
ally travels anterior to the aorta but can be posterior and
this should be noted as it may influence operative approach.
Other venous anatomy such as a duplicated or left-sided
inferior vena cava (IVC) should be noted as well.
FIG 2 • Axi a l cut of a CTA s h ow i n g the takeoff or t h e r i g h t renal
a rtery a n d t h e m o re com m o n l y seen re n a l vei n l y i n g a nterior to
t h e a o rta.
SURGICAL MANAGEMENT
• The decision to operate on an asymptomatic patient is based
on three primary factors: the risk of the aneurysm's ruptur­
ing, the risk associated with aneurysm repair, and the pa­
tient's life expectancy. The operative risk and overall life
expectancy should be assessed. Assuming that a patient is fit
enough to proceed with repair, size is currently our best pre­
dictor of rupture. The UK Small Aneurysm Trial and ADAM
VA Trial recommend treatment for all patients with an in­
frarenal AAA larger than 5 . 5 em in size, with consideration
for repair in women with AAA of 5 . 0 em given their higher
risk of rupture and likely smaller baseline aortic size. These
studies also support repair for those patients who have an
increase in diameter of greater than 0.5 em over a 6-month
period (Table 1 ) . 10• 1 1
• Although there are n o large trials looking specifically at
iliac aneurysms, repair is generally recommended when they
reach 4 em or greater in size. Iliac aneurysms are more often
seen in patients with a concomitant aortic aneurysm and
only a quarter of patients with iliac aneurysms will have iso­
lated disease.
• All open repairs should be performed under general anes­
thesia. It is preferable for the anesthesia team to evaluate
the patient prior to the day of surgery so that appropri­
ate time for developing an anesthetic plan, lines, and other
means of hemodynamic monitoring is allowed. The use of
an epidural for pain control in the postoperative period is
useful. In addition, arrangements should be made for auto­
transfusion given the unavoidable amount of intraoperative
blood loss.
• Preoperative understanding of anatomy is of the utmost im­
portance. The surgeon must understand the proximity of
the aneurysmal aorta to the renal and visceral vessels and if
these branch vessels are affected, as this will impact where
the proximal cross-clamp will be applied. If at all possible,
clamping should only be done on nonaneurysmal aorta with
minimal thrombus or calcification to minimize risk of distal
embolization of debris or clamp inj ury, and all aneurysmal
aorta should be resected even if this means involvement of
the visceral or iliac segment. If the aorta contains a signifi­
cant amount of debris or there is little space between branch
vessels, a more proximal clamp site in the supraceliac aorta
should be considered. It is important to discuss the proposed
clamp site with anesthesia preoperatively, as this will af­
fect their management of the patient. The choice of clamp
site should be made during the preoperative stage, as the
intraoperative need to move the clamp higher is associated
with adverse outcomes.
Table 1 : I n d i cations for Repa i r of Abdo m i n a l
Aortic Aneurysm
• Leak or fra n k rupture
• Size ( 5 . 5 em in males, 5 em in females for aortic aneurysm, 4 em for i l i a c
aneurysms)
• I n crease i n size of > 0 . 5 em over a 6-month period
• Symptomatic (pain, compression on adjacent structures)
• Dissection with i n aneurysm
C h a p t e r 22 ADVA N C E D A N E U RY S M MANAG E M E N T TECH N I Q U E S : Open S u r g i c a l Anatomy a n d Repa i r
• Planning for the distal anastomosis requires review not
only of the aortic bifurcation but the iliacs as well. If there
is aneurysmal or occlusive disease within the iliac arteries,
concurrent repair with a bifurcated graft may be appropri­
ate; otherwise, the maj ority of AAAs are repaired with a
tube graft to the iliac bifurcation. Anastomosis may predi­
cate method of distal control, which can be obtained with
a single clamp across the bifurcation or both iliac origins,
or occlusion balloons (Foley catheters or Pruitt occlusion
balloons) for heavily diseased vessels.
• Key pre-operative planning concerns are summarized in
Table 2 .
• There a re two a pproaches for the open repa i r of the in­
frarenal o r j uxta re n a l aortic a n e u rysm : transperitoneal or
retroperitoneal (FIG 3). Which a p p roach is used for a n i nfra­
ren a l AAA is based o n several factors: body h a b itus (obese
patients a re often best approached via retroperitoneal),
A B
TRANSPERITONEAL APPROACH
• Positi o n i n g : The patient is positioned s u p i n e on a sta n ­
d a rd operat i n g r o o m ( O R ) t a b l e w i t h b o t h a r m s ex­
te n d e d . The a rea from the n i p p l e l i n e to m i d t h i g h s
s h o u l d be i n c l uded i n the prep field to a l low exposu re
for a h i g h i n c i s i o n as we l l as the g r o i n s s h o u l d access to
the fe m o ra l vesse l s be needed. The h a i r is c l i p ped and a
towe l is p l aced over t h e peri n e u m . Any previous i n cisions
with i n the prep field a re m a rked . A Steri-Drape o r l o b a n
is u s e d to secure the d ra pes i n posit i o n . O n ce i n positi o n ,
check p u lse vo l u m e record i n g (PVRs) a n d/o r d ista l p u l ses.
• I n c i s i o n : A g e n e rous m i d l i n e i n c i s i o n from the x i p h o i d
to the p u b i s is m a d e a n d d i ssected u n t i l the perito n e a l
1 997
Table 2: Operative P l a n n i n g
• Is a retroperitoneal or transperitoneal a pproach better?
• Where is the best location for p roxim a l contro 1 7 Are there any alternatives
should i ntraoperative findings preclude using this site?
• Will clamping i nvolve renal or visceral isch e m i a ?
• Will the r e n a l or visceral a rteries n e e d to be reconstructed as part of t h e
repair? If s o , w h a t s i z e g rafts should be u s e d f o r the bypass?
• Where is the renal vei n 7 Does it pass a nteriorly or posterior to the aorta ?
Will the kidney be taken up or left down ?
• How will distal control be obtained? Will reconstruction involve the i l i a c
a rteries or can the dista l a nastomosis be to the b ifurcatio n ?
• W h a t size/type graft s h o u l d be used?
prior su rgery (co ncern for i ntraperitoneal adhesions), and
l ocation of clamp (above the ren a l a rteries may favor a ret­
roperitoneal a p p roach), whereas p l a n ned i ntervention o n
the r i g h t r e n a l o r i l iac a rtery wou l d be better a p p roached
from the front (tra nsperitoneal).
FIG 3 • Incision for the two a p p roaches to
a n e u rysm repa i r. A. Tra nsperito n e a l a n d (B) ret­
roperito n ea l . The retro perito n e a l a p p roach ca n
be mod ified for h i g h e r exposu re on the viscera l
a o rta.
cavity is ente red (FIG 3) . It may be n ecessa ry to exte n d
the i n c i s i o n cep h a l a d l atera l a l ongside the x i p h o i d if
h i g h e r exposu re is needed o r i n e m e rgent situations
such as a rupt u re w h e re i m med iate su prace l i a c control
is needed. A self-reta i n i n g retractor syste m s h o u l d t h e n
be posit i o n e d . W e p refer the O m n i retractor as the open
confi g u ration of the system does n ot l i m it the width
of exposure.
• D i ssect i o n : Refl ect t h e g reater omentum and t r a n s­
verse co l o n ce p h a l a d a n d p a c k t h ese structu res away
i n a m o i stened towel o r lap pad o n top of t h e patie nt's
ch est. The s m a l l bowel s h o u l d be retracted to t h e
r i g h t a n d p a c k e d with i n a sepa rate m o i stened towe l .
1 998 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

d i ssect i o n . T h i s a l l ows a ccess to t h e i nfraren a l a o rta

where t h e ove r l y i n g retro p e r i to n e a l tissue can be d i s­
sected free. D e pe n d i n g o n how m u c h a o rta i s needed
for a n a d e q u ate cuff of t h e p rox i m a l a n a stomosis, an
Su perior a nt e r i o r renal ve i n m a y need to be m o b i l ized ce p h a l a d ,
mesenteric w i t h l i g a t i o n of t h e g o n a d a l a n d/o r a d re n a l ve i n f o r
artery bette r exposu re (FIG S) .
• Exposure o f t h e su prace l i a c a o rta (FIG 6) : T h e m a n e uver
is o n ly needed in cases w h e re h i g h a b d o m i n a l a o rt i c ex­
f-+--- Left
renal vein posu re is needed, such a s in a rupture. The l eft l o b e of
the l iver m u st be retracted l atera l ly by t a k i n g down t h e

�
Duodenum
Inferior
mesenteric
artery
FIG 4 • Division of the l i g a ment of Tre itz (LOT) . After
reflect i n g the colon cep h a l a d a n d the s m a l l bowe l to the
patie nt's rig ht, the LOT ca n be d ivided to expose the i nfra re n a l
aorta.
T h e s m a l l bowel i s g e ntly p l aced b e h i n d a self-reta i n i n g
retractor, ta k i n g ca re n o t t o co m p r o m i se t h e s u p e r i o r
mesente r i c a rtery ( S M A ) . T h i s exposes t h e l i g a m e n t o f
Tre itz, w h i c h ca n be d ivided a l o n g t h e j ej u n u m to t h e
l e v e l of t h e a o rta (FIG 4) . R e p o s i t i o n t h e retractor t o
a l low a s m u c h s m a l l b o w e l to be out of t h e f i e l d a s
poss i b l e, a n d take down t h e l i g a m e n t of Treitz with
e l ectrocautery, ta k i n g care not to i nj u re t h e bowe l . T h e
i nf e r i o r mesente r i c ve i n i s u s u a l ly l i g ated d u r i n g t h i s
t r i a n g u l a r l i g a m e nt. N ext, i d e ntify a n d d i ssect f r e e t h e
g a stroeso p h a g e a l j u n ct i o n after d ivid i n g t h e g a stro­
hepatic l i g a m e nt, w h i c h is m ost exped i t i o u s l y done by
p a l pati n g for the n a sogastric t u b e a n d a p p l y i n g ca u d a l
tract i o n . D i v i s i o n of t h e g a stro hepatic l i g a m e n t m u st
be d o n e with t h e t h o u g ht that a repl aced l eft h e patic
a rtery wo u l d be co u r s i n g beneath this struct u re . The
eso p h a g u s can be retracted to t h e patie nt's l eft, and
t h i s m a n e uver will expose t h e a o rt a . An a o rt i c co m p res­
sor can be used in extreme c i rc u m sta n ces; h oweve r, d i s ­
sect i o n of t h e a o rta c i rcumferenti a l ly a n d su rrou n d i n g
t h e a o rta w i t h a shoest r i n g if t h e patie nt's co n d i t i o n a l ­
l ows i s p refe r a b l e . T h i s exposu re, a lt h o u g h usefu l w h e n
u rg e n t s u p race l i a c c o n t r o l i s n e e d e d , w i l l n ot a l low a c ­
c e s s to t h e visce ra l seg m e n t of t h e a o rt a . I n o r d e r t o
g a i n t h i s exposu re, a r i g ht o r l eft m ed i a l viscera l rota­
t i o n s h o u l d be i n co r p o rated i nto the d i ssect i o n . The
use of a r i g h t m e d i a l visce r a l rota t i o n w i l l a l low access
to t h e r i g ht re n a l a rte ry, a s we l l a s p l a c i n g the SMA on
90-deg ree t e n s i o n and i s usef u l for c l e a r i n g a c l a m p site
i n those patie nts with a j u xta re n a l a n e u rysm w h o h ave
very l itt l e room between the re n a l s a n d S M A (FIG 7) .
The u s e o f a l eft med i a l visce r a l rota t i o n a l so a l l ows for
exposure to t h e e n t i re viscera l seg m e n t of t h e a o rta a s
we l l a s t h e l eft re n a l a rte ry. Care i n t h i s a p proach m u st
be m a d e to avo i d i n j u ry to t h e s p l e e n a n d ta i l of t h e
p a n c reas.

Renal vein SMA

Left renal
artery

FIG S • (i l l ustration a n d p h oto): M o b i l i zation

of the l eft re n a l ve i n . Cep h a l a d o r ca u d a l
m o b i l i zation o f the l eft renal ve i n to expose t h e
o r i g i n o f the re n a l a rteries. Ligation o f severa l
ve n o u s sidebra nches may be needed for safe
Right renal artery Aorta m o b i l izat i o n . (contin ued)
C h a p t e r 22 ADVA N C E D A N E U RY S M MANAG E M E N T TECH N I Q U E S : Open S u r g i c a l Anatomy a n d Repa i r 1 999

Left renal Adrenal

artery vein

Renal vein
retracted
su periorly

Inferior

Aorta Gonadal Renal

vein lum bar vein
FIG 5 • (con tinued)

A c

FIG 6 • G a i n i n g control of the s u p ra c e l i a c a o rta. A. Dotted line s h ows the

locat i o n for d ivision of the gastro hepatic l i g a m e nt. B. O n ce the l i g a m ent is
d ivided, the crus is encou ntered . C. B l u ntly d ivide the fibers of the crus. D. Using
f i n g e rs for retraction, control of the a o rta can be g a i ned with a c l a m p, a l t h o u g h
ci rcumferenti a l control i s opti m a l .
2000 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY
Liver
Right
k id ney
Right
renal
artery
RETROPERITONEAL APPROACH
• Positio n i n g : Once asleep, position the patient in the latera l
position with the left side up at an a p p roxi m ately GO-deg ree
a n g l e (FIG 8). Extend the right arm o n an arm boa rd, being
sure to leave room for an O m n i or other self-reta i n i n g re­
tractor post. The upper left arm should be placed o n an­
other arm boa rd and padded to p revent neural i nj u ry. The
bed should be fl exed at the patient's f l a n k to open u p the
a rea between the ribs and the a nterior superior i l iac spine.
Position the legs so that the lower leg is stra i g ht and the
upper leg is bent. Use two p i l lows as padd i n g between
legs. A bea nbag can be i nfl ated to keep the patient i n
p lace, and u s e t h i c k cloth t a p e over t h e h i p t o secure t h e
patient o n his or her s i d e . Ideal ly, the patient s h o u l d b e
p l aced on a bea n bag; however, b l a n ket rol l s c a n be used
a nteriorly and posteriorly to further secu re the patient. Be
sure to a l l ow access to prep from the spine posteriorly to
the u m b i l icus a nteriorly and from the n i pple line to the
groins. A l l bony promi nences and p ressu re poi nts should
be we l l padded to avoid injury. Use c l i p pers to remove hair
shoulder
elevated at 60"
FIG 7 • Exposu re of the a o rta and right re n a l a rtery via
r i g h t medial viscera l rotat i o n .
with i n t h e prep a rea. Prep from t h e axi l l a a n d n i p p l e l i n e to
the upper t h i g h . M a rk a l l previous incisions and use a Steri­
Drape or laban over the entire p repped a rea to secu re the
dra pes. Once i n position, check PVRs a n d/or d ista l pu lses.
• I nc i s i o n : U n less c l a m p i n g is p l a n ned at o r above the level
of the S M A, a sta n d a rd retroperito n e a l i n cision over the
1 1 th rib w i l l provide adeq uate exposu re (FIG 3) . Ca rry
the i n cision from the posterior axi l l a ry l i n e to the anterior
border of the rectus. Avo id entry i nto the pleural cavity
if poss i b le, b e i n g cog n izant that the f u rther poste rior the
i ncision is carried, the h i g h e r l i ke l i h ood t h i s w i l l occu r.
• Divide the tra nsversa lis fascia and enter the retroperitoneal
space down to but not violating Gerota's fascia. This space
can be more easily identified by resecting a d ista l seg ment
of the 1 1 th rib, as the tra nversa l i s fascia and tra nsversus
abdom i n a l m uscu lature i nserts a long the i nferior border
of this rib. It is possible to stay entirely wit h i n a retroperi­
toneal pla ne; however, if the peritoneum is violated, the
abdom i n a l contents can be packed away with retractors or
the peritoneum can be repa i red with a ru n n i n g 3-0 chromic
FIG 8 • Posit i o n i n g for retro peritoneal i ncision.
C h a p t e r 22 ADVA N C E D A N E U RY S M MANAG E M E N T TECHN I Q U E S : O p e n S u r g i c a l Anatomy a n d Repa i r 2001

Left lobe suture. The aorta may be approached via an a nterore n a l

(col loq u i a l ly referred to as " leavi ng the kid ney dow n " ) or
Left crus
retroren a l p l a n e ("ta king the kidney u p " ) (FIG 9). Gen­
Su perior eral ly, the aorta i s a p p roached via a retrore n a l a p p roach
mesenteric u n less there is a ren a l ve i n r u n n i n g posterior to the aorta .
artery
As the retroperitoneal d issection cont i n u es, the left u reter
Inferior
should be identified and swept toward the m i d l i n e a n d
mesenteric
placed b e h i n d a retractor to avo id injury d u r i n g d i ssection
vein
of the a o rta. The ren a l a rtery is identified a n d d i ssected
Left kidney
back to its origin to identify the aorta
• Dissection: The ren a l a rtery should be cephalad to the vei n ,
Inferior
mesenteric a n d o n c e this is identified, it can be u s e d as a l a n d m a rk a n d
artery d issected b a c k to the aorta.The ren a l l u m ba r vei n should b e
identified a n d l igated t o avoid injury a n d excessive bleed­
U reter ing. Once the origin of the renal a rtery is identified, a right
a n g l e can be placed a l o n g the s u rface of the aorta a n d the
overlying retroperitoneal tissue d ivided with e lectroca utery.
Left lobe It is i m perative here to get on the aorta a n d stay on the
Divided crus aorta to avoid excessive b l eed i n g from the retroperitoneal
tissue. The aorta is exposed to the bifurcation a n d ca n be
Spleen Cel iac axis
d issected c i rcu mferentia l ly here if a c l a m p site is p l a n ned;
Su perior h owever, the left i l iac vei n can cou rse posterior to the bi­
mesenteric fu rcation a n d should be avoided. It is often easier to expose
artery a n a rea of the l eft common i l iac a rtery for c l a m p i n g a n d
Left renal control the r i g h t c o m m o n i l iac a rtery w i t h a n occlusion b a l ­
artery l o o n from with i n . It is u nwise t o g a i n circu mferential con­
trol of the i l iacs i n this situation as the i l iac vei n s a re often
,___..,.____ Inferior
mesenteric a d herent to the posterior aspect of the a rtery and a re easily
vein i nj u red, lead i n g to rapid exsa n g u i nating b l ood loss. Identify
B
� Gonadal vein
a n d isolate the i nferior mesenteric a rtery (I MA) with a vessel
loop. Pay particular attention to i dentifyi ng and not injur­
U reter i n g the u reters, which w i l l eventua l ly cross a nterior to the
FIG 9 • The a o rta ca n be a p p roached in an a nterore n a l i l iac vessels. If n ecessary a n d if the i ncision is p l aced a l o n g
p l a n e (A) o r a retrore n a l p l a n e (B) . a h i g her rib space, the d i ssection can be carried ca u d a l t o
expose the e n t i r e viscera l seg ment if n e e d be (FIG 1 0).

Shoestring for
supraceliac
control

Celiac axis Left renal

artery
SMA

Left kidney
Right renal
artery

Left renal
vein

FIG 10 • Expos u re of the entire a bdo m i n a l

a o rta from a retroperito n e a l a p proach. H e re,
Aortic the k i d n ey is " left d ow n " in an a nterore n a l
bifurcation p l a n e . A l l vesse ls a re su rro u nded w i t h vesse ls
loops.
2002 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY
AORTIC CLAMPING AND REPAIR
• Reg a r d l ess of a p p roach, it is i m p o rtant d u r i n g c i rc u mfer­
e nt i a l d i ssect i o n of t h e a o rta to avo i d i nj u ry to t h e poste­
rior l u m ba r a rteri es, w h i c h a re u s u a l ly pa i re d . If t h ey a re
encou ntered a n d req u i re l igation, ca refu l l y c i rcu mfere n ­
t i a l l y d issect out t h e a rte ry, tyi n g t h e proxi m a l s i d e of the
vesse l, a n d using a n oth e r tie, double clip o n t h e d i st a l
s i d e p r i o r to d ivid i n g . W h e n d i ssect i n g o n t h e a o rta, c a r e
m u st be taken to m i n i m i ze a g g ressive m a n i p u l a t i o n a n d
su bseq u e n t atheroe m b o l ization, p a rti c u l a rly if preopera­
tive i m a g i n g s h ows exte nsive m u ra l d e b r i s .
• Choice of g raft: There a re seve r a l choices for con d u it d u r­
i n g repa i r. G e n e r a l ly, a polytetrafl u o roethy l e n e (PTFE) o r
Dacron t u b e g raft i s sewn from t h e p roxi m a l a o rta to t h e
bifu rcat i o n . I n th ose patie nts w i t h extensive b i f u rcation
o r i l ia c d i sease, a bifu rcated g raft may be used. If t h i s i s
t h e case, the prox i m a l s i n g l e l u m e n p o r t i o n of the g raft
s h o u l d be as short as poss i b l e to prevent k i n k i n g , i d e a l l y
l e s s t h a n 4 e m . Tu n n e l i n g the l i m b to the femora l level
s h o u l d be done only if n ecessa ry, and if so, care m ust be
taken to r u n the g raft poste r i o r to the u reter. The a o rta
can be m e a s u red for the a p propriate g raft with a o rtic
sizers, but often, a n est i mation of size ca n be m a d e from
t h e preoperative CTA. Reg a rd l ess, the majority of patients
can be repa i red with an 1 8- to 22-mm g raft (FIG 1 1 ).
B of a self-reta i n i n g retracto r with i n the opened sac o r stay
FIG 1 1 • A. Tu be g raft from i nfra re n a l a o rta to b i f u rcati o n
a n d ( B ) bifu rcated g raft f r o m i nfrare n a l a o rta to i l i a c o r
fe m o ra l vesse ls.
• C h o o s i n g t h e site of t h e p rox i m a l a n astomosis: T h i s w i l l
d e p e n d o n t h e q u a l ity o f t h e proxi m a l neck o f t h e a n e u ­
rysm a n d t h e vici n ity o f t h e viscera l vesse ls. I n t h e m ost
stra i g htforwa rd sce n a r i o, an a d e q u ate cuff of n o r m a l
a o rta i s present b e l o w t h e rena I s to a l low for i nfra r e n a l
c l a m p i n g a n d a n e n d -to-e n d a n a stomosis. A s u p r a re n a l
c l a m p ca n b e u s e d to p rovide s p a c e to s e w to a s h o rt
i nfra r e n a l cuff. If a n e u rysm a l tissue extends to t h e vis­
cera l b r a n c h es, o r if t h e re i s s i g n ificant a nt h e roscle rot i c
d i sease of t h e b r a n c h es, a beve l e d a n asto mosis may be
req u i red, poss i b ly i n c l u d i n g a n e n d a rte rectomy of the
o r i g i n of a branch vesse l o r a bypass to t h e l eft re n a l a r­
tery (FIG 1 2) . T h i s s h o u l d be a p p a rent based on ca refu l
review of preoperative i m a g i n g a n d p l a n ned for we l l be­
fore c l a m p i n g of t h e a o rt a . From t h e retroperito n e a l ap­
p roach, every effort s h o u l d be made to i ncorporate the
r i g ht re n a l a rtery i nto the a n a sto mosis.
• I n preparation for c l a m p i n g , t h e patient should be sys­
temica l ly h e p a r i n ized at a dose of 70 u n its of h e p a r i n
per k i l o g ra m a n d a l l owed t o ci rcu l ate for 3 to 5 m i n utes.
It is i m p o rtant to com m u n i cate with a n esthesia prior to
c l a m p i n g and u n c l a m p i n g so they may a nt i c i pate a n d
a d d ress s u bse q u e n t h e m odyn a m i c sh ifts. G e n e r a l ly, t h e
syste m i c p ress u re s h o u l d be d ropped i n p repa rat i o n
for t h e prox i m a l c l a m p i n g . I f t h e viscera l seg m e nt i s i n ­
volved, b u l l d o g c l a m ps s h o u l d be a p p l i e d to t h e viscera l
vesse ls p r i o r to aortic c l a m p i n g to avo i d e m bo l izat i o n .
The p roxi m a l c l a m p i s ca refu l ly a p p l i e d a n d secu red with
a shoest r i n g around t h e c l a m p . The a o rt i c sac i s then
opened with e l ectroca utery and h eavy scissors p roxi m a l ly
a n d d i st a l ly. M u ra l d e b r i s s h o u l d be ca refu l ly removed
to i d e ntify a l l patent l u m b a r a rteries. D ista l control can
then be o bta i n ed with b a l l o o n occ l u s i o n i nto each i l i a c
with F o l ey catheters if exte r n a l control was n ot p revi­
ously done due to c a l cific d isease. All l u m b a r vesse l s with
back-bleed i n g i nto t h e a o rta s h o u l d b e s u t u re l i g ated
with 2-0 s i l k in a f i g u re-of-e i g h t fash i o n . In heavi ly c a l c i ­
fied a o rtas, foca l e n d a rterectom ies m a y be necess a ry f o r
effective l i g a t i o n of each vesse l .
• Sew i n g o f t h e prox i m a l a n asto moses: T h e re a re seve r a l
w a y s to co m p l ete t h e a n asto mosis, a n d c h o i ce i s based
o n a com b i n a t i o n of surgeon preference and tissue
q u a l ity. Reg a r d l ess of tech n i q ue, t h e poste r i o r row of su­
tu res should b e d o n e fi rst. E n s u re that t h e re i s a d e q u ate
expos u re of the p roxi m a l a o rta; t h i s may req u i re the use
sutu res on the edges of the sac. Place the g raft o n the pa­
t i e nt's ch est u p s i d e d own, so the poste r i o r as pect of t h e
g raft l i es a nterio rly. If t h e poster i o r r o w is to be d o n e i n
a n i nterru pted fas h i o n , t h e fi rst m attress sutu re i s p l aced
in t h e m i d d l e of t h e g raft from outside to in, p l a c i n g a
s n a p on t h e n e e d l e d e n d s of t h e s u t u res. Place fo u r more
m attresses, two o n each s i de, wo r k i n g y o u r way to t h e
3 o ' c l o c k a n d 9 o ' c l o c k p o s i t i o n s o n t h e g raft. Care m ust
be taken to e n s u re t h e re a re no g a p s betwee n sutu res;
a l l travel m u st be with i n a m attressed stitch a n d n ot be­
twee n stitches. O n ce a l l s u t u res a re p l a ced in the g raft,
beg i n p l a c i n g t h e a o rt i c s u t u res from i n s i d e to outside o n
t h e a o rta. The p roxi m a l a o rta i s usua l ly n o t co m p l etely
transected and t h e poste r i o r wa l l can be used to create
C h a p t e r 22 ADVA N C E D A N E U RY S M MANAG E M E N T TECHN I Q U E S : O p e n S u r g i c a l Anatomy a n d Repa i r 2003

Right renal Su perior mesenteric

artery artery
Cel iac
artery

graft

FIG 1 2 • Beve l e d a n asto mosis with

bypass to t h e l eft re n a l a rte ry. The
sutu re l i n e r u n s j u st i nfer i o r to t h e
Anterior Lateral r i g h t re n a l a rte ry.

a Creech b ite that uses the a o rt i c wa l l as a p l e d g et. Once
all s u t u res a re p l aced, each i n d iv i d u a l stitch i s p l e d g eted
and tied down s n u g ly. The a nterior row i s then com­
p l eted, sta rti n g from each side and work i n g yo u r way
to the center, such that the a nterior-m ost stitch i s t h e
fi n a l stitch p l aced. T h e s e a re a l so p l e d g eted a n d tied i nto
p l ace. Once the proxi m a l a n asto mosis i s co m p l eted, a n
atra u matic c l a m p s h o u l d b e a p p l i e d t o t h e body o f t h e
g raft, a n d t h e proxi m a l a o rt i c c l a m p slowly r e l eased t o
test for i ntegrity of t h e re p a i r. Any l e a ks i n t h e sutu re
l i n e s h o u l d be a d d ressed at t h i s t i m e, p a rti c u l a rly a l o n g
the poste r i o r row, as t h i s w i l l be i n access i b l e o n c e t h e
d ista l a n a stomosis is in p l a c e . It is u nwise to atte m pt to
p l ace stitches on a fu l ly perfused a o rta, a n d t h e p roxi m a l
c l a m p s h o u l d be rea p p l i ed if repa i r stitches a re n ecessa ry.
I n a d d it i o n , p l e d g ets s h o u l d be used with these stitches.
A r u n n i n g a n a stomosis c a n a lso be pe rfo rmed with a 3-0
P ro l e n e and a n atra u m atic n e e d l e . The back row i s a g a i n
b e g a n i n t h e m i d d l e o f t h e g raft w i t h d e e p Creech b ites
o n the a o rta. The g raft can b e parach uted in to m a ke
t h e suture l i n e taut. The back row s h o u l d be i nspected to
e n s u re that it is s n u g a n d a d d i t i o n a l s u t u res a re used at
t h e 3 o'clock a n d 9 o'clock positions to secu re t h e back
row and r u n to t h e top of t h e a o rta (FIGS 1 3 and 1 4) .

FIG 1 3 • Construct i o n o f t h e poste r i o r row o f t h e

p roxi m a l a n a stomosis. N ote t h a t t h e a nterior a n d l atera l
aspects of t h e a o rta is d ivided b u t t h e poste r i o r wa l l is l eft
i ntact i n t h i s f i g u re, u s i n g " Creec h " s ut u r i n g tec h n i q u e .
2004 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY
FIG 1 4 • Aortic cuff. The a o rta can be tota l l y transected a n d
stay sutu res a p p l ied i n preparation f o r t h e a n asto mosis.
• I M A i m p l a ntati o n : A l th o u g h t h e I M A c a n g e n e ra l ly be
l i g ated without c l i n i c a l conseq u e n ce, t h e re a re certa i n
s i t u a t i o n s w h e re it m a y be b e n efi c i a l t o re i m p l a nt t h e
vess e l to avo i d bowe l i sc h e m i c co m p l icat i o n s . Patie nts
with a ltered p e l v i c b l ood fl ow, such a s those with p r i o r
g a stroi ntest i n a l s u r g e ry o r occ l u d e d hypogastric a rter-
i es, s h o u l d espec i a l ly be co n s i d e red for I MA re i m p l a n ­
tati o n . F u rt h e r m o re, v i s u a l i n spect i o n o f t h e s i g m o i d
co l o n p r i o r to c l o s u r e s h o u l d b e d o n e , a n d I M A re i m ­
p l a ntat i o n d o n e if t h e re a p p e a rs to be q u est i o n a b l e v i ­
a b i l ity o f t h e bowe l . Ad d i t i o n a l ly, p r i o r to I M A l i g a t i o n ,
a n assess m e n t of back-b l ee d i n g (a n d t h u s t h e co l l atera l
c i r c u l a t i o n to t h e I M A territory) s h o u l d be p e rfo r m e d
a n d re i m p l a ntation co n s i d e red i n c a s e s w h e re t h e b a c k ­
b l e ed i n g i s poor.
• Creat i n g t h e d i sta l a n a stomosis: After t h e p roxi m a l
a n a sto m o s i s i s co m p l eted a n d h e m osta s i s i s e n s u red,
t h e g raft s h o u l d be p u l l e d taut to t h e location of t h e
d ista l a n asto m o s i s (or a n astomoses if a bifu rcated g raft
is to be used). The g raft s h o u l d be m e a s u red to e n s u re
no red u n d a n cy or k i n k i n g occu rs b u t n ot so t i g h t as to
p u t u n d u e stra i n on t h e p roxi m a l a n stomosis. T h e d i s-
ta l can b e d o n e in a r u n n i n g or i nterru pted fash i o n , as
described prev i o u s ly. W h e n sewi n g , t h e assista nt s h o u l d
use a forceps to p u l l t h e g raft d i sta l l y a n d rem ove ten­
s i o n o n t h e a n a stomosis, d ecrea s i n g t h e c h a nce t h e s u ­
t u res w i l l be t o o l o o s e .
• F l u s h i n g a n d u n c l a m p i n g : J u st p r i o r to t h e co m p l et i o n
of t h e d i sta l a n a st o m o s i s , t h e g raft w i l l n e e d to b e
f l u s h e d proxi m a l l y a n d d i sta l l y to r e m ove c l ot, a i r, a n d
d e b r i s . Aft e r f l u s h i n g , i r r i g ate t h e g ra ft w i t h h e p a r i n ­
i z e d sa l i n e a n d co m p l ete t h e a n a st o m o s i s . O n ce both
a n asto m oses a re co m p l et e d , c o m m u n i cate w i t h the
a n est h e s i o l o g ist t h a t t h e c l a m ps a re ready to b e re­
m oved . T h e re i s oft e n a s u bsta nt i a l d ro p in syste m i c
b l o o d p r e s s u r e a s t h e l ow e r extre m it i e s a re r e p e rfused,
and t h e y w i l l n e e d to p r e p a re to react accord i n g l y. It
i s m o re a p p ro p r i ate to t o l e rate a s l i g ht l y l o n g e r c l a m p
t i m e a n d a l low t h e a n est h e s i o l o g ist to reg u l ate t h e
b l o o d p ress u re accord i n g l y t h e n u n c l a m p a hypote n ­
s i ve p a t i e n t . As t h e s u rg e o n s l ow l y u n c l a m ps, t h e a s ­
s i st a n t c a n h o l d m a n u a l p ress u re at t h e l e v e l of t h e
fe m o ra l a rt e r i e s to a l l ow a n y d e b r i s to f l u s h i nto t h e
p e l v i s, w h i c h m a y t o l e rate e m b o l i z a t i o n better d u e t o
t h e exte n s i ve c o l l a te ra l n etwo r k . Press u re i s t h e n re­
l e a se d o n the fe m o r a l vesse l s and syste m i c p re ss u re
is m o n i t o re d . If t h e re is a s u bsta n t i a l hypote n s i ve re­
s p o n se, p a rt i a l o r co m p l ete recl a m p i n g m a y need to
b e p e rfo r m e d to a l l ow the a n es t h e s i a team t i m e to
treat the h e m o d y n a m ics. O n ce u ndam p e d , i n s pect t h e
a n asto m o s i s a n d s a c for b l e ed i n g . T h e re m a y b e n ew
l u m b a r b l e e d i n g as a res u lt of p e l v i c r e p e rf u s i o n t h a t
was not a p p a re n t d u r i n g t h e g ra ft p l a c e m e nt. D i ffuse
ooz i n g c a n b e treated w i t h S u rg i c e l and G e lfoa m . O n ce
u nda m pe d , c h e c k p u l s e s a n d D o p p l e r s i g n a l s in i l i a cs
a n d a ny c l a m ped b r a n c h vesse ls, as we l l as d i sta l p u l ses
a n d/o r PVRs. I f l ow e r ext r e m ity PVRs a re s i g n ifica n t l y
worse t h a n p re o p e rative l y, t h i s s h o u l d r a i s e c o n c e r n
for e m b o l i z a t i o n a n d m a y w a r r a n t a g r o i n exp l o ra t i o n
a n d t h r o m becto my.
• Sac closure: T h i s is espec i a l ly i m p o rtant d u ri n g t h e trans­
perito n e a l a p proach, as a n u n c o m m o n but d isastro u s
l ate co m p l icat i o n f r o m o p e n a o rt i c su r g e ry i s t h e a o rta­
enteric fist u l a, w h i c h occu rs when g raft a n d/o r a n a sto­
mosis erodes i nto the bowe l . To h e l p p revent t h i s, t h e
wa l l s of t h e now deco m p ressed a o rt i c sac s h o u l d be
c l osed over t h e g raft, and sewed i n a r u n n i n g fas h i o n
w i t h a l o n g 3 - 0 s i l k o r c h r o m i c s u t u re . If t h e re i s i nsuf­
ficient sac to c l ose, a f l a p of o m e n t u m ca n be m o b i l ized
and p l aced ove r t h e g raft prior to retu r n i n g t h e visce r a l
to i t s a n ato m i c locat i o n . The sac of t h e a o rta can be a not
i ns i g n ificant sou rce of b l e e d i n g , so e l ectroca utery s h o u l d
be u s e d a l o n g t h e cut e d g e of t h e sac to e n s u re h e m osta­
sis p r i o r to sac closu re, and persistent b l e ed i n g s h o u l d be
sutu re l i gated.
• D ra i n a g e and c l o s u r e : I f the p l e u ra l cavity was e n t e r e d ,
d r a i n a g e w i l l b e req u i re d e i t h e r by u s e of a red r u b­
b e r s u c t i o n catheter p l a c e m e n t d u r i n g d i a p h ra g m a t i c
r e p a i r o r posto p e rative c h est t u b e p l a c e m e n t . Ad d i ­
t i o n a l p l a c e m e n t o f a c l osed s u ct i o n J a c k s o n - P ratt (J P)
or B l a ke d ra i n in t h e p e r i to n e a l or retro p e r i to n e a l ( R P)
cavity c a n be d o n e on a s e l ective b a s i s; we g e n e r a l l y
p l a c e a d ra i n i f t h e re i s s o m e c o n c e r n ove r excessive
m o b i l i za t i o n n e a r the ta i l of the p a n c re a s and t h o u g ht
a p a n c r e a t i c l e a k m a y occ u r, or i n c o a g u l o pa t h i c p a ­
t i e nts w h e re o n g o i n g b l e e d i n g m a y b e of c o n c e r n .
S p ec i a l atte n t i o n s h o u l d b e p a i d to i n s p e ct i n g t h e
s p l e e n , a n d we h ave a l o w t h re s h o l d for s p l e n ecto my
i f t h e re i s a n y i nj u ry to t h e o r g a n . T h e a b d o m i n a l wa l l
s h o u l d t h e n b e c l osed i n layers.
C h a p t e r 22 ADVA N C E D A N E U RY S M MANAG E M E N T TECHN I Q U E S : O p e n S u r g i c a l Anatomy a n d Repa i r 2005

PEARLS AND PITFALLS

• I d e a l ly, p roxi m a l c l a m p t i m e s h o u l d be l ess t h a n 30 m i n utes. It is t h e refo re i m p e rative to h a ve a l l too l s a n d g rafts ready a n d a l l
tea m m e m bers b r i efed o n t h e ope rative p l a n p r i o r t o c l a m p i n g . H owever, for a n i nfra r e n a l c l a m p, t h e o p e rator w i l l have seve r a l
h o u rs if n ecessa ry to co m p l ete t h e a n a stomosis. I f t h e c l a m p is s u p ra r e n a l , co m p l icati o n s beg i n with m o re t h a n 40 m i n utes o f
isch e m i a .
• I nj u ry to t h e c o m m o n i l i a c ve i n o r d i staiiVC d u r i n g d issect i o n i s a potent i a l l y l et h a l co m p l icati o n . It i s i m portant to co m p l etely
m o b i l ize t h e ve i n and p e rform a p r i m a ry repa i r under d i rect vision. B l i n d sutu r i n g i n a b l e ed i n g field wi l l o n ly l e a d to d isaste r. I f
e x p o s u r e ca n n ot be obta i ned, it i s acce pta b l e to transect t h e ove r l y i n g a rtery (aorta o r i l i a c) to a l l ow a ccess to t h e ve i n . T h i s i s a
co m p l i cation that is m uc h better to avo i d t h a n treat.
• The u reters c a n b e i nj u red d u ri n g t h e transperito n e a l o r retro pe rito n e a l a p p roach, and every time t h e retracto rs a re repositi o n e d
o r as you beg i n to d i ssect a new p l a ne, t h e u reters s h o u l d be i d e n t i f i e d .

POSTOPERATIVE CARE • Splenic inj ury (consider adding splenectomy to operative

• Patients should be monitored in an intensive care unit (ICU)
postoperatively, with blood pressure goals generally of a sys­
tolic blood pressure from 100 to 140 mmHg for a straight­
forward infrarenal or j uxtarenal repair. Blood pressure goals
should be higher for thoracoabdominal repairs to promote
spinal cord perfusion.
• Patient may be weaned to extubated as soon as possible after
the operation, even in the OR if appropriate.
• An NGT is kept in place given the bowel manipulation, and
this is left in place for the first postoperative day. Although
it is not imperative to keep in place until there is full return
of bowel function, we will keep in place an additional day
if outputs are unusually high. We generally start standing
rectal suppositories on the first postoperative day.
• If there is a chest tube in place, we leave this to suction
until removal, which is done when output is less than 1 5 0
m L per 2 4 hours and the chest x-ray ( CXR) shows n o large
effusion.
•
Mobilization should be done as soon postoperatively as pos­
sible. These patients will require physical therapy and many
will ultimately require inpatient rehab.
OUTCOMES
• Mortality for an elective, open infrarenal AAA repair is less
than 5 % , and although the risk increases for those with a
j uxtarenal or suprarenal repair, our recent experience shows
that 3 0-day mortality in patients with j uxtarenal repair is
2 . 5 % . Mortality increases in the instance of an urgent or
rupture to as high as 70 % . 1•5
• Patient-specific predictors of postoperative complications
include older age, COPD, chronic renal disease (creatinine
> 1 . 8 ) or history of myocardial infarction (MI)/congestive
heart failure (CHF ) .1
•
Operative-specific predictors of postoperative complications
include long OR or clamp times, hypothermia, high blood
turnover, and a high perioperative fluid requirement.
COMPLICATIONS
• Bleeding
• Infection
consent)
• Renal failure
• MI
• CVA
• Spinal cord ischemia ( increased risk with suprarenal and
thoracoabdominal repairs )
• Anastomotic breakdown
• Aortoenteric fistula
• Pancreatitis
REFERENCES
1. Brewster DC, Cronenwett JL, Hallett JW Jr, et al. Guidelines for the
treatment of abdominal aortic aneurysms. Report of a subcommittee
of the Joint Council of the American Association for Vascular Surgery
and Society for Vascular Surgery. j Vase Surg. 2003;37:1106-1117.
2. Cronenwett JL, Sargent SK, Wall MH, et al. Variables that affect the
expansion rate and outcome of small abdominal aortic aneurysms.
J Vase Surg. 1990;11(2):260-269.
3. Darling RC III, Brewster DC, Darling RC, et al. Are familial abdomi­
nal aortic aneurysms different? J Vase Surg. 1989;10(1):39-43.
4. Strachan DP. Predictors of death from aortic aneurysm among middle­
aged men: the Whitehall study. Br J Surg. 1991;78(4):401-404.
5. Tsai S, Conrad MF, Patel VI, et al. Durability of open repair of juxtare­
nal abdominal aortic aneurysms. J Vase Surg. 2012;56(1):2-7.
6. McFalls EO, Ward HB, Moritz TE, et al. Clinical factors associated
with long-term mortality following vascular surgery: outcomes from
the Coronary Artery Revascularization Prophylaxis (CARP) Trial.
J Vase Surg. 2007;46(4):694-700.
7. Chaikof EL, Brewster DC, Dalman RL, et al. SVS practice guidelines
for the care of patients with an abdominal aortic aneurysm: executive
summary. J Vase Surg. 2009;50(4):880-896.
8. Dawson I, Sie RB, van Boeke! JH. Atherosclerotic popliteal aneurysm.
Br J Surg. 1997;84(3):293.
9. Johnston KW, Rutherford RB, Tilson MD, et al. Suggested standards
for reporting on arterial aneurysms. Subcommittee on Reporting
Standards for Arterial Aneurysms, Ad Hoc Committee on Reporting
Standards, Society for Vascular Surgery and North American Chap­
ter, International Society for Cardiovascular Surgery. J Vase Surg.
1991;13(3):452-458.
10. Lederle FA, Johnson GR, Wilson SE, et al. The aneurysm detection
and management study screening program: validation cohort and final
results. Aneurysm Detection and Management Veterans Affairs Coop­
erative Study Investigators. Arch Intern Med. 2000;160:1425-1430.
11. Lederle FA, Wilson SE, Johnson GR, et al. Immediate repair compared
with surveillance of small abdominal aortic aneurysms. N Eng/ J Med.
2002;346(19):1437-1444.
 -

Chapter 23 Advanced Aortic Aneurysm

Management: Endovascular
Aneurysm Repair-Standard
and Emergency Management
I
1
- ----------------------------------------------------------------------------------------- ·

Vinit N. Varu Ronald L. Dalman

DEFINITION may be prevented by elective surgical repair, either by open in­

• An abdominal aortic aneurysm (AAA) is defined as a
localized enlargement of more than 1 .5 times the diameter of
the most adj acent, proximal uninvolved aorta; by consensus,
this represents more than 3 . 0 em in most persons. Defini­
tions vary somewhat between men and women, most likely
normalized by body surface area or body mass index (BMI ) .
• The most common etiology o f AAAs is progressive, trans­
mural degeneration of the aortic wall. The full scope of
pathogenetic considerations and relevant mechanisms is be­
yond the scope of this chapter but, in summary, although
aneurysm disease shares many important risk factors for
aortic and peripheral vascular occlusive disease, important
differences exist, and current thinking regarding pathogen­
esis recognizes that aneurysmal and occlusive disease of the
aorta are distinct pathologic processes. Hence, the colloquial
term " atherosclerotic aneurysm, " although in common use,
is an inaccurate and potentially misleading characterization
of the most common clinical presentation for AAA.
• Risk factors for development, expansion, and rupture are
multifactoriaP (Table 1). Smoking is the only modifiable risk
factor that has been associated with all three.
• The risk of AAA rupture increases with progressive diameter en­
largement.2 Rupture and subsequent aneurysm-related mortality
Table 1: Risk Factors for Aneurysm Development,
Expansion, and Rupture
Symptom Risk Factors
AAA deve l o p m e n t • Tobacco u s e
• Hypercho l estero l e m i a
Hypertension
•
terposition grafting or endovascular aneurysm repair (EVAR) .
• EVAR provides similar long-term survival versus traditional
open repair, as well as enhanced perioperative survival. The
perioperative survival benefit is sustained for several years
following surgery. 3 EVAR is now the de facto standard of care
for both elective and ruptured AAA repair in patients who are
anatomically suited to receive currently available devices.
PATIENT HISTORY AND PHYSICAL FINDINGS
• Patients may be entirely asymptomatic despite suffering from
large, advanced AAAs. Most commonly, AAAs are found
incidentally on imaging studies obtained for other reasons.
Occasionally, they may be identified by the presence of prom­
inent aortic pulse, proximal to the umbilicus, on physical
exam. Less frequently, AAAs may cause distal limb ischemia
secondary to embolization, or fulminate congestive heart
failure if they rupture into the adj acent inferior vena cava,
creating an acute aortocaval fistula. Only 3 0 % to 4 0 % are
noted on physical examination, with detection of pulsatile
abdominal mass dependent on aneurysm size. As noted by
Sir William Osler, prior to the era of ubiquitous availability
and use of cross-sectional abdominal imaging in the evalua­
tion of abdominal pain: "There is no disease more conducive
to clinical humility than aneurysm of the abdominal aorta . "
• Patients with a ruptured AAA may present with moderate or
extreme back and abdominal pain, syncope, hypotension, and
mottling of the lower extremities, in conjunction with progres­
sive abdominal distension. When sufficiently stable to remain
conscious and conversant, pain is reproducibly elicited by
direct palpation of the abdominal aorta. Many patients with
ruptured AAA present in extremis, others with progressively
hemodynamic deterioration and pain of several hours dura­
tion. Patients may actually linger for several days with "con­

• Male gender
• Fa m i ly h i story ( m a l e predo m i n a nce) tained" retroperitoneal hemorrhage following AAA rupture.
AAA expa nsion • Advanced a g e • A thorough vascular history should be noted and modifiable
• Severe c a r d i a c disease risk factors, including smoking, hyperlipidemia, and hyper­
Previous stroke
•
tension, addressed in patients with AAAs. Smoking cessa­
• Tobacco use
• C a rd i a c o r re n a l tra n s p l a n t
tion is recommended to reduce the risk of aneurysm growth
AAA rupture • Female gender and rupture, and statins may also be beneficial in this regard.
•
.J. FEV1 • AAAs occur almost exclusively in the elderly (mean age of repair
• Larger i n it i a l AAA d i a m eter 72 years of age) and male patients outnumber female by 4 to 6 is
H i g h e r m e a n blood pressure
to 1 . 1 When AAA is recognized in younger patients, it is usually
•

• C u rrent tobacco use

( l e n gth of time smoking > > a m o u nt)
• C a rd iac o r renal tra n s p l a n t
• C ritical wa l l stress-wa l l strength relati o n s h i p
AAA, abdominal aortic aneurysm; FEV1, forced expiratory volume i n 1 second.
From Chaikof EL, Brewster DC, Dalman RL, et a/. The care of patients with an abdominal
aortic aneurysm: The Society for Vascular Surgery practice guidelines: executive summary. J
Vase Surg. 2009;50(4):880-896.
2006
in association with hereditary risk, syndromic aortic conditions
such as Marfan syndrome, or in the setting of focal aortitis or
mycotic aneurysms. The latter tend to occur most frequently in
the suprarenal abdominal aorta, at or directly proximal to the
origin of the celiac artery, underneath the crus of the diaphragm.
Aneurysmal degeneration of the abdominal aorta may also
occur late following thoracic and abdominal aortic dissection.
 C h a p t e r 23 ADVA N C E D AORT I C A N E U RYSM MANAG E M E NT: Endovascu lar Aneurysm Repai r 2007

• Factors associated with increased risk of rupture include repair. Ideally, precise diameter and path length measure­
female gender, large initial diameter, low forced expiratory ments are derived from three-dimensional ( 3 - D ) recon­
volume m 1 second (FEV 1 ) , current smoking history, and el­ struction of the two-dimensional (2-D) source images (via
evated mean blood pressure. TeraReconTM, OsiriX™, or similar software) .
• Precision i s most essential i n determining diameter through­
IMAGING AND OTHER DIAGNOSTIC STUDIES out the surgical neck and common iliac landing zones proxi­
mal to the bilateral iliac bifurcations. Graft oversizing of
• Screening decreases aneurysm-related mortality in AAA dis­
1 0 % to 20% is typically used in the region of the surgical
ease.4 Current guidelines recommend a screening ultrasound
neck. Length measurements are obtained from the lowest
for 65- to 75-year-old at-risk individuals, defined as men
renal artery to the iliac bifurcation, using path lengths, when
who have smoked more than 1 0 0 cigarettes in their lifetime
available, from image reconstruction software noted earlier.
or men or women with a family history of AAAs.5
• Multiple aortic endografts are approved for use in the United
• Thin-slice computed tomography ( CT) imaging, with in­
States at the current time, and device selection should be tai­
travenous contrast injection timed to opacify the abdomi­
lored to individualized anatomic requirements. Contraindi­
nal aorta and runoff vessels, remains the standard modality
cations to endovascular repair may include inadequate neck
for operative planning. The extent, morphology, and acces­
length, diameter, and angulation; thrombus volume and dis­
sibility of the aneurysm via retrograde iliofemoral access
tribution in the neck; insufficient iliac artery diameter, and ex­
determine the suitability for an endovascular repair. Other
cessive iliac or aortic tortuosity. It is the responsibility of the
relevant anatomic considerations include the location and
operating surgeon to ensure that for each selected device the
volume of laminar intraluminal thrombus in the region of
the " surgical" neck ( defined as the length between the lowest
instructions for use (IFU) are understood and appropriat for �
the planned repair. Experienced operators, with careful plan­
renal artery and the start of the aneurysm); angulation of the
mng, may knowingly place devices in off-label circumstances
surgical neck, size and tortuosity of access vessels; presence
and significance of anomalous and accessory renal arteries;
depending on the patient-specific anatomic and physiologi �
nsk assessment, with the expectation of reasonably long-term
dtameter at the aortic bifurcation; and diameter of the more
results. In off-label applications, however, the onus is on the
proximal abdominal aorta (provides useful guidance as to
surgeon to confirm that sufficient proximal and distal fixa­
the likely long-term diameter of the surgical neck ) .
tion and sealing zones exist to ensure a reasonable result. 7
• F o r cases of suspected AAA rupture, bedside transcutaneous
• Femoral access must also be evaluated with ultrasound or
ultrasonography may be used to detect the presence of intra­
CT imaging to determine if the patient is a candidate for per­
or retroperitoneal fluid ( or blood) or assess for confounding
cutaneous repair. The "preclose " technique (see the follow­
condtttons ehettmg abdominal pain. When sufficiently he­
ing text) can be used for arteriotomy closure for devices up to
modynamically stable, however, CT aortography should be
21 French (Fr) in diameter. Contraindications to percutane­
obtained to assess for suitability for endovascular repair.6
ous repair include calcification of the anterior femoral artery
wall, diameter less than 7 mm, the presence of an aneurysmal
SURGICAL MANAGEMENT
femoral artery, and excessive scaring at the access site.
Indications • The superior mesenteric artery ( SMA) and celiac arteries
should be examined for patency and the presence of flow­
• Patients with "symptomatic " AAAs (e.g., pain likely originat­
limiting stenosis or occlusion; if found, revascularization of
mg from the aneurysm despite absence of retroperitoneal hem­
the SMA and celiac artery should be considered prior to at­
orrhage on CT aortography) are at increased risk of rupture
tempted EVAR, or open repair is considered as an alternative
and urgent intervention is recommended. Of those AAAs that
approach. In planning for EVAR, attention must be paid to
rupture, more than half will die prior to hospitalization. Of
the status of the inferior mesenteric artery and the total vis­
those that undergo attempted operative repair, approximately
ceral vascularity assessed in terms of consequences of obli­
5 0 % mortality is to be expected. The latter estimate is highly
gate inferior mesenteric artery (IMA) coverage during EVAR.
dependent on hemodynamic conditions, duration of symp­
Occasionally, depending on anatomic circumstances, custom
?
tom� , and comor id conditions present at the time of surgery
fenestration or parallel grafting options may be considered
and IS not useful m predicting survival of individual patients. 1
as alternatives, allowing for EVAR management despite the
• For asymptomatic AAAs, management is determined by
presence of significant celiac or SMA disease. The latter op­
the maximal orthogonal transverse diameter at the time of
ttons agam, however, should only be considered by opera­
evaluation or rate of aneurysm enlargement over time. AAAs
tors experienced in these techniques or facile with rapid open
less than 4 . 0 em are at low risk of rupture and should be
conversion when indicated to preserve intestinal perfusion.
monitored with serial imaging; those larger than 5 . 4 em are
• Facilities are an essential consideration. Fixed imaging is the
at high risk of rupture and should be repaired. Surveillance
preferred option for procedural guidance and aortography,
is recommended for most patients in the range of 4 . 0 to 5 . 4
preferably when available in a "hybrid" operating room config­
e m , although young healthy patients a n d especially women
uration. This is especially true when tolerances are low regard­
may benefit from repair in AAAs between 5 . 0 and 5.4 cm.1
mg IFU status and related anatomic considerations. Anesthesia
can be either general or local with conscious sedation, depend­
Preoperative Planning
mg on the habitus of the patient, their suitability for conscious
• Anatomic measurement obtained from high-quality CT aor­ sedation, and the potential likelihood of open conversion. In
tography, preferably reconstructed with millimeter or sub­ our practice, all patients are consented for open conversion,
millimeter slices, is paramount to successful endovascular even though in practice this happens in less than 1 % of cases.
2008 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY
ENDOVASCULAR ANEURYSM REPAIR
STANDARD
Percutaneous Access
• U s i n g u ltraso u n d g u i d a nce to determ i n e t h e location of
t h e fe m o r a l b i f u rcation a n d pote nti a l presence of a nte­
rior c a l cified athe rosc l e rotic p l a q ue, b i l ateral c o m m o n
fe m o ra l a rteries (CFAs) a re accessed with 0 . 0 1 8-i n m i ­
c ro p u n ct u re k i t s . F e m o ra l a rteriog ra p h y i s pe rfo rmed t o
c o n f i r m s u i ta b i l ity of t h e sel ected access s i t e with i n the
CFA p r i o r to seri a l d i l a t i o n .
• A 0 . 0 3 5 - i n g e n e r a l p u rpose w i re (e . g ., B e ntson, C o o k
M e d i c a l , B l o o m i n gton, I N ) i s a dva n ced i nto t h e a o rta
t h r o u g h the m i cropu n ctu re sheath and 1 1 -cm, 7-Fr
sheaths a re exch a n g e d ove r t h e B e ntson i nto t h e ex­
tern a l i l i a c a rteries ( E IA) u n d e r conti n uo u s f l u o rosco p i c
g u i d a nce. F u l l i ntrave n o u s a nticoa g u lation i s esta b l ished
with u nfract i o n ated heparin (at least 1 00 u n its/kg) a n d
confirmed b y su bse q u e n t dete r m i nation o f a ctivated
c l ott i n g time (ACT) g reater than 2 5 0 seco n d s .
Preclose Technique
• I n a l l c i rc u m st a n ces, t h e s u rg e o n s h o u l d c o n s u l t t h e
respective I F U s f o r a l l d e v i c e s e m p l oyed d u r i n g t h e s e
p roced u re s .
• W h i l e t h e assista nt m a i nta i n s d i rect co m p ress i o n p roxi­
mal to t h e i n g u i n a l l i g a m e nt to m a i nta i n h e m osta sis, the
7-Fr sheaths a re i n d iv i d u a l l y rem oved over each respec­
tive w i re and re p l a ced with a Perclose ProGiideTM (Ab­
bott, Abbott Park, I L) device. This i s back- l o a d e d o n the
w i re and advanced u n t i l t h e g u i d ew i re exit l i n e o n the
Closed
arteriotomy
device. The wire is t h e n t e m p o r a r i l y rem oved a n d t h e de­
vice advanced u nt i l p u lsat i l e b l ood i s v i s u a l ized t h r o u g h
t h e p i l ot t u b e l u m e n . The fi rst device i s t u r n e d to t h e
1 0 o ' c l o c k p o s i t i o n a n d foot p l ate a ctivated. H o l d i n g b a c k
tension o n t h e device, t h e sutu re i s d e p l oyed, a n d t h e
e n d s a re re m oved f r o m t h e d e v i c e a n d contro l led w i t h
a padded s u t u re c l a m p . After t h e w i re i s reposit i o n e d
t h r o u g h t h e w i re p o rt i nto t h e a o rta u n d e r f l u o rosco p i c
g u i d a nce, t h e foot p l ate i s released a n d t h e device i s
b a c k e d out of t h e fe m o r a l a rte ry. Press u re i s rea p p l i e d
ove r t h e p u nctu re site d u r i n g t h i s m a n e uver (FIG 1 ) .
• A seco n d Perclose ProGiideTM (Abbott) device i s back­
loaded o n t h e wire and the afore m e n t i o n e d ste ps a re re­
peated with t h e device t u rned to t h e 2 o'clock posit i o n .
• After both ProGiid esrM (Ab bott) a re d e p l oyed, t h e 7 - F r
s h e a t h i s refo rmed a n d repl aced o v e r t h e w i re to m a i n ­
ta i n h e m ostasis. The sutu re c l a m ps a re positi o n ed con­
s i stent with t h e c l ockface o r i e ntation of each suture
p l acement.
• The p roced u re i s t h e n repeated for t h e contra l atera l
fe mora l a ccess site.
Delivery and Deployment of Endograft
• W i re exc h a n g e i s p e rformed t h r o u g h a g u i d i n g cath­
eter (e . g . , 1 00-cm G l i d ecathrM, Te r u m o M e d i c a l , Som­
e rset, NJ) for a stiffe r access w i re (e . g ., L u n d e rq u ist'M,
Cook M e d i c a l ) . S e r i a l d i l a t i o n i s p reformed ove r t h e stiff
wi re, u n d e r f l u o rosco p i c g u i d a nce, to g e ntly d iste n d a n d
e n l a rg e t h e respective a rteriotomy sites. F o l l o w i n g d i l a ­
t i o n to at least 1 4 Fr, t h e p r i m a ry a n d seco n d a ry access
sheaths a re adva n ced u n d e r f l u o rosco p i c g u i d a nce i nto
the a o rt a .
FIG 1 • Preclose tec h n i q u e . Two ProGi i d esrM a re de­
p l oyed, o n e at t h e 10 o'clock position and t h e oth e r at
t h e 2 o'clock posit i o n before beg i n n i n g seri a l d i l a t i o n
m a n e uvers a n d d e p l oyment of d e l ivery catheters.
O n ce the p roced u re i s co m p l ete, and l a rg e d i a m eter
devices a re rem oved, both k n ots a re seated to c l ose t h e
a rteri otomy ( s e e i nset) . U nt i l closu re, t h e f r e e sutu res
a re contro l l ed o n sutu re boots. O n ce the proce d u re is
co m p l ete, both k n ots a re p u s h e d down to c l ose t h e
a rteri otomy.
 C h a p t e r 23 ADVA N C E D AORT I C A N E U RYSM MANAG E M E NT: Endovascu lar Aneurysm Repai r 2009

• The m a i n b o d y e n d o g raft i s p l a ced u p t h e i p s i l atera l i l i a c Gate Cannulation

a rtery to the level of t h e re n a l a rteries. Late r a l ity of m a i n
• The contra late ra l sheath is p l aced 1 to 2 em d i st a l to t h e
body d e p l oyment i s dete r m i n e d based o n t h e tortuosity
a n d d i a m eter of the access a rteri es, a s we l l a s the de­ contra late r a l g ate. U s i n g a n O m n if l u s h T M (An g iodyna m ­

s i red a n g l e at which t h e m a i n body w i l l i nterface with i cs) o r G l i d eTM catheter (Te r u m o), t h e gate is ca n n u lated
t h e re n a l a rteries. The m a i n body s h o u l d be o r i e nted so with a n a n g l e d G l i dewi reTM (Te r u m o ) . W h e n s u ccessf u l ,

that the gate d e p l oys in a nterol atera l fas h i o n for easy the O m n if l u s h catheter s h o u l d b e exc h a n g e d ove r a w i re

contra latera l l i m b access. The i m a g e i ntensifier s h o u l d be a n d rei ntroduced i nto t h e e n d o g raft. The t i p is a l lowed

adj usted to l i m it p a ra l l a x by acco u n t i n g for some deg ree to refo rm by with d rawi n g t h e w i re and t h e c u r l e d f l u s h

of a nterior a n g u l at i o n ( u s u a l ly in t h e range of 1 0 % , oc­ catheter i s s p u n 360 d e g rees seve r a l t i m e s to confirm

cas i o n a l ly m o re) and l atera l a n g u l a t i o n in the s u rg i c a l gate ca n n u l a t i o n . Fa i l u re to confirm t h i s step may res u l t
neck, b a s e d o n preproce d u r a l assessment f r o m t h e refor­ i n d e p l oyment o f t h e contra l atera l l i m b o u t s i d e of t h e
m atted CT a o rto g r a m (FIG 2A) . g a t e , l i ke l y g e n e ra t i n g " e n dotra s h " (e . g . , g raft l i m b free
• An O m n i F l u s h catheter (An g i oDyn a m i cs, Lat h a m , NY) in t h e a n e u rysm, outside t h e m a i n body, w h i c h w i l l n ot

i s p l aced up the contra l atera l i l i a c a rtery to the level of re m a i n in c i rc u l at i o n ) (FIG 2C) .

• If t h e contra latera l gate c a n not be s u ccessfu l l y ca n n u ­
the r e n a l a rteries. The g a ntry position i s t h e n confirmed
to be a p p ro p r i ate for t h e patient's a n atomy, e n s u r i n g l ated u s i n g sta n d a rd g u i d e w i re a n d catheter tec h n i q u e s

t h a t t h e i m a g e p l a n e i s o rth o g o n a l to t h e takeoff of t h e ( d i fferent-s h a pe d catheters s h o u l d b e e m p l oyed, a s

l owest re n a l a rte ry. U s u a l ly, a " 2 0 for 1 0 " contra st r u n we l l a s reposit i o n i n g t h e s h e a t h i n r e l a t i o n to t h e c o n ­

i s pe rfo rmed d u ri n g b reath - h o l d u n d e r m a g n ificati o n tra l atera l g ate), ca n n u l a t i o n m a y b e acco m p l i s h e d b y

vi ews, d e l ive r i n g 1 0 m L of contra st at a rate of 20 m L per a d va n c i n g a s n a re u p t h e contra l atera l s h e a t h i nto t h e

seco n d , to confirm t h e device position vis-a-vis t h e renal a n e u rysm a n d e n g a g i n g t h e m a i n body e n d o g raft b i ­

a rtery o r i g i n s . fu rca t i o n w i t h a 5os O m n i o r s i m i l a r c u rved catheter.
• The m a i n b o d y e n d o g raft i s t h e n d e p l oyed accord i n g T h e i ps i latera l w i re is t h e n adva n ced t h r o u g h t h e g ate,

t o t h e I F U , w i t h t h e p roxi m a l fa b r i c m a rg i n posit i o n e d to b e s n a re d from the contra latera l s i d e . O n ce the w i re

j ust b e l ow t h e l owest re n a l a rte ry. D e p l oyment co n t i n ­ is w i t h d rawn t h r o u g h t h e contra l a t e ra l s h e a t h , a cath­

ues u nt i l t h e contra l atera l g a t e i s fu l ly o p e n (a lth o u g h eter m a y b e b a c k- l oa d e d and adva n ced i nto t h e m a i n

tech n i q ues may va ry between devices). Depen d i n g o n body, w h i c h i n t u r n a l l ows a n exch a n g e t o a stiffe r

the device-specific I F U , t h e m a i n b o d y may be resheathed w i re t h r o u g h t h e g a t e . W h e n n ecessa ry, a w i re c a n a l so

and reposit i o n e d , if n ecessa ry, to o bta i n opti m a l posi­ b e adva n ced from bra c h i a l a rte ry access for the s a m e

t i o n i n g (FIG 28) . p u rpose.

• Repeat a o rtog ra phy i s pe rfo rmed t o e n s u re a d e q uate
p l acement. The s i d e - h o l e, a o rtic flush catheter i s with­
d rawn i nto t h e a n e u rysm through t h e prox i m a l l a n d i n g
zone, ove r a w i r e . If t h e device u s e s s u p r a re n a l ste nt fixa­
tion, t h e s u p r a re n a l stents a re d e p l oyed when m a i n body
p l a c e m e n t i s d e e m e d suffi c i e nt. Care s h o u l d b e taken to
prevent p u l l i n g the m a i n body of the e n d o g raft down
i nto t h e a n e u rysm .
Limb Extension
• Retro g ra d e i l i a c a n g i o g r a p h y is pe rfo rmed t h r o u g h t h e
s h e a t h , w i t h t h e g a ntry positi o n i n t h e contra late r a l
o b l i q u e posit i o n . T h i s w i l l i d e ntify t h e o r i g i n of t h e i n ­
tern a l i l i a c a rte ry. O n ce t h i s i s confi rmed, d i st a n ce from
t h e gate to t h e i ntern a l i l i a c i s measu red using a m a rker
catheter and a n a p propriately sized l i m b i s chose n .

A B c D

FIG 2 • D e l ivery a n d d e p l oyment of e n d o g raft. A. The m a i n body is broug ht up the i ps i late r a l i l i a c

a rte ry to t h e l evel of t h e ren a l a rteries. An O m n i F l u s h catheter i s b r o u g h t u p t h e contra l atera l i l i a c
a rt e ry a n d a n a n g i og r a m i s p e rfo r m e d . B. The m a i n b o d y e n d o g raft i s d e p l oyed u n d e r f l u o rosco p i c
.
g ui d a n ce u ntil t h e contra l atera l g a t e i s o p e n e d . C. The contra late r a l g a t e i s ca n n u lated. D. An
exte n s i o n l i m b is p l aced p roxi m a l to the i l i a c b i f u rcati o n o n t h e contra latera l s i d e a n d t h e i ps i latera l
e n d o g raft is f i n ished b e i n g d e p l oyed (o n e d o c k i n g l i m b systems) or an exte n s i o n l i m b is p l a ced (two
d o c k i n g l i m b systems) to t h e l evel of t h e i ps i latera l i l i a c bifu rcat i o n .
201 0 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY
For t h ree-p i ece bifu rcated devi ces (e.g., TriVasc u l a r
Ovat i o n 1M, C o o k Zen ith 1M), t h i s p roce d u re h a s to b e
perfo rmed o n both s i d es . O pti m a l l i m b d e p l oyment
m a i nta i n s s uffi c i e nt contact with t h e gate to m a i nta i n
sea l (see respective I F U ) a n d suffi cient d i sta l cove rage to
co m p l etely excl u d e the com m o n i l i a c a rtery without i m ­
p i n g i n g o n t h e o r i g i n o f t h e i ntern a l i l i a c a rtery (FIG 20) .
• Occa s i o n a l ly, w h e n t h e d i stance req u i red for proper l i m b
placement d oes n o t precisely correl ate with t h e s i zes
ava i l a b l e , the n ext s ize-l o n g e r l i m b may be d e p l oyed
i nto t h e gate and slowly a l o n g its l e ngth . D u r i n g d e p l oy­
m e n t (once out of t h e g ate), conti n u ed u pward p ressure
o n t h e d e p l oyment h a n d l e i s m a i nta i n ed to encourage
t h e g raft to take a somewhat m o re serpig i n o u s route,
ta k i n g up some of the a d d i t i o n a l l e a k . P a rt i a l cove rage
of t h e i ps i l atera l i ntern a l i l i a c a rtery orifice i s a l so a p pro­
pri ate when d e p l oyment can be p recisely m o n itored i n
t h e contra l atera l o b l i q u e g a ntry posit i o n .
Balloon Molding
• An a p p ro p riately sized semicom p l i a nt b a l l o o n (e . g .,
Coda1M, Cook M e d i c a l ) is expa n d e d with d i l ute contrast
s o l u t i o n at a l l t h ree l a n d i n g zones and ove r l a p a reas
with i n t h e gate(s) as a p p ro p r i ate fo r t h e specific device
(FIG 3). W h e n exist i n g common i l i a c a rtery ste nosis i s
p rese nt, k i ss i n g b a l l o o n s s h o u l d be d e p l oyed to o bta i n
o pt i m a l i ntern a l d i a m eter a n d prevent l i m b k i n k i n g o r
occl u s i o n . S i m i l a rly, t h e a o rt i c b i f u rcati o n s h o u l d a l so
b e d i l ated w h e n n e cessa ry. Occa s i o n a l ly, se lf-expa n d i n g
b a r e meta l n it i n o l stents m a y be d e p l oyed at a reas of
ste nosis or from the d ista l l i m b i nto exte r n a l i l i a c a rte ry,
to p revent k i n k i n g of t h e e n d o g raft o r native exte r n a l
i l i a c a rtery d i sta l to t h e device.
Completion Arteriography
• Co m p l et i o n a rteriography is p e rformed with h i g h e r
vo l u m e a n d l o n g e r i nj e ct i o n t i m e t o co m p l etely fi l l t h e
e n d o g raft, e n s u re l i m b patency, a n d i d e n tify e n d o l ea ks
(FIG 4) . A l l type I or I l l e n d o l ea ks, w h e n p resent at t h e
e n d of t h e c a s e , s h o u l d be a d d ressed with a d d i t i o n a l
m a n e uvers to e n s u re sea l . T h i s may i n c l u d e d e p l oyment
of proxi m a l e n d o g raft cuffs, p ro l o n g e d m o l d i n g b a l l o o n
i nf l a t i o n t i m e, o r, o n occa s i o n , p l acement of e m b o l i s m
co i l s i n reca lcitrant l e a ks. W h e n s m a l l l e a ks persist, even
when a n at o m i c cove rage seems a d e q u ate, a n t i coag u l a ­
t i o n s h o u l d be reversed a n d sheaths rem oved w i t h t h e
p l a n f o r fo l l ow-up C T a o rtography with i n a few days.
Care s h o u l d be taken to ca refu l ly eva l u ate t h e n a t u re
of a l l l e a ks (type, vo l u m e, l ocat i o n i n regard to l u m b a r
b r a n c h es, stat u s o f g raft l i m b d e p l oyme nt, a d e q u acy
of m o l d i n g , etc.) before seco n d a ry i nterve n t i o n s a re
c o n s i d e red for pe rsistent l e a ks . The majo rity of type I I
e n d o l ea ks resolve i n t h e fi rst year. I n o u r practice, we
never resort to d e p l oy m e nt of a l a rg e d i a m eter, ba l l oo n ­
expa n d a b l e stent i n t h e p rox i m a l neck-accu rate s i z­
i n g a n d d e p l oyment of t h i s ste nt may be d iffi c u l t a n d
" stretc h i n g " t h e p rox i m a l orifice o f t h e m a i n b o d y i n
t h i s way m a y d a m a g e t h e g raft, without sufficient as­
s u r a n ce that t h e p roxi m a l type I leak w i l l b e a d e q u ately
a d d ressed .
Closure
• The contra lateral sheath is rem oved ove r t h e w i re a n d
m a n u a l p ress u re i s h e l d . The p revi o u s l y p l a ced p reclose
polypropy l e n e sutu res a re d e p l oyed seq u e n t i a l ly in each
access site and c i n c h e d down with a k n ot p u s h e r ove r
a w i r e . W h e n i n it i a l h e m osta s i s a p p e a rs a d e q u ate, t h e
w i re i s rem oved a n d s l i g htly m o re p ress u re i s a p p l i e d t o
t h e k n ot p u s h e r. After b o t h sutu res a re d e p l oyed i n o n e
g r o i n , dete r m i n a t i o n i s m a d e a s to w h i c h of t h e t w o a p ­
pea rs to prov i d e more effective h e m ostas i s a n d m a n u a l
pressure i s h e l d t o t h i s suture f o r 5 a d d i t i o n a l m i n utes.
This is repeated for t h e i p s i l ateral s i d e .
• Proced u ra l a nticoa g u l a t i o n is reve rsed once a l l sheaths
and c l a m ps a re rem oved . It is essentia l to wait for f i n a l
i ntrod ucer device rem ova l before revers i n g t h e a nt i co­
a g u l at i o n , beca use the l a rg e d i a m eter sheaths used to
d e l iver EVAR devices may a l m ost entirely occl u d e t h e
i ps i l atera l exte r n a l i l i a c a rte ry, ca u s i n g potent i a l ly cata­
stro p h i c g raft l i m b and i l i a c a rtery t h ro m bosis i n t h e ab­
sence of fu l l a nticoa g u l at i o n .
FIG 3 • B a l loon m o l d i n g . A se m i co m p l i a nt b a l l o o n i s
i n f l ated at prox i m a l a n d d i sta l l a n d i n g z o n e s as we l l as at a l l
ove r l a p p i n g e n d o g rafts.
 C h a p t e r 23 ADVA N C E D AORT I C A N E U RYSM MANAG E M E NT: Endovascu lar Aneurysm Repai r 201 1

A B

c D
FIG 4 • Co m p l et i o n a rte r i o g r a p hy. Speci a l atte ntion is p a i d to e n s u re t h e re n a l a n d i l i a c a rteries a re patent, as we l l as to i d e n tify
if an e n d o l e a k is present. The e n d o g raft itself s h o u l d be scrut i n ized for a n y evidence of l i m b k i n k i n g . A. R e n a l a rtery patency
confi r m e d . B. No Type 1 A e n d o l e a k confi r m e d . C. Exte r n a l a n d i nt e r n a l i l i a c a rtery pate n cy confi r m e d a n d e n d o g raft itse lf s h o u l d
be scruti n i zed f o r a n y evidence o f l i m b k i n k i n g . D. N o type 1 B, 2, 3, o r 4 e n d o l e a k i d e ntified w i t h d e l ayed i m a g i n g .

• R a p i d catheter a n d g u i d ewi re exch a n g e s a re pe rfo rmed,

ENDOVASCULAR ANEURYSM REPAIR FOR
RUPTURED ANEURYSMS, OR REVAR
Percutaneous Access
• B i l atera l CFA access is o bta i n e d u n d e r loca l a nesth esia.
The preclose tech n i q u e (descri bed i n the p revi o u s section)
can be e m p l oyed when t i m e a n d co n d itions perm it, but if
n ot poss i b l e, the case ca n p roceed percuta neously i n it i a l ly,
with conversion to open femoral closure when the endo­
g raft is fu l ly d e p l oyed a n d i nter n a l bleed i n g h a s sto pped.
with sheath u p s i z i n g as n oted i n t h e p revi o u s sect i o n .
The use of i ntrave n o u s a nticoag u l at i o n i s controvers i a l i n
t h i s sett i ng-a g a i n i t i s h i g h ly d e p e n d e n t o n t h e h e m o ­
dyn a m i c statu s of t h e patient, p resence of a ctive b l ee d ­
i n g , a n d exist i n g consu m ptive coa g u l o pathy. Often w h e n
treat i n g r u pt u red a n e u rysms, t h e c a s e beg i n s without
a nticoa g u l at i o n , which is s u bseq u e ntly i n stituted once
t h e m a i n body and exten s i o n l i m bs a re d e p l oyed.
• In t h e case of r u pt u re proced u res, preoperative CT a o r­
tography may not exist or may n ot p rovide s uffi cient
201 2 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

a n ato m i c deta i l to g u i d e d e p loyment. In t h i s c i r c u m ­

sta n ce, catheter a rte riography with a m a rker f l u s h cath­
eter s h o u l d b e e m p l oyed to determ i n e path l e n gt h s,
l a n d i n g zon es, a n d opti m a l g raft s i z i n g .

Aortic Balloon Control

• F o l l o w i n g access a n d w i re exch a n g e, a L u n d e rq u i stTM -

(Cook M e d i c a l ) o r s i m i l a r stiff w i re i s adva n ced i nto the
a o rta, ove r w h i c h a 1 4- F r x 5 5-cm b r a i d e d sheath i s ad­
vanced to the l evel of t h e r e n a l a rteries. O n ce loca l i za­
tion i s confi rmed, t h e s h eath i s sutu red to t h e skin at the
access site.
• A semicom p l i a nt b a l l o o n (Co d a rM, Cook M e d i c a l ) o r
s i m i l a r a o rt i c occl u s i o n b a l loon i s d i rected to a posi­
tion i m m ed i ately p roxi m a l to t h e visce r a l a rteries u n d e r
FIG 6 • M a i n body d e p l oyment for R EVAR. After a n
f l u o rosco p i c g u i d a nce (FIG 5) . O n ce positioned, it c a n
a n g i o g r a m i s p e rformed to i d e ntify t h e re n a l a rteries a n d
be m a i nta i n ed i n t h e defl ated s i t e u n t i l o r u n l ess t h e
a o rt i c neck, t h e m a i n body i s d e p l oyed u p t h e i p s i latera l
patie nt's h e m odyn a m i c status req u i res i nflation a n d a o r­ i l i a c a rte ry. T h i s can be d o n e with t h e s e m i c o m p l i a nt b a l l o o n
t i c occl u s i o n . i nfl ated .
• O n ce b i l atera l t h e ra peutic sheath a ccess is o bta i n ed a n d
t h e deflated occ l u s i o n b a l l o o n i s positioned proper ly,
g e n e ra l a n esthesia may be i n d uced.
deflated a n d removed t h r o u g h t h e contra late r a l sheath.
B a l l o o n p l acement should be p e rformed i n s u c h a way
Endograft Delivery and Deployment
that t i m e without b a l l o o n cove rage i s kept to an a bso­
• Ao rto g r a p h y is pe rfo rmed t h r o u g h t h e contra late r a l l ute m i n i m u m . Retro perito n e a l h e m o r r h a g e can con­
s h e a t h b e l ow t h e ba l l oo n to l oca l ize t h e o r i g i n s of t h e tinue at a r a p i d rate t h r o u g h out this proce d u re, a n d in
re n a l a rteries. t h e a bsence of exte r n a l b l e e d i n g , neither t h e s u rg e o n s
• The m a i n body e n d o g raft is p l aced u p t h e i ps i late r a l n o r t h e a n esth e s i o l o g ists may a p p reciate t r u e m a g n it u d e
s h e a t h to t h e l e v e l of t h e re n a l a rteries. It s h o u l d be ori­ of b l o o d l o s s a n d ci rcu l atory reserve. U nd e r t h e s e c i r c u m ­
ented so that t h e gate d e p l oys i n a nterol atera l fas h i o n . sta n ces, h e m odyn a m i c co l l a pse c a n be precip ito us a n d,
• The m a i n body e n d o g raft is t h e n d e p l oyed accord i n g to u nfort u n ate ly, ca l a m itous, u n l ess an occ l u s i o n b a l l o o n i s
t h e I F U , j ust d ista l to t h e l owest re n a l a rte ry. D e p l oy m e nt properly positioned a n d i m m ed iately i nfl ated at t h e fi rst
cont i n ues u n t i l t h e contra l atera l gate is f u l l y d e p l oyed i n d icat i o n of r a p i d h e m odyn a m i c dete r i o rati o n .
(FIG 6).
• The i ps i latera l l i m b of t h e e n d o g raft is ca n n u lated
and t h e sheath advanced i nto t h e m a i n body of t h e
e n d o g raft.
• A seco n d Coda b a l l o o n is p l aced i n t h e i p s i l atera l s h eath
and i n f l ated in t h e m a i n body (FIG 7) . The fi rst b a l l o o n i s

-
FIG 5 • Aortic b a l l o o n control for R EVAR. A semicom p l i a n t
ba l l oo n i s p l aced u p t h e contra late r a l i l i a c a rte ry proxi m a l to
the ce l i a c t r u n k . It c a n be i n f l ated d e p e n d i n g o n h e modyn a m i c
i n sta b i l ity.
Figure 7 • B a l loon excha n g e a n d gate ca n n u lation for R EVAR.
The entire ipsilateral gate is deployed prior to contra l atera l gate
ca n n u lation. A secon d sem i-co m p l iant bal loon is placed u p the
ipsilatera l endog raft l i m b (top of i m a g e) and p laced i nto the
m a i n body of the endog raft. It ca n be i nfl ated depe n d i n g on
hemodyna m i c i n sta b i l ity. The fi rst sem i-co m p l iant ba l l oo n is
removed a n d the sheath is brought to d i stal to the contra latera l
g ate to prepare for gate ca n n u latio n . Retrograde a n g iography
with a marking catheter is performed through the contra latera l
sheath to i dentify the i l iac bifurcation a n d desi red l i m b extension
length.
 C h a p t e r 23 ADVA N C E D AORT I C A N E U RYSM MANAG E M E NT: Endovascu lar Aneurysm Repai r 201 3

Gate Cannulation
- -�

• G ate ca n n u l a t i o n p roceeds i n a sta n d a rd fas h i o n d u r i n g

R EVAR .

Limb Extension

• L i m b exte n s i o n proceeds i n a sta n d a rd fas h i o n d u r i n g

R EVAR . Ti m e awareness i s critical d u ri n g sta n d a rd EVA R
ste ps to e n s u re that a n e u rysm sea l i n g i s acco m p l i s h e d i n
t h e m ost exped itious m a n n e r possi b l e .

Balloon Molding

• CodaTM b a l l o o n (Cook M e d i c a l ) m o l d i n g is pe rfo rmed at

a l l s e a l zones to o pt i m ize h e m ostasis. O n ly after m o l d i n g
is co m p l ete i s h e m ostasis assured. FIG 8 • C o m p letion a o rto g r a p h y for R EVAR .

Completion Aortography Closure

• Co m p l et i o n a o rto g r a p h y is pe rfo rmed as p revi o u s l y de-
scribed. Atte ntion s h o u l d be p a i d to a l l t h e u s u a l co n ­
s i d e ratio ns, i n c l u d i n g p resence a n d n a t u re o f e n d o l ea ks,
i l i a c l i m b o r a rteri a l k i n k i n g , suffi c i e n t ove r l a p in t h e
l a n d i n g zones to m e et I F U , a n d so forth (FIG 8) .
• Closure proceeds as i n d i cated for sta ndard EVAR, with ca­
veat that if ProG l ides were not deployed prior to percuta ne­
ous access, then surgical i ncisions will need to be made to
expose the femora l a rtery sites for control a n d closure under
d i rect vision as the therapeutic sheaths a re withd rawn .

PEARLS AND PITFALLS

Access • U ltraso u n d g u i d a nce i s essent i a l to l i m it i n g a ccess co m p l i cations. Vis u a l ize the need l e tip enteri n g t h e
a nterior a rtery wa l l , i n a n a rea d e e m e d a p p ro p r i ate for access.
G ate ca n n u l a t i o n • In g e n e r a l , m a i n body s h o u l d be adva n ced t h r o u g h the m o re tort u o u s of the two i l i a c a rteries to a l l ow
a more " stra i g h t s h ot " for t h e contra l atera l gate ca n n u l at i o n . T h i s p reference is not a lways p ractica l,
h owever, a n d late ra l ity may need to be decided based o n m o re pract i c a l co n s i d e rations (e . g . , I s t h e tortu­
osity suff i c i e nt to p revent m a i n body positi o n i n g and d e p l oyment a ltogether?).
Tort u o u s i l i a cs • Pe rfo rm t h e com p l et i o n a o rtog ram with soft cath eters i nstead of stiff wi res i n p l a ce . Stiff w i res may
stra i g hten out a tort u o u s vesse l , which may e n d up k i n ked when t h e wi res a re removed and l e a d to l i m b
occ l u s i o n . A lso, rete ntion o f stiff wi res a t t h e t i m e o f co m p l et i o n a o rtog raphy m a y mask t h e d eve l o p ­
m e n t of t y p e I p roxi m a l e n d o l e a ks, w h i c h may d eve l o p situati o n a l ly w h e n stiff wi res a re re m ove d .
C l o s u re • T i e d o w n t h e s u t u res of t h e c l o s u re device w i t h t h e w i re i n p l ace. If t h e re i s sti l l s i g n ificant b l e ed i n g ,
e i t h e r d e p loy a n ot h e r c l o s u re d e v i c e o r p l ace a n occ l u s ive sheath a n d p roceed with o p e n convers i o n o f
t h e fe m o ra l a rtery c l o s u re u n d e r m o re contro l led c i rc u m stances.
R u ptu res • O utco m e s a re vastly i m p roved w h e n REVA R p rotoc o l s a re esta b l ished and p ra cticed. Abdom i n a l c o m p a rt­
m e n t syn d ro m e i s a rea l a n d freq u e nt com p l i cation fo l l ow i n g R EVAR-if t h e re i s any i n d i cation that ven­
t i l at i o n p ressu res a re rising o r a b d o m i n a l p ressu res a re s i g n ificantly e l evated at t h e e n d of t h e p roced u re
by measu r i n g b l a d d e r p ressu re, strong c o n s i d e ration s h o u l d be g iven to d e co m p ressive l a p a rotomy at t h e
i n it i a l sett i n g .

POSTOPERATIVE CARE
• Patients should remain supine for a minimum of 3 hours
and are free to ambulate thereafter. Most elective EVARs can
be discharged on postoperative day 1 or 2. For cases well
within the IFU, same-day surgery is now a reality and can
safely be offered to patients who can remain in reasonably
close proximity to the hospital the evening after surgery.
• Following REVAR, consideration should be given to de­
compressive laparotomy whenever abdominal pressures are
elevated at the end of the initial procedure. When decompres­
sive laparotomy is performed, free peritoneal blood should
be evacuated but retroperitoneal hematomas should not be
explored or evacuated. Abdominal wound suction systems
should be deployed to control drainage and provide a moist
environment for intestinal viability. Dressing changes should
be performed daily or every other day until the wound can
be safely closed.
• Initial postprocedural CT aortography is performed at
1 month to document presence or absence of endoleaks
201 4 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY
FIG 9 • Posto pe rative i m a g i n g . 3-D reconstruct i o n of a CT
a o rtog r a m in a patient w h o h a ve u n d e r g o n e su ccessf u l EVA R at
1 month fo l l ow-u p .
and graft position and confirm visceral perfusion ( FIG 9) .
Follow-up imaging i s performed with either ultrasound + / ­
noncontrast CT scanning or by CT aortography, based on
the last known status of endoleaks (presence or absence ) ,
symptomatic status, a n d comorbid conditions such a s
chronic renal insufficiency. I n general, w e prefer serial ultra­
sound evaluations, with CT scanning reserved for aneurysms
which are enlarging following endografting or evidence of
significant changes in endoleak volume or location.
OUTCOMES
• All-cause mortality is similar in patients undergoing open or
EVAR for AAA at 2 years.3•8• 9
• There is higher perioperative survival in patients undergoing
EVAR, which is sustained for several years. 3 The loss of this
is due to late ruptures in the EVAR group.
• Secondary interventions are similar in open and EVAR.3
COMPLICATIONS
• Endoleak
• Delayed rupture
• Renal dysfunction
• Thromboembolism
• Limb occlusion
• Colon ischemia
• Abdominal compartment syndrome (ruptured EVAR)
REFERENCES
1. Chaikof EL, Brewster DC, Dalman RL, et al. The care of patients
with an abdominal aortic aneurysm: the Society for Vascular Sur­
gery practice guidelines: executive summary. J Vase Surg. 2009;50(4):
880-896.
2. Lederle FA, Johnson GR, Wilson SE, et al. Rupture rate of large ab­
dominal aortic aneurysms in patients refusing or unfit for elective re­
pair. ]AMA. 2002;287(22):2968-2272.
3. Lederle FA, Freischlag JA, Kyriakides TC, et al. Long-term compari­
son of endovascular and open repair of abdominal aortic aneurysm.
N Eng/ ] Med. 2012;367(21):188-197.
4. Lindholt JS, Norman PE. Meta-analysis of postoperative mortality
after elective repair of abdominal aortic aneurysms detected by screen­
ing. Br J Surg. 2011;98(5):619-622.
5. Guirguis-Blake JM, Beil TL. Ultrasonography screening for abdominal
aortic aneurysms: a systematic evidence review for the U.S. Preventive
Services Task Force. Ann Intern Med. 2014;160(5):321-329.
6. Mehta M. Endovascular aneurysm repair for the ruptured abdominal
aortic aneurysm: the Albany Vascular Group approach. J Vase Surg.
2010;52(6):1706-1712.
7. Lee JT, Ullery BW, Zarins CK, et al. EVAR deployment in anatomi­
cally challenging necks outside the IFU. Eur J Vase Endovase Surg.
2013;46(1):65-73.
8. De Bruin JL, Baas AF, Buth J, et al. Long-term outcome of open or en­
dovascular repair of abdominal aortic aneurysm. N Eng/ J Med. 2010;
362:1881-1889.
9. Greenhalgh M, Allison OJ, Bell PRF, et al. Endovascular versus open
repair of abdominal aortic aneurysm. The United Kingdom EVAR
Trial Investigators. N Eng/ J Med. 2010;362:1863-1871.

Chapter 24 Advanced Aneurysm
Management Techniques:
Management of Internal
I liac Aneurysm Disease
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - "1 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
W Anthony Lee
DEFINITION
• Iliac aneurysm is defined as an iliac artery whose diameter is
20 mm or more. Iliac aneurysms are present in up to 2 0 % of
abdominal aortic aneurysms, 1 and common iliac aneurysms
occur far more frequently than internal iliac aneurysms.
• Isolated iliac aneurysms represent less than 5% of all aor­
toiliac aneurysms.
• External iliac aneurysms are extremely rare and mostly
either associated with underlying connective tissue disorders
or represent traumatic pseudoaneurysms.
DIFFERENTIAL DIAGNOSIS
• Differential diagnoses of iliac aneurysm are limited to true
degenerative aneurysms, which are most common; mycotic,
traumatic, or surgical pseudoaneurysms; or aneurysmal en­
largement of the false lumen from a primary dissection.
PATIENT HISTORY
AND PHYSICAL FINDINGS
• Most iliac aneurysms are clinically silent ( asymptomatic) .
Rarely, i n very thin individuals with large aneurysms, a pul­
satile aneurysm may be palpable on physical examination.
Even more rarely, a patient being evaluated for hydroureter
may be determined to have an iliac aneurysm. Ureteral ob­
struction in this circumstance derives from perianeurysmal
inflammation (similar to retroperitoneal fibrosis) rather than
mechanical compression by the aneurysm.
IMAGING AND
OTHER DIAGNOSTIC STUDIES
• Although a plain abdominal x-ray can detect an aortoiliac
aneurysm if there is heavy mural calcification, the most
common imaging modalities include ultrasound, computed
tomography (CT), and magnetic resonance imaging (MRI ) .
• Thin-cut ( 1 mm), intravenous contrast-enhanced, spiral C T (CT
arteriogram) represents the "gold standard" for diagnosis and
anatomic evaluation of abdominal aneurysms. Even in patients
with stage III/IV chronic kidney disease, high-qualiry imag­
ing may be obtained relatively safely using reduced volumes
of isoosmolar, nonionic contrast with multidetector (32, 64,
128, or 220) scanners, particularly following preprocedural
intravenous hydration. The CT dataset is rendered into three­
dimensional (3-D) images for dimensional postprocessing, a
critical requirement for complex endovascular case planning.
• Conventional arteriography adds little to the identification
and analysis of iliac aneurysms; penetrating ulcers may
appear like saccular aneurysms, and large aneurysms with
I
�
circumferential mural thrombus may appear to have a nor­
mal contour.
SURGICAL MANAGEMENT
• In general, iliac aneurysms are repaired when they reach
30 mm in diameter, become symptomatic, or rupture.
• Due to the relatively inaccessible location of iliac aneurysms,
situated deep in the pelvis, as well as densely adherent pel­
vic veins posterior to the arteries and frequent co-occurrence
of calcific occlusive disease, conventional surgical repair is
challenging and fraught with risk of significant hemorrhage.
Thus, evolving endovascular methods of repair have largely
supplanted open surgical reconstruction.
• A variety of off-label devices and hybrid techniques have been
applied to iliac aneurysm management. The variabiliry derives,
in large part, from uncertainty regarding the need to preserve
antegrade internal iliac artery flow in most patients. Indica­
tions for internal iliac preservation remain controversial due to
the added complexity, cost, and uncertain benefit derived from
such procedures; analysis of the relative merits of intentional
unilateral occlusion versus preservation in the management of
iliac aneurysm disease is beyond the scope of this chapter.
Preoperative Planning
• As in all things endovascular, high-quality imaging is critical
for precase planning and, as previously mentioned, CT arte­
riography is optimal for this purpose. Using a combination
of axial imaging and 3-D postprocessing, complete evalua­
tion should, note the following:
Locations, diameter, and length of proximal and distal
landing zones
Iliac artery tortuosity and angulation
Presence and severity of associated occlusive disease
Ipsilateral and contralateral internal iliac artery patency
Status of the ipsilateral deep femoral artery
Concomitant abdominal or thoracic aortic pathology
• In general, landing zones are sited in nonaneurysmal arterial seg­
ments, manifesting minimal occlusive disease, with relative ab­
sence of angulation or tortuosiry. The allowable diameter range
for treatment may vary, depending on the particular device to be
deployed. In all circumstances, reference should be made to the
"Instructions for Use" included in tlte package insert.
• Device selection is based on the need for durable aneurysm
exclusion and endograft fixation, accomplished with the
fewest component pieces possible.
• This chapter focuses on endovascular and hybrid manage­
ment strategies for the iliac bifurcation in the context of large
common or internal iliac aneurysms. Standard techniques suf­
fice for management of smaller ( <24 mm) aneurysms that do
201 5
201 6 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY
not involve the bifurcation, either in isolation or associ­
ated with larger proximal aortic aneurysms.
Positioning
• Nearly all endovascular aortoiliac aneurysm repairs are per­
formed with the patient in the supine position, with both
arms tucked. The operative team stands on the patient's right,
with the C-arm brought in from the left. Although some
ENDOVASCULAR COMMON ILIAC
ARTERY ANEURYSM REPAIR WITH
INTERNAL ILIAC ARTERY OCCLUSION
• After o bta i n i ng b i l atera l fem o r a l access, a s h e p h e rd 's
hook-type (e.g., O m n iTM F l ush) side-hole catheter is a d ­
vanced f r o m the contra l atera l s i d e for p e l v i c a rter i o g ra­
phy. Typical i njection tech n i q u e is 10 to 15 m l contrast at
1 5 ml per seco n d . Following satisfactory a n at o m i c d e l i nea­
tion, a steera b l e hydro p h i l ic 0.035 g u i dewire (e . g ., a n g l e d
G l idewi re®, Ter u m o) is advanced t h r o u g h the sa m e cath­
eter i nto the i p s i l atera l exter n a l i l i a c a rtery. F o l l ow i n g
exc h a n g e for a stiffer g u idewire ( e . g . , Rosen®), the f l u s h
catheter a n d contra l atera l femora l sh eath a re removed
a n d replaced with a 45-cm 6-French (Fr) g u id e sheath (e. g .,
B a l ka n ® or s i m i l a r braided sheath), posit i o n i n g the t i p i n
t h e d i sta l t h i rd o f t h e common i l ia c a n e u rysm (FIG 1 ).
• A 65-cm 4-Fr a n g l e d catheter (e . g . , K u m pe®) is advanced
through t h e sheath a n d, u nd e r d i g it a l s u btract i o n road­
m a p p i n g g u i d a nce, d i rects t h e hyd ro p h i l i c g u i dewire i nto
6-Fr x 45-cm sheath
Flush port
FIG 1 • A 45-cm, 6-Fr g u i d e sheath i s i ntrod u ced from t h e
contra late r a l fe m o ra l access. T h i s p rovi des a sta b l e p l atfo rm
for i nte rva l a n g i o g ra p hy, s e l ective cath ete rization, a n d co i l
e m b o l ization o f t h e i ntern a l i l i a c a rte ry.
operators prefer to access the left groin from the left side
of the table, for a right-handed operator, it is ergonomically
more natural to access both groins from the right.
• Electrocardiogram (EKG) leads and other monitoring
cables and lines are positioned so that they are not in the
x-ray beam and do not entangle the C-arm gantry.
• The left arm should be available for brachial artery
access when necessary; it is not routinely prepped into
the surgical field.
t h e i ps i latera l i n t e r n a l i l i a c a rtery (FIG 2) . T h e cath eter i s
t h e n adva n ced securely i nto e i t h e r t h e a nterior o r poste­
r i o r d iv i s i o n s . The C-a rm g a ntry i s positioned at a p p roxi­
mately 30 deg rees contra latera l a nterior-o b l i q u e for
opti m a l visu a l i zation d u r i n g this m a n e uver. With access
secured, the 6-Fr s h eath i s then adva nced over the 4-Fr
catheter i nto the proxi m a l i ntern a l i l i a c a rtery.
• A sel ective i nt e r n a l i l i a c a rte r i o g r a m is obta i ned t h r o u g h
the 6-Fr s h e a t h , a n d t h e a n g l e catheter i s retracted to t h e
fi rst b i f u rcat i o n of the i nt e r n a l i l i a c a rte ry. Typ i c a l ly, d i sta l
access is m a i nt a i n e d with the w i re d u r i n g t h i s m a n euver.
• [Altern ate tech n i q ue] D e pe n d i n g on a nato m i c consid­
erat i o n s (e . g . , tortu osity, i l i a c b i f u rcation a n g l e, i nter­
n a l i l i a c b r a n c h a n ato my, etc.), i p s i l ateral access may be
6-Fr x 45-cm sheath
4-Fr x65-cm
catheter
Flush port
FIG 2 • A 65-cm, 4-Fr a n g led catheter i s used to sel ectively
engage t h e i ntern a l i l i a c a rte ry. Typ i c a l ly, t h e catheter is used in
com b i nation with a soft-t i p ped a n g l e d hyd ro p h i l i c g u idewire.
After the g u i dewire crosses t h e origin of t h e i ntern a l i l i a c
a rte ry, it i s adva n ced deep i nto a n y o n e of i t s d i st a l branches,
a n d the catheter adva n ced over the g u idewire. The hyd rop h i l ic
g u i dewire is re m oved, a n d an a n g iogram is perfo rmed
through the catheter to confirm correct position i n t h e m a i n
t r u n k o f t h e i nte r n a l i l ia c a rte ry. The 6 - F r g u i d e sheath m a y b e
opti o n a l ly adva n ced closer t o t h e o r i g i n o f t h e a rtery before
re m ovi n g the g u idewire to g a i n a d d i ti o n a l sta b i l ity.
 C h a pter 24 ADVANCED ANEURYSM MANAGEMENT TECHNIQUES 201 7

A B
FIG 3 • A.B. W h e n u s i n g t h e i p s i l ateral a p p roach, a va r i ety of catheter s h a pes may be used d e p e n d i n g on t h e a n g l e of t h e
i nterna l-extern a l i l i a c bifu rcation a n d t h e l u m i n a l d i a meter of t h e c o m m o n i l i a c a n e u rysm . The th ree m ost u sefu l a re t h e
s h e p h e rd 's h o o k, Cobra®, a n d rig ht-a n g l e cu rved catheters.

fea s i b l e . In this case, a 2 5-cm, 6-Fr sheath i s advanced

from t h e i p s i latera l fe m o r a l a rte ry. A 4- o r 5-Fr a p p ro­
p r i ately s h a ped catheter (cu rve o r reverse c u rve) d i rects
the hyd ro p h i l i c g u idewi re i nto the i ntern a l i l ia c a rtery
(FIG 3) . If a s h e p h e rd 's hook catheter type is e m p l oyed,
t h e hook may be refo rmed e i t h e r i n t h e i l i a c a n e u rysm
o r in the a o rta, d e p e n d i n g o n t h e i r respective l u m i n a l 6 - F r x 45-cm sheath
d i a m eters. T h e i p s i l atera l a p proach i s more d e m a n d i n g
tech n ica l ly a n d i s n ot reco m m e n d e d w h e n conco m itant
catheter
i ntern a l i l i a c a n e u rysm e m b o l ization i s a l so i n d i cate d .
• S i ze-a ppropriate p lati n u m occ l u s i o n coils a re d e p l oyed
through the 4-Fr catheter i nto the m a i n i ntern a l i l iac a rtery
tru n k, with care taken to avo i d p l acement or d ista l m i g ra­
tion i nto arborizing branches or reflux back i nto the m a i n
i l iac ci rcu lation. Alternative vascu l a r occlusion d evices may
a lso be used for inte r n a l i l iac e m b o l ization, i n c l u d i n g hy­
d rogel co i l s a n d n i t i n o l mesh (e.g., A m p l atzer®) p l ugs. I n ­
terva l a rteriograms a re o bta i n e d u s i n g sma l l vo l u m e h a n d
i njections through the sheath o r catheter t o g u i d e d e p l oy­
ment a n d confirm positi o n i n g . Co m p l ete occl usion of the
target a rtery d u ri n g d e p l oyment is n ot necessa ry or even
desira b l e . Following s u bsequent endog raft d e p l oyment
over the i ntern a l i l iac a rtery orifice, i n the a bsence of a nte­
g ra d e fl ow, the extensive su rface a rea of the coi l s i n d uces
ra p i d t h rom bosis fo l l owi n g reversa l of a nticoa g u lation at
the e n d of the p roce d u re . U s u a l l y l ess than five co i l s wi l l
suffice t o u lt i m ately i n d uce com p l ete occ l u s i o n .
• [Alternate tech n i q ue] The p resence of an i ntern a l i l i ac
FIG 4 • In the sett i n g of i psi latera l concom itant i ntern a l i l i a c
a n e u rysm treat m ent, the contra late r a l a p p roach s h o u l d be
a n e u rysm, either with o r without a n associated p roxi m a l
used, and g u i d e s h eath advanced we l l with i n t h e i ntern a l
common i l iac a n e u rysm, deserves speci a l considerat i o n . I n
i l i a c a rtery itself. I n d ivid u a l branches a r i s i n g from t h e i ntern a l
these situations, m o re exten sive e m b o l ization o f t h e i nter­ i l i a c a n e u rysm m a y p rove d iffi c u l t t o i d e n tify a n d cath ete rize.
n a l i l ia c circulation w i l l be n ecessa ry to p revent retro g rade M u lt i p l e p roj ect i o n s of t h e C-a rm g a ntry, both in lateral o b l i q u e
(type I I) endoleak. I n d iv i d u a l i ntern a l i l ia c branches m ust a n d c ra n ioca u d a l d i rect i o n s, s h o u l d be e m p l oyed to visu a l i ze t h e
be sepa rately e m b o l ized at the i n it i a l p roce d u re (FIG 4). branches.
201 8 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY
If l eft u ntreated, d u e to co l l atera l pelvic flow, these
branches u nfortu nately re m a i n patent fo l l owi n g endo­
g raft d e p l oyme nt, seve rely l i m it i n g options for seco n d a ry
p roced u res. Com p l ete branch vessel e m b o l ization ca n be
time consu m i n g a n d ted i ous, due to the sheer n u m ber,
a n atomy a n d sizes of the branches that m u st be occ l u d ed,
req u i r i n g patie n ce, expert catheter and g u idewire s k i l ls,
and exce l l ent i ntraoperative i m a g i n g .
• [Alte rn ate tech n i q ue] W h e n t h e co m m o n i l i a c a n e u rysm
tapers to a f u n n e l n e a r t h e i l i a c b i f u rcat i o n , t h e so-ca l l ed
s l e eve tech n i q u e may be e m p l oyed to occl u d e t h e adja­
cent i nt e r n a l i l i a c a rte ry. I n this method a n a p p ro p r i ately
s i zed a o rt i c cuff i s d e p l oyed i nto t h e d ista l co m m o n i l i a c
a rtery a n d o v e r t h e i nt e r n a l i l i a c a rtery o r i g i n . The d ista l
e n d of t h i s cuff is pa rti a l ly extended i nto t h e exte r n a l
i l i a c a rte ry. The i l i a c l i m b i s n ext passed t h r o u g h t h e a o r-
t i c cuff a n d d e p l oyed n o r m a l ly from its proxi m a l l a n d -
i n g z o n e a n d i nto t h e exte r n a l i l i a c a rtery 20 m m d ista l
to t h e a o rt i c cuff (FIG 5) . The p utative b e n efit of t h i s
tech n i q u e is avo i d a nce of pote nti a l atheroe m b o l ization
that may occ u r d u r i n g sta n d a rd co i l occ l u s i o n tech n i q ues
from catheter m a n i p u lation, which s o m e spec u l ate i s t h e
cause of isch e m i c co m p l icat i o n s fo l l ow i n g i ntern a l i l i a c
a rtery occl u s i o n .
• F o l l o w i n g i ntern a l i l i a c occ l u s i o n , s u bsequent a n e u rysm
exc l u s i o n p roced u res va ry as f u n ct i o n s of l a n d i n g zone
Proximal end of il iac
l i m b partially deployed
Aortic cuff
Distal end of il iac limb
in the external i l iac artery
FIG 5 • N ote that in t h i s tech n i q ue, t h e d ista l segment of
the co m m o n i l i a c a n e u rysm m u st f u n n e l down so that t h e
a o rtic cuff w i l l c o a p t sec u re l y a g a i nst t h e i ntern a l i l i a c orifice.
The a o rt i c cuff should be expa n d e d fo l l owi n g d e p l oyment
with a com p l i a nt m o l d i n g b a l l o o n to securely seat i n position
to prevent s u bseq u e n t i n a dvertent d is l o d g e m e n t w h e n
adva n c i n g t h e i l i a c l i m b d e l ivery syste m .
and a n e u rysm a n atomy. E n d o g raft d e p l oyment nea rly
a l ways fo l l ows m a n a g e m e nt of t h e i ntern a l i l i a c a rtery
in some form or a n other. In t h e typ ica l sce n a rio, fo l l ow­
ing i nte r n a l i l i a c e m b o l ization, the e n d o g raft posit i o n ­
i n g a n d d e p l oyment proceeds i n t h e sta n d a rd fas h i o n
except f o r exte n s i o n of t h e i ps i l atera l d i sta l l a n d i n g z o n e
beyo n d t h e i l i a c b i f u rcat i o n to t h e exte r n a l i l i a c a rte ry.
At l e a st 20 m m of p u rchase i nto t h e exte r n a l i l i a c a rtery
is reco m m e n d e d .
• I n t h e u n us u a l case of an isol ated c o m m o n i l i a c a n e u ­
rysm without a o rtic i nvolve m e nt, w i t h a proxi m a l u n i n ­
volved seg m e nt at l e a st 20 mm i n d i a m eter a n d 1 5 m m
i n l e n gth, a s h o rt e n d o g raft m a y be d e p l oyed t o b r i d g e
t h e prox i m a l c o m m o n a n d exte r n a l i l i a c a rteries. 2 Device
o pt i o n s fo r this a p p roach i n c l u d e either t h e " off- l a b e l "
d e p l oy m e nt o f a n a o rto u n i i l i a c converter g raft o r p l ace­
m e n t of a f l a red o r " b e l l botto m " i l i a c e n d o g raft l i m b
that h a s been p revi o u s l y d e p l oyed, reve rsed, a n d re­
loaded i nto the d e l ivery sheath at the back ta b l e (way
off- l a be l ) . These a d a ptati o n s a re often necess a ry because
a lt h o u g h n o n a n e u rysm a l , t h e common i l i a c a rtery i s sti l l
too l a rg e t o securely seat t h e p roxi m a l e n d o f m ost i l i a c
l i m bs. To o bta i n a satisfactory proxi m a l seal, t h e d ista l
f l a red seg m e nt, co m m o n ly ava i l a b l e i n d i a m eters u p to
24 mm, i s d e p l oyed p roxi m a l ly by s i m p l y revers i n g t h e
l i m b i n t h e s h e a t h (FIG 6) .
>15 m m length
Embol ization coils
FIG 6 • Not a l l e n d o g raft syste m s have an a o rto u n i i l i a c
device o r converter. S i m i l a r ly, n o t a l l e n d o g rafts c a n b e
d e p l oyed ex vivo a n d resheat h e d . Cu rrently, t h e o n l y system
i s t h e Zenith F l ex® (Cook, B l o o m i ngton, IN). I f t h e o r i g i n of
t h e contra late r a l com m o n i l i a c a rtery i s p a rt i a l ly covered
and flow co m p rom ised for any reason, a bare meta l b a l l o o n ­
expa n d a b l e ste nt s h o u l d be d e p l oyed i n a " kiss i n g " m a n n e r.
 C h a pter 24 ADVANCED ANEURYSM MANAGEMENT TECHNIQUES 201 9

ENDOVASCULAR COMMON ILIAC spea k i n g , cuff d e p l oyment is essent i a l ly i n t h e a n e u ­

rysm itself; l ate outcomes f r o m t h e s e proce d u res a p p e a r
ARTERY ANEURYSM REPAIR WITH
favo ra b l e, w i t h a l ow re p o rted i n c i d e n ce of m i g ration o r
INTERNAL ILIAC PRESERVATION type l b e n d o l e a k .
• D i rect i ntern a l i l ia c a rtery revasc u l a rization can a l so be
• These tech n i q ues specifica l l y perta i n to c o m m o n i l i a c
acco m p l ished by s u rg i c a l bypass from o r tra nsposition to
a n e u rysms without a n associ ated i ps i latera l i nt e r n a l
the i p s i l atera l exter n a l i l i a c a rtery d i st a l to the i p s i l atera l
i l i a c a n e u rysm . I n c a s e s o f a n i ntern a l i l i a c a n e u rysm (see
e n d o g raft l i m b . Like a l l o p e n vasc u l a r p roced u res, expo­
except i o n b e l ow), preservati o n methods a re not poss i b l e
s u re i s t h e m ost critica l req u i re m e n t for tec h n i c a l s u ccess.
a n d sel ective b r a n c h occ l u s i o n (see a bove) a n d e n d ovas­
• Proper i n c i s i o n placement and entry i nto the retro peri­
c u l a r exc l u s i o n a re n ecessa ry.
tonea l space i s tanta m o u nt to g a i n i n g a d e q u ate a n d
• I n d icat i o n s for i ntern a l i l i a c a rtery preservati o n may
safe i l i a c b i f u rcation exposure a n d m i n i m i z i n g post­
i n c l u d e t h e fo l l owi n g :
ope rative d i scomfort. For these exposu res, the p r i m a ry
• Routi n e revasc u l a rization as p roced u r a l p refe rence
s u rg e o n sta n d s on opposite s i d e of t h e ta b l e . The i n c i ­
• The p resence of contra l atera l intern a l i l i a c occl u s i o n
s i o n is centered ove r e i t h e r l ower q u a d ra n t a n d sta rts
• Active patient with concern/pote ntia I for b uttock
at a p a ra m e d i a n location at l evel of t h e u m b i l i cus a n d
c l a u d ication
gently c u rves toward t h e m i d l i ne over t h e fi rst t h i rd of
• D i a betic with d i seased i p s i l ateral d e e p fe m o r a l
the d i stance from the u m b i l icus to the sym p hysis p u b i s
a rtery (re d u ce d pote n t i a l co l l atera l s u p p ly)
(FIG 8) . Exposu re p roceeds t h r o u g h t h e a nterior rectus
• P r i o r t h o racic e n d o g raft repa i r (concern reg a rd i n g
sheath fo l l ow i n g t h e hockey-stick shape of t h e skin i n c i ­
a nterior s p i n a l a rtery co l l atera l flow a r i s i n g from
s i o n . Care i s taken not to d iv i d e t h e rect u s m uscle-t h i s i s
t h e i ntern a l i l i a c c i r c u l a t i o n and pote n t i a l for post­
a com p l ete " m uscl e-spa r i n g " tech n i q u e . The s h eath itse lf
o p e rative p a r a p l e g i a )
i s i n cised at l e a st 3 to 5 em m e d i a l to t h e se m i l u n a r l i n e .
• The s i m p l est i ntern a l i l i a c p reservation tech n i q u e i n ­
Kee p i n g t h e rectus m uscle i ntact red u ces i n ci s i o n a l h e r­
volves d e p l oyment of f l a red o r so-ca l l ed b e l l - bottom d e ­
n i a r i s k a n d decreases posto perative p a i n .
v i c e s . Alth o u g h a n ecd ota l l y a p p l ied to l a rg e r a n e u rysms,
• The rect u s m uscle is d issected away from t h e sheath
conventi o n a l ly, t h i s tech n i q u e is l i m ited to c o m m o n i l i a c
and retracted m e d i a l ly. The retroperito n e a l space is
a rtery a n e u rysms with 24- m m o r s h o rter d i a m eter d is­
deve l o ped below t h e a rcu ate l i n e (linea s e m i c i rc u l a ris)
t a l l a n d i n g zones. As an off- l a b e l m o d ification of t h i s
j ust s u p e r i o r to the i nfe r i o r e p i g astric vesse ls, w h i c h a re
tech n i q ue, f o r com m o n i l i a c a n e u rysms w i t h l a rg e r o r
p o o r l y defi ned d i sta l l a n d i n g zon es, t h e maxi m a l d i a m ­
e t e r f l a red i l i a c l i m b i s i ntent i o n a l l y d e p l oyed a p p roxi­
mately 2 e m p roxi m a l to t h e i ntern a l i l i a c a rtery orifice.
An a o rt i c exte n s i o n cuff without a p roxi m a l u n cove red
ste nt (typ i ca l ly 28 mm) i s then d e p l oyed h a lfway i nto
the u nsecured i l i a c l i m b a n d f l a red out i nto the d ista l
a n e u rysm, essent i a l ly creat i n g a l a r g e r l a n d i n g zone t h a n
t h a t conventi o n a l ly ava i l a b l e (FIG 7) . Alth o u g h strictly

Lateral border of
rectus sheath �
I

I
I
I
\
\
,_

FIG 8 • I n some patients, t h e d ista nce betwee n t h e

FIG 7 • In this i n st a n ce, t h e patient had b i l atera l c o m m o n
i l i a c a n e u rysms. The r i g h t s i d e was l a rg e a n d l eft was s m a l l e r.
The r i g ht i nt e r n a l i l i a c a rtery was occ l u d ed a n d the i l i a c
l i m b extended to t h e exte r n a l i l i a c a rte ry. The b e l l - botto m
tech n i q u e was a b l e to be used for t h e s m a l l e r l eft c o m m o n
i l i a c a n e u rysm b e c a u s e it was o n l y 24 m m .
u m b i l i cus a n d t h e sym p hysis p u b i s may be q u ite s h o rt . If so,
the l o n g it u d i n a l segment of the i n c i s i o n i s exten d e d more
i nfe riorly than d e p i cted i n this d ia g r a m . The m ost i m p o rtant
tec h n i c a l p o i n t of t h i s exposure i s to p l a ce t h e i n c i s i o n
suffi c i e ntly m e d i a l ly as t h e late ra l b o r d e r of t h e rect u s s h eath
i s not p a l p a b l e and t h e re a re n o obvious s u rface l a n d m a rks.
2020 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

preserved a n d g e ntly swept i nferio rly. In w o m e n without

p r i o r hyste rectomy, t h e ro u n d l i g a m e n t of t h e uterus i s
often encou ntered as a f i b r o u s c o r d d u r i n g t h i s exposure
and is d ivided betwee n ties. The perito n e a l sac i s swept
b l u ntly m e d i a l l y u n t i l the exte r n a l i l i a c a rtery a n d t h e
d ista l h a lf of t h e co m m o n i l ia c a n e u rysm a re expose d .
The u reter i s v i s u a l ized cross i n g t h e i l i a c a rtery a n d
s h o u l d be l eft u n d i st u rbed . Self- reta i n i n g retractors (e . g . ,
Bookwalter®) a re p l aced at t h i s poi nt.
• C h o i ce of retractors a n d proper p l acement a re esse n t i a l
for proced u ra l s u ccess. The retractor p o s t i s p l aced o n
t h e o p posite s i d e a bout t h e l e v e l of t h e costa l m a rg i n,
a n d a s m a l l r o u n d r i n g is fixed a n d centered d i rectly over
t h e i n c i s i o n . A B a lfour® b l a d e i s p l aced ove r t h e i n g u i n a l I ntraluminal stent
l i g a m e nt, a n d a m ed i u m Kel ly® b l a d e o r i e nted toward
t h e o p posite s h o u l d e r. A n a rrow m a l l e a b l e b l a d e i s ori-
e nted m ed i a l ly to retract t h e b l a d d e r. Fol lowi n g retrac-
tor p l a c e m e nt, if the i n c i s i o n was sited properly, the i l i a c
b i f u rcation s h o u l d be posit i o n e d d i rectly i n t h e c e n t e r o f
the surgical field.
• The m i dsegment of t h e exte r n a l i l i a c a rtery is exposed
and contro l l e d . The i nt e r n a l i l i a c a rtery i s n ext isol ated
from t h e s u r ro u n d i n g tissue, from its o r i g i n to t h e b i f u r­
cat i o n of t h e a nterior a n d poste r i o r d iv i s i o n s, w h i c h a re
FIG 10 • A n 8 - m m g raft i s a n asto mosed to t h e d i sta l e n d
of t h e i nt e rn a l i l i a c a rt e ry fi rst. D u e to t h e d e e p n a t u re
i n d iv i d u a l l y contro l l e d . No atte m pt s h o u l d be m a d e to
of t h i s a rte ry, t h i s a n asto m o s i s ca n be d i ffi c u l t . An o p e n
expose a n yt h i n g m o re t h a n a s m a l l a nterior aspect of t h e
( " p a ra c h ute " ) a n asto m o t i c tech n i q u e c a n b e h e l pf u l i n
d i st a l c o m m o n i l i a c a n e u rysm d u ri n g t h i s m a n e uver. v i s u a l i z i n g t h e s u t u re l i n e t h r o u g h o u t p l a c e m e n t . T h e
• The i ntern a l i l i a c a rtery o r i g i n is l i gated with a-polypro­ d i st a l a n asto m o s i s i s tested for h e m osta s i s a n d a n y l e a ks
pyl e n e sutu re, and the a nterior and poste r i o r d iv i s i o n s com p l et e l y r e p a i red before t h e p roxi m a l a n a sto m o s i s i s
of t h e i nt e r n a l i l i a c a rtery a re contro l led i n d e pe n d e ntly. p e rf o r m e d , a s t h e fo r m e r m a y b e d iffi c u lt to see o n c e
Ad d it i o n a l s m a l l branches a r i s i n g from t h e m a i n tru n k t h e l atter i s c o m p l eted . T h e exte r n a l i l i a c a n asto m os i s
a re c l i pped for h e m ostasis. T h e i ntern a l i l i a c a rtery i s i s p e rfo r m e d at l e a st 5 e m d i st a l to i t s o r i g i n a l o n g its
d ivided a s proxi m a l ly a s poss i b le, a n d t h e stu m p c l o s u re poste ro m e d i a l aspect.
is rei nforced a n d i m b r i cated with a 5-0 polypropy l e n e
sutu re (FIG 9) . The d i sta l i ntern a l i l i a c a rtery i s t h e n
m o b i l ized from t h e s u bjacent i ntern a l i l i a c ve i n . • A segment of t h e i ps i latera l , adjacent exte r n a l i l ia c
• The patient is system ica l ly a nticoa g u l ated at t h i s p o i nt. a rte ry, at least 5 em d ista l t o its o r i g i n , i s n ext m o b i l ized
An 8-mm x 1 0-cm g raft k n i tted, co l l a g e n - i m p re g n ated and contro l l e d . F o l l ow i n g creati o n of a poste rome­
polyester g raft i s a n a stomosed to t h e d ista l stu m p of the dial a rteriotomy, t h e g raft i s t r i m m e d and beve led to
i nt e r n a l i l i a c a rtery in a n e n d -to-e n d m a n n e r. The g raft l e n gth and a nastomosed to the exte r n a l i l i a c a rtery i n
i s occ l u d ed at its o p e n end a n d d i sta l control r e l eased to a n e n d -to-s i d e m a n n e r. T h e g raft i s f l u s h e d rout i n e ly a n d
test a n asto motic l e a ks . The g raft i s t h e n recontro l l ed j u st flow restored t o t h e i ntern a l a n d exte r n a l i l i a c a rteries
prox i m a l to t h e d ista l a n asto mosis. (FIG 1 0). 3
• A l a rg e c l i p is sewn tra n sve rsely at t h e h e e l of t h e
exte r n a l i l i a c a rtery a n asto mosis to esta b l ish a f i d u c i a l
p o i n t for t h e i ntern a l i l i a c bypass. After h e m ostas i s i s
confi rmed, t h e retracto r system i s rem oved a n d retro­
perito n e a l contents a l l owed to co l l a pse back i nto t h e
wo u n d . The e n d ovascu l a r p o rt i o n of t h e p roced u re c o m ­
p l eted t h r o u g h femora l a rtery a ccess s i t e s i n a sta n d a rd
fash i o n .
• After e n d o g raft d e p l oyment a n d satisfactory c o m p l e ­
t i o n a o rto g r a p hy, t h e retro perito n e u m i s r e i n spected f o r
h e m ostas i s fo l l owi n g reversa l of a nticoa g u lati o n . T h e
a nterior rectus sheath i s c l osed with a r u n n i n g 1 -0 PDS
sutu re, fo l l owed by c l o s u re of Sca rpa's layer and s k i n .
FIG 9 • W h e n t h e incision i s properly posit i o n e d , t h e i l i a c
• [Altern ate tech n i q ue] Occa s i o n a l ly, t h e co m m o n tru n k o f
b i f u rcat i o n s h o u l d be located d i rectly i n t h e c e n t e r of t h e
wo u n d . The c o m m o n i l i a c a n e u rysm i s m i n i m a l ly exposed t o t h e i ntern a l i l i a c a rte ry i s l o n g a n d r u n s p a ra l l e l to t h e
a l low t h e stu m p of t h e d ivided i nt e r n a l i l i a c a rtery to b e safe ly cou rse o f t h e exte r n a l i l i a c a rtery for some d ista nce. I f
oversewn . suffi cient l e n gth i s p resent, t h e i ntern a l i l i a c a rtery may
 C h a pter 24 ADVANCED ANEURYSM MANAGEMENT TECHNIQUES
FIG 11 • N ote that a n e n d ovasc u l a r exte r n a l -to-inte r n a l i l i a c
bypass h a s been created o n t h e r i g ht s i d e w h i c h a lso exc l u d es
t h e c o m m o n i l i a c a n e u rysm . The d u ra b i l ity of t h i s bypass i s
comprom ised g iven i t s re l i a nce o n retro g ra d e perfu s i o n
t h r o u g h t h e femora l-fe m o r a l bypass g raft, t h e a n g u lated
n a t u re of the g raft posit i o n , and t h e propensity for one o r
b o t h e n d s to " back out" o f t h e o r i g i n a n d ta rget a rteri es,
g iven s uffi c i e nt t i me, pressu re, a n d move m ent.
be tra n sposed to t h e exte r n a l i l i a c a rte ry, as l o n g as t h e
a n asto mosis i s tension-free.
• [Alte rn ate tech n i q ue] Another hybrid a p p roach i s ava i l ­
a b l e t o preserve i nt e r n a l i l i a c fl ow. I n t h i s method, a cov­
ered se lf-exp a n d i n g ste nt (e . g . , V i a b a h n®, W. L. G o re,
F l a g staff, AZ) is d e p l oyed to prov i d e retro g ra d e flow
from t h e exte r n a l to i nterna l i l i a c a rte ry, i ps i late ra l to t h e
c o m m o n i l i a c a n e u rysm to be excl u d e d . An a o rto u n i i l i a c
e n d o g raft is t h e n d e p l oyed from t h e contra l atera l s i d e,
a n d t h e p roce d u re co m p l eted with a fem o ra l-fe m o r a l
bypass g raft (FIG 1 1 ) . Seve r a l c i rc u m st a n ces l i m it t h e
A B
FIG 1 2 • Like a l l " c h i m ney" tech n i q ues, t h e p roxi m a l seal i s d e p e n d e n t o n t h e l e ngth of t h e p a ra l l e l seg m e nt. I n t h i s i nsta nce,
it s h o u l d be m o re than 5 em to promote t h ro m bosis of t h e " g utte rs" betwee n the p a ra l l e l ste nts. It i s not u n c o m m o n for a s m a l l
type I l l e n d o l e a k t o b e seen o n t h e co m p l et i o n a n g i og ra m with t h e patient a nticoa g u l ated.
2021
g e n e ra l a p p l i ca b i l ity of t h i s tech n i q ue, i n c l u d i n g a n
acute exte r n a l-inte r n a l i l i a c bifu rcati o n a n g l e a n d s i g ­
n ificant d i a m eter d i screpancy ( > 2 m m ) betwee n t h e two
a rteries. Al so, the d u ra b i l ity of t h i s tech n i q u e is not w e l l
esta b l ished a n d may be l i m ited b y t h e propensity of t h e
covered ste nt to back out of e i t h e r t h e o r i g i n o r dest i n a ­
t i o n a rtery o r k i n k . T h i s tech n i q u e a lso req u i res advanced
catheter and g u i dewire ski l l s and a l a rg e device i nven­
tory to re l i a b ly com p l ete t h e p roced u re .
• [Alte rn ate tech n i q ue] M o re rece ntly, a va riation of t h e
c h i m n ey (pa ra l l e l ) stenti n g tec h n i q u e h a s been d e ­
scribed for co m p l ete e n d ovascu l a r repa i r of c o m m o n
i l i a c a n e u rysms • I n t h i s tech n i q ue, t h e p roxi m a l brach i a l
a rtery i s exposed t h r o u g h a n axi l l a ry i n c i s i o n to a l l ow
safe i ntroduction of a l o n g (90 em) b r a i d e d 9-Fr sheath.
B ri efly, after t h e bifu rcated main body e n d o g raft i s de­
p l oyed, t h e l o n g 9-Fr sheath i s a dvanced from t h e l eft
b rach i a l a rte ry, t h ro u g h t h e m a i n body, a n d positioned
i nto t h e i p s i l atera l common i l i a c a rte ry. The i ntern a l
i l i a c a rtery is cat h ete rized, fo l l owed b y w i re exch a n g e
f o r a stiff w i r e . A covered se lf-exp a n d i n g stent g raft
(e . g ., V i a b a h n®), sized for the ta rget i nt e r n a l i l i a c a rtery
d i a m eter, is d e p l oyed from t h e i ps i latera l i l i a c g ate to t h e
i nt e r n a l i l i a c a rtery l a n d i n g z o n e . A seco n d covered self­
expa n d i n g ste nt g raft is adva n ced from t h e i p s i l atera l
fe m o r a l a rtery access retrog rade i nto t h e a n e u rysm a n d
p roxi m a l exte r n a l i l i a c a rtery a n d d e p l oyed at t h e s a m e
l evel as p r i o r i ntern a l i l i a c a rtery ste nt g raft. B o t h stent
g rafts a re expa n d e d with i n t h e i psi late r a l i l i a c l i m b of
t h e a o rt i c e n d o g raft u s i n g a kissi n g - ba l l oo n tec h n i q u e .
T h i s p roced u re can be repeated f o r t h e contra late r a l s i d e
i n cases o f b i l atera l co m m o n i l i a c a n e u rysms (FIG 1 2) .
Care s h o u l d be taken d u r i n g t h i s m a n e uver to d e p l oy
each ste nt g raft seq u e nt i a l ly, rath e r t h a n s i m u lta neously,
i n order to position t h e covered stents accu rate l y rel ative
to each other.
• [Altern ate tech n i q ue] Alth o u g h o n ly ava i l a b l e u n d e r
a n i nvest i g ati o n a l device exe m pt i o n ( I D E), U . S. Food
and Drug Ad m i n i stration (F DA)-a p p roved c l i n i c a l t r i a l
at t h e c u rrent t i me, a n i l i a c b r a n c h device ( I B D) i s u n d e r
2022 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

d eve l o p m e n t for tota l e n d ovasc u l a r repa i r of co m m o n

i l i a c a n e u rysms (FIG 1 3) . B ri efly, t h i s bifu rcated d evice i s
i n se rted i p s i latera l to t h e c o m m o n i l i a c a n e u rysm p r i o r t o
m a i n b o d y d e p l oyment. It i s d e s i g n e d to be used i n con­
j u nction with a sta n d a rd bifu rcated aortic e n d o g raft. The
p a rt i a l ly constra i n e d b r a n c h i n t h e i nvest i g at i o n a l device
and adjacent i nt e r n a l i l i a c a rtery a re cath ete rized from
t h e contra late r a l side e m p loyi n g a preloaded catheter i n
t h e d e l ivery syste m a n d cross-fe m o r a l g u i d ewire a ccess.
A b r i d g i n g cove red ste nt i s adva n ced from the b r a n c h to
the i ntern a l i l i a c a rte ry. F o l l o w i n g t h is, a sta n d a rd b i f u r­
cated e n d ovascu l a r a n e u rysm re p a i r is com p l eted i n t h e
usual manner s

FIG 1 3 • T h i s fig u re d e p i cts t h e I B D used i n t h e repa i r of a l eft

co m m o n i l i a c a n e u rysm . A covered ste nt is req u i red to b r i d g e t h e
i l i a c b r a n c h to t h e native i ntern a l i l i a c a rte ry. Alth o u g h t h i s b r i d g i n g
ste nt i s typica l ly d e l ivered from t h e contra latera l s i d e, it m a y a lso b e
i ntrod u ced t h r o u g h t h e l eft brach i a l a rte ry.

PEARLS AND PITFALLS

C hoose t h e r i g h t
p roced u re fo r t h e
r i g h t patient.
Exte r n a l -to- i ntern a l
i l i a c bypass exposure
Use a cross-over i nt ro­
d u c e r sheath for i nter­
n a l i l i a c e m b o l izati o n .
Pelvic b l ee d i n g
I nflow t o t h e i nt e r n a l
i l i a c bypass
• Alth o u g h perfu s i o n i s opti m a l ly m a i nt a i n e d to at least one i n t e r n a l i l i a c a rte ry, p reservat i o n s h o u l d be
atte m pted sel ectively, weig h i n g t h e risks and b e n efits of pote n t i a l isch e m i c co m p l icati o n s associated
with i ntenti o n a l occ l u s i o n vs. t h e a d d i ti o n a l co m p l exity and l o n g-term d u ra b i l ity issues associated with
p reservation tech n i q ues.
• M a ke s u re t h e l o n g it u d i n a l segment of t h e s k i n incision i s suffi c i e ntly m e d i a l to t h e l atera l e d g e of t h e
rect u s to acco m m o d ate a s i n g l e l a y e r fasc i a l closure. The p reserved rect u s m uscle p rovides a n a t u r a l
b a r r i e r a g a i n st posto pe rative a b d o m i n a l wa l l h e r n i a form a t i o n .
• The cross-over s h eath a l l ows f o r i nterm ittent contrast i nject i o n a n d sta b i l ization of t h e e m b o l i zation
cath eter. I nt e r n a l i l i a c sheath a ccess a lso m i n i m izes t h e proba b i l ity that d e p l oyed co i l s may refl ux retro­
g ra d e i nto the a x i a l i l i a c c i r c u l a t i o n , req u i ri n g ofte n p r o l o n g e d and frustrat i n g attem pts at retri eva l .
• T h e i ntern a l i l i a c ve i n i s poste r i o r a n d a d h e rent t o t h e a rtery a n d m a y be t h e sou rce s i g n ifica nt,
u n a nt i c i pated h e m o r r h a g e if i nj u red d u r i n g ci rcumferent i a l a rte r i a l d issect i o n .
• C hoose a s i t e on the exte r n a l i l i ac a rtery sufficiently d i sta l to i t s o r i g i n so t h a t the ste nt g raft ca n l a n d i n
a seg ment free from k i n k i n g a n d p revent subsequent deve l o p m ent o f a n i ps i latera l type l b e n d o l e a k .

POSTOPERATIVE CARE
• Postoperative care is similar to a standard endovascular
aneurysm repair. A complete blood count and a basic meta­
bolic panel are checked the following morning.
• If the procedure was performed entirely using endovascular
techniques, oral intake is started immediately, Foley catheter
is removed, and patient is encouraged to ambulate and dis­
charged on following postoperative day.
• If the procedure involved a surgical internal iliac revas­
cularization, the patient is started on clear liquids and
advanced as tolerated. The retroperitoneal approach is not
typically associated with a clinically significant ileus, and the
muscle-sparing exposure is well tolerated. Patients may be
discharged typically on the second postoperative day.
OUTCOMES
• Ipsilateral hip and buttock claudication develops in as
many as 4 0 % of patients following acute internal iliac ar­
tery occlusion. Fortunately, more severe forms of postpro­
cedural pelvic ischemia, although potentially lethal, occur
extremely rarely. Although claudication symptoms, when
present, are reported to improve within 6 months following
 C h a pter 24 ADVANCED ANEURYSM MANAGEMENT TECHNIQUES
the procedure, this improvement m a y be attributable t o life­
style alteration (e.g., walking less) rather than collateral ves­
sel formation. It is generally agreed, however, that complete
symptom resolution rarely occurs.
• Internal iliac bypass grafting (surgical or endovascular)
effectively maintains pelvic perfusion, with excellent long­
term patency. Most patients enjoy a symptom-free postop­
erative course in perpetuity. Thus, in active individuals, as a
general recommendation, internal iliac circulation should be
preserved whenever possible.
COMPLICATIONS
• Complications for management of common iliac aneurysms
can be a result of internal iliac revascularization or occlusion
techniques.
• The main complication associated with revascularization
is bleeding. This can occur intraoperatively from venous
injury and/or postoperative anastomotic or other arterial
sources. Other less common complications include ureteral
injury, bowel injury, ipsilateral leg ischemia, and early graft
thrombosis.
• Complications associated with acute occlusion of internal
iliac artery include the spectrum of ischemic symptoms
ranging from hip and buttock claudication to more severe
2 0 23
forms such as perineal necrosis, ischemic sacral plexopathy,
and vasculogenic impotence.
• The internal iliac artery serves as an important outflow
branch in maintaining patency of the iliac limb after
endovascular aneurysm repair. Iliac limbs whose distal land­
ing zone is placed in the external iliac artery may have an
increased risk of thrombosis. However, this is not an indica­
tion for any additional antiplatelet or anticoagulation treat­
ments beyond what is customary.
REFERENCES
1. Armon MP, Wenham PW, Whitaker SC, et al. Common iliac artery
aneurysms in patients with abdominal aortic aneurysms. Eur J Vase
Endovase Surg. 1998;15(3):255-257.
2. Boules TN, Selzer F, Stanziale SF, et al. Endovascular management of
isolated iliac artery aneurysms. j Vase Surg. 2006;44(1):29-37.
3. Lee WA, Nelson PR, Berceli SA, et al. Outcome after hypogastric
artery bypass and embolization during endovascular aneurysm repair.
j Vase Surg. 2006;44(6):1162-1168.
4. Lobato AC. Sandwich technique for aortoiliac aneurysms extending
to the internal iliac artery or isolated common/internal iliac artery
aneurysms: a new endovascular approach to preserve pelvic circula­
tion. J Endovase Ther. 2011;18(1):106-111.
5. Parlani G, Verzini F, De Rango P, et al. Long-term results of iliac an­
eurysm repair with iliac branched endograft: a 5-year experience on
100 consecutive cases. Eur] Vase Endovase Surg. 2012;43(3):287-292.
 -

Chapter 25 Occlusive Disease

Management: Isolated
Femoral Reconstruction,
Aortofemoral Open
Reconstruction, and Aortoiliac
Reconstruction with Femoral
Crossover for Limb Salvage
1
I
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ·

Na th a n /toga E. John Ha rris, Jr.

DEFINITION DIFFERENTIAL DIAGNOSIS

• Aortoiliac occlusive disease falls under the umbrella of pe­ • Neurogenic claudication is frequently confused for arterial
ripheral artery disease where atherosclerosis and chronic claudication. Neurogenic claudication is variable-some
plaque accumulation leads to diminished blood supply to good days, some bad-whereas arterial claudication is very
distal arterial beds. consistent. Neurogenic claudication can be relieved by the
• The aortic bifurcation near the level of the L4 disc space is use of spinal support while walking, such as a shopping cart,
one of many areas of decreased shear stress and is an area of or wheeled walker. These aids do not influence arterial clau­
early atherosclerosis. dication symptoms.
• Peripheral arterial disease (PAD ) is usually classified into in­ • Osteoarthritis of the hips can be frequently confused with
flow and outflow disease. arterial claudication. Like arterial claudication, pain is
• The infrarenal aorta and iliac vessels are of larger caliber brought on by activity and relieved by rest and is more com­
and are classified as inflow vessels. mon with increasing age.
• The infrainguinal outflow from the common femoral ar­ • Venous claudication from chronic venous outflow obstruc­
tery is via the profunda femoral and superficial femoral tion is described as a bursting type pain, comes on at longer
arteries . distances, requires a longer rest period that requires leg el­
• The patterns o f arterial stenosis a n d occlusion can be broken evation, and is frequently associated with leg swelling and
up into five types (Table 1 ) . When a combination of both discoloration.
inflow and outflow disease exists, treatment is focused on
the aortoiliac system first or femoral artery occlusive disease. PATIENT HISTORY AND PHYSICAL FINDINGS
Outflow occlusive disease is addressed in Part 6, Chapters
• The diagnosis of aortoiliac occlusive disease can readily be
26-2 8 , 3 1-3 3 .
made from a patient's clinical history and physical examination.
• Patient's with aortoiliac disease have up to a 5 0 % risk of
concomitant coronary artery disease with the same risk fac­
Table 1: Type of Lower Extremity Disease tors of smoking, hypertension, lipid abnormalities, diabetes
Patterns mellitus, male gender, increased age, and family history.
• The disease burden in the internal and external iliac blood
Distribution Notes
supply leads to a variety of clinical presentations which is
Type 1 Confi n e d to the d ista l infrarenal 1 0 % of disease patte rns­ most notable for Leriche syndrome which comprises the
aorta a n d common i l iac fou n d in younger fe m a l e symptoms of buttock claudication, impotence in men, mus­
arteries patie nts. Long-term patency
cle atrophy, and absent or diminished femoral pulses.
after bypass is lower when
d o n e i n patie nts <50 years Claudication is the most common presenting symptom
of age. and is not limited to the buttocks but can occur in the hip,
Type 2 Fou n d within i nfra ren a l a o rta, Most co m m o n presentation of thigh, and, rarely, in the calf muscles.
co m m o n a n d exte rnal i l i acs aorto i l i a c d isease
Impotence as an isolated symptom in men should be eval­
Type 3 Occl usive d isease in the Fo u n d com m o n l y i n critica l l i m b
aorto i l iac segment isch e m i a
uated for other possible causes. Impotence is only seen
is combined with in 3 0 % of men with decreased hypogastric perfusion as
femoropopl iteal or tibial there are abundant collaterals from the mesenteric, pro­
d isease. funda, and lumbar arteries.
Type 4 Isol ated s u p e rficia l fe moral a n d
Ankle-brachial indices (ABI) are usually diminished but
popl itea l a rtery
Type 5 Diffuse d isease in the fe moral rarely lower than 0.5 in isolated aortoiliac occlusive dis­
popl itea l a n d tibial vessels ease for the same reason cited earlier. It is rare to see criti­
cal limb ischemia, which encompasses rest pain and/or

2024
 C h a p t e r 25
tissue loss, i n the setting o f isolated aortoiliac disease a s
there are multiple collaterals through the ilioprofunda
system.
Severe common femoral disease, with both superficial
femoral and profunda femoral artery high-grade stenosis
or occlusion, can mimic aortoiliac occlusive disease.
IMAGING AND OTHER DIAGNOSTIC STUDIES
• Ultrasound studies available in noninvasive vascular labora­
tories can help aid in diagnosis and assess the degree of PAD .
• ABI measurements can be supplemented b y exercise, where
a decrease in 1 5 % of the ABI is considered significant as
a decrease in peripheral resistance during exercise leads
to diminished blood flow distal to the point of stenosis or
obstruction.
• Duplex ultrasound for the aortoiliac system is difficult and is
limited by body habitus and bowel gas. With an experienced
technician, arterial disease of the intraabdominal vessels can
be detected with greater sensitivity.
• For vascular surgeons, computed tomography angiography
( CTA) is the noninvasive imaging study of choice for pre­
operative planning. Considerations for kidney disease and
contrast dye allergies need to be taken into account. The
evaluation usually involves the abdomen pelvis and runoff
to the feet. It is difficult, especially in tall patients, to evalu­
ate the thoracic aorta during one contrast bolus due to tim­
ing of the contrast injection. A CTA study provides accurate
estimation of luminal flow and with good visualization of
degree of calcification.
• Magnetic resonance (MR) angiography is also useful but is
found to, at times, overestimate the degree of stenosis, and
motion artifacts may limit the quality of the study.
• Direct arteriography under fluoroscopy is considered the
gold standard, but improvements in CTA approach this
accuracy in evaluating PAD .
• Arteriography may be difficult in the setting of a n iliac occlu­
sion and may need to be performed through the descending
thoracic artery using a radial or brachial artery approach.
• Some surgeons may forego computed tomography ( CT)
studies and proceed with a contrast digital subtraction angio­
gram in the setting of a reliable history and physical and/or
noninvasive ultrasound testing. This may limit the amount of
contrast dye the patient is exposed to by proceeding directly
with endovascular intervention. Like CTA, catheter-based
arteriographic studies should include infrainguinal outflow
OCCLUSIVE D I S EASE MANAG E M E N T 2025
of the femoral, popliteal, and tibial vessels, in addition to the
abdominal and pelvic views.
• Although rarely used, pressure catheters can also be used
during arteriography to identify significant lesions with a
mean arterial pressure drop of 5 to 1 0 mm Hg across the
stenosis considered significant.
• Preoperative imaging is essential in preoperative planning.
The degree of aortoiliac disease in combination with infrain­
guinal and tibial occlusive disease needs to be considered in
choosing the appropriate intervention for the patient.
• Graft selection, location of cross-clamping, and enlarged
collaterals need to be accounted for prior to surgery.
• Identifying the degree and extent of arterial occlusive disease
also enlightens the decision between an open or endovascu­
lar approach.
• The Trans-Atlantic Inter-Society Consensus (TASC ) Classi­
fication ( FIG 1 ) is a multispecialty consensus approach to
managing aortoiliac occlusive disease. Routinely, TASC A
and B lesions are treated with endovascular approaches with
balloon angioplasty and/or scenting. TASC C and D lesions
have a better outcome with an open approach.
SURGICAL MANAGEMENT
• Before surgical management is pursued, medical manage­
ment should be initiated due to the high incidence of coro­
nary artery disease with peripheral artery disease.
• Patients should be advised to quit smoking; placed on a
regular walking program, ideally supervised; and started on
statin therapy and aspirin when appropriate and tolerated.
• Preoperative anesthesia visits should include inquiries into
cardiac, lung, and renal systems to evaluate overall opera­
tive risk.
• Age and comorbidities should be factored into decisions re­
garding an open versus endovascular approach, as should
procedural durability and invasiveness of the intervention.
• The aims of therapy in aortoiliac occlusive disease are to
relieve symptoms and, in cases of critical limb ischemia,
prevent limb loss. Revascularization of the aortoiliac sys­
tem can be done in a variety of endovascular and open ap­
proaches. The choice of procedure depends on the disease
pattern, patient risk factors, available resources, and sur­
geon experience.
• We describe three common operative interventions for inflow
disease: aortobifemoral bypass, femoral-femoral bypass, and
femoral endarterectomy.
2026 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

A
TYPE A Lesions
• U n i l ateral or b i l ateral stenosis of CIA
• U n i l ateral or bilateral single short (<3 em) stenosis of EIA

TYPE B Lesions
• Short (<3 em) stenosis of infrarenal aorta
• U n i l ateral CIA occlusion
•Single or multiple stenoses totaling 3-1 Ocm involving
the EIA not extend i n g i nto the C FA
• U n i l ateral E IA occlusion not involving the origins of

internal i l iac of CFA

TYPE C Lesions

AA A
• Bilateral CIA occlusions
• Bilateral EIA stenoses 3-1 Ocm long not extend i n g
into the CFA
• U n i l ateral E IA stenosis extend i ng into the CFA
• U n i l ateral E IA occlusion that involves the origins of
internal i l iac and/or CFA
• H eavily calcified unilateral EIA occlustion with or

without involvement of origins of internal i l iac

and/or CFA

TYPE D Lesions
• l nfrarenal aortoil iac occlusion
• Diffuse d i sease involving the aorta and both i l iac
arteries req uiring treatment
• Diffuse multiple stenoses involving the unlateral

C IA, E IA, and CFA

• U n i lateral occlusions of both CIA and EIA
• Bilateral occlusions of EIA
• I l iac stenoses in patients with AAA req u i ring treatment
and not amenable to endograft placement or other
lesions req u i ring open aortic or i l i ac surgery

FIG 1 • TASC I I Classification scheme for i l i a c d isease. (Ad a pted from Norgren L, H i att WR, D o r m a n d y JA, et a l . I nter-Soci ety Consensus
for t h e M a n a g e m e n t of Peri p h e r a l Arte r i a l D i sease [TASC II]. J Vase Surg. 2007;45 [su p p l 5 ] : 5 5-567 .)

ISOLATED FEMORAL RECONSTRUCTION as we l l as t h e b i f u rcat i o n i nto t h e s u perfi c i a l a n d p ro­

f u n d a a rteries.
FOR LIMB SALVAGE WITH POSSIBLE
ENDOVASCULAR INTERVENTION Second Step-Incision and Exposure

First Step-Landmarks • Two types of i n c i s i o n s c a n be m a d e to expose t h e com­

m o n fem o r a l a rte ry. A vertica l i n ci s i o n a bove t h e com­
• T h e patient is p l aced prone on t h e o perati n g ta b l e, with
m o n fe m o ra l a rtery and b i f u rcation a l l ows for g reater
a soft b u m p under t h e knee and t h e leg s l i g htly a b d ucted
a ccess to t h e p roxi m a l and d i sta l vesse l s in exte nsive
and exte r n a l ly rotated . T h e i n g u i n a l l i g a m e nt m a rks t h e
d i sease. An o b l i q u e i n c i s i o n is better for cosmesis a n d i s
t r a n s i t i o n p o i nt f r o m t h e exte r n a l i l i a c a rtery to t h e c o m ­
m a d e ce p h a l a d to t h e g r o i n c r e a s e a n d i s a ccepta b l e i n
m o n fe m o r a l a rtery a n d i s i d e ntified by co n n ecti n g t h e
foca l i s o l ated l e s i o n s a n d i n obese patie nts.
a nterior s u p e r i o r i l i a c s p i n e to t h e p u b i c sym p hysis. T h e
• After a s k i n i n c i s i o n is made, t h e su bcuta n e o u s tissue i s
c o m m o n femora l a rtery i s u s u a l ly l ocated ove r t h e me­
t h e n d i ssected w i t h e l ectroca utery w i t h ca refu l atte ntion
dial t h i rd of t h e fe m o ra l h e a d b u t may b e d iffi c u l t to pal­
to l i g ate su p e rfi c i a l cross i n g vesse l s to control b l e e d i n g
pate i n a o rto i l i a c occ l usive d i sease. Pre- o r i ntra o p e rative
a n d l i g a t i n g lym p h atics to prevent sero m a format i o n .
u ltraso u n d can be used to i d e ntify the com man femora I
 C h a p t e r 25
A self-reta i n i n g retractor is used to h e l p expose t h e
t i s s u e s a n d is reposit i o n e d as t h e d i ssect i o n p roceeds
d e e p e r. O n ce t h e fe m o r a l sheath is i d entified and en­
tered t h e femora l a rtery l i es l atera l to t h e fe m o ra l ve i n .
T h e d ista l exte r n a l i l i a c a rte ry, t h e c o m m o n fe m o ra l a r­
te ry, t h e p roxi m a l p rofu n d a femora l a n d s u perfic i a l fem­
o r a l a rteries a re c i rc u mferent i a l ly d issected with scissors
and tagged with a vesse l loop o r m o i st u m b i l i c a l tape
u s i n g a right a n g l e . Oth e r a rte r i a l side branches may be
i d e ntified and a re contro l l e d with vesse l loops o r tem po­
r a ry c l i ps but rarely l i g ated in occ l usive d isease.
T hird Step-Clamping
• B efore c l a m p i n g of t h e a rteri es, h e p a r i n is g iven i ntra­
ve n o u s l y as a weig ht-based bolus at 1 00 u n its/kg a n d
a l l owed t o c i rc u l ate f o r 3 m i n utes. H e p a r i n h a s a h a lf­
l ife of a p p roxi m ately 90 m i n utes and i s c h ecked p e r i o d i ­
ca l ly with activated c l ott i n g t i m e (ACT) m e a s u re m e nts. A
r a n g e of 2 5 0 to 3 5 0 is d e s i ra b l e a n d 1 ,000 to 3,000 u n its
b o l u ses can be g iven period ica l ly to m a i nta i n t h i s l evel
of a nticoa g u l a t i o n . G a i n i n g p roxi m a l and d i st a l control
of t h e fe m o ra l a rteries can be done with a v a r i ety of
c l a m ps. An a n g l e d N ova re c l a m p o r fem o ra l C-c l a m p c a n
be used at t h e proxi m a l c o m m o n fe m o r a l a rte ry. N ext,
a p rofu n d a c l a m p is used to c l a m p t h e p rofu n d a femo­
ra l a rtery and t h e s u perfi c i a l fe m o ra l a rte ry. C l a m ps a re
p l aced on soft a reas of t h e a rtery past t h e a rea of t h e
h i g h p l a q u e b u rd e n . S i d e b r a n c h es c a n be contro l l e d
w i t h vessel l o o p s p u l led t i g htly a r o u n d t h e a rtery a n d
c l a m ped w i t h a h e m ostat o r t e m p o ra r i ly c l a m ped w i t h a
m ed i u m or l a rg e c l i p .
Fourth Step-Endarterectomy, Tacking sutures
• A l o n g itud i n a l i n c i s i o n is m a d e a l o n g t h e exposed co m ­
m o n fe m o r a l a rtery u s i n g a n o . 1 1 b l a d e sca l p e l fo l l owed
by Potts scissors. The adventitia i s g rasped with vasc u l a r
forceps a n d a freer e l evator is u s e d to d i ssect t h e p l a q u e
away f r o m t h e adventit i a . The p l a q u e i s rem oved with
b l u nt d i ssect i o n u n less sharp d i ssect i o n i s needed to
FIG 2 • A s i n g l e 7-0 Pro l e n e U -stitch is
a p p l ied t h r o u g h the e n d a rterecto my/
i n t i m a i nterface (A), t h e n l i g ated (B), with
t h e sutu res typica l ly p l aced at 4 o'clock
and 8 o'clock positi o n s (C) .
OCCLUSIVE D I S EASE MANAG E M E N T 2027
d i ssect t h e p l a q u e off t h e poste r i o r wa l l . Tac k i n g s u t u res
with 7-0 P ro l e n e a re used to secu re the rema i n i n g p l a q u e
t o t h e poste r i o r wa l l to avo i d a d i ssect i o n p l a n e a n d e m ­
b o l i (FIG 2) .
Fifth Step-Patch Angioplasty
• Rarely is t h e c o m m o n fe m o ra l a rtery closed p r i m a r i ly
after e n d a rte rectomy as t h i s decreases t h e a rtery d i a m ­
eter. Patch a n g i o p l asty w i t h bov i n e perica rd i u m , po lyes­
ter (Dacron), o r sa p h e n o u s ve i n i s used. A patch i s cut out
to match the l e n gth of the e n d a rte rectomy i n ci s i o n with
taperi n g at the proxi m a l and d i sta l edges to fac i l itate a
c u rved e n d of t h e e l l i pse. The patch is secu red with 6-0
P ro l e n e s u t u re . A parach ute tech n i q u e o r th ree k n ots is
used to a nc h o r t h e patch at t h e p roxi m a l o r d i st a l e n d .
The patch i s t h e n sewn w i t h a r u n n i n g sutu re l i n e . Be­
fore t h e patch i s co m p l etely sewn in, back-bleed i n g is
pe rfo rmed from t h e p rofu n d a a rtery, s u p e rfi c i a l fe m o r a l
a rte ry, a n d c o m m o n fe m o r a l a rte ry. Repa i r s u t u res w i t h
6 - 0 o r 7-0 sutu res can be m a d e i n t h e c a s e o f s u t u re l i n e
b l e ed i n g . O n ce t h e patch i s i n p l ace, a m ic ro p u nctu re kit
c a n be used to access t h e co m m o n fe m o r a l a rtery if en­
dovasc u l a r t h e r a p i e s i n a retrograde fas h i o n a re p l a n n ed
for t h e i l i a c a rteries (FIG 3) . In t h e case of exte nsive
p rofu n d a fe m o r a l a rte r i a l occ l usive d isease, t h i s a rtery
s h o u l d be exposed beyo n d t h e extent of a n y p a l p a b l e
p l a q ue, a n d a sepa rate a rteriotomy, e n d a rterecto my,
a n d patch a n g i o p l asty of t h e s u p e rfi c i a l fe m o r a l a n d the
p rofu n d a fe m o r a l a rteries a re performed (FIG 4). I n t h e
situation where exte nsive e n d a rterecto my y i e l d s a n a d ­
v e n t i t i a that i s t o o t h i n, t h e fe m o r a l b i f u rcation c a n b e
reco nstructed with prosthetic g raft mate r i a l (FIG 5) .
Sixth Step-Closure
• If an e n d ovascu l a r tech n i q u e is pe rfo r m e d i n t h e s a m e
o p e r a t i o n , s i m p l e P ro l e n e stitches can be used to c l ose
the sheath access site. Ca refu l atte ntion i s then made to
e n s u re h e m ostasis. The fe m o ra l sheath may o r may n ot
be c l osed ove r t h e vessels, but ca refu l atten t i o n m u st
2028 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

-- Abdominal aorta

Profu nda
femoral artery

Common femoral
artery

Profu nda femoral artery

Su perficial femoral artery

Su perficial femoral artery FIG 4 • An exte n d e d fe m o r a l e n d a rterectomy. The patch

FIG 3 • A c o m m o n fe m o ra l patch a n g i o p l asty exte n d i n g
from t h e i l iofe m o ra l j u n ct i o n o n t o t h e o r i g i n o f t h e s u p e rfi c i a l
fe m o ra l a rtery (S FA), b e l o w a c o m m o n i l i a c a rtery (CIA) ste nt.
exte n d s form t h e exter n a l i l i a c a rtery ( E IA), across t h e e n t i re
co m m o n fe m o r a l a rtery (CFA) onto t h e proxi m a l s u p e rfi c i a l
fe m o ra l a rtery (SFA) . A sepa rate e n d a rte rectomy a n d patch
a n g i o p l asty of t h e p rofu n d a fe m o ra l a rtery (PFA) i s a l so
d e p i cte d .

FIG S • F e m o r a l a rtery reconst r u ct i o n with exte r n a l i l i a c

to deep fe m o r a l bypass with 8-mm Dacron a n d fe m o ra l t o
s u p e rfi c i a l fe m o ra l bypass with 6 - m m D a c ro n . The i n g u i n a l
l i g a m ent is m o b i l ized ce p h a l a d f o r expos u re .
 C h a p t e r 25 OCCLUSIVE D I S EASE MANAG E M E N T
be m a d e to a p p roxi m ate tissues to close d e a d space to
prevent seroma fo rmati o n . U s u a l ly, a th ree- l ayer c l o s u re
is used. At t h e e n d of t h e operation, fe m o r a l a n d d ista l
flow s h o u l d be checked with p u lse p a l pation a n d co n t i n ­
u o u s w a v e D o p p l e r i nsonati o n . W e d o n ot rout i n e ly e m ­
p l oy co m p l et i o n a n g i og ra p h y o r d u p l ex u ltraso n o g r a p hy.
AORTOFEMORAL OPEN
RECONSTRUCTION
Positioning
• The patient is s u p i ne, with a soft b u m p u n d e r t h e l eft
h i p for a retrope rito n e a l expos u re a n d t h e t a b l e s l i g htly
fl exed, o r stra i g h t s u p i n e o n a flat ta b l e for a transab­
d o m i n a l a p p ro a c h . The e n t i re abdomen; t h e peri n e u m,
b l ocked with a ste r i l e d ra pe; a n d t h e g r o i n s a n d both
legs a re ci rcumferenti a l ly prepped and d ra ped i nto t h e
ste r i l e f i e l d .
First Step-Exposure of Femoral Vessels
• T h e femora l vesse l s a re typ ica l ly exposed fi rst t h r o u g h
b i l atera l l o n g i tu d i n a l o r o b l i q u e i n ci s i o n s to m i n i m i ze
the t i m e w h i c h the a bd o m e n i s o p e n . The cross i n g ve i n
off t h e femora l ve i n b e n eath t h e i n g u i n a l l i g a m e n t m u st
be l i g ated or ca refu l ly avo i d e d as t h i s m a y be i n j u re d
w h e n t h e g raft i s t u n n e l e d from t h e a b d o m e n later i n
t h e o p e rat i o n . After a soft spot i s i d e ntified for a n a sto­
mosis in the co m m o n femora l a rte ry, o r t h e p rofu n d a
femora l a rtery w h e n t h e s u p e rfi c i a l fe m o r a l a rtery i s
occl u d e d , a n d a d e q u ate c i rc u mferent i a l exposure i s
a c h i eved, t h e co m m o n femora l a rtery a l o n g with s u p e r­
f i c i a l femora l a n d p rofu n d a a rtery a re t a g g e d with ves­
sel loops o r m o i st u m b i l i c a l t a p e . The g r o i n i n c i s i o n is
t h e n packed with an a nt i bacte r i a l sa l i n e-soaked g a uze
to avo i d desicca t i o n .
Second Step-Exposure o f the Aorta
• A transperito n e a l a p p roach is rout i n e l y used to expose
t h e i nfra re n a l a o rta, a l t h o u g h a retroperito n e a l a p p roach
may a lso be used. A l o n g it u d i n a l m i d l i n e incision i s made
from j ust b e l ow t h e x i p h o i d p rocess to a few centi m eters
b e l ow t h e u m b i l i cus o r d own to t h e sym physis p u b i s w h e n
i l i a c a rt e r i a l exposu re w i l l be req u i re d . S u bcuta n e o u s t i s ­
s u e i s d i ssected a n d t h e a b d o m e n i s e n t e r e d between
the rect u s m u scles. With routi n e CTA p reoperative l y, a
t h o ro u g h a b d o m i n a l exploration is d i scouraged, w h i c h
w i l l m i n i m ize posto pe rative i l e us. The tra n sverse c o l o n i s
retracted c e p h a l a d , a n d t h e s m a l l bowel i s s h i fted to t h e
patie nt's r i g h t s i d e a n d p a c k e d i n soft, m o i st l a p s p o n g e s
to t h e r i g ht. The l i g a m e n t of Tre itz i s taken down a n d
t h e d u o d e n u m i s m o b i l ized to t h e r i g ht. A self-reta i n i n g
retractor i s t h e n p l aced t o sweep t h e bowel t o t h e r i g ht
with a m o i st l a p a roto my p a d . The retro perito n e a l tissue
ove r l y i n g t h e a o rta is d i ssected, a n d the a o rta i s exposed
s u p e r i o rly to t h e l evel of the l eft re n a l ve i n . Extra retrac­
to rs a re used a s needed for expos u re . D i st a l control of
2029
Prota m i n e m a y be g iven, d e p e n d i n g o n t h e t i m e o f l a st
h e p a r i n b o l u s or accord i n g to t h e i ntraoperative ACT
rea d i n g . A p p roximately 1 0 m g i s g iven fo r every 1 , 000
u n its of h e p a r i n g iven, a dj u sted for t i m e decay and t h e
h e p a r i n h a lf- l ife o r c a n be est i m ated off t h e l a st ACT
m e a s u re m ent.
t h e i nfra re n a l a o rta wi l l be n ecessa ry if a n e n d -to-s i d e
a o rt i c a n asto mosis i s p l a n n e d . Preoperative i m a g i n g a n d
m a n u a l p a l pati o n o f the a o rta identify a soft spot f o r t h e
prox i m a l a nastomosis. Accessory r e n a l a rteries a n d t h e
i nfe r i o r mesente ric a rtery s h o u l d be i d entified a n d b e
eva l uated if re i m p l a ntat i o n i s n ecessa ry. E n d a rte recto my
of the o r i g i n of t h e re i m p l a nted viscera l vesse l s i s reco m ­
m e n d e d , a n d extra a o rt i c t i s s u e i s u s e d a s a C a r r e l patc h .
L u m b a r a rteries s h o u l d a lso be i d e ntified a n d contro l l e d
with s u t u re l i gation o r a vesse l loop with ca re to avo i d ex­
cessive b l eed i n g . D e pe n d i n g o n the type of a o rt i c occ l u ­
s i v e d i sease, a n e n d -to-s i d e o r a n e n d -to-e n d a n asto mosis
will be fash i o n e d and t h e d issect i o n n ecessa ry i s d i ctated
by t h i s decisi o n . In g e n e r a l , an e n d -to-e n d a n astomosis
i s m o re favora b l e h e modyn a m ica l ly, yet with p reserved
i nfe r i o r mesenter i c o r i l i a c a rteri es, an e n d -to-s i d e a n a s­
tomosis may be m o re fea s i b l e .
T hird Step-Tunneling
• After a d e q u ate exposure of t h e a o rta is ach i eved, focus
turns to m a k i n g t u n n e l s for t h e fe m o ra l l i m bs of the
bypass. Tu n n e l s s h o u l d track d i rect l y a l o n g t h e a nterior
aspect of t h e exte r n a l i l i a c a rtery a n d by e l evat i n g soft
tissues a n d e n s u r i n g u reters re m a i n a nterior. M o ist u m ­
b i l i c a l t a p e s o r Pen rose d r a i n s a re passed w i t h a sm ooth
a o rt i c c l a m p to m a rk t h e t u n n e l s .
• G raft s e l ecti o n can a lso be m a d e at t h i s t i m e with an 1 8
x 9-mm o r a 1 6 x 8-mm g raft used for m a les a n d a 1 4 x
7 - m m or 1 2 x 6 - m m g raft typica l l y used for fe m a les. Typ i ­
c a l ly, a po lyester (Dacron) g raft i s u s e d , a lt h o u g h others
p refe r polytetrafl u o roet h y l e n e (PTF E ) . P r i o r to a o rt i c
c l a m p i n g, h e pa r i n i s g iven i ntrave n o u s ly, as exp l a i n e d
e a r l i e r with a ta rget A C T r a n g e of 2 5 0 to 3 50.
Fourth Step-Clamp Placement
• The c h o i ce of c l a m p d e p e n d s on t h e a p proach if e n d -to­
side a n asto mosis o r an e n d -to-e n d i s chose n . The patency
is s i m i l a r for both a p p roaches a n d , i n m ost cases, is m a d e
by s u rg e o n p refe rence. For a n e n d -to-e n d a n asto m os i s,
t h e p roxi m a l c l a m p is p l a ced j ust b e l ow t h e re n a l a rter­
ies if t h e d i sease patte rn does n ot o b l i gate s u p r a re n a l
c l a m p i n g, w i t h as l ittl e d i ssect i o n o f t h e re n a l a rtery ori­
g i ns as poss i b l e . The d ista l i nfra r e n a l a o rta i s t h e n d iv i d e d
a n d oversewn i n t w o l ayers with 4 - 0 P ro l e n e suture. The
prox i m a l a o rt i c cuff may req u i re e n d a rte recto my, which
i s pe rfo rmed u p to t h e proxi m a l clamp. For a n e n d -to­
side a n a stomosis, two a o rt i c c l a m ps a re used o r a side­
b i t i n g Satinsky clamp i s used to o bta i n p roxi m a l a n d
d i sta l contro l . With f l u s h occ l u s i o n o f t h e a o rta at t h e
2030 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

SMA M eandering artery

Left renal
vein

I nferior
mesenteric
artery

Femoral
artery

FIG 6 • CTA i d e ntify i n g f l u s h a o rt i c occl u s i o n at t h e l evel

of t h e re n a l a rteri es, j u st deep to t h e l eft re n a l ve i n , with
reconstitution of both co m m o n fem o ra l a rteries. N ote the
co l l atera l n etwo rk from t h e s u pe r i o r mesenteric a rtery (SMA),
t h r o u g h t h e m e a n d e r i n g a rtery to t h e i nfe r i o r mesenteric
a rtery (I MA), and i nto t h e pelvis, which h a s n o hypogastric
a rteria I fl ow.

l eve l of t h e re n a l a rteries (FIG 6), s u p r a re n a l d i ssect i o n

i s req u i red, with m o b i l ization a n d control o f t h e o r i g i n s
o f t h e r e n a l a rteri es, w h i c h a re contro l led w i t h d o u b l y FIG 7 • With a patent i nfra re n a l a o rta a n d i nfe r i o r mesenteric
passed s i l astic loops so t h a t t h ey may be occl u d e d d u r­ a rtery ( I M A), a n e n d -to-s i d e a o rt i c a n asto mosis is d e p i cted,
positioned latera l ly a s m e n t i o n e d . With i l i a c occ l u s i o ns, an
i n g e n d a rte recto my to p revent atheroma e m b o l izat i o n .
e n d -to-e n d femora l a n asto mosis i s d e p i cted b i l atera l ly.
A s u p r a re n a l c l a m p i s p l a ce d to a l low t h r o m b oe n d a rter­
ectomy of t h e i nfrare n a l a o rt i c cuff, t h e n t h e c l a m p i s
m o v e d ca u d a l ly p r i o r to g raft a n a stomosis.

d iseased, we w i l l d i rectly revasc u l a rize the i nt e r n a l i l i a c

Fifth Step-Proximal Anastomosis
a rtery with t h e bifu rcated g raft l i m b a n d t h e n j u m p g raft
• I n t h e case of t h e e n d -to-e n d a n asto mosis, t h e tech­ down to the fe m o ra l posit i o n (FIG 8) .
n i q u e i s stra i g h t forward and t h e g raft d i a m eter s h o u l d
m atch t h e re m a i n i n g a o rt i c d i a m eter. I n t h e s i d e-to-s i d e Sixth Step-Graft Tunneling
a n asto mosis, t h e g raft i s cut at a beve l to m a x i m i z e t h e
• U s i n g t h e u m b i l ic a l tape or Pen rose d ra i n as a g u i d e, a
a m o u nt of b l o o d flow a n d t h e a rte r i otomy i s l atera l ly
sm ooth a o rtic c l a m p is t h e n used to t u n n e l each g raft
p l aced to a l low t h e g raft to enjoy a m o re retroperito n e a l
l i m b from the a b d o m e n i nto the femora l i n c i s i o n . The
position to m i n i m ize t h e c h a nce for deve l o p m e n t of a n
g raft i s t h e n p u l led g e ntly through t h e t u n n e l a bove t h e
a o rtoente r i c fist u l a (FIG 7). The g raft i s sewn i n p l a c e
exte r n a l i l i a c vesse l s a n d b e l ow t h e u reter. Care m u st be
with ru n n i n g 3-0 o r 4 - 0 P ro l e n e s u t u res u s i n g a p a r a ­
taken to m i n i m ize k i n k i n g and red u n d a n cy i n t h e g raft
c h ute tech n i q u e o r sec u r i n g t h e s u t u re with t h ree kn ots,
t u n n e l s . O n ce t u n n e l e d the g raft l i m bs a re f l u s h e d to
sta rt i n g from the poste r i o r wa l l to v i s u a l ize the p l ace­
confi rm a d e q u ate i nfl ow, rec l a m ped in the a b d o m e n
m e n t of each stitch . The g raft l i m bs a re then c l a m ped
a n d f l u s h w i t h h e p a r i n ized sa l i n e s o l u t i o n .
and t h e proxi m a l c l a m p i s then r e l eased to c h eck for su­
t u re line b l e e d i n g . Repa i r sutu res ca n be used for a n y
Seventh Step-Distal Anastomosis
sutu re l i n e b l e ed i n g with 4 - 0 o r 5 - 0 sutu res o n a p l e d ­
get as n e e d e d . The a b d o m e n is t h e n p a c k e d a n d atte n ­ • C l a m p i n g of t h e fe m o ra l a rte ry is t h e n p e rformed as
t i o n i s t h e n t u r n e d to t h e fe m o r a l a n a stom oses. I n some described e a r l i e r so that t h e common fe m o r a l a rte ry,
i n st a nces, where a s i n g l e i nt e r n a l i l i a c a rte ry i s pate nt, su p e rfi c i a l fe m o ra l a rte ry, a n d p rofu n d a fe m o r a l a rtery
but the d i sta l a o rta or p roxi m a l c o m m o n i l ia c a rtery is a re contro l l e d . A l o n g itud i n a l i nc i s i o n is t h e n m a d e with
 C h a p t e r 2 5 OCCLUSIVE D I S EASE MANAG E M E N T 2031

a n o . 1 1 b l a d e fo l l owed by Potts scissors to a p p roxi m ate (FIG 8) . T h e s a m e proce d u re i s co m p l eted f o r t h e contra­

the g raft l i m b . The g raft is then cut o n a taper to a l l ow l atera l l i m b .
a natu r a l re i m p l a ntation a n g l e i nto t h e c o m m o n femo­
r a l a rtery with m i n i m a l tensi o n . The a n asto m o s i s i s t h e n Eight Step-Closure
co m p l eted a s a n e n d -to-s i d e fash i o n w i t h 5 - 0 o r 6-0
• After h e m ostas i s is a c h i eved, ca refu l attention is m a d e
P ro l e n e s u t u re in a r u n n i n g fash i o n . In some situations,
to e n s u re t h e a n a stomoses a re s e c u r e l y d o n e a n d
where retrog ra d e exte r n a l i l i a c flow is n ot poss i b le, a n
d e a d s p a c e i s c l osed to p revent s e r o m a fo rmation a n d
e n d-to-e n d fe m o ra l a n asto mosis i s p referred t o e i t h e r
m i n i m i ze g r o i n i nfect i o n s . Prota m i n e may be g iven as
t h e c o m m o n fe m o r a l o r t h e p rofu n d a fe m o r a l a rtery
described e a r l i e r.

FIG 8 • An e n d-to-e n d a o rt i c a n asto mosis is d e p i cted. In t h i s

case, a n i s o l ated i ntern a l i l i a c a rtery (I IA) w a s p resent a n d
p reserved w i t h e n d -to-en d a n asto m o s i s from t h e r i g ht l i m b of
the bifu rcated g raft. A j u m p g raft i s t h e n b r o u g h t off t h i s l i m b
t o t h e r i g h t c o m m o n fe m o ra l a rtery (C FA) . With occ l u s i o n o f t h e
l eft s u p e rfi c i a l femoral a rtery (S FA), t h e l eft l i m b is pe rfo rmed i n
e n d -to-e n d fas h i o n to t h e p rofu n d a fe m o r a l a rtery (PFA) .

AORTOILIAC RECONSTRUCTION WITH necess a ry if there is s i g n ificant p l a q u e b u rd e n . The s u p ra ­

FEMORAL CROSSOVER
• T h i s tech n i q u e c a n be used to restore b l o o d flow to a
l ower l i m b w h e n o n e of t h e i l i a c a rteries is obst r u cted
and t h e contra l atera l i l i a c a rteries a re patent. The s u r g i ­
c a l proced u re can a l so be u s e d i n conj u n ct i o n w i t h a n
e n d ovasc u l a r p roce d u re, f o r exa m p l e, a n g i o p l asty a n d/o r
ste nti n g of t h e n o n occl u d e d i l i a c vesse l s . G ro i n i n ci s i o n s
a re m a d e i n a n o b l i q u e o r l o n g it u d i n a l fash i o n . Control
of t h e common, s u p e rfi c i a l fe m o r a l , and prof u n d a femo­
r a l a rteries a re performed a s previo u s l y descri bed. E n d a r­
terectomy of t h e c o m m o n femoral a rte ry is pe rfo rmed a s
p u b i c t u n n e l i s m a d e with b l u nt d issect i o n u s i n g a b l u nt­
e n d e d h e m ostat o r o n e 's f i n g ers. The key i s to create
t h e t u n n e l j u st a nterior to t h e a b d o m i n a l fasc i a . E it h e r
a b l u nt t u n n e l i n g d e v i c e o r a l o n g a o rt i c c l a m p c a n b e
used to p a s s t h e g raft f r o m o n e s i d e to t h e other i n t h e
s u bcuta n e o u s t i s s u e , avo i d i n g entry i nto t h e perito n e a l
cavity. The a na stomosis i s performed so t h e g raft s i t s i n a
c u rved confi g u ration over t h e s u p ra p u b i c tissue (FIG 9) .
Meticu l o u s atte ntion i s g iven to closu re to avo i d k i n k i n g
o r c o m p ress i o n o f t h e g raft a n d to avoid d e a d space that
c a n l e a d to p r o b l e m atic seromas and t h e poss i b i l ity of
soft tissue i nfect i o n , with s u bs e q u e n t g raft i nfect i o n .
2032 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

FIG 9 • A r i g h t to l eft c o m m o n fe m o r a l a rtery

to c o m m o n fe m o r a l a rtery (C FA) is d e p icte d .
I d e a l ly, t h e g raft exte n d s ove r t h e o r i g i n of t h e
Su perficial p rofu n d a fe m o r a l a rtery (PFA) o n t o t h e o r i g i n o f
femoral artery t h e s u p e rfi c i a l fe m o ra l a rtery (S FA) .

PEARLS AND PITFALLS

I s o l ated femoral recon struct i o n
Ao rtofe m o ra l reconstruct i o n
Femora l-fe m o r a l crossover
• Care m u st b e taken to be ce rta i n that p rox i m a l a n d d ista l atherosc l e rotic p l a q u e i s n ot
ca u s i n g res i d u a l ste nosis.
• Patch a n g i o p l asty i s critica l to t h e s u ccess of t h i s proced u re .
• D i st a l tacki n g sutu res s h o u l d b e e m p l oyed g e n e ro u s ly.
• A d e q u ate exposure is critica l to s u ccess.
• Loca l i zed e n d a rte recto my at both p roxi m a l and d i st a l a n a stomotic sites is g e n e ra l ly req u i re d .
• Tu n n e l i n g e r rors c a n l e a d to l a t e co m p l icati o n s a n d e a r l y g raft fa i l u re .
• A d e q u ate i n f l ow and outflow m ust be assu red for success.
• Concom itant fe m o r a l e n d a rterectomy s h o u l d be used freely.
• Tu n n e l i n g a n d c l o s u re e rrors freq u e ntly ca use early g raft fa i l u re .

POSTOPERATIVE CARE
Table 2: Long-term Outcomes for Aortoiliac Disease
• Patients are admitted to a cardiac monitored floor postop­
Type of Operation Patency Rates
eratively as patients are at high risk for or have documented
coronary artery disease. Immediately, postoperative vascu­ Femoral e n d a rterectomy 5-year patency-iliac ste nting without fe moral
with i l i a c stenting e n d a rterecto my-56 % ; i l i a c stenting without
lar checks are performed with high frequency to assess early
femoral e n d a rterectomy-88%
graft thrombosis requiring reintervention or initiation of Aorto bifemoral bypass 5-year p r i m a ry patency, 90 %-93 % ; S·ye a r sec­
anticoagulation. Patients are encouraged to ambulate 4 to o n d a ry paten cy, 87%-97%; 1 0-ye a r paten cy,
6 hours after the operation, with adequate pain control a 7 2 %-94 % ; 1 5-year paten cy, 63 %-8 2 %
point of focus. When the abdomen is entered, in the case Fem o ra l-femoral bypass 5-year patency rate, 4 2 % to 8 8 % ; weig hted
average, 66%
of aortobifemoral grafting, patients are kept from an oral
diet until bowel function returns. While anticoagulation is
not routinely used for graft patency, aspirin is standard, and
subcutaneous heparin is given for secondary prevention of
deep vein thrombosis (DVT ) . COMPLICATIONS
• Early
OUTCOMES
Hemorrhage
• See Table 2 . Early thrombosis
 C h a p t e r 25 OCCLUSIVE D I S EASE MANAG E M E N T 2033

Infections SUGGESTED READINGS

Colon ischemia
1. Cronenwett JL, Johnston KW. Rutherford's Vascular Surgery. 7th ed.
Femoral nerve inj ury
Philadelphia, PA: Elsevier; 2010.
• Late 2. Mulholland MW, Lillmoe KD, Doherty GM, et al. Greenfield's Sur­
Aortoenteric fistula gery: Scientific Principles and Practices. 5th ed. Philadelphia, PA: Lip­
Restenosis, thrombosis of graft pincott Williams & Wilkins; 2011.
Anastomotic pseudoaneurysm 3. Rasmussen TE, Clouse WD, Tonnessen BH. Handbook of Patient
Sexual dysfunction Care in Vascular Diseases. 5th ed. Philadelphia, PA: Lippincott Wil­
liams & Wilkins; 2008.
Spinal cord ischemia
4. Norgren L, Hiatt WR, Dormandy JA, et al. Inter-society consen­
Graft infection sus for the management of peripheral arterial disease. Tnt Angiol.
2007;26(2):81-157.

Chapter 26
I
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - � - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
DEFINITION
• Multilevel atherosclerotic occlusive disease involving the
distal aorta, iliac vessels, and common femoral arteries is
a common occurring pathology seen often by vascular
surgeons. Traditional approaches to this disease process
involved open surgical reconstruction with an aortobifemo­
ral bypass or iliofemoral bypass. Recently, however, there
has been a paradigm shift toward endovascular and hybrid
approaches. Combining femoral endarterectomy with endo­
vascular iliac stenting is an increasingly common minimally
invasive approach to this problem, providing an effective
alternative to open strategies with the potential of shorter
hospitalizations and decreased morbidity. Compared to iliac
stenting alone, proper evaluation of femoral disease and, if
indicated, a hybrid approach with concomitant femoral end­
arterectomy have been associated with increased durability
of endovascular aortoiliac interventions. 1
PATIENT HISTORY AND PHYSICAL
FINDINGS
• Aortoiliac and femoral occlusive disease can present, as with
all peripheral arterial diseases (PADs ) , in a variety of ways.
• The typical presentation of aortoiliac occlusive disease in­
cludes claudication of the buttock and upper thigh and erec­
tile dysfunction. When multilevel vascular disease occurs,
as in the case of combined aortoiliac and femoral occlusive
llGit u:n
.., AI LUI Dws1th rtdh
"I11:1U S!lttd : "
FIG 1 • Arte r i a l wavefo rms and ABis for a patient with a o rto i l i a c
d isease. N ote t h e m o n o p h as i c wavefo rms o n t h e r i g ht.
2034
-
Occlusive Disease
Management: I liac Angioplasty
and Femoral Endarterectomy
�
Ven ita Cha n dra
disease, distal lower extremity symptoms such as calf claudi­
cation, rest pain, and tissue loss may ensue.
• Typical physical exam includes the absence or diminution of
femoral pulses. Other than the peripheral pulse assessment,
the physical exam can demonstrate other signs of PAD such
as cool digits and active wounds.
IMAGING AND OTHER DIAGNOSTIC
STUDIES
• The initial evaluation of a patient with PAD should involve
noninvasive evaluation of peripheral blood flow with arte­
rial waveforms and ankle-brachial indices (ABis ) ( FIG 1 ) .
These studies provide obj ective data regarding the extent of
occlusive disease; however, they do not provide adequate
anatomic data for preoperative planning.
• Once the degree and physiologic impact of the disease are
determined by noninvasive testing, high-resolution anatomic
imaging via either computed tomographic angiography
( CTA) or magnetic resonance angiography (MRA) should
be obtained for surgical planning.
• CTAs are currently the gold standard for preoperative
planning. They have the advantage of providing information
regarding the degree and location of stenosis as well as the
anatomy of the arterial wall (including degree of calcification
and presence of aneurysms). Three-dimensional reformatting
can provide additional valuable information ( FIG 2 ) . CTAs,
however, are limited by the fact that they involve the use of
contrast as well as radiation exposure. MRAs avoid radiation
exposure and contrast often, however, at the risk of reduced
anatomic precision. Gadolinium magnetic resonance (MR)
contrast also entails risk of long-term renal dysfunction.
FIG 2 • CTA with 3-D reconstruct i o n d e m o nstrati n g d iffuse
a o rto i l i a c as well a s fe m o ra l occ l usive d isease.
 C h a p t e r 26 OCCLUSIVE D I SEASE MANAG E M E N T: I l i a c A n g i o p l asty a n d Femora l E n d a rterectomy
• Catheter-based diagnostic aortography also provides ana­
tomic data; however, this study has a number of limitations
including the fact that it is an invasive procedure with po­
tential complications. In addition, arteriograms only provide
an understanding of the luminal anatomy, occasionally ob­
scuring features such as aneurysms, inclusion cysts, or peri­
arterial inflammation. Particularly for aorto-iliac-femoral
disease, preprocedural CTA has the ability to identify sig­
nificant common femoral disease that may benefit from con­
comitant open endarterectomy at the time of catheter-based
intervention. Alternatively, relying on catheter-based arte­
riography as the primary diagnostic modality may reduce
overall contrast burden, radiation exposure, and need for
additional procedures if common femoral level intervention
is not required. In general, careful preprocedural physical
examination and duplex imaging may suffice to help deter­
mine whether the additional cost, risk, and inconvenience
of CTA are j ustified prior to catheter-based intervention for
aortoiliac arterial occlusive disease.
SURGICAL MANAGEMENT
• As with all patients with PAD, initial treatment approach
should include comprehensive assessment and management
of concomitant cardiovascular disease risk factors. Details
regarding maximal medical management of PAD are beyond
the scope or purpose of this chapter; at a minimum, how­
ever, consideration should be given to beginning statin and
antiplatelet therapy prior to intervention, along with consid­
eration of beta blockade and angiotensin receptor blocker or
converting enzyme inhibitor therapy in selected patients.
• Regardless of medical or anesthetic risk, however, all
patients with critical limb ischemia should be considered
candidates for revascularization when limb loss is a distinct
possibility. Despite platitudes to the contrary, major limb
amputation above or below the knee is not necessarily a
"safer " surgical alternative to multilevel hybrid revascular­
ization. Indications for intervention for intermittent claudi­
cation are somewhat more complicated, however. The risks
of a procedure are weighed against the potential gain; typi­
cally, only patients with severe lifestyle-limiting claudication
who have failed nonoperative strategies are offered surgical
revascularization.
Preoperative Planning
• Determining the anatomic distribution of disease is essential
to obtaining optimal results. The imperative for precision
2035
imaging cannot be emphasized enough-if you cannot ap­
preciate the full extent of disease, you cannot expect to com­
prehensively address it. As in all aspects of vascular surgery,
the biggest disappointments, both during and after the pro­
cedure, usually arise from underestimating the extent of un­
derlying disease.
• The Trans-Atlantic Inter-Society Consensus (TASC) II guide­
lines provide a classification scheme based on anatomic pat­
terns of disease { FIG 3 ) . 2 The recommendations of the TASC II
guidelines is an endovascular management for TASC A and
B iliac lesions, whereas open surgical reconstruction is rec­
ommended for TASC C and D lesions in good-risk patients.
Frequently, however, patients with multilevel disease as seen
in TASC C and D lesions have more virulent atherosclerotic
processes that often make them poorer surgical candidates.
In addition, the development of an increasingly sophisti­
cated armamentarium of endovascular tools and strategies
are leading more and more vascular surgeons to attempt
endovascular revascularization, even for patients with TASC
C or D lesions. Further updates of the TASC classification
guidelines are under review and will likely be published in
the near future, highlighting the dynamic nature of surgical
management of this challenging condition.
• Targeted perioperative risk assessment should be undertaken
in appropriate patients, particularly those with reduced
exercise tolerance, known or suspected congestive heart
failure, clinically significant pulmonary disease, exercise­
induced angina, arrhythmias, or those with recent history of
myocardial infarction. The presence of additional relevant
comorbidities, including diabetes, reduced glomerular fil­
tration rate, iodinated contrast allergies, thrombophilia or
coagulopathic disorders, concomitant bacterial infection,
or liver disease should also be identified and, when present,
evaluated.
Positioning
• Patients are generally placed in the supine position, either in
a hybrid operating suite with fixed imaging capabilities or
on a radiolucent table with a mobile imaging unit (C-arm) in
a traditional operating room environment.
• Positioning should be arranged in such as way as to ensure
adequate exposure of the entire aortoiliac and femoral vas­
culature, with room on either side of the patient to rotate the
imaging unit to various angles in order to obtain appropriate
oblique images. In angiographic parlance, in many important
circumstances (such as identifying and protecting the origin
of the ipsilateral internal iliac artery) , " one view is no view. "
2036 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

A
TYPE A Lesions
• U n i l ateral or b i l ateral stenosis of CIA
• U n i l ateral or b i l ateral single short (<3 em) stenosis of EIA

TYPE B Lesions
• Short (<3 em) stenosis of i nfrarenal aorta
• U n i l ateral CIA occlusion
•Single or m u ltiple stenoses total ing 3-1 Ocm i nvolving
the EIA not extending into the CFA
• U n i l ateral EIA occlusion not involving the origins of
i nternal i l iac of C FA

TYPE C Lesions

AA A
• B i l ateral CIA occlusions
• B i l ateral EIA stenoses 3-1 Ocm long not extend i ng
into the C FA
• U n i l ateral EIA stenosis extending i nto the C FA
• U n i l ateral EIA occlusion that i nvolves the origins of

i nternal i l iac and/or C FA

• H eavily calcified unilateral EIA occlustion with or

without involvement of origins of i nternal i l i ac

and/or C FA

TYPE D Lesions
• l nfrarenal aortoiliac occlusion
•Diffuse disease involving the aorta and both i l iac
arteries req uiring treatment
• Diffuse multiple stenoses involving the unlateral

C IA, EIA, and C FA

• U n i l ateral occlusions of both CIA and EIA
• B i l ateral occlusions of EIA
• I l iac stenoses in patients with AAA req uiring treatment
and not amenable to endograft placement or other
lesions req u i ring open aortic or i l iac surgery

FIG 3 • TASC I I Classification scheme for i l i a c d i sease. (Ad a pted from Norgren L, H i att WR, D o r m a n d y JA, et a l . I nter-Soci ety Consensus
for t h e M a n a g e m e n t of Peri p h e ra l Arte r i a l D isease [TASC II]. J Vase Surg. 2007;45 [su p p l 5 ] : 5 5-567.)

FEMORAL ENDARTERECTOMY be p a l pated i n t h i s a re a . Alternatively, d u p l ex u ltraso u n d

o r f l u o roscopic i m a g i n g may be u s e d to e n s u re accu rate
First Step p l a ce m e n t of the i n c i s i o n . Fa i l u re to i ncise d i rectly over
• For exte n d e d fe m o ra l e n d a rterectomy (often req u i r i n g the c o m m o n fe m o ra l a rtery may i nc rease risk for c h r o n i c
exposu re o f t h e proxi m a l d e e p fe m o r a l a rtery as we l l as lym p h at i c d r a i n a g e, d e l ayed o r com p l i cated w o u n d

t h e e n t i re l e ngth of c o m m o n fe m o r a l a rte ry), opti m a l hea l i n g , a n d fe m o r a l n e rve o r ve n o u s i nj u ry. A l t h o u g h

exposure i s o bta i n ed v i a a l o n g itud i n a l i n c i s i o n p l aced o b l i q u e fem o r a l i nc i s i o n s h ave g a i ned i n p o p u l a r ity, es­

d i rectly ove r t h e femora l a rtery (FIG 4) . The i n g u i n a l peci a l ly when used to o bta i n fe m o ra l access for proxi m a l

l i g a m e n t s h o u l d be i d entified b y p a l pation o f t h e p u b i c a n e u rysm repa i r, these often d o n ot prov i d e expos u re

tu bercle a n d a nterior s u pe r i o r i l i a c s p i n e (a n o b l i q u e sufficient for co m p r e h e n sive e n d a rte rectomy as previ­

l i n e betwee n these two structu res i s t h e typ i c a l cou rse ously d eta i l e d .
• The su bcuta n e o u s t i s s u e s a re d iv i d e d , l i g a t i n g a n y l y m ­
of the i n g u i n a l l i g a m e nt) a n d used as a g u i d e for femo­
ra l loca l izat i o n . Typ i c a l ly, t h e fe m o r a l a rtery i s located phatic c h a n n e l s that a re encou ntered . The i nfe r i o r edge

a pp rox i mately one-t h i rd t h e d i st a n ce from t h e p u b i c of t h e i n g u i n a l l i g a m e n t i s i d e ntified a n d t h e common

tu bercle to a nterior s u p e r i o r i l i a c crest. E v e n w h e n n o fe m o ra l a rtery i s exposed through t h e fe m o r a l sheath as

p u lse i s p a l p a b le, a f i r m c a l c i f i e d l i n e a r mass can u su a l ly it exits u n d e rneath t h e i n g u i n a l l i g a m e nt.

 C h a p t e r 26 OCCLUSIVE D I SEASE MANAG E M E N T: I l i a c A n g i o p l asty a n d Femora l E n d a rterectomy 2037

circumflex
il iac vein
Inguinal
ligament External
il iac vein
Common
femoral Great
artery saphenous
vein

Profu nda Femoral vein

Superficial
femoral artery
FIG 4 • Typ i c a l l o n g itud i n a l fe m o r a l a rtery exposure a n d
Sartorious a n atomy. CFA, c o m m o n fe m o r a l a rte ry; E IA, exte r n a l i l i a c
Deep
muscle a rte ry; E I V, exte r n a l i l i a c ve i n ; G SV, g reater s a p h e n o u s
femoral
vein ve i n ; DCIV, deep c i rc u mflex i l i a c ve i n ; S FA, s u p e rfi c i a l
fe m o ra l a rte ry.

Second Step s h o u l d be c o n s i d e red to prevent accidental tea r i n g of

• F u l l ci rcumferent i a l d issect i o n of t h e d i st a l exte r n a l
i l i a c a rtery ( u n d e r t h e i n g u i n a l l i g a m e nt), t h e c o m m o n
fe m o ra l a rte ry, t h e s u perfi c i a l fe m o ra l a rtery, a n d t h e o r i ­
g i n of t h e deep fe m o ra l a rte ry a n d i t s i n it i a l branches a re
o bta i n e d seq u e n t i a l ly (FIG 4) .
• The i n d iv i d u a l a rteries s h o u l d be assessed for a reas of
c a l cificat i o n a n d extensive p l a q u e b u rd e n . Soft sect i o n s
with m i n i m a l ca lcification, o r p l a q u e l i m ited to t h e pos­
terior a rte r i a l wa l l , s h o u l d be i d e ntified for c o n s i d e r­
ation of c l a m p p l acement as a p p ro p r i ate for t h e p l a n n e d
proced u re .
• The i n g u i n a l l i g a m e n t may be d ivided fo r a d e q u ate
exposure of t h e d i sta l exte r n a l i l i a c a rte ry w h e n neces­
sa ry to e n s u re a d e q u ate e n d a rte rectomy When c o n s i d e r-
i n g t h e re l ative m a r g i n of d i st a l e n d a rte rectomy versus
prox i m a l ste nt p l acement, it i s i m p o rtant to avo i d ste nt
p l a c e m e n t across t h e i n g u i n a l l i g a m e nt, as t h i s may
g reatly reduce l o n g-term patency of t h e proced u re a s
we l l as com p l icate ste nt d e l ivery t h r o u g h a n i p s i late r a l
retro g ra d e sheath. I n g e n e r a l , ope rato rs s h o u l d e r r o f
the s i d e o f m o re exte n sive p roxi m a l e n d a rte recto m ies a s
o p posed to d ista l exte n s i o n of exte r n a l i l i a c ste nts.
• Ca refu l l i gation of the ci rcumflex i l i a c ve i n as it crosses
ove r the exte r n a l i l i a c a rtery u n d e r the i n g u i n a l l i g a m e n t
the vesse l d u r i n g c l a m p i n g .
• External i l iac col l atera ls, l i ke t h e epigastric a rtery or circum­
flex iliac a rtery, should be p reserved during d i ssection and
endarterectomy whenever poss i b l e to ensure opti m a l long­
term outcome.
T hird Step
• O n ce exposure is co m p l ete, t h e c o m m o n fe m o r a l a rtery
c a n be p u n ctu red u n d e r d i rect v i s i o n with adva n c e m e nt
of a w i re u n d e r f l u o roscop i c g u i d a nce across t h e i l i a c
l e s i o n (FIG 5) .
• T h i s e l i m i nates t h e poss i b i l ity o f creat i n g a retro g ra d e
d issect i o n w h e n a w i re i s passed after t h e e n d a rte rec­
tomy i s p e rformed, as w e l l as the need to p u n ct u re t h e
e n d a rte rectomy p a t c h to g a i n access.
• If t h e d i sease b u rd e n i s confi n e d to t h e co m m o n i l i a c
a rtery o r o n ly t h e p rox i m a l exte r n a l i l i a c a rte ry, t h e n
i l i a c ste nti n g can p roceed at t h i s p o i nt, p r i o r to p roceed­
ing with t h e e n d a rte rectomy. Occa s i o n a l ly, h oweve r,
t h e a m o u nt of fe m o r a l d isease b u rd e n is so g reat that
t h e sheath w i l l be occ l usive o r oth e rwise i m p a i r r u n off,
w h i c h may l i m it t h e a b i l ity to o bta i n d i g ita l s u btrac­
tion a n g i og ra p h y (DSA) i m a g e s d u ri n g o r after ste nt
p l a ce m e n t . So c o n s i d e ration s h o u l d be g iven to i n it i a l

FIG 5 • Tech n i q u e f o r concu rrent fe m o r a l e n d a rte recto my

and i l ia c stent i n g . A. D i rect p u n ct u re of c o m m o n fe m o r a l
a rtery a n d a d v a n c e m e n t of w i re u n d e r f l u o roscop i c
g u i d a nce. B. W i t h w i re across i l i a c l e s i o n , c l a m p prox i m a l
a n d d i sta l a n d p roceed w i t h a rteriotomy. C. After
e n d a rterectomy, patch i s sewn in. P r i o r to co m p l et i o n of
patch center, t h e d ista l p o rt i o n of t h e patch is p u n ctu red
with an 1 8- g a u g e need l e and t h e w i re i s passed t h r o u g h
t h e p a t c h . D. After co m p l et i o n of t h e patch, flow i s
restored a n d a sheath c a n be adva n ced o v e r t h e w i re a n d
i l i a c ste n t i n g c a n p roceed. For patie nts with d i st a l exte r n a l
i l i a c d i sease, t h e i l i a c stents can be carried d o w n i nto t h e
A B D p roxi m a l p o rt i o n of t h e e n d a rte recto my a n d patc h .
2038 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY
e n d a rterectomy d e p e n d i n g on i n d iv i d u a l a n at o m i c c i r­
c u m stances.
• W h e n retrog rade w i re passa g e i s not poss i b l e due to
extensive proxi m a l p l a q u e b u rd e n , tortuosity, o r oth e r
a n ato m i c c o n s i d e ra t i o n s, a n t e g r a d e passage f r o m t h e
contra late r a l i l i ofe m o r a l system (obta i n ed v i a e i t h e r
percuta n e o u s or o p e n fem o r a l a ccess) or l eft axi l l a ry
or brach i a l access may be atte m pted. Obvious ly, l o n g e r
sheath/catheter/g u idewire co m b i n at i o n s w i l l be needed
for these p roced u res and positi o n i n g co n s i d e rations w i l l
be affected as we l l (e.g., a r m w i l l n e e d t o b e exposed a n d
prepped o n a ra d i o l ucent su rface). O n ce a nteg rade w i re
is acco m p l ished, t h i s may be used to d e l iver treatment
devices d i rectly o r s n a red and exte r n a l ized t h r o u g h the
i ps i latera l fe m o r a l a ccess fo r retro g ra d e i nterve n t i o n a s
o r i g i n a l ly p l a n n e d .
Fourth Step
• Leav i n g t h e w i re i n p l ace, syste m i c a nt i c oa g u l a t i o n i s
acco m p l i s h e d w i t h s u ffi c i e n t d oses of u nfract i o n ated
i n t rave n o u s h e p a r i n a d m i n i strat i o n and p r ox i m a l a n d
d i sta l fe m o r a l c o n t r o l i s o bta i n e d w i t h vasc u l a r c l a m ps .
E s p ec i a l l y p r ox i m a l ly, a p a d d e d c l a m p s h o u l d b e c h o -
s e n to a l l ow t h e exte r n a l i l i a c a rt e ry to b e c l a m p e d
ove r t h e e x i st i n g w i re to p revent o r m i n i m i z e w i re­
r e l ated i nj u ry.
• A l o n g it u d i n a l c o m m o n fe m o ra l a rteriotomy is per­
formed to expose t h e fu l l extent of fe m o r a l d isease that
needs to be a d d ressed to e n s u re a d e q u ate r u n off from
t h e i l i a c i n te rve n t i o n . T h i s ca n a l m ost a lways be accom­
p l ished with i n t h e fem o ra l incision itse l f without need
for a d d it i o n a l d i st a l fe m o ra l bypass p roced u res, u n less
exte nsive forefoot g a n g re n e i s present a s a conseq u e nce
of m u lt i l eve l a rte r i a l occ l u s i ve d i sease. Exte n d e d deep
fe m o ra l e n d a rte rectomy i s h i g h l y effective i n a c h i e v i n g
s u ita b l e r u n off w h e n f e w other revasc u l a rization opti o n s
may be ava i l a b l e (FIG 4).
• The a rteriotomy can exte n d o n t o e i t h e r t h e s u p e rfi c i a l
o r d e e p fe m o r a l a rte ry. Occa s i o n a l ly, a n evers i o n e n d a r­
terectomy of t h e d e e p fe m o r a l a rtery c a n be p e rformed
w h e n t h e a rteriotomy exte n d s o nto t h e s u p e rfi c i a l
fe m o r a l a rte ry. Alte r n ative ly, t h e a rteriotomy may be
exte n d e d down t h e deep fem o ra l a rtery when t h e su­
perfi c i a l fe m o r a l a rtery is c h ro n i ca l ly occ l u d e d . S e l ec­
t i o n of the reconstruct i o n tech n i q u e i s i n f l u e n ced by
the occ l u s ive pathol ogy, l evel of d e b i l ity, i n d icat i o n s for
revasc u l a rization, a n d o pt i m a l revasc u l a rization strategy
(FIG 6).
Fifth Step
• Ca refu l ly, an e n d a rte rectomy p l a n e is deve l o ped be­
twee n t h e p l a q u e and re m a i n i n g m u ra l media or
adventitia u s i n g a Penfi e l d d i ssector o r B e a v e r b l a d e . T h e
p l a n e m ost typica l ly i s deve l o ped with i n o r exte r i o r t o
t h e m e d i a , leavi n g t h e a d v e n t i t i a i ntact. Fa i l u re to a p p re­
ciate t h e a p p ro p ri ate e n d a rte recto my p l a n e may weaken
t h e adventitia, l e a d i n g to b l eed i n g o r posto pe rative
h e m atoma o r pse u d o a n e u rysm formati o n . Care s h o u l d
be t a k e n to d i ssect t h e p l a q u e a w a y f r o m t h e rema i n i n g
a rte r i a l wa l l , n o t vice versa. T h e e n d a rte rectomy p l a n e i s
deve l o ped o n e a c h s i d e o f t h e vessel a n d advanced pos­
teriorly u n t i l the p l a nes meet i n the m i d l i n e . Fo l l ow i n g
t h i s m a n e uver, t h e p l a q u e i s tran sected f l u s h with t h e
a rte r i a l wa l l . Care s h o u l d be taken to ach i eve g o o d
FIG 6 • Va r i o u s fe m o ra l e n d a rte rectomy
closure strate g i es . A. Typ i c a l a n atomy;
occas i o n a l ly, p r i m a ry repa i r can be
c o n s i d e red if common fe m o r a l a rtery i s of
a d e q uate size. B. Arte r i otomy a n d patch
exte n d e d o n to s u p e rfi c i a l fe m o ra l a rte ry;
d e e p fe m o r a l a rtery e n d a rte rectomy c a n
be pe rfo rmed u s i n g a n evers i o n tech n i q u e .
C. Arte riotomy a n d patch exte n d e d onto
d e e p fe m o ra l a rte ry. P a rt i c u l a rly usef u l in
c h ro n i ca l ly occ l u d ed s u perfi c i a l fe m o r a l
a rtery (SFA) . D. I nterposit i o n repa i r o f
co m m o n fe m o ra l a rte ry; c a n syn d a cty l i z e
d e e p fe m o r a l a rtery a n d S FA if n e e d e d .
 C h a p t e r 26 OCCLUSIVE D I SEASE MANAG E M E N T: I l i a c A n g i o p l asty a n d Femora l E n d a rterectomy
q u a l ity a n d m i n i m a l ly d i seased e n d po i nts in both t h e su­
p e rfi c i a l a n d d e e p fe m o r a l a rteries as n ecessa ry (FIG 7).
Tac k i n g sutu res, as co m m o n ly e m p l oyed d u ri n g ca rot i d
e n d a rte rectomy, may a l so be n e cessary i n t h e fe m o r a l
a rtery to e n s u re a d e q u ate e n d p o i nts. P a rt i c u l a rly i n t h e
c a s e of t h e d e e p femora l a rte ry, care s h o u l d be taken t o
extend t h e e n d a rte rectomy we l l past t h e mass of c o m ­
m o n fe m o r a l a rte ry-re l ated p l a q u e . T h i s may req u i re
expos i n g t h e d e e p fe m o r a l a rtery w e l l beyo n d its i n it i a l
b r a n ches, d ivid i n g cross i n g b r a n c h e s o f t h e d e e p fe m o r a l
ve i n , a n d avo i d i n g excessively deep p l a ce m e n t of self­
reta i n i n g retractors to l i m it t h e poss i b i l ity of tract i o n
i n j u ry to fe m o r a l n e rve b r a n c h e s .
•
Ofte n, s i g n ificant poste r i o r p l a q u e exte n d s proxi m a l l y
we l l i nto t h e exte r n a l i l i a c a rteries. A s p revi o u s l y d i s­
cussed, care s h o u l d be taken in deci d i n g at w h i c h p o i n t
t h e e n d a rterecto my s h o u l d e n d v e r s u s d i sta l exte n s i o n o f
i l i a c stents (FIG S) .
A g raft i n g may be p e rformed i n l i e u of p a t c h a n g i o p l a sty.
FIG 7 • F e m o r a l e n d a rte rectomy tech n i q u e . A. Lo n g itu d i n a l
a rteri otomy a n d deve l o p m e n t o f e n d a rte rectomy p l a n e .
B. E n s u re a d e q u ate e n d po i nts o n e i t h e r e n d . C . Patch closu re.
COMMON ILIAC STENTING
First Step
• Typ i c a l ly, a 6- or 7-Fr s h eath is a d e q u ate for i l i a c ste n t i n g .
Once t h e s h eath is p l aced after co m p l et i o n of t h e patch,
a p p ro p r i ate a rte r i o g r a m i m a g e s a re obta i n e d .
• For d i st a l a o rta a n d proxi m a l c o m m o n i l i a c d i sease, often
t h e best a p p roach i s passage of a flush catheter i nto t h e
a o rta a n d a power-i njected a o rto g ra m .
2039
Sixth Step
• Once the fu l l extent of p l a q u e h a s been removed a n d su it­
a b l e i rrigation performed to identify a n d e l i m i n ate rem a i n ­
i n g m o b i l e fra g m e nts o f res i d u a l m e d i a , patch a n g i o p l a sty
s h o u l d be performed typ i ca l ly u s i n g r u n n i n g 5-0 polypro­
pylene sutu re i n itiated at both the prox i m a l and d i stal
e n d p o i nts a n d tied i n the middle. B ovi n e pericard i u m,
extruded polytetrafl u o roethylene (ePTFE), a n d po lyester
o r a utogenous vei n seg m ents a l l may represent reaso n a b l e
patch options, depend i n g on i n d iv i d u a l c i rc u m stances.
I n g e n e ra l , a utogenous ve i n is more resista nt to i nfection,
whereas p rosthetic patch options a re ava i l a b l e off the
shelf i n a va riety of confi g u rations. e PTFE patches tend to
b l eed m o re through their suture holes fo l l owing p lace­
m ent, although this tendency may be tem pered by use of
e PTFE patches. Cu rrently, o u r p reference is to use bovi n e
pericard i a ! patch as the defa u lt choice i n the a bsence o f
i nfection o r oth e r contra i n d ication (e.g., patient objection
d u e to re l i g i o u s reasons) (FIG 6).
• Rarely, w h e n a rte r i a l wa l l i nteg rity a p pe a rs c o m p ro­
m ised fo l l owi n g e n d a rterecto my, fe m o r a l i nterposit i o n
I nterposit i o n g rafti n g may a l so be a good cho ice w h e n
t h e fe m o ra l p l a q u e b u rd e n i s so g reat that e n d a rterec­
tomy i s i m p ractica l ; in t h i s case, an i nterpositi o n g raft
(ePTFE or kn itted polyester) ca n be p l aced i n stead of a
patc h . T h i s can be confi g u red i n a n y n u m be r of ways:
• D ista l a n asto mosis to d i st a l co m m o n fe m o ra l a rtery
• D ista l a n asto mosis to syn d actyl ized s u p e rfi c i a l a n d
d e e p femora l a rteries (FIG 6)
• D ista l a n a stomosis to s u perfi c i a l fem o r a l a rtery with
rei m p l a ntat i o n of t h e d e e p fe m o ra l a rtery
• D ista l a n asto mosis to t h e deep fe m o ra l a rtery with
re i m p l a ntat i o n of s u p e rfi c i a l fem o ra l a rtery
• D ista l a nastomosis to the deep fem o r a l a rtery
o n l y, when the superfi c i a l femoral a rtery is a l ready
occ l u d ed
Seventh Step
• Before com p l et i o n of patch closu re, t h e m i d d l e or d i s­
tal p o rt i o n of the patch i s p u n ctu red with an 1 8- g a u g e
need l e a n d t h e back of t h e p revi o u s l y p l aced w i re
is routed t h r o u g h t h e need l e . Patch c l o s u re is t h e n
co m p l eted a n d t h e c l a m ps removed; at t h i s poi nt, a n
a p p ro p r i ately sized s h e a t h c a n be adva n ced ove r t h e
wi re, t h r o u g h t h e p a t c h , i n p r e p a r a t i o n for i l i a c stenti n g .
• For p r i m a r i ly i l i a c d isease, retrograde a rte r i o g r a p h y
t h r o u g h t h e fe m o r a l s h eath i s u s u a l ly sufficient to o bta i n
a d e q uate i l i a c opa cificat i o n .
• Contra latera l a nterior o b l i q u e ( 1 5- to 30-deg ree) p roj ec­
t i o n s a re typica l ly chosen for v i s u a l ization of the respec­
tive i l i a c systems to e n s u r e i d e ntification of the o r i g i n of
the i ps i latera l i nt e r n a l i l i a c a rteries. A l so, the fu l l exte nt
of d i sease b u rd e n may be m ost a d e q u ately a d d ressed by
m u lt i p l e o b l i q u ities in any c i r c u m stance.
2040 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY
• A m a r k i n g catheter m a y be u s e d to a s s i st i n l e n g t h
m e a s u re m e nts a n d " b u d d y " w i re s m a y a l s o b e p l a c e d
f r o m c o n t ra l a te ra l fe m o r a l a c c e s s . E v e ry effo rt s h o u l d
b e m a d e to m a i nta i n p e rf u s i o n to t h e h y p o g a s t r i c
a rt e r i e s .
Second Step
• Sel ect i o n of t h e a p p ro p r i ate b a l l o o n a n d ste nt d i a m eter
i s of g reat i m porta nce. S l i g ht ove r s i z i n g of 5 % to 1 0 %
is reco m m e n d ed, except i n t h e case of heavily calcified
l e s i o n s, w h e re overs i z i n g may predi spose to a rte r i a l
r u pt u re .
• O pt i m a l ta rget vesse l d i a m eter may b e est i m ated p re­
o p e ratively by m e a s u r e m e nts from t h e CTA, p a rtic u l a rly
looking at t h e d i a m eter of adjacent o r contra late r a l
n o r m a l a rte r i a l seg m e nts. S i m i l a r ly, d i a m eter a n d l e n gt h
measureme nts may a lso b e o bta i n e d d u ri n g t h e h y b r i d
proced u re itself. G e n e ra l ly spea k i n g , com m o n i l i a c a rtery
ta rget d i a m eters may r a n g e from 7 to 1 0 m m , d e p e n d i n g
o n g e n d e r, body h a b it u s, a n d b u r d e n o f d i sease. Exte r n a l
i l i a c a rtery d i a m eters r a n g e f r o m 5 to 8 m m u n d e r s i m i l a r
q u a l ificat i o n s .
• B a l l o o n " p red i l ati o n " may fac i l itate ste nt p l a c e m e n t a n d
assist with ste nt s i z i n g .
• M i l d p a i n d u ri n g d i l a t i o n is to be a nt i c i pated a n d i n d i ­
cates stretc h i n g o f t h e adventitia; excessive o r p e rs i s­
tent p a i n , h owever, m a y i n d icate a rte r i a l c o m p r o m ise
o r r u pt u re . In t h e l atte r c i rc u m st a n ce, c o n s i d e ration
should b e g iven to a d d i t i o n a l p l a c e m e n t of a covered
stent when contrast extravasat i o n i s p resent o n a rteri­
o g r a p h y and not i m m ed i ately contro l l e d with exte n d e d
b a l l o o n d e p l oy m e n t . I n t h e retro perito n e u m , u n l i ke t h e
lower extrem ities, ta m p o n a d e w i l l not l i ke l y l i m it f u r­
t h e r b l e ed i n g a n d exte n d e d b a l l oo n d e p l oy m e n t m a y
n ot b e advisa b l e a s defi n itive t r e a t m e n t . W h e n g e n e r a l
a n esth e s i a i s req u i re d f o r t h e concomitant e n d a rte rec-
tomy, t h i s wa r n i n g s i g n m a y n ot be present a n d com­
p l et i o n a rte r i o g r a p h y s h o u l d b e ca refu l ly scrut i n ized
for i n d ications of i l i a c a rtery compromise o r contrast
extravasati o n .
• T h e re a re n u m e ro u s co m m erc i a l l y ava i l a b l e stents t o
c h oose f r o m , m a ny of w h i c h a re specifica l l y i n d icated
for i l i a c a rte r i a l i nte rve ntion (e . g . , "on l a b e l " ) . Appropri­
ate d i a meter and l e n gth ste nts g e n e ra l ly fa l l i nto two
categori es, b a l loo n-expa n d a b l e or se lf-expa n d i n g a n d
c a n be covered or u n covered (e . g . , with a d h erent g raft
mate r i a l ) .
• The l e n gth of t h e b a l loon o r ste nt s h o u l d cover t h e e n -
t i re l e n gt h of t h e d i seased a re a .
• B a l l o o n -expa n d a b l e stents h ave t h e a d v a n t a g e of
hig her precision of p l a c e m e n t a n d g re a t e r ra d i a l
stre n g t h ; h oweve r, t h e y a re l ess f l ex i b l e t h a n se lf­
expa n d i n g stents. As a g e n e r a l r u l e of t h u m b, b a l l o o n ­
expa n d a b l e stents a re best s u ited for co m m o n i l i a c
a rt e ry l e s i o n s w h e re " k i s s i n g " stents i n t h e c o n t ra l at-
e r a l i l i a c a rt e ry m a y be n e e d e d to d e a l w i t h excess ive
p l a q u e b u rd e n o r ca l cificat i o n o r t h e a o rt i c b i f u rcat i o n
m a y n e e d to b e " a dv a n c e d " i nto t h e d i sta l a o rta t o
co m p l et e l y e n s u r e a d e q u ate l u m i n a l reca n a l i za t i o n .
A l t e r n a t i ve ly, exte r n a l i l iac l e s i o n s a re oft e n b e s t
treated w i t h se lf-expa n d i n g s t e n t s , w h i c h by t h e i r
n a t u re a re m o re f l ex i b l e a n d com p l i a nt w i t h t h e
ra d i u s of c u rvat u re p re s e n t i n t h i s a rte ry. Except i o n s
exist for b o t h i n d i c a t i o ns, h oweve r, a n d device p l a c e ­
m e n t s h o u l d b e i n d i v i d u a l i z e d to s p e c i f i c a n at o m i c a n d
c l i n i ca l req u i r e m e nts.
T hird Step
• I n t h e sett i n g of b i l ate r a l or even u n i l atera l p roxi m a l
c o m m o n i l i a c a rte ry d i sease o r d i sta l a o rt i c d isease,
b i l atera l a o rt i c b i f u rcati o n b a l l o o n d i l a t i o n and stent­
ing s h o u l d be co m p l eted s i m u lta neously to p rotect t h e
contra late r a l com m o n i l i a c a rtery f r o m d i ssect i o n , p l a q u e
d is l o d g e m e nt, o r s u bseq u e n t e m b o l izat i o n . T h i s i s g e n e r­
a l ly refe rred to as " ki ss i n g " ste nts.
• B a l loo n-expa n d a b l e stents a re typica l ly used for these
prox i m a l common i l i a c lesions and they may be d e p l oyed
we l l i nto the d i st a l a o rta, essent i a l ly " a d va n c i n g t h e
a o rtic b i f u rcati o n . "
Fourth Step
• For co m m o n i l i a c l e s i o n s i m m ed i ately adjacent to t h e
a o rtic b i f u rcat i o n , after p r e c i s e a rte r i o g ra p h i c loca l i za ­
t i o n of t h e a o rt i c a n d i l i a c b i f u rcations a n d extent of
p l a q u e b u rd e n , a p propriately sized stents a re s e l ecte d .
U n i- o r b i latera l s h e a t h s of suffi cient d i a m eter for t h e
sel ected stents a re a d v a n c e d i nto t h e d i st a l a o rta. W h e n
c o m m o n i l i a c l es i o n s a re not strictly " o rifici a l , " conco m i ­
t a n t contra lateral ste n t i n g i s g e n e ra l ly n o t req u i re d .
Ag a i n , ca refu l a n g i o g ra p h i c assessment s h o u l d be m a d e
to determ i n e the extent of p l a q u e b u rd e n p resent a t
t h e o r i g i n of t h e c o m m o n i l i a c a rteries to m a ke t h i s
dete r m i nati o n .
• Appropriately sized b a l l o o n -expa n d a b l e stents a re a d ­
va n ced with i n t h e sheaths a n d positi o n e d across t h e
respective l e s i o n s . T h e sheaths a re t h e n p u l l e d b a c k to
expose the e n t i re ste nt; t h i s seq u e n ce p revents acciden­
ta l d is l o d g e m e n t of t h e ste nt off t h e b a l loon, atte m pt i n g
to cross t h e l e s i o n , a n d l i m its t h e risk of p l a q u e e m b o l iza-
t i o n d u ri n g ste nt passa g e .
• O n ce both stents a re posit i o n e d a p p ro p r i ately, they a re
i nfl ated s i m u lta neously to a c h i eve t h e kiss i n g confi g u ra ­
t i o n (FIG 8) .
Fifth Step
• C o m p l et i o n a rte r i o g r a p h y, typica l l y t h r o u g h a pres­
s u re i nj e ct i o n in the d i st a l a o rta t h r o u g h " s i d e- h o l e "
o r fl u s h cath ete rs, i s obta i n e d to c o n fi r m ste nt p l ace­
m e nt, eva l u ate d e g ree of resi d u a l ste n o s i s, and r u l e
o u t co m p l i c a t i o n s s u c h a s d i ssect i o n o r t h r o m b u s/
e m b o l i z at i o n .
• W h e n pressu re m e a s u r e m e n t a re req u i red, p u l l-back
p ress u res a re obta i n ed with t h e g o a l of e l i m i n ati n g
p ress u re g ra d i e nts a c ross t h e treated l e s i o n at rest o r
l i m it i n g to l e s s t h a n 1 5 m m H g fo l l owi n g i nject i o n of a
d ista l vaso d i l ator s u c h as pa pave r i n e .
 C h a p t e r 26 OCCLUSIVE D I SEASE MANAG E M E N T: I l i a c A n g i o p l asty a n d Femora l E n d a rterectomy 2041

FIG 8 • B i latera l co m m o n i l i a c a rte ry ste nosis treated with kiss i n g ste nt tech n i q u e . A. I n it i a l a o rtogram d e m o nstrati n g
h i g h-grade b i l atera l p roxi m a l c o m m o n i l i a c ste nosis. B. B a l l o o n d i l at i o n d e m o nstrati n g w a i st i n b a l l o o n at locat i o n of ste n osis.
C. Co m p l et i o n a o rtogram with b i l atera l kissi n g i l i a c stents, ra i s i n g t h e a o rtic bifu rcati o n by a few cent i m eters.

EXTERNAL ILIAC ARTERY STENTING T hird Step

First Step • Pred i l ation a n d postd i l ation may be pe rfo rmed as n eces­
sa ry with a p p ro p riately sized b a l l o o n s before and after
• W h e n t h e exte r n a l i l i a c a rtery is d iseased, p a rt i c u l a rly t h e
ste nt d e p l oyment.
d i sta l seg m ent, self-expa n d i n g stents a re typica l ly u s e d • I n t h e sett i n g of ve ry d i st a l exte r n a l i l i a c a rtery d is­
d u e to t h e i n creased tortuosity o f t h e s e vesse l s a n d t h e
ease o r i n c o m p l ete d ista l exter n a l i l i a c e n d a rte rectomy
i ncreased f l exi b i l ity of se lf-exp a n d i n g stents as o pposed
(as described e a r l i e r), t h e d i sta l e n d of t h e ste nt may be
to b a l l o o n -expa n d a b l e ste nts.
carried down to t h e l evel of t h e e n d a rterecto my, a g a i n
• T h e s a m e p r i n c i p l e s exist i n terms of s i z i n g , a lt h o u g h
w i t h c a r e to be t a k e n to avo i d cross i n g t h e i n g u i n a l l ig a ­
for se lf-expa n d i n g ste n ts, 1 0 % to 2 0 % overs i z i n g i s
m e n t a s p revi ously described (FIG 5) .
typica l ly reco m m e n d e d i n t h e respective i n st r u ct i o n s for
use ( I F U ) . Fourth Step

• J ust as i n co m m o n i l i a c ste n t i n g , co m p l et i o n a rteria­

Second Step
• D e p l oyment of self-expa n d i n g stents d oes n ot req u i re
adva ncement of t h e i ntrod ucer sheath past t h e lesi o n .
T h e se lf-expa n d i n g stents u s u a l ly a re m o u nted o n a ca r­
r i e r a n d constra i n e d . The stents s h o u l d be posit i o n e d
across t h e l e s i o n a n d d e p l oyed .
• C l ose f l u o rosco p i c m o n ito r i n g should occ u r
d e p l oyme nt, as self-expa n d i n g stents t e n d to b e fa r
l ess p recise i n positi o n i n g i n comparison to b a l l o o n ­
expa n d a b l e stents a n d typ i ca l ly may a d v a n c e a c ross t h e
l e s i o n d u ri n g d e p loyment.
grams should be pe rfo rmed, and p ress u re g ra d i e nts may
be o bta i n ed as n ecessa ry to confi rm s uffi c i e nt reso l ut i o n
of t h e ste nosis.
Fifth Step
• U s u a l ly, a s i n g le-re p a i r stitch can be used to close t h e
during
p a t c h s h e a t h access s i t e , reg a r d l ess of t h e d i a m eter o f
t h e sheath used for ste nt d e p l oyment.
• O n ce h e m ostasis i s a c h i eved, t h e sheaths re m oved, a n d
a nticoag u l ation reversed with p rota m i n e i nject i o n , t h e
fe m o ra l exposu re s h o u l d be c l osed with a m u lt i l ayer,
a n ato m i c c l o s u re with a bsorba b l e sutu re.

PEARLS AND PITFALLS

Occ l u d ed i l i a c a rtery strate g i e s
Reentry devices • When atte m pt i n g to cross a n occ l u d e d segment with catheter-g u i d ew i re c o m b i natio ns, a s u b i nt i m a l
p l a n e m a y b e deve l o p e d . T h i s s u b i n t i m a l tech n i q u e i s a pp r o p r i ate a s l o n g as t h e t r u e l u m e n ca n
once a g a i n be reg a i ned p r i o r to ente r i n g t h e a o rta. I n some c i r c u m st a n ces, t h i s reentry may be c h a l ­
l e n g i n g . I n t h e s e situatio ns, reentry devices can be e m p l oyed. These devices h a v e n i t i n o l ca n n u l a
that c a n be adva n ced t h ro u g h t h e device a n d used t o p u n ct u re i nto t h e t r u e l u m e n ; a 0 .0 1 4- i n w i re
is t h e n advanced. Free passage of t h e w i re i n d i cates t r u e l u m e n access, w h i c h is confirmed by con­
trast i nject i o n . The passage can t h e n be d i l ated a n d ste nted i n a convent i o n a l m a n n e r (FIG 9) . Care
s h o u l d be taken to atte m pt reentry before t h e d issect i o n p l a n e i s advanced too fa r proxi m a l ly i nto
the d i sta l a o rta, a s t h i s may co m p ro m ise the a b i l ity to properly d e p loy ba l l oo n -expa n d a b l e stents
a n d/o r comprom ise i nfer i o r mesenteric a rte r i a l fl ow. S i m i l a rly, reentry systems s h o u l d be used with
c a u t i o n i n t h e i l i a c a rte r i a l system to avoid pe rfo rat i o n a n d retroperito n e a l b l e ed i n g .
2042 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

FIG 9 ®
• Use of an O utback ree ntry catheter (Cord is Corporat i o n ,
H i a l e a h , F L) i n treatment of a c h ro n i c tota l i l i a c occ l u s i o n . A.
Aorto g r a m s h ow i n g co m p l ete occ l u s i o n of t h e l eft i l i a c a rte r i a l
syste m . B. The majority of t h e occ l u s i o n w a s crossed; h owever,
reentry i nto t h e t r u e a o rt i c l u m e n was u n s u ccessfu l u s i n g tra d i t i o n a l
tech n i q ues. The Outback ® reentry catheter was advanced a n d
positi o n e d . C. After adva ncement o f t h e ree ntry need l e, a 0 .0 1 4- i n
w i re w a s a b l e to be passed i nto t h e a o rt a . D. Retrog rade kiss i n g
b a l l o o n expa n d a b l e ste nt placement i nto b i latera l co m m o n i l i a c
a rteries. E. Co m p l et i o n a o rto g r a m d e m o n strat i n g reconstitution o f
flow i n l eft i l i a c syste m .

Altern ative a p p roach
Severe ca l cified d i sease
strate g i e s
• Antegrade a p p roach from either a b rac h i a l o r contra lateral fe m o r a l access s o m et i mes provides m o re
" p u s h a b i l ity" a c ross reca lcitrant l e s i o n s a n d m a y be more s u ccessf u l at obta i n i n g w i re access. T h i s
i s p a rt i c u l a rly t r u e w h e n a s m a l l i nva g i n a t i o n i s a p p a rent a n g i o g ra p h ica l ly i n t h e i p s i late ra l c o m ­
m o n i l i a c a rtery (wh e n tota l ly occl u d e d ) . O n ce t h e occ l u s i o n o r ste nosis i s traversed, t h e w i re can
be s n a red from t h e i p s i l atera l fe m o r a l a n d a n i p s i l atera l sheath can sti l l be advanced to co m p l ete
the proce d u re a s p revio u s l y described from the i p s i l atera l fe m o ra l a ccess. This i s g e n e ra l ly advisa b l e
a s compa red to atte m pted ste nt placement f r o m l eft b rac h i a l a ccess, d u e to p roxi m ity a n d control
issu es, as well as t h e ava i l a b i l ity of su ita b l y sized stents o n long d e l ivery catheters.
• I n patie nts with s i g n ificant atherosc l e rotic b u rd e n , ca re s h o u l d be taken d u ri n g t h e i nterve n t i o n
to m i n i m ize atheroe m b o l izat i o n . Use of cove red ste nt g rafts ca n be c o n s i d e red i n these sce n a r i os.
Ad d it i o n a l ly, as a n added b e n efit of t h e hybrid a p p roach, f l u s h i n g m a n e uvers of t h e patch
a n g i o p l asty site may be pe rfo rmed to e l i m i nate e m b o l i c d e b r i s .

Arte r i a l r u pt u re • Cover with ste nt g raft. C o n s i d e r proxi m a l ba l l oo n occ l u s i o n .

Arte r i a l d i ssect i o n • Exte n d ste nt if flow l i m it i n g d i ssect i o n .

POSTOPERATIVE CARE One-year primary patency and primary-assisted patency rates

• Following femoral endarterectomy and iliac stems, patients
are usually monitored in the hospital for 1 to 2 days.
• Postoperative antithrombotic management is not well stud­
ied in this population; however, most surgeons treat patients
with dual antiplatelet therapy such as aspirin and clopi­
dogrel, with a loading dose of clopidogrel followed by a
daily dose, for the first 6 weeks following the procedure.
Long-term anti platelet management is usually achieved with
acetylsalicylic acid (ASA) alone, except in circumstances of
aspirin allergy.
• Routine follow-up with arterial duplex and ABis is impor­
tant to monitor for continued patency and potential need for
secondary intervention.
OUTCOMES
• Early and long-term results of concomitant common femoral
artery endarterectomy and iliac stenting have been excellent.
have been reported to be 84% and 97%, respectively.3 Five­
year primary, primary-assisted, and secondary patency rates
were 6 0 % , 97%, and 9 8 % in a recent report of 1 7 1 patients.4
• There is some evidence that covered stem grafts may have
improved patency compared to bare metal stems, particu­
larly in TASC C and D lesions.4•5
• Iliac artery stenting combined with open femoral endarter­
ectomy also appears to be equally effective as open surgi­
cal revascularization. Piazza and colleagues6 found similar
3 0-day morbidity and mortality as well as primary patency
at 3 years when comparing a 1 0 -year cohort of patients
treated in both manners. These similarities were maintained
even after stratification for TASC group.
COMPLICATIONS
• Contrast nephropathy
• Wound complications, including infection, dehiscence, seroma
formation, and nerve entrapment
 C h a p t e r 26 OCCLUSIVE D I SEASE MANAG E M E N T: I l i a c A n g i o p l asty a n d Femora l E n d a rterectomy 2 043

• Arterial rupture 3. Nelson PR, Powell RJ, Schermerhorn ML, et a!. Early results of
• Arterial dissection external iliac artery scenting combined with common femoral artery
• Embolization endarterectomy. J Vase Surg. 2002;35(6):1107-1113.
4. Chang RW, Goodney PP, Baek JH, et a!. Long-term results of combined
common femoral endarterectomy and iliac stentinglstent grafting for
REFERENCES occlusive disease. j Vase Surg. 2008;48(2):362-367.
5. Mwipatayi BP, Thomas S, Wong J, et a!. A comparison of covered
1. Rzucidlo EM, Powell RJ, Zwolak RM, et a!. Early results of scent­ vs bare expandable stents for the treatment of aortoiliac occlusive
grafting to treat diffuse aortoiliac occlusive disease. J Vase Surg. disease. J Vase Surg. 2011;54(6):1561-1570.
2003;37(6):1175-1180. 6. Piazza M, Ricotta JJ II, Bower TC, et al. Iliac artery scenting combined
2. Norgren L, Hiatt WR, Dormandy JA, et a!. Inter-Society Consensus with open femoral endarterectomy is as effective as open surgical
for the Management of Peripheral Arterial Disease (TASC II). J Vase reconstruction for severe iliac and common femoral occlusive disease.
Surg. 2007;45(suppl S):S5-S67. J Vase Surg. 2011;54(2):402-411.
 -

Chapter 27 Management of the Infected

Femoral Graft
-+
I

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - .....

Ma tth e w Mel/

PATIENT HISTORY AND PHYSICAL • Graft replacement material

• Graft material should be considered prior to surgery to
FINDINGS
ensure availability.
• The symptoms of an infected femoral graft can vary widely, • Potential options for graft material include the following:
from a chronically draining wound to sepsis and hemody­ Autogenous vein (saphenous vein, cephalic vein, basilic
namic collapse. vein, superficial femoral vein [SFV] )
• Symptoms may have been present from hours to weeks. Cryopreserved tissue ( aorto-iliac-femoral artery, femoral
• Physical examination should include inspection of the surgi­ vein, saphenous vein)
cal wounds and graft tunnels for induration, erythema, ten­ Prosthetic graft (rifampin-soaked Dacron™, polytetra­
derness, open wounds, aneurysmal degeneration of the graft fluoroethylene [PTFE] )
or anastomosis, or drainage. • Consider the need for wound coverage:
Debridement of an infected groin wound may result in a
IMAGING AND OTHER DIAGNOSTIC large defect that either cannot be covered or closed. Muscle
STUDIES flaps can provide coverage of healthy well-vascularized
tissue to protect the repair.
• When possible, causative organisms should be identified
Small to medium defects can be covered with a sartorius
prior to surgery to aid in choosing appropriate systemic
muscle flap, which is divided from its attachment to the
antibiotics and the optimal surgical approach.
anterior superior iliac spine and mobilized medially to
• Prior to surgery, detailed imaging with computed tomo­
cover the wound.
graphic angiography ( CTA) can provide critical information
A pedicled flap from the leg or abdominal wall may
for developing a cohesive plan for surgical exploration and
be required for larger wounds. These flaps include rec­
graft removal and replacement.
tus femoris, rectus abdominis, tensor fasciae latae, or
• Computed tomography ( CT) can accurately identify anatomic
gracilis.
signs of infection, including abscess or anastomotic aneurysm.
CT can also provide clues to the extent of infection.
• CTA provides high-resolution imaging of the aorta and run­
off vessels, which will aid in determining the options for
revascularization, including in situ reconstruction, obturator
bypass, or ilioprofunda bypass.
• Radionuclide scans may provide evidence for graft infection
when other imaging studies are nondiagnostic.

SURGICAL MANAGEMENT
• Aggressive and wide debridement of devitalized or infected
tissue must accompany graft excision and replacement in the
setting of infection.
• Partial or complete excision of infected prosthetic grafts is
generally required to eliminate the infection.
• Excision of infected autogenous graft infections may be nec­
essary when associated with sepsis caused by Escherichia
coli, Pseudomonas, Klebsiella, or Proteus spp.
• Graft excision without reconstruction: Infected thrombosed
grafts with adequate collateral circulation may require only
excision without reconstruction.
• Excision and extraanatomic bypass is preferred with pres­
ence of severe sepsis and/or hemorrhage. Examples of
extraanatomic bypasses include axillary-to-femoral bypass
{ FIG 1 ), obturator bypass, or cross-femoral bypass.
• In situ replacement: Low-grade infections without sepsis
or invasive infection and those with distal occlusive disease FIG 1 • F i g u re 1 : Axi l l o-fe m o r a l bypass. N ote that t h e proxi m a l
may be best treated with in situ graft replacement. g raft i s p l aced b e h i n d t h e pecto ra l i s m i n o r m u scle.

2044
 C h a p t e r 27 MANAG E M E N T OF T H E I N FECTED F E M O RAL G RAFT
G ENERAL CONSID ERATIONS
• It is desi ra b l e w h e n consi d e r i n g an extra a n ato m i c reco n ­
struct i o n to revasc u l a rize before exc i s i n g t h e i n fected
g raft. T h i s can be acco m p l ished with a bypass and t u n n e l
pe rfo rmed a cross c l e a n tissue p l a nes. O n ce t h e bypass i s
co m p l eted a n d wo u n ds c l osed, t h e g r o i n can be exp l o red
and t h e i n fected g raft removed. With this a p p roach, the
cont i n u ity betwee n the s u p e rfi c i a l fe m o ra l and deep
fem o r a l a rteries s h o u l d be m a i nta i n ed by either over­
sew i n g the d i sta l c o m m o n fe m o ra l a rtery o r a n asto mos­
ing t h e p rofu n d a fe m o r i s a rtery (PFA) to t h e s u p e rfi c i a l
fem o r a l a rtery w i t h p rox i m a l l i g a t i o n (FIG 2) .
/ I nfected graft Excised
Deep Su perficial
femoral femoral
artery artery
Oversew Syndactalize
OBTURATOR BYPASS
• U s i n g t h e obtu rator fora m e n may be a usef u l a p proach
for bypass i n g a n i n fected g ro i n t h r o u g h a ste r i l e fi e l d . 2 A
reinfo rced PTFE g raft is best s u ited for t h i s tech n i q u e a n d
c a n be used if sepsis h a s b e e n contro l l ed a n d t h e bypass
c a n be p e rformed without violati n g t h e i n fected f i e l d .
• The p roxi m a l a n asto mosis can be pe rfo rmed to t h e
co m m o n i l i a c a rtery, exte r n a l i l i a c a rtery (ipsi l atera l o r
contra l ateral), o r p revi o u s g raft if n o t i n fected (FIG 3).
Exposu re can be o bta i n ed t h r o u g h a sta n d a rd retro­
perito n e a l i n ci s i o n , by d i v i d i n g the exte r n a l a n d i ntern a l
o b l i q u e a n d tra nsve rsus a b d o m i n is m uscl es, i d e ntifyi n g
2045
• D e b r i d e m e n t of t h e i nfected site m u st i n c l u d e rem ova l
of i n fected or n ecroti c tissue a n d co m p l ete exc i s i o n of
t h e a nasto mosis. D i ssect i o n m a y be a i d e d by l a c k of
i n corporation of t h e i n fected g raft but a lso may p rove
ch a l l e n g i n g from exten s ive sca r r i n g in the reope rative
f i e l d . S h a r p d i ssect i o n tech n i q ues a re critica l to m i n i m iz­
ing the risk of i n a dvertent i n j u ry to vesse l s o r adjacent
structu res.
• It i s i m porta nt to send c u l t u res of the perig raft f l u id, tissue,
and g raft ' I n structions s h o u l d be g iven to the m icro b i o l ­
ogy l a b to perform son ication of the g raft to sepa rate
b i ofi l m from g raft and maxim ize the bacte riology y i e l d .
FIG 2 • S u r g i c a l options fo r m a i nta i n i n g
cont i n u ity o f a rte r i a l flow to t h e prof u n d a fe m o r i s
a rtery after obtu rator bypass a n d c o m m o n
Re-implant fe m o r a l a rtery l i g a t i o n
t h e preperito n e a l space, a n d retract i n g t h e perito n e u m
m ed i a l ly w i t h b l u nt d i ssect i o n tech n i q ues. The obtu rator
fora m e n i s j u st poste r i o r to t h e a nterior ra m u s of the
pelvis, a l t h o u g h it may not be easily p a l pated due to the
ove r l y i n g obtu rator m e m b r a n e .
• D i st a l a n asto mosis ca n be performed to the d i st a l s u p e rfi­
cial fem o r a l a rtery, t h e m i d po rt i o n of the PFA (see t h e fo l ­
lowi n g section, l atera l a p p roach to t h e Late ra l Profu n d a
F e m o r i s Artery Exposu re), o r the p o p l itea l a rtery. D u r i n g
t h i s d i ssect i o n , t h e a d d uctor l o n g u s a n d m a g n u s can be
i d e ntified with t h e leg a b d u cted and exte rn a l ly rotated .
The t u n n e l w i l l be p l aced deep to t hese m uscles, w h i c h
i n se rt o n t h e exte r n a l s u rface of t h e obtu rato r fora m e n .
2046 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

Common il iac
artery and vein

·.
··-

FIG 3 • Ope rative i nc i s i o n for retro pe rito-

artery and neal exposu re of t h e i l ia c a rtery. Perito n e u m

vein and its contents a re retracted m ed i a l ly to
a i d in exposu re.

• The t u n n e l s h o u l d be pe rfo rmed in a c ra n i a l d i rect i o n
with a l o n g a o rtic c l a m p o r t u n n e l i n g i n st r u m e n t (FIG 4) .
T h e i nstr u m e n t i s passed d e e p to t h e a d d u ctor m a g -
n u s w h i l e a h a n d is p l aced over t h e o b t u rator fora m e n
f r o m t h e retroperito n e a l i nc i s i o n . The i nstru m e n t c a n
be d i rected t h r o u g h t h e obtu rator fora m e n . The t u n -
n e l s h o u l d be m a d e t h r o u g h t h e late r a l p o rt i o n o f t h e
o bt u rator fora m e n to avo i d t h e obtu rator a rtery and
n e rve, w h i c h traverse a ntero m e d i a l ly.
• O n ce the t u n n e l is m a d e, the g raft can be p l a ced a n d t h e
bypass p e rfo r m e d . Once co m p l eted, t h e i nc i s i o n s s h o u l d
be c l osed a n d p rotected before p rocee d i n g w i t h exc i s i o n
o f t h e i nfected g raft.

Su perficial
femoral
artery
and vein
Add uctor Anterior
Sartorius mag nus il iac spine �
muscle ---1-1 muscle
I nguinal

\
ligament
Add uctor
mag nus Ligament
canal of Cooper
\
�\
Lacunar
Pubic ligament �
tubercle

FIG 4 • Exposure of the su perfi c i a l fe m o r a l

Obtu rator nerve
Obtu rator artery
and vein
a rte ry a n d t u n n e l i n g for a n obtu rator
bypass. Left: creat i n g the t u n n e l b e h i n d the
a d d uctor m a g n u s m uscl e . R i g ht: placement
of the t u n n e l t h r o u g h the obtu rator
m e m brane.
 C h a p t e r 27 MANAG E M E N T OF T H E I N FECTED F E M O RAL G RAFT
LATERAL PROFUND A FEMORIS ARTERY
EXPOSURE
• A n o t h e r o p t i o n f o r r e m ot e revasc u l a r i z a t i o n is to u s e
t h e seco n d p o rt i o n of t h e P FA, e x p o s e d t h r o u g h a
l at e r a l i n c i s i o n 3 T h i s a p p ro a c h m a y be u s ef u l if t h e
s u p e rf i c i a l f e m o r a l a rt e ry i s o cc l u d ed a n d t h e g o a l i s
to esta b l i s h f l o w f r o m t h e a x i l l a ry a rt e ry v i a a t u n n e l
A C
_,:a__
""""'Tft""U'I -
Lateral
SUPERFICIAL FEMORAL VEIN H ARVEST
• S FV c a n be a s u it a b l e g raft for reco nstruct i o n , with a l ow
i nc i d e n ce of recurrent or u n contro l l e d i nfect i o n .• Pre­
ope rative eva l u a t i o n s h o u l d i n c l u d e d u p l ex i m a g i n g of
t h e SFV to exc l u d e deep ve n o u s t h r o m bosis and to d eter-
m i n e t h e vesse l d i a m eter.
• D i ssect i o n can be performed through a sta n d a rd a ntero­
m e d i a l leg i n cision, o r p laced ove r the l atera l border of
the sarto r i u s (FIG 6). The ve i n s h o u l d be d i ssected from
its conf l u e n ce with the p rofu n d a femoris ve i n d i sta l ly to
obta i n sufficient l e n gth for reconstruct i o n . Care s h o u l d be
2 047
m e d i a l to t h e a n t e r i o r i l i a c s p i n e a n d l a t e r a l to t h e
f e m o ra l i n fect i o n .
• T h e P FA is exposed t h r o u g h a n i n c i s i o n p l aced a l o n g t h e
lateral border of t h e s a rto r i u s m uscle 4 to 6 e m b e l ow
t h e a nterior s u pe r i o r i l ia c s p i n e (FIG 5) . T h e s a rto r i u s
a n d s u perfi c i a l fe m o ra l vess e l s ca n b e retracted m e d i ­
a l ly to expose t h e a d d u ctor l o n g u s . I t s overlyi n g fascia i s
d ivided, a n d with m e d i a l retract i o n , t h e PFA i s exposed.
Sartorius
Add uctor
longus
FIG 5 • Late r a l exposu re of t h e profu n d a
fe m o r i s a rte ry. A. I n c i s i o n a l o n g t h e latera l
border of t h e sa rto r i u s m u sc l e . B. M e d i a l
retract i o n o f t h e s u perfi c i a l fe m o r a l a rtery
a n d ve i n to expose t h e a d d ucto r l o n g u s .
C. Fasc i a l i n c i s i o n a n d m e d i a l retract i o n
of t h e a d d u cto r l o n g u s to expose t h e
p rofu n d a fem o r i s vesse ls.
taken to p reserve the profu n d a femoris ve i n a n d the com­
m o n femora l vei n a n d to stop the d i ssection at the a d d uc­
tor ca n a l . These l i m its w i l l preserve i m porta nt co l l ateral
c i rc u l ation betwee n the prof u n d a femoris and the p o p l i ­
tea l ve i n , which w i l l m i n i m ize posto perative leg edema.
• O n ce h a rvested, b r a n c h es of t h e S FV should be d o u b ly
l i gated or suture l i gated a d i stance 2 mm from t h e i r
j u nction w i t h t h e S FV to p revent s l i p p a g e of t h e l i g a ­
t u re once t h e co n d u it is p ress u rized. The S FV can be used
i n a reversed m a n n e r o r n o n reversed after d i s r u pt i n g
t h e va lves.
2048 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

I Femoral
nerve
I
I
I
I
I
I
I
I
I
I
I
I

A
Deep
femoral
artery

Su perficial
femoral vessels FIG 6 • Exposu re of t h e s u p e rfi c i a l fe m o ra l
ve i n . A . I nc i s i o n a l o n g t h e s a rto r i u s m uscle.
B B. medial retract i o n of t h e s a rto r i u s to expose
t h e s u p e rfi c i a l fe m o ra l ve i n .

• G rafts should b e prepa red i m med iately before i m p l a ntation.

CRYOPRESERVED GRAFTS
• S o m e stu d ies have shown favora b l e resu lts for cryo­
preserved a l l o g rafts with regard to l i m b l oss, rec u r­
rent i nfect i o n , a n d s u rviva l co m p a red with other in situ
replacements. 5
• W h e n c o n s i d e r i n g an a l l o g raft, g reater t h a n 24 h o u rs
may be req u i red to l ocate s u i ta b l e g raft m a te r i a l a n d
l e n gth if t h e re i s n o o n -site i nventory.
The thaw-a nd-rinse process takes approximately 45 m i n utes.
• L i g ated b raches s h o u l d be tested fo r h e m ostas i s a n d
s u t u re l i g atu res p l aced if n ecessa ry. If u s i n g a n a o rto i l i a c
h o m o g raft, it i s easier to confirm h e m ostas i s if t h e g raft
is p l aced with the l u m b a r branches faci n g a nterior.
• G raft l e n gth s h o u l d a l l ow for a tension-free a n a stomosis .
W h e n poss i b le, avo i d a l l o g raft-to-a l l og raft a n a stomoses.

PEARLS AND PITFALLS

Preoperative c o n s i d e rations
Prox i m a l a n d d i st a l
vessel control
I ntraoperative c u l t u res
Tu n n e l s
• W h e n poss i b le, c o n s i d e ration s h o u l d be made prior to su rgery for t h e best o pt i o n (s) of g raft
mate r i a l , a l l o w i n g t i m e to o bta i n it if req u i re d . For a utog e n o u s ve i n , preoperative d u p l ex i s
esse nti a l to determ i n e t h e size a n d q u a l ity of t h e p r o p o s e d co n d u it.
• When poss i b l e, prox i m a l and d ista l vessel control s h o u l d be o bta i ned t h ro u g h extension of the
o r i g i n a l i n c i s i o n o r t h ro u g h sepa rate i ncisions before d i ssect i n g the i n fected vessels. Remote
bypass with su bseq uent rem ova l of i n fected mate r i a l may be p refe ra b l e to in situ repa i r.
• It is i m p o rtant to o bta i n G ra m sta i n , a e ro b i c, a n d a n a e ro b i c c u ltu res of t h e p e r i g raft f l u i d ,
p e r i g raft tissue, a n d g raft. The y i e l d of t h e g raft w i l l be i n creased if s o n i cation of t h e g raft i s
pe rfo rmed i n t h e m ic ro b i o l ogy l a b p r i o r to i n cu bati o n .
• Tu n n e ls, w h e n poss i b le, s h o u l d be p l aced i n ste r i l e f i e l d s .

Syste m i c a n t i b iotic treatment
• B road-spectrum antibiotics s h o u l d be i n it i a l ly considered f o r patients w i t h severe sepsis. For those
without sepsis, blood and wou n d cu ltu res s h o u l d be performed prior to sta rti n g antibiotics.
I n it i a l antibiotics s h o u l d i n c l u d e coverag e for methici l l i n-resista nt Staphylococcus au reus (M RSA) .
After s u rgery, p a renteral antibiotics s h o u l d be considered for 4-6 weeks, especia l ly for i nvasive
i nfections or in situ rep a i r.
 C h a p t e r 27
POSTOPERATIVE CARE
• Antibiotics should be continued for at least 2 to 6 weeks,
depending on the type of organism, and should be chosen
based on antimicrobial sensitivity when available.
• Patients should be inspected daily for signs of infection,
which may include fever, leukocytosis, erythema or drainage
from the wound, or wound breakdown. Persistent infection
should trigger consideration of wound exploration and re­
evaluation of the antibiotic regimen.
• Drains, if placed, should be removed as soon as possible,
based on quantity and appearance of fluid. Ongoing pu­
rulent drainage or continued fever and leukocytosis may
indicate lack of source control, which may require wound
exploration and washout.
•
Arterial surveillance should be performed prior to discharge
to confirm the integrity of the repair and establish a baseline
for future surveillance examinations.
COMPLICATIONS
• Bleeding from the wound should raise immediate concerns
of arterial disruption from persistent infection leading to
MANAG E M E N T OF T H E I N FECTED F E M O RAL G RAFT 2 049
tissue destruction. If present, patients should undergo arte­
rial duplex and be considered for reexploration. Under these
circumstances, complete evaluation of the arterial recon­
struction (even if remote) is advisable as vascular resection
and reconstruction may be required. At times, arterial liga­
tion may be the only option for local control of sepsis.
• If not already performed, patients requiring reexploration
and debridement for persistent infection will most often ben­
efit from muscle flap coverage of the defect.
REFERENCES
1. Bandyk OF, Bergamini TM, Kinney EV, et al. In situ replacement of
vascular prostheses infected by bacterial biofilms. ] Vase Surg. 1991;
13(5):575-583.
2. Pearce WH, Ricco JB, Yao JS, et al. Modified technique of obturator
bypass in failed or infected grafts. Ann Surg. 1983;197(3):344-347.
3. Bridges R, Gewertz BL. Lateral incision for exposure of femoral
vessels. Surg Gynecol Obstet. 1980;150(5):732-733.
4. Smith ST, Clagett GP. Femoral vein harvest for vascular reconstruc­
tions: pitfalls and tips for success. Semin Vase Surg. 2008;21(1):35-40.
5. Kieffer E, Gomes D, Chiche L, et al. Allograft replacement for infrare­
nal aortic graft infection: early and late results in 179 patients. ] Vase
Surg. 2004;39(5):1009-1017.

Chapter 28
r
-+
r
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
t
DEFINITION
• Chronic lower extremity ischemia, also known as peripheral
artery disease (PAD ) , is a common condition managed by
vascular specialists. The primary etiology is atherosclerosis.
Atherosclerotic stenosis or occlusion of the peripheral arte­
rial tree results in arterial insufficiency and end-organ (limb)
ischemia. PAD is a major contributor to morbidity, reduced
quality of life (QOL), and mortality in an increasing elderly
demographic in the Western world.
DIFFERENTIAL DIAGNOSIS
• The challenge for the vascular specialist is to determine
whether the nature and severity of presenting symptoms cor­
relate with the degree of chronic arterial insufficiency present
or whether alternative etiologies, such as neuropathy, inflam­
mation, infection, lymphatic or venous disease, and repeti­
tive trauma, are more likely responsible. Definitive diagnosis
is derived from detailed historic and physical examination
findings correlated with appropriately directed noninvasive
vascular laboratory and adjunctive imaging studies.
PATIENT IDSTORY AND PHYSICAL FINDINGS
• Patients with PAD may present with a spectrum of symptoms
ranging in severity from none to varying degrees of claudica­
tion to severe or " critical" limb ischemia ( " CLI" ischemic =
rest pain, ulceration, and gangrene) . Pulse palpation is an
integral component of the physical examination. Femoral,
popliteal, posterior tibial, and dorsal pedal pulses should be
noted and graded ( 0 = absent; 1 = present but diminished;
2 = normal; 3 = enlarged, aneurysmal ) . Claudication is de­
fined as muscular pain, cramping, aching, or discomfort in
the lower limb, reproducibly elicited by exercise and relieved
within 10 minutes of cessation. CLI has been traditionally
defined as ( 1 ) persistent, recurring ischemic rest pain reguir­
ing opiate analgesia for more than 2 weeks and ( 2 ) ankle
systolic pressure less than 50 mmHg or toe systolic pressure
less than 30 mmHg (or absent pedal pulse in patients with
diabetes) . 1 Ischemic rest pain typically is nocturnal, worsens
with elevation, and is relieved by dependency. Pedal pulses
are absent; dependent rubor, elevation pallor, and calf mus­
cle atrophy are frequent accompaniments. CLI also includes
ischemic foot ulceration and gangrene in the setting of ankle
systolic pressure less than 50 to 70 mmHg or toe systolic
pressure less than 40 mmHg in patients without diabetes
( < 5 0 mmHg in diabetics) .
SURGICAL MANAGEMENT
Indication
• All patients with PAD require comprehensive medical man­
agement and risk factor modification. Revascularization
(either open bypass or endovascular intervention) is indicated
2050
-
Surgical Exposure of the Lower
Extremity Arteries
�
Luke X. Zha n Joseph L. Mills, Sr.
in patients who remain symptomatic and significantly lim­
ited despite adequate risk factor modification, exercise, and
medical management. The primary goal of intervention, in
patients with lifestyle-limiting claudication, is to improve
exercise tolerance and hence QOL. Patients with rest pain,
tissue loss, and gangrene are at greater risk for limb loss and
cardiovascular mortality (stroke, myocardial infarction) as­
sociated with systemic atherosclerosis than those who present
with claudication alone. Revascularization in the CLI cohort
is focused on wound healing and functional limb salvage as
well as symptomatic relief and improvement in QOL.2•3
Preoperative Planning: Imaging and Risk Assessment/
Mitigation
• The vascular specialist must first determine, given the un­
derlying disease burden, the severity of ischemic and infec­
tious complications as well as the patient's comorbidities,
functional status, and anticipated longevity. Once it is
decided that revascularization will improve the patient's
functional status and QOL, these same variables, in con­
cert with anatomic assessment of the location, extent, and
severity of occlusive arterial lesions will determine whether
endovascular, open, or hybrid revascularization options are
indicated. When bypass is selected as the preferred revascu­
larization option, the goals of preoperative planning involve
delineation of diseased arterial segment(s), identification
of the most appropriate arterial inflow source, selection of
the optimal bypass target for maximal outflow and target
bed perfusion, and selection of the best available conduit.
In practice, conduit availability is almost always a critical,
rate-limiting factor because good quality, autogenous vein
conduit is preferred in almost every circumstance.
• Adequate preoperative planning depends on a thorough his­
tory and detailed physical examination.
• The delineation of the relevant arterial anatomy on the index
limb is facilitated by high quality, noninvasive vascular labo­
ratory studies ( ankle-brachial index and toe pressure mea­
surements) . These are supplemented by arterial color duplex
ultrasound imaging. Arterial duplex is extremely accurate in
the assessment of iliofemoral and femoropopliteal arterial oc­
clusive disease but less so for infrageniculate (tibial-peroneal)
lesions. Duplex enables differentiation of stenosis from oc­
clusion and determination of lesion length and degree of cal­
cification. Cross-sectional imaging studies such as computed
tomography angiography ( CTA) or magnetic resonance arte­
riography (MRA) may add complementary information, but
most experienced operators prefer the precision and resolu­
tion inherent in catheter-based, intraarterial contrast arteri­
ography for definitive preoperative planning, especially when
bypass will be required to distal calf or pedal targets.
• PAD is a coronary artery disease equivalent. Therefore, pre­
operative risk evaluation for overall cardiovascular-related
mortality represents a component of preoperative planning.
 C h a p t e r 28 S U R G I CAL EXPOS U R E OF T H E LOWER EXTREM ITY ARTE R I E S
I n most patients with stable o r minimally symptomatic coro­
nary disease, preoperative risk-reduction efforts are best
focused on optimizing medical management. Frequently,
this includes statin and antiplatelet therapy, 13-blockade, and
optimization of hypertension management.
• The surgical plan should be tailored to each patient's needs
based on extent of disease, conduit availability, and realistic
• Refer to refe rences 4 t h r o u g h 9 for t h i s sect i o n .
FEMORAL VESSEL EXPOSURE
Positioning
• The patient is p l aced i n s u p i n e posit i o n . A F o l ey catheter
i s i n se rte d . Arms may be tucked to fa c i l itate i ntraopera­
tive prebypass and co m p l et i o n a n g i o g ra phy.
Placement of Incision
• The co m m o n femora l a rtery (CFA) is l ocated on a l i n e
between t h e p u b i c tu bercle a n d a nterior i l ia c s p i n e, two
f i n g e rbreadths latera l to p u b i c tu bercle. P a l pation of t h e
i n g u i n a l l i g a ment a n d fe m o r a l p u l se o r d i rect a rte r i a l
v i s u a l ization w i t h d u p l ex i m a g i n g can loca l ize t h e CFA
b i f u rcat i o n a n d g u i d e opti m a l i nc i s i o n p l acement. Even
when p u l se l ess due to excessive calcification o r occ l u s ive
d i sease, the CFA may be loca l i zed by re l i a nce o n a n at o m i c
Popliteal artery
FIG 1 • Placement of incisions for i nfra i n g u i n a l arterial exposure.
I ncisions (A) a n d (B): Femoral vessel exposure at proxi m a l thigh.
I ncisions (C-F): Exposure of mid- a n d d ista l s u perficial a n d deep
femoral arteries. Incisions (G) a n d (H): Latera l a n d m ed i a l exposure
of popl iteal a rtery a bove the knee.
2051
long-term functional potential. Infrainguinal bypass may
originate from the common, superficial, or deep femoral
artery or the popliteal artery with a bypass target of the
popliteal, tibial, or pedal/plantar arteries. The positioning,
choice of incisions, and surgical techniques are dictated by
type of bypass procedure deemed most appropriate under
the circumstances.
l a n d m a rks a n d d i rect p a l pation, reco g n ized as a firm tu­
bular struct u re positi o n e d with i n the fem o r a l sheath.
• The vertica l groin i ncision is most commonly e m p l oyed to
p rovide opti m a l access to the entire length of the CFA. This
should be created coaxi a l ly along the a rte ry itself, contin­
ued from the i n g u i n a l l igament d i sta l ly, a n d a i med at the
medial aspect of the knee. The i ncision ca n be extended
su periorly or inferiorly to i ncrease a rterial exposure as nec-
essa ry to achieve opti m a l inflow (FIG 1 , dashed line A).
• Alternative ly, especi a l ly i n obese patie nts with su bsta ntial
abdom i n a l p a n n us, a cu rvi l i near i ncision can be p laced 1
em below a n d para l le l to the i n g u i n a l l i ga m e nt to avoid
potential skin maceration a n d wound com p l i cations that
may accompany vertical i ncisions i n this situation (FIG 1 ,
dashed line B). Althou g h the prox i m a l superficial femoral
a n d deep femoral a rteries can be exposed via this i ncision,
such a cu rvi l i near or o b l i q u e i ncision l i m its further d i stal a r­
terial exposure. It therefore would not be selected if an ex­
tensive common a n d deep femoral a rtery e n d a rterectomy
is a ntici pated as potentia l ly n ecessa ry to opti m ize inflow.
• The i n c i s i o n is carried s h a rp l y t h r o u g h t h e s u bcuta n e o u s
tissue a n d s u p e rfi c i a l fasc i a .
Dissection and Control of the Common, Superficial,
and Proximal Deep Femoral Arteries
• Deep to the su bcuta neous tissue a n d superficial fascia, the
dissection is extended longitu d i n a l ly, even when using an
oblique i ncision, to opt i m ize the length of femora l expo­
s u re. Depe n d i n g on the depth of dissection and su bcu­
taneous a d i posity, self-reta i n i n g Weitlaner or cerebe l l a r
retractors a re ca refu lly placed t o optim ize exposu re w h i l e
avo i d i n g traction injury t o femoral nerve branches or t h e
com m o n femoral vei n . Further dissection through the femo­
ral sheath exposes the a nterior s u rface of the femoral a rtery.
• The d i ssection p l a n e should rem a i n centered d i rectly over
the femoral a rtery. E n cou ntering venous structures i n d i ­
cates m e d i a l deviation from the opti m a l pla ne; expos u re
of the i l iopsoas m uscle, femora l n e rve fibers, or lymphatic
vessels is a n i n d ication of l ateral deviatio n . An i n creasing
incidence of femoral incisional com p l ications, i n c l u d i n g
w o u n d e d g e necrosis a n d separation, lymphatic leaks, fem­
oral neu ropraxia, and venous i nj u r ies a re associated with
i n correctly p laced i n g u i n a l incisions for femoral exposu re.
• D i ssect d i rectly along t h e CFA both proxi m a l ly a n d
d i sta l ly. Placement o f s i l astic vesse l loops a r o u n d the
2052 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

fe m o ra l a rtery a n d its l a rg e r branches a i d s in retract i o n ,
d issect i o n , a n d m o b i l izat i o n .
• Prox i m a l d i ssect i o n i s conti n u e d a l o n g t h e CFA to t h e i n ­
g u i n a l l i g a m e nt. The i n g u i n a l l i g a m e n t may be d ivided
to a i d i n exposu re o r to enable exte n d e d e n d a rte rec­
tomy. Caution i s necess a ry in t h i s a rea, a s a p ro m i n e nt
fe m o ra l ve i n t r i b uta ry crosses a nteriorly ove r t h e CFA i n
t h i s a rea a n d i s prone t o i nj u ry if n o t i d e ntified, l i g ated,
and d iv i d e d early in the d issect i o n . I n a dvertent i n j u ry
to t h i s "ve i n of p a i n " p rod uces retract i o n a n d t ro u b l e-
some b l e e d i n g . The m e d i a l a n d l atera l fem o ra l c i r c u m -
flex a rteri es, i m p o rta nt co l l atera l s i n i l iofe m o ra l a rte r i a l
occ l u s ive d i sease, a re i d e ntified at l evel of t h e i n g u i n a l
l i g a m e n t a n d i n d iv i d u a l l y contro l l e d with re m ova b l e
c l i ps o r s i l astic vesse l l o o p s . Use of t h e fo r m e r red u ces
c l utter i n t h e wound d u ri n g e n d a rterectomy o r creat i o n
o f t h e proxi m a l a n asto mosis.
• As the d i ssection p roceeds d ista l ly, a n a b r u pt change i n ca l i ­
ber ma rks the femoral bifurcation a n d the o r i g i n s o f t h e
deep (a lso known as " profu n d a femoris" in Latin) and su­
perficial femoral a rteries (SFA) . The l atter conti nues d i sta l l y
i n the same p l a ne; the former u s u a l l y cou rses posteriorly
a n d l atera l l y away from the femoral bifurcation. After s i l as­
tic loops a re p laced on each vesse l, gentle u pward traction
o n the CFA or SFA may h e l p bring the deep femoral a rtery
i nto view. The latera l c i rcumflex i l ia c vei n may cou rse a nte­
riorly over the o r i g i n of the deep femoral artery and s h o u l d
be l i g ated a n d d ivided to opti m i ze exposure a n d control o f
the fi rst seg m e nt of this vessel (FIG 2A) .
• M e d i a l a n d d i st a l d i ssect i o n p rovides exte n d e d exposu re
of t h e prox i m a l S FA (FIG 1, dashed line F). T h i s vesse l o n ly
occa s i o n a l ly h a s s m a l l b r a n c h es i n its p roxi m a l seg m e nt .
A sensory b r a n c h of t h e fe m o ra l n e rve may be p resent
cross i n g t h e S FA from latera l to m e d i a l . Tra nsect i o n may
res u lt i n medial thigh d i scomfort . Even exte n d e d fe m o r a l
b i f u rcation d issect i o n s r a r e l y req u i re d ivision of fe m o r a l
n e rve b r a n c h es, w h i c h s h o u l d be avo i d e d to m i n i m ize
posto pe rative pa resthesias and dysesthesias.

Lateral femoral
circumflex artery
Medial femoral
circumflex artery
::=-==----- Common femoral artery
::;;;ilt:f---- Common femoral vein
CO:II�f--- Great saphenous
vein
Femoral vein
Lateral circumflex
femoral vein
Superficial femoral
artery
Profunda femoris
artery

I
, Incision D and E
! Sartorius muscle
:
Rectus femoris muscle
I
I

> · · · Incision F
. ·
�t:�;;;���:-- Ad d uctor longus muscle
Gracilis muscle

�4...u- Profu nda femoral vessels FIG 2 • A. Exposure of fe m o ra l

�'-:,.-- Adductor magnus muscle
.:._ r--- Semitendi nosus muscle
r'i";. -:,.,.....--r
B Lateral Medial
vesse l s a t g ro i n . B . Anteromed i a l
a n d poste rol atera l a p p roaches
to expose m i d d l e a n d d i sta l
seg m e nts of t h e s u p e rfi c i a l a n d
d e e p fe m o ra l a rteries. I n c i s i o n s
(C-F) corres p o n d to FIG 1 .
 C h a p t e r 28 S U R G I CAL EXPOS U R E OF T H E LOWER EXTREM ITY ARTE R I E S
Exposure o f the Middle and Distal Segments o f Deep
Femoral Artery
• Exposure of t h e d i sta l port i o n s of t h e d e e p femora l a r­
tery often e n a b l es use of s h o rter ve i n cond u it i n d i st a l
l e g bypass o r may i m p rove o utflow f r o m p roxi m a l r e ­
vascu l a rization proce d u res ( i l i a c a n g i o p l asty a n d stent­
ing o r a o rtofe m o ra l bypass) . These seg m e nts a re e a s i l y
exposed f r o m e i t h e r poste romed i a l o r a nterom e d i a l a p ­
proaches (FIG 1 , dashed line C-F). The a p p roach s h o u l d
be d i ctated b y t h e i n d ication (i nflow sou rces o r outflow
ta rg et); a n a d d i t i o n a l co n s i d erat i o n i s t h e n ecessity to
o bta i n expos u re in a n ative f i e l d , e i t h e r in the sett i n g of
p r i o r d i ssect i o n or fe m o ra l g raft i nfect i o n .
• I nc i s i o n s a re p l aced a l o n g e i t h e r t h e m e d i a l (anterome­
d i a l a p p roach; dashed line C and F i n FIG 1 ) o r late r a l
borders (poste rolatera l a p p roach) of t h e s a rto r i u s m us­
cle (FIG 1 , dashed line D and E) . The d i ssect i o n p l a n e is
deve l o ped t h r o u g h the s u bcuta n e o u s tissue and fascia,
POPLITEAL ARTERY EXPOSURE
Medial Exposure of the Above-Knee Popliteal
Artery
• P l a ce patient i n s u p i n e posit i o n . Rotate l e g l atera l ly, flex
t h e leg, and p l ace a b u m p u n d e rneath t h e knee j o i nt .
Patel l a -----­
Femoral condyle �
��115;��===== Vastus medialis
------
"--"''-----
"'
• ---
'------ Venae com itantes
"------ Popl iteal artery
'------ Popl iteal vein
B supragen i c u l ate popl itea l a rte ry. (continued)
2053
pass i n g latera l or m e d i a l to t h e s a rto r i u s, respective ly.
M o b i l ize a n d retract sa rto r i u s m uscle latera l ly or m e d i ­
a l ly, d e pe n d i n g o n a p p ro a c h .
• The d i ssection is cont i n ued posteriorly, pass i n g l atera l t o
the superfic i a l f e m o r a l vesse ls a n d accompanying nerve,
to the space between the add uctor l o n g u s m uscle (medi­
a l ly) a n d vastus medialis (l atera l ly) (FIG 28, incisions C-E).
The deep femoral a rtery a n d vei n pass d i rectly u n d e rneath.
• D i ssect i o n between a d d u ctor longus a n d vast u s m e d i a l i s
m uscle exposes the m i d d l e seg m e nts of the deep femo­
ra l a rtery. Cross i n g venous t r i b utaries s h o u l d be l i g ated
and d ivided as necessa ry to provide opt i m a l exposu re.
The m o re d ista l seg m e nts of deep femora l a rtery beg i n to
cou rse posterior to the fem u r beyo n d t h i s point and a re
therefo re less usef u l for bypass o r i g i nation or d esti nation.
• Alte r n ative ly, exposure betwee n t h e a d d u ctor l o n g u s
(a nte r i o rly) a n d g ra c i l i s m uscle (postero m e d i a l ly) e n a b l es
m e d i a l exposure of t h e d e e p fe m o ra l a rtery i n t h e d ista l
t h i g h (FIG 1 , dashed line F; FIG 28, i n ci s i o n F) .
• P l a ce a 1 0- t o 1 2-cm l o n g itu d i n a l i n c i s i o n a l o n g t h e
g roove formed betwee n t h e edges o f t h e vast u s m e d i a l i s
(anterio rly) a n d t h e sa rto r i u s m u scles (postero m ed i a l ly)
(dashed line A in FIG 3A) . The i n c i s i o n i s carried t h r o u g h
t h e s u bcuta n e o u s t i s s u e a n d fasc i a . P l a ce se lf-reta i n i n g
retractor. Ta ke care n o t t o t r a p a n d i nj u re t h e g reat
s a p h e n o u s ve i n and t h e sa p h e n o u s n e rve. The g reat
Rectus femoris
Adductor longus
Sartori us
Saphenous nerve
FIG 3 • A. I ncisions for medial a p p roaches
to exposu re of the su pra- (incision A) a n d
i nfrageniculate (incision B ) popl itea l a rtery.
B. M e d i a l a p p roach for expos u re of the
2 0 54 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

FIG 3 • (con tin ued) C. M e d i a l

a p p roach f o r exposu re o f t h e
� Sartorius i nfra g e n i c u l ate p o p l itea l a rtery
a n d its b r a n c h es. D. Poste r i o r
------- Gracilis exposu re of t h e p o p l it e a l a rtery.

Soleus (partially d ivided) ,:-_..:._

...
Poplite al artery
_..:::._
.._ ____

::----:--- Anterior tibial artery

Popl iteal vein

'----- Posterior tibial artery

'----- Peroneal artery

Sartorius -------��....- .. :!..

Gracilis ------��
Sem itend inosus -------7:.:,
Sem imembranosus ----;.;­
Biceps femoris ----�'-11�
Popl iteal vein -----�-..:.
Popliteal artery ----�.._=::.._;j�
Tibial nerve ---------=-J-'---•�

Common peroneal nerve ----;.:._¥-/

Gastrocnem ius :
Lateral head ------.;..,.��
.
M edial head ---------;c..;,-:,_,-';-�•-f! -�
Popliteal artery

D
Left leg Right leg

s a p h e n o u s v e i n i s l i ke l y to be encou ntered m o re postero­ Lateral Exposure of the Above-Knee Popliteal Artery

m e d i a l l y to the i n c i s i o n in the s u bcuta n e o u s tissue. T h e
• Lateral exposu re of the a bove-knee (AK) popl iteal a rtery is
s a p h e n o u s n e rve may be encou ntered at d i sta l e n d o f
t h e i n ci s i o n as it j o i n s t h e s a p h e n o u s ve i n n e a r t h e m e d i a l usefu l i n a va riety of c i rcu msta nces-for i n sta nce, axi l lopop­
aspect o f t h e knee. l itea l bypass or when the m ed i a l a p p roach has previously
• I ncise t h e d e e p fascia l o n g itu d i n a l ly a n d a b ove t h e sa r­ been developed or is com p l icated by i n fection or i nj u ry.
• P l ace patient i n s u p i n e posit i o n . Rotate leg m e d i a l ly, f l ex
t o r i u s m u sc l e to enter t h e p o p l ite a l foss a . The p o p l itea l
a rtery c a n be p a l pated up a g a i n st t h e poste r i o r s u rface t h e k n ee, a n d p l ace a b u m p u n d e rneath t h e knee j o i nt.
• P l ace 1 0- to 1 2-cm l o n g itud i n a l i n c i s i o n betwee n t h e vas­
of the fe m u r (FIG 38) .
• T h e popl itea l a rtery i s often surrounded b y m u lt i p l e ve­ tus l atera l i s and t h e biceps fe m o r i s m uscles (dashed line

nous col l atera l s, o r "venae com itantes" in Latin; the pop­ A in FIG 4A) . The i n c i s i o n is carried t h r o u g h the s u bcuta­
l iteal vei n is usua l ly posterol atera l to the a rtery i n t h i s neous tissue and fasc i a .
• M a ke a g e n e ro u s l y cruc iate i n ci s i o n ("T-e d " ) at both e n d s
locat i o n . The popl itea l a n d/or su perficia l fe moral ve i n s
may be d u p l icated t h r o u g h o ut the popl itea l fossa a n d o n t h e fasci a l a t a to prevent bypass g raft i m p i n g e m e n t

d ista l t h i g h . Isolation a n d control o f the a rtery u s u a l l y re­ by i t s d e nse fi bers .

• P l ace retractor a n d enter t h e p o p l ite a l space. S c i a t i c
q u i res l igation and d ivision of s u rro u n d i n g co l l atera l vei ns.
n e rve t h e n p o p l itea l ve i n w i l l be encou ntered fi rst before
 C h a p t e r 28 S U R G I CAL EXPOS U R E OF T H E LOWER EXTREM ITY ARTE R I E S 2055

A muscle

Popl iteal artery

and venae com itantes

Biceps femoris
muscle
B
Soleus
(divided)

Tibioperoneal
c trunk muscle

FIG 4 •
A. I ncisions for latera l exposu re of supra- a n d i nfragenicu late popl itea l a rtery a n d its
trifu rcation. B. Lateral expos u re of suprageniculate popl itea l a rtery. C. Late r a l exposure of
i nfrag e n i c u l ate p o p l itea l a rtery a n d its trifu rcat i o n .

p o p l itea l a rte ry. G e ntly retract sciatic n e rve d ownwa rd.
T h e n m o b i l ize and retract p o p l itea l ve i n to expose and
control t h e p o p l itea l a rte ry.
Posterior Exposure of the Popliteal Vessels
• Poste r i o r exposure may be t h e p referred a p p roach for
m a n a g e m ent of p o p l itea l a rtery entra p m e nt, p o p l itea l
cyst, foca l p o p l itea l a rtery a n e u rysm, or a rte r i a l i nj u ry
fo l l ow i n g tra u m atic poste r i o r knee d i s l ocat i o n . Alth o u g h
d i rect a n d re l ative ly u n c o m p l icated, poste r i o r access i s
l i m ited b y t h e h e a d s of t h e g a stroc n e m i u s m uscle d i sta l ly
a n d t h e biceps fe m o r i s/" h a m stri n g " m u scles p roxi m a l ly;
o n ly foca l, l i m ited p o p l it e a l a rtery access i s a c h i eva b l e
t h r o u g h t h i s i n ci s i o n .
• Pat i e n t i s p l aced i n prone posit i o n with p i l low to prop u p
t h e l o w e r leg a n d foot.
• The i nc i s i o n is 5-s h a ped, a cross t h e poste r i o r crease of the
knee j o i nt, with its s u p e r i o r extent beg i n n i n g m e d i a l ly.
• The i n c i s i o n i s ca rried a nteriorly t h r o u g h the s u bcutane­
o u s tissue and s u p e rfi c i a l fascia to e nter t h e pop l it e a l
fossa . E x p o s u r e i s m a x i m ized by m o b i l i z i n g t h e p o p l i ­
tea l a rtery betwee n t h e t w o heads of t h e g a stroc n e m i u s
m u scl e i nfe riorly a n d betwee n se m i m e m branosus a n d
b i ceps fe m o r i s m uscle s u pe r i o r ly.
• The m uscles a re g e ntly retracted to expose the e n t i re
p o p l itea l fossa . The t i b i a l a n d c o m m o n pero n e a l n e rves
a re e n c o u ntered s u p e rfi c i a l ly in t h i s expos u r e . The p o p l i ­
tea l a rtery is a nterior, o r d e e p to t h e ve i n , i n t h e d e pt h s
of t h e wo u n d .
• It m a y be n ecessa ry t o m o b i l i ze t h e popl itea l vei n with l iga­
tion a n d d ivision of popl itea l venous tributaries to fu l ly ex­
pose the a rtery. Once the appropriate seg ment is exposed,
s i lastic vessel loops a re p laced proxi m a l ly and d ista l ly.
2056 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

INFRAG ENICULAR EXPOSURE Lateral Exposure of the Infragenicular Popliteal

Medial Exposure of the Infragenicular Popliteal
Artery and Its Branches
• The m ost c o m m o n a p p roach is a m e d i a l o n e (FIG 3A) .
• P l a ce patient i n s u p i n e posit i o n . Rotate leg l atera l ly, flex
t h e leg, and p l ace a b u m p u n d e rneath t h e knee j o i nt.
• M a ke a l o n g it u d i n a l i n c i s i o n from b e l ow t h e e d g e of
t h e t i b i a a l o n g t h e cou rse of t h e g reat s a p h e n o u s v e i n
(dashed line 8 i n FIG 3A) .
• C a r ry t h e i n c i s i o n t h r o u g h s u bcuta n e o u s t i s s u e a n d fas­
cia i nto the deep poste r i o r co m p a rt m e n t . T h e b e l ow­
knee ( B K) p o p l ite a l vess e l s reside deep in the wo u n d
a n d a re p a rt i a l ly cove red b y t h e o r i g i n o f t h e s o l e u s
m us c l e .
• D i v i s i o n of t h e s o l e u s o r i g i n m e d i a l l y (FIG 3C) w i l l fa­
c i l itate expos u re of the t i b i o pe ro n e a l t r u n k, and o r i g i n
o f t h e a nt e r i o r t i b i a l a rte ry, b u t i s n o t rea l ly n ecessa ry
for expos u re of t h e p o p l itea l a rt e ry itse lf. As was d e ­
s c r i b e d for t h e poste r i o r a p p ro a c h , t h e a rt e ry l i e s i n
c l ose p rox i m ity t o t h e p o p l itea l ve i n a n d t i b i a l n e rve.
M o b i l i z a t i o n of t h e p o p l itea l ve i n from t h e adjacent
a rt e ry i s n ecessa ry for s u ffi c i e n t expos u re of a l l re l ­
eva nt structu res, i n c l u d i n g t h e a nt e r i o r t i b i a l a rte ry,
t i b i o p e r o n e a l t r u n k, a n d d e r i vative b r a n c h e s (poste r i o r
t i b i a l a n d p e r o n e a l a rt e r i es) . I t i s u s u a l l y n e c e s s a ry t o
l i g ate a n d d iv i d e t h e a nt e r i o r t i b i a l ve i n at i t s confl u ­
e n c e w i t h t h e (oft e n p a i red) p o p l itea l ve i n to g a i n s u f­
f i c i e n t expos u re to i s o l a t e a n d m o b i l i z e t h e m o re d i st a l
branches.
• D i ssect i o n m ust proceed d e l i b e rate ly to avoid i n j u ry to
t h e n e i g h bo r i n g t i b i a l n e rve a n d its d i st a l branches.
Artery and Its Trifurcation
• The latera l a p p roach is rarely req u i red b u t may be p a r­
t i c u l a rly usefu l to avo i d sca r r i n g from a p revi o u s m e d i a l
a p p ro a c h .
• P l ace t h e i n c i s i o n poste r i o r to t h e h e a d of t h e f i b u l a
a n d exte n d a l o n g t h e cou rse o f t h e fi b u l a . D i ssect d i ­
rectly o n t o f i b u l a ( i n c i s i o n i s m a rked as dashed line 8
i n FIG 4A). N ote t h e location of t h e c o m m o n pero n e a l
n e rve, w h i c h cou rses f r o m poste r i o r to a nterior a r o u n d
t h e neck of t h e u p pe r f i b u l a j u st b e l ow i t s h e a d , before i t
b r a n c h es i nto t h e s u p e rfi c i a l a n d d e e p p e r o n e a l n e rves.
• Ci rcu mferent i a l ly e l evate t h e peri oste u m of t h e f i b u l a
a n d excise t h e exposed s e g m e n t of t h e f i b u l a w i t h a saw.
The p o p l itea l vesse l s a n d b r a n c h es a re fo u n d d i rectly
beneath the f i b u l a r perioste u m , with the a rtery u s u a l ly
located a nterior to t h e poste r i o r t i b i a l n e rve a n d t h e
p o p l itea l ve i n .
• Exte n d i n g t h e d issect i o n d i sta l ly a l l ows expos u re a n d
control o f d i sta l p o p l itea l a rte ry, as w e l l as t h e o r i g i n s of
the a nterior t i b i a l a n d the t i b i o p e ro n e a l t r u n k .
Exposure o f the Anterior Tibial Artery
• Proximal segment
• The proxi m a l seg m e nt of t h e a nte r i o r t i b i a l a rtery i s
exposed i n a fas h i o n s i m i l a r to t h e e x p o s u r e for t h e
i nfra g e n i c u l a r p o p l itea l a rtery a n d i t s b r a n c h es.
• M iddle seg ment
• The m i d d l e segment exposu re of t h e anterior t i b i a l
a rtery is usef u l w h e n t h e re i s l i m ited l e n gth o f a u ­
tog e n o u s ve i n .

Tibialis anterior
muscle Tibialis posterior muscle
Extensor dig itorum Flexor hallucis Posterior tibial
longus muscle vessels and
Extensor hallucis Flexor digitorum tibial nerve
longus muscle longus muscle

Peroneal
vessels

--'-7''--�Y..:.�
. Soleus
""'�...\---....
- � ., � muscle

Gastrocnemius
muscle (medial)
Gastrocnemius
muscle (lateral) Transected
segment
of fibula
Fibu laris longus muscle

Right Left
FIG 5 • Exposure of a nterior t i b i a l , poster i o r t i b i a l , and peroneal a rteries at m i d - l ower l e g .
 C h a p t e r 28 S U R G I CAL EXPOS U R E OF T H E LOWER EXTREM ITY ARTE R I E S
• P l a ce an a x i a l i n c i s i o n in a vertica l p l a n e a bout two
f i n g e rbreadths lateral to t h e anterior e d g e of t h e
t i b i a (FIG SA) .
• Deepen t h e i n c i s i o n between t h e t i b i a l i s a nterior
a n d t h e exte nsor h a l l u c i s longus m u scles.
• The a nterior t i b i a l a rtery is s u perfi c i a l to t h e i nte ros­
seus m e m b r a n e betwee n the c l eft formed by these
two m u scles.
• D i ssecti n g away t h e ove r l y i n g co l l atera l ve i n s a l l ows
exposu re a n d control of t h e m i d d l e segment of t h e
a nterior t i b i a l a rte ry. Use of a prox i m a l ste r i l e to u r­
n i q uet d u r i n g expos u re of a l l t h e c r u ra l a rteries may
s i g n ificantly a cce l e rate t h e d i ssect i o n w h i l e l i m it i n g
bleed i n g f r o m t h e n u m e ro u s a n d red u n d a nt co l l at­
e ra l ve i n s .
Exposure o f the Posterior Tibial Artery
• Proximal segment
• The p roxi m a l seg m e n t of t h e poste r i o r t i b i a l a rtery i s
a p p roached i n a s i m i l a r fas h i o n to t h e exposu re f o r
t h e i nfrag e n i cu l a r p o p l itea l a rtery a n d i t s branches
a n d req u i res ta k i n g down t h e s o l e u s m us c l e from
the tibia.
• M iddle segment
• The m i d d l e segment exposure of t h e poste r i o r t i b i a l
a rtery i s usefu l w h e n t h e r e i s l i m ited l e ngth o f ve i n
g raft t o bypass t o t h e poste r i o r t i b i a l a rte ry.
• I nc i s i o n is m a d e j ust a nterior to t h e s o l e u s m u scle.
D i v i d e t h e ove r l y i n g s o l e u s to expose t h e u n d e r lyi n g
vesse ls (FIG 58) .
EXPOSURE OF PED AL VESSELS
Exposure of the Inframalleolar Posterior Tibial
Artery
• D i st a l poste r i o r t i b i a l exposu re e n a b l es ped a l bypass at
or b e l ow t h e a n kle, w h i c h may be espec i a l l y usefu l i n
patie nts with adva n ced d i a betes.
• M a ke a l o n g itud i n a l i n c i s i o n t h r o u g h s k i n a n d fascia
at t h e m i d po i nt betwee n t h e m e d i a l m a l l e o l u s a n d
t h e Ach i l les te n d o n . If t h i s exposu re i s used f o r a n i n
situ bypass proce d u re, t h e i n c i s i o n s h o u l d be s i g hted
s l i g htly m o re a nteriorly to acco m m o d ate t h e a nterior
cou rse of t h e g reat saphenous ve i n a s it crosses t h e me­
dial m a l l e o l u s .
• I d e ntify a n d d iv i d e t h e fl exor reti n a c u l u m as needed to
prov i d e opti m a l expos u re . The poste r i o r t i b i a l vesse l s
a re l ocated between t h e flexor d i g it o r u m l o n g u s a n d
flexor h a l l u c i s l o n g u s m uscl es/te n d o n s .
• P l a ce a s m a l l Weit l a n e r self- reta i n i n g retracto r. The
n e u rovascu l a r b u n d l e i s u s u a l ly envelo ped by fatty tis­
s u e b e l ow t h e fasc i a .
• D i ssect i o n proceeds a l o n g t h e n e u rovascu l a r b u n d l e .
T h e poste r i o r t i b i a l a rtery i s u su a l ly a nterior to t h e
t i b i a l n e rve. T h e re i s typica l l y a r i c h n etwork of ve n o u s
2057
• The poste r i o r t i b i a l a rtery l i e s a nterior to s o l e u s
m uscle with t h e peroneal a rtery l ocated lateral ly, i n
t h e s a m e p l a ne, betwee n t h e s o l e u s a n d t i b i a l i s pos­
terior m uscles.
• Avo i d i nj u ry to t h e t i b i a l n e rve, w h i c h co m m o n ly
r u n s between t h e poste r i o r t i b i a l a n d peroneal
vesse ls.
Exposure of the Peroneal Artery
• Proximal and middle seg ments
• Exposure of t h e p roxi m a l seg m e nt of t h e peronea l
t i b i a l a rtery is via d i sta l exte n s i o n of t h e i nfra g e n ic­
u l a r p o p l itea l a rtery a p p ro a c h .
• M iddle segment
• The m i d d l e segment may a lso be a p p roached a n ­
terolate r a l ly. The fo l l owi n g descri pti o n rel ates to
l atera l exposure req u i ri n g f i b u l ectomy.
• P l a ce a vertica l i n c i s i o n ove r t h e f i b u l a at t h e desi red
l evel (FIG SC) .
• C a r ry down t h e i n c i s i o n t h r o u g h t h e ove r l y i n g m u s­
c l e down to t h e f i b u l a . E l evate t h e peri oste u m of
t h e fi b u l a c i rcu mfere nt i a l l y.
• Tra n sect t h e ove r l y i n g seg m e n t of fi b u l a . I ncise the
inner p e r i ostea l m e m b r a n e . T h e p e ro n e a l vesse l s
a re fo u n d i m m e d i ately b e n e a t h . The a rtery u s u a l ly
is a nterior to fl exor h a l l u c i s l o n g u s a n d poste r i o r to
the t i b i a l i s poste r i o r m uscles.
• The pero n e a l a rtery is exposed a n d contro l l e d after
m o b i l ization from ci rcumferent i a l co l l atera l ve i n s
a n d t h e m a i n peroneal ve i n .
co l l atera l s p resent. These m a y e i t h e r be m o b i l ized o r
( m o r e com m o n ly) d ivided to fa c i l itate d ista l poste r i o r
t i b i a l a rtery expos u re .
• W h e n m o re d i st a l bypass ta rg ets a re n e e d e d (e . g . ,
p ro h i b itive b u rd e n of d i s e a s e i n t h e poste r i o r t i b i a l a r­
t e ry itse l f), t h e d i ssect i o n m a y be c o nt i n u e d a l o n g t h e
poste r i o r t i b i a l a rt e ry d i sta l l y to t h e b i f u rcat i o n of t h e
m e d i a l a n d l atera l p l a nta r a rt e r i e s . I n a l l s u c h cases,
h oweve r, p r e o p e rative i m a g i n g i s p a ra m o u nt to i m m e­
d i ate a n d l o n g -t e r m s u rg i ca l s u ccess, a n d o n l y i n r a r e
c i rc u m sta nces s h o u l d t h e o p e rative p l a n b e c h a n g ed
by u n ex p e cted fi n d i n g s at t h e t i m e of s u r g e ry. T h e
p re s e n c e of l u m i n a l c a l cificat i o n a l o n e , w i t h o u t s u b ­
sta n t i a l c o m p r o m i s e to t h e ta rget l u m e n d i a m et e r, i s
n ot a c o n t r a i n d i c at i o n to b y p a s s c o n s t r u ct i o n . W h e n
u n c e rt a i nty i s p r e s e n t reg a r d i n g t h e o p t i m a l bypass
t a r g e t despite a d e q u ate p r e o p e rative i m a g i n g , con­
s i d e ra t i o n s h o u l d b e g i ven to o n -ta b l e, i nt r a o p e rative
a rte r i o g r a p h y to g u i d e s u r g i c a l d e c i s i o n m a k i n g a n d
confi rm o utco m e . To t h i s e n d , we p e rform a l l o p e n by­
pass p ro ce d u re s in a h y b r i d o p e ra t i n g room e n v i r o n ­
m e n t w i t h h i g h -q u a l ity i m a g i n g ca p a b i l i t i e s to e n s u re
t h e o pt i m a l o utco m e of a l l p roced u res, reg a r d l ess of
t h e i n it i a l o p e rative p l a n .
2 0 58 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

--- Soleus muscle

Tibialis posterior tendon

lVIrUI.,._- Tibial nerve

Posterior tibial vessels

Flexor d i g itorum longus tendon

Flexor hallucis longus tendon

� Flexor reti nacu l u m

Lateral plantar artery, nerve, and vein

A Medial plantar artery, nerve, and vein

Extensor dig itorum

/14
longus muscle
Extensor hall ucis
longus muscle
-:'1-----'\
-7- c--- Anterior tibial artery
Su perior extensor I'!-'--�- Deep fibular (peroneal) nerve

�/
reti nacu l u m

Lateral mal leolus

Inferior extensor �( I ---- Extensor hallucis

retinacu l u m l o n g u s tendon
fl 1 \:-'-�t-r- Dorsal pedis artery
Extensor dig itorum .:,..l.o!-\----r- Arcuate artery
longus tendons -"'-�--...L Extensor halluc is brevis muscle
Medial branch of deep fibular
Dorsal metatarsal
(peroneal) nerve
arteries

FIG 6 • A. Exposure of infra m a l l e o l a r poste rior

tibial a rtery a n d its branches. B. Exposu re of
s u p ra m a l l e o l a r a nterior tibial a n d d o rsa l pedal
B a rteries.

Exposure of the Supramalleolar Anterior Tibial
Artery
• The d i st a l a nterior t i b i a l a rtery may se rve as a s u i ta b l e
d i st a l bypass ta rget, espec i a l ly w h e n s u bsta nti a l d i sease
i s p resent more proxi m a l ly. It may a lso be p refe ra b l e to
bypass to t h i s seg m e nt in the presence of a d o rs a l foot
wo u n d .
• The i n c i s i o n is p l a ced betwee n t h e t i b i a l i s a nterior m e d i ­
a l ly a n d extensor h a l l u c i s l o n g u s a n d t h e extensor d i g ito-
r u m l o n g u s latera l l y (FIG 68) .
• Ante r i o r t i b i a l a rtery a n d peroneal n e rve u s u a l ly cou rse
t h r o u g h the g roove betwee n t h e m .
• D i ssect betwee n t h e s e t e n d o n s a n d retract t h e m t o
expose t h e s u p ra m a l l e o l a r s e g m e n t of a nterior t i b i a l
a rtery.
Exposure of the Dorsal Pedal Artery
• The d o rs a l ped a l a rtery (or " d o rsa l i s p e d i s " i n Lati n) i s
t h e exte n s i o n of t h e a nt e r i o r t i b i a l a rtery a s it passes b e ­
neath t h e extensor reti n a c u l u m . It c a n se rve a s a s u i ta b l e
d i st a l bypass ta rg et, espec i a l l y i n patie nts w i t h d i a betes.
• The a rtery is best exposed beyo n d t h e i nfe r i o r exte nsor
reti n a cu l u m . P l a ce a n incision betwee n t h e 1 st and 2nd
m etata rsa l shafts a n d d i sta l to t h e exte nsor reti n a c u l u m
(FIG 68) .
• The d o rsa l i s ped i s a rtery resides i n t h e g roove betwee n
t h e 1 st a n d 2 n d m etata rsa l heads, u s u a l ly j u st lateral
to t h e exte nsor h a l l u c i s longus tendon, w h i c h i s rea d i ly
i d entified by d o rsiflexion of t h e g reat toe, a n d m e d i a l to
exte nsor h a l l uc i s b revis.
• Carry down dissection through su bcuta neous tissue a n d lon­
g itu d i n a l ly d ivide the fascia to expose and control the a rtery.
 C h a p t e r 28 S U R G I CAL EXPOS U R E OF T H E LOWER EXTREM ITY ARTE R I E S 2059

PEARLS AND PITFALLS

• Preope rative u ltraso u n d d u p l ex m a p p i n g a i d s t h e s e l ecti o n a n d p l acement of t h e i n c i s i o n . D i ssect i o n can be g u ided by pa l pa ­
t i o n of t h e u n d e rlyi n g a rte r i a l p u lse. I n most cases, beca use d ista l p u l ses a re freq u e ntly a bsent o r d iffi c u l t to p a l pate, use of a n
i ntraoperative D o p p l e r probe w i l l a i d t h e loca l i zation a n d d i ssect i o n of vesse l . N o n e t h e l ess, knowledge of a p p ro p r i ate a n ato m i c
l a n d m a rks w i l l g reatly fac i l itate carefu l a n d exped itious expos u r e . I n a l l c i rc u msta n ces, d i ssect i o n s h o u l d be d i rectly targeted o n
a n d a r o u n d t h e a rte ry. T h i s g u i d a nce i s s i m i l a r i n m a ny ways to t h e o rt h o p e d i c a x i o m to " stay o n t h e b o n e " d u ri n g d i ssect i o n­
kee p i n g exposure centered on t h e ta rget a rtery m i n i m izes ven o u s b l e e d i n g a n d d a m a g e to s u r ro u n d i n g struct u res. Placement of
an e n c i rc l i n g s i l astic vess e l l o o p w i l l a i d in f u rt h e r m o b i l izat i o n .
• I n t h e exposu res o f t h e t h i g h a rteri es, t h e s a rto r i u s m uscle serves as a n i m porta nt l a n d m a rk f o r t h e exposu re of t h e c o m m o n ,
s u perfic i a l , a n d p rof u n d a fe m o ra l a rteries.
• I n the sett i n g of reoperation, a lternative surgical exposu res a l low operation i n a v i rg i n field that is u n scarred by p revio u s operati o n .

COMPLICATIONS placed retractor, injudicious spreading and clamp place­

• Bleeding complication: Aim to achieve satisfactory hemosta­
sis for surgical bleeding prior to skin closure. Full antico­
agulation from heparin can be reversed with protamine to
reduce the risk of postoperative bleeding.
• Vessel injury: Vascular clamps or silastic loops can lift ath­
erosclerotic plaques and create dissection and arterial injury
in the presence of arterial calcification. The vascular clamp
should be placed at a relatively soft, disease-free segment.
Occasionally, this requires lateral positioning of a clamp to
provide anterior/posterior rather than lateral compression of
a vessel. In the CFA, the accumulation of significant pos­
terior plaque often mandates modification of " atraumatic "
clamp placement. In the tibial vessels, care should be taken
to obtain control in the least traumatic fashion possible to
limit compression of inelastic runoff vessels and the potential
for clamp inj ury and restenosis. Often, alternative devices
such as " flow arresters " or intraarterial no. 2 embolectomy
catheters attached to stopcocks may provide sufficient con­
trol to maintain a hemostatic field during completion of the
distal anastomosis without exerting undue force on the tar­
get artery. In any extent, pressure is reduced to begin with
in distal tibial arteries, so the amount of force exerted to ob­
tain control should be modified accordingly. As previously
mentioned, strategic use of proximal thigh tourniquets and
Esmarch bandage, deployed following creation of the proxi­
mal anastomosis and graft tunneling, may also be useful in
limiting bleeding and the risk of clamp injury and dissection
in diseased tibial vessels.
• Distal embolization: Most frequently, periprocedural em­
bolization is due to fragmentation of atherosclerotic plaque
fragments or thrombus during dissection or clamping. Full
systemic anticoagulation with intravenous (IV) heparin prior
to clamping the vessel and intraoperative monitoring of ac­
tive coagulation time (ACT) will minimize the risk of graft
or native vessel thrombosis. Prior to closure of arteriotomy
and clamp release, all involved arteries must be meticulously
and repeatedly flushed and back-bled to remove residual
thrombus or loosen plaque fragments. Attention to this
portion of the procedure, as well as to the precise course
of graft tunneling, will optimize outcome and eliminate the
need for reanticoagulation, embolectomy, and revision at the
end of an often long procedure.
• Nerve inj ury: Nerves and vessels are often intimately asso­
ciated. Nerve injury can be caused by dissection, a poorly
ment, and thermal energy from the electrocautery. These in­
j uries can be reduced by knowledge of appropriate anatomic
landmarks, accurate incision placement, and meticulous
sharp dissection directly down to and immediately around
the intended artery. Importantly, excessively deep placement
of self-retaining retractors in an extended common or deep
femoral artery exposure can cause traction injuries to motor
branches of the femoral nerve, significantly limiting the abil­
ity of patients to stand or bear weight for weeks following
the procedure. In general, to avoid nerve inj ury, retractors
should be placed in the most superficial plane possible to
obtain sufficient exposure of target vessels. In all circum­
stances, retractors should be removed immediately as soon
as they are no longer needed or if attention is turned to
alternative sites or other portions of the procedure that do
not require continuous exposure.
• Lymphatic leakage: Lymphatic vessels usually course close
to the arteries and veins. Avoid transection of lymph nodes.
If necessary, cauterize the divided end of lymphatics. Visible
lymphatic vessels should be suture ligated. Careful dissec­
tion respecting tissue planes allows layered closure to elimi­
nate dead space and lymphatic accumulation, formation of
seroma, or hematoma. When lymph nodes are inj ured, extra
time should be taken to control, ligate, and divide afferent
and efferent vessels and remove the node completely.
POSTOPERATIVE CARE
• Following bypass, patients should be maintained on a com­
prehensive medical regimen to optimize their cardiopulmo­
nary status. Lower extremity bypass operations are often
performed on patients with diabetes and debilitating symp­
toms of claudication or CLI. Postoperative care should also
aim to optimize nutritional status, functional status, and
control of blood sugar level.
• Most surgeons routinely employ routine antiplatelet and
selective anticoagulation therapy to improve graft patency
in lower extremity bypass patients. The D utch Bypass Oral
Anticoagulants or Aspirin (BOA) trial suggested that oral
anticoagulation improved vein graft patency compared
with aspirin, whereas aspirin improved prosthetic graft
patency compared with anticoagulation. The antiplatelet
and/or anticoagulation regimen must be tailored to indi­
vidual patient with lower extremity bypass considering
their risk for graft failure and risk of bleeding. We routinely
2060 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY
administer aspirin to bypass patients and reserve warfarin
for high-risk situations (redo bypass, marginal or alterna­
tive vein conduits, spliced vein grafts, poor outflow, prior
graft thrombosis) due to the increased bleeding risk associ­
ated with anticoagulation.
• Wound care: Considerable efforts on wound care are re­
quired to achieve wound healing after lower extremity
revascularization in patients with CLI with tissue loss. Me­
ticulous nursing care and early ambulation are also crucial
to prevent decubitus ulcer in the lower extremities and the
sacrum, creating new wounds in patients with lower extrem­
ity ischemia.
OUTCOMES
• Outcomes of revascularization should be reported and inter­
preted through the reporting standards created and updated
by the Society for Vascular Surgery.
• In general, autogenous vein conduits are superior to all
others for infrainguinal bypass, even for the AK popliteal
insertion site, where vein has proven superior to polytetra­
fluoroethylene (PTFE) beyond 2 to 3 years. Ipsilateral and
contralateral greater saphenous vein ( GSV) conduits exhibit
patency rates superior to alternative veins such as small sa­
phenous vein, arm vein, and spliced veins. Vein graft pri­
mary patency rates for femoral BK popliteal bypasses are
approximately 70 % to 75 % at 5 years, and assisted primary
patency can be improved even further by a duplex vein graft
surveillance protocol. Infrapopliteal vein graft primary pa­
tency rates range from 60% to 70% at 5 years. Multiple
randomized trials have shown no benefit of reversed versus
in situ vein configurations. PTFE grafts have acceptable
short- and intermediate-term patency rates only in the AK
popliteal position and therefore should only be used in limb
salvage situations if autologous vein is truly unavailable.
When PTFE must be used, an adj unctive venous Miller cuff
or Taylor patch may improve results. The primary factors
influencing graft patency are indication, conduit type, and
conduit quality. Poor runoff adversely impacts prosthetic
graft patency.
• The reader is further referred to standard textbook sources
such as Cronenwett et al. 's Rutherford's Vascular Surgery,
7th edition, Chapter 1 0 9 for a more detailed discussion of
the expected outcomes after surgical revascularization for
infrainguinal disease.
REFERENCES
1. Norgren L, Hiatt WR, Dormandy JA, et al. Inter-society consensus for
the management of peripheral arterial disease (TASC II). J Vase Surg.
2007;45(suppl S):S5-S67.
2. Mills JL. Infrainguinal bypass. In: Cronenwett JL, Johnston
KW, Rutherford RB, eds. Rutherford's Vascular Surgery. 7th ed.
Philadelphia, PA: Saunders/Elsevier; 2010:1682-1703.
3. London, NJM. Surgical intervention for lower extremity arterial oc­
clusive disease: femoropopliteal and tibial interventions. In: Hallett JW,
Mills JL, Earnshaw J, et al, eds. Comprehensive Vascular and Endovas­
cular Surgery. 2nd ed. Philadelphia, PA: Mosby, Inc; 2009:192-214.
4. Netter FH. Atlas of Human Anatomy. 5th ed. Philadelphia, PA: Saun­
ders/Elsevier; 2010.
5. Ouriel K, Rutherford RB. Atlas of Vascular Surgery : Operative Proce­
dures. Philadelphia, PA: Saunders; 1998.
6. Rohen JW, Yokochi C, Lutjen-Drecoli E. Color Atlas of Anatomy:
A Photographic Study of the Hum an Body. 7th ed. Baltimore, MD:
Lippincott Williams & Wilkins; 2011.
7. Zarins CK, Gewertz BL. Atlas of Vascular Surgery. New York, NY:
Churchill Livingstone; 1989.
8. Mills JL, ed. Management of Chronic Lower Limb Ischemia. London,
United Kingdom: Arnold Publishing Inc and New York, NY: Oxford
University Press; 2000.
9. Mills JL, Lucas LC. Reversed vein bypass grafts to popliteal, tibial
and peroneal arteries. In: Fischer JE, ed. Mastery of Surgery. 6th ed.
Philadelphia, PA: Lippincott Williams & Wilkins; 2012.
 I

Chapter 29 Percutaneous Femoral-Popliteal

Reconstruction Techniques:
Reentry Devices
. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - , _ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - �

Danielle E. Cafasso Peter A. Schneider

DEFINITION PATIENT HISTORY AND PHYSICAL FINDINGS

• Reentry devices facilitate true lumen reentry after subinti­ • Patients with clinical symptoms and signs of lower extremity
mal recanalization for endovascular treatment of complex ischemia may benefit from subintimal recanalization and the
lesion morphologies and occlusions in the femoral-popliteal use of reentry techniques in the course of their clinical care,
segment. • Patients present with claudication, rest pain, nonhealing
• Subintimal recanalization and reconstruction of the femo­ ischemic ulcers, or gangrene. The history and physical ex­
ral and popliteal arteries have diminished reliance upon amination is consistent with these lower extremity presenta­
femoral-popliteal bypass. Reentry into the true lumen can tions and is described elsewhere in this atlas.
be challenging and is often the rate-limiting factor for the
success of this procedure. Improved wires and support cath­ IMAGING AND OTHER DIAGNOSTIC STUDIES
eters, and also reentry devices, have been developed for
• Patients who might benefit from subintimal recanalization
crossing chronic total occlusions ( CTOs) .
•
and reentry typically have complex lesion morphology, such
Tools for managing CTOs are listed i n Table 1 . CTO support
as arterial occlusion, that may be managed by creating a new
catheters may be used to support the guidewire that is being
channel outside of the potential space offered by the subinti­
used to cross the occlusion. These typically have lubricious
mal area. Imaging studies that define the anatomy and lesion
surface and a stiff tip. Distal access may be used to recanalize
morphology are useful prior to revascularization. This may
infrainguinal occlusions from a retrograde direction. Reen­
include duplex scanning, magnetic resonance angiography,
try catheters may be used to reenter the true lumen. CTO
or computerized tomographic angiography. We usually per­
crossing catheters are not discussed in the chapter. These are
form duplex mapping prior to any lower extremity inter­
relatively new and use either mechanized or hand power to
vention. Long lesions, occlusions, and complex lesions are
manipulate through an occlusion in hopes of remaining in
typically identifiable with preoperative imaging.
the true lumen.
• Patients with lower extremity ischemia should have obj ective
• Planning and performing subintimal recanalization and
physiologic confirmation of the degree to which perfusion is
reentry into the true lumen of the femoral and popliteal
diminished, This may be accomplished by ankle-brachial in­
arteries are described herein.
dices or toe pressures.

Table 1: Tools for Managing Chronic Total
Occlusions in the Lower Extremity
Tool for
Managing CTO Purpose
CTO support catheters S u pport d u r i n g w i re
cross i n g
D i s t a l access Access for b i d i rec-
t i o n a l a p proach
Ree ntry catheters E nter true l u m e n
from s u b i n t i m a l
space
CTO crossi n g devices True l u m e n crossi n g
CTO, chronic total occlusion; SFA, superficial femoral artery
Examples
CXITM (Cook Medical)
Q u ick-C rossrM (Spectra netics)
Tra i l B lazer (Covi d i e n )
G o p h e r (Vascu l a r S o l utions)
Retrograde p u n ct u re of
SFA-popl iteal
Ti b i a l-ped a l
OutbackTM (Cordis)
P i o n eerrM (M edtro n i c)
E nteer (Covi d i e n )
OffRoad (Boston Scie ntific)
C rosser ( B a rd)
Frontru n n e r (Cordis)
Laser (Spectra netics)
Tru e Path (Boston Scie ntific)
Wildcat (Avinger)
Viance (Covid ien)
SURGICAL MANAGEMENT
Preoperative Planning
• Preoperative planning includes identifying the best access site
for arterial entry. Subintimal recanalization of the femoral­
popliteal segment may be performed using an up and over
approach, from the contralateral common femoral artery, or
using an antegrade approach from the ipsilateral common
femoral artery. A reentry catheter may be used through either
of these access choices. Preoperative noninvasive imaging is
very helpful in making this plan for approach.
• The location of lesion helps determine access site and
approach. Many patients with superficial femoral artery ( SFA)
and/or popliteal artery disease are treated with an up and over
approach. If the patient has inflow iliac artery disease or has
an SFA lesion that begins near the origin of the SFA, an up and
over approach is warranted. Reentry devices require place­
ment of a 6-Fr sheath. If an up and over approach is antici­
pated, the aortic bifurcation should also be assessed to make
sure that the reentry device can be passed.
• Patients with extensive disease below the knee and without
iliac or proximal SFA disease and who are not obese can be
treated using an antegrade approach.

2061
2062 P a rt 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

RECANALIZATION STRATEG Y reca n a l ization is u s i n g a l o o p of hyd ro p h i l ic w i re to d is­

• I n m a n a g i n g co m p l ex l e s i o n s of t h e fe m o r a l a n d p o p l i -
tea l a rteri es, it i s q u ite co m m o n to atte m pt to reca n a l ize
t h e true l u m e n . Ste nosis ca n a l m ost a lways be crossed
transl u m i n a l ly u s i n g a w i re s u p p o rted by a catheter.
A steera b l e , hyd ro p h i l i c, l ow-profi l e w i re is best. Long
l e s i o n s, espec i a l ly if occ l u d ed, may not b e possi b l e to
cross i n t h e t r u e l u m e n . I n t h i s case, s u b i n t i m a l reca n a l i ­
zation a n d reentry i s t h e best o pt i o n .
• Strategy i s b a s e d o n s e l ecti o n of a reentry s i t e w h e r e t h e
a rtery h a s a n a ccepta b l e l u m e n , co l l atera l s ca n be pre-
served, ca lcification i s avo i d e d , and pote nti a l bypass sites
re m a i n i ntact. Sta y i n g i n t h e t r u e l u m e n w h e n poss i b l e
offe rs t h e s h o rtest reconstruct i o n a n d preservati o n of
m ost co l l atera ls. W h e n s u b i nt i m a l passage i s req u i red,
reenter t h e t r u e l u m e n as c l ose to t h e d i sta l reco nstitu­
tion as poss i b l e . The m ost common method of s u b i nt i m a l
sect the s u b i nt i m a l space and the loop can a lso be used
to reenter the true l u m e n .
• T h e re i s typ i ca l ly a l a rg e i n c o m i n g co l l ateral feed i n g t h e
reconstituted segment. If t h e reentry site i s ca lcified, t h e
su ccess rate f o r l o o p passa g e i s lower a n d u s e o f a reentry
catheter is m o re l i kely to be i n d i cate d .
• If t h e re is a s u bsta ntia l p l a q u e at the i ntended reentry
site, consider a site m o re d i sta l t h a n t h e i n it i a l reco nsti­
tution site. If t h e re i s a n ot h e r lesion d i sta l to but n e a r
t h e reentry site, t h i s can p o s e a c h a l l e n g e for pass i n g t h e
g u i d ewire d ista l ly after it h a s p o p p e d i nto the true l u m e n .
• T h e o p e rator m u st decide i n t h i s case whether it wou l d b e
a p p ro p r i ate to reenter d i sta l to a l l the lesio ns, g iven that
it m i g ht negatively affect bypass options. If t h e reentry
fa i l s a n d the patient needs a bypass, ta rget s ites for d ista l
a nastomosis s h o u l d be a ntici pated, a l t h o u g h fa i l ed reen­
try usua l ly does n ot result i n throm bosis of that seg m e nt.

TREATMENT PLATFORM a n g i o p l asty a n d ste n t i n g , u s u a l ly 7 F r. T h i s perm its

Sheath Placement
• Place sheath t i p close to t h e o n g m of t h e occ l u s i o n .
Contrast a d m i n istered t h r o u g h sheath fi l l s t h e d ista l
reconstituti o n site t h r o u g h co l l atera l s . For a n S FA oc­
c l u s i o n , the tip of the sheath i s u s u a l ly positioned n e a r
t h e f e m o r a l bifu rcati o n a n d t h e d ista l a rtery i s v i s u a l ­
ized with contra st flow i n g t h r o u g h prof u n d a col l atera l s .
Use a s h e at h that i s o n e s i z e l a rg e r t h a n that used for
contra st a d m i n i strat i o n even if a reentry device i s b e i n g
positi o n e d (FIG 1 ) .
Entering the Subintimal Space
• P l a ce an a n g l e d t i p catheter p o i n t i n g towa rd t h e a rtery
wa l l at t h e o r i g i n of t h e occl u s i o n . Point it o p posite t h e
l ocat i o n where t h e l a rgest r u n off col latera l i s locate d .
Adva nce a G l i dewi reTM i nto t h e wa l l . Push it a n d t h e t i p
w i l l catch a n d a l o o p w i l l f o r m (FIG 2) .

A B
FIG 1 • S h eath p l acement. A. There is a stu m p of prox i m a l S FA that is patent. The sheath was p l aced u p a n d ove r t h e a o rt i c
bifu rcat i o n . The t i p of t h e s h e a t h i s i n t h e co m m o n fe m o ra l a rtery a n d ca n be recog n i zed by a rad io p a q u e t i p . The catheter i s
used to d i rect t h e g u i dewire i nto t h e b l i n d sac of t h e occ l u d ed p roxi m a l S FA. B. T h i s a rte r i o g r a m s h ows a s h o rt p o p l ite a l a rtery
occ l u s i o n . The t i p of t h e sheath is p l aced d i rectly i nto t h e proxi m a l p o p l itea l a rtery to s u p po rt t h e reca n a l izati o n . T h e re is a
l a rg e peri g e n i c u l a r co l l atera l that o r i g i n ates from t h e p o p l it e a l a rtery at t h e l ocat i o n where t h e a rtery occ l udes. Typ ica l ly, t h e
s u b i n t i m a l s p a c e i s e n t e r e d by d i rect i n g t h e catheter t i p a n d t h e g u i dewire to t h e a rte r i a l wa l l o n t h e s i d e o p posite t h e o r i g i n
o f t h e l a rg e col l atera l .
 C h a pt e r 2 9 PERCUTAN E O U S F E M O RAL-POPLITEAL RECONSTRUCT I O N TEC H N I Q U E S : Ree ntry Devices 2063

A B c

D E
FIG 2 • Enter t h e s u b i nt i m a l space. A. After sheath t i p p l acement n e a r t h e o r i g i n of t h e occ l u s i o n a n d where t h e a d m i n istered
contra st w i l l opacify t h e l ocat i o n where t h e a rtery reconstitutes. An a n g l e d tip catheter i s used (arro w) to d i rect t h e w i re
towa rd t h e s u p e rfi c i a l femora l a rtery o r i g i n . B. I n t h e p o p l itea l a rte ry, t h e catheter is poi nted to t h e i nterface betwee n t h e
a rtery a n d t h e occ l u s i o n o n t h e s i d e o p posite t h e l a rgest exiti n g co l l atera l (arrow). C. The t i p of t h e catheter i s poi nted a g a i nst
the a rtery wa l l at the l ocati o n where the occ l u s i o n starts. D. The hyd ro p h i l ic g u i d e w i re i s p u s h e d i nto the wa l l u n t i l the t i p
o f t h e w i re catches a n d a l o o p forms. T h e l o o p u s u a l ly forms at t h e transition z o n e a l o n g t h e w i re betwee n t h e soft, f l o p py t i p
o f t h e hyd ro p h i l i c w i re a n d t h e stiffe r s h aft o f the w i r e . E. After t h e w i re l o o p is e m bedded with i n t h e occl u s i o n , t h e s u p po rt i n g
catheter is advanced.

LOOP MANAGEMENT the loop is i n the s u b i n t i m a l space, keep i n g the loop n a r­

row keeps the s u b i n t i m a l space tig ht. T h i s h e l ps to d i rect
Loop Advancement the wire in a stra i g hter trajectory toward its ta rget a n d
• Vis u a l ization, loop m a n a g e m e nt, a n d assessment of the a lso m a kes the k n u c k l e o f the w i r e l o o p a m o re effective

reentry site are the m a n e uvers that e n h a nce success. The tool for p i e rci n g tissue to get i nto the true l u m e n .
• T h e sta n d a rd G l i d ewi rerM (Te r u mo) h a s a d i rect i o n a l
looped hyd ro p h i l ic w i re is advanced past the lesion (FIG 3).
The loop is kept n a rrow a n d is o pti m a l if l e s s t h a n the t i p w i t h a soft s h aft. If s u b i nt i m a l passage i s b e i n g p e r­

d i a meter of the a rtery l u m en, a n d t h i s i s d o n e by closely formed past a h e a v i l y ca l cified l e s i o n , t h e a rtery wa l l

fo l l owi ng the l o o p with a s u p po rt i n g catheter. B eca u se m a y b e m o re a d h e re n t t o t h e ca l cified s e g m e nt, m a k i n g

2064 P a rt 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

A B c
FIG 3 • Loop a d va ncement. A. After e n t e r i n g t h e s u b i nt i m a l spa ce, t h e l o o p is advanced with t h e s u p port of
t h e catheter. The l o o p works best w h e n it is m a i nta i n ed i n a n a rrow confi g u ra t i o n . T h i s is e n h a nced by closely
fo l l owi n g t h e l o o p with t h e s u p porti n g catheter. If t h e loop e n c o u nters a heavily c a l cified seg m e nt, it tends to
w i d e n o r to spiral around t h e calcific segment. B. The l o o p i s adva n ced to t h e a rteri a l segment where t h e t r u e
l u m e n i s reconstituted . Q u ite co m m o n ly, t h e loop of w i re w i l l p a s s i nto t h e t r u e l u m e n . The l ocat i o n w h e re
t h e a rte ry reconstitutes is visu a l ized by a d m i n iste r i n g contrast i nto t h e sheath. C. After t h e l o o p passes i nto
the true l u m e n , advance the catheter i nto the true l u m e n . Always confirm l ocat i o n in the true l u m e n before
sta rt i n g reco nstruct i o n . T h i s i s u s u a l ly d o n e by removi n g the w i re and a d m i n i ste r i n g contra st i nto the cath eter.
The g u i dewi re of choice for use d u r i n g treatm ent c a n t h e n be p l a c e d .

w i re passa g e a l o n e m o re d iffi c u l t . C a t h e t e r s u p po rt i s t i s s u e a n d b re a ks across t h e m e m b r a n e f r o m s u b i nt i m a l

req u i red, a n d s o m et i mes a low-p rofi l e ba l l oo n m ust be
used to create space i n t h e s u b i nt i m a l p l a n e . Typ i c a l ly, a
sta n d a rd G l i dewi reTM is used, b u t w h e n passi n g a ve ry
ca l c ified l e s i o n , a stiff G l i d e w i re T M s h o u l d be c o n s i d e r e d .
A n y l o n catheter, 4 o r 5 Fr, with a n a n g l e d t i p a n d a
h y d ro p h i l i c coat i n g is best.
• A rece nt deve l o p m e n t i s t h e ava i l a b i l ity of CTO s u p po rt
cath eters, s u c h as t h e Q u i c k-CrossTM (Spectra netics) o r
t h e C X I T M ( C o o k M e d i c a l ) offe r i n g m o re s u p po rt a n d l ow
p rofi l e . The l o o p u s u a l ly seeks t h e wea kest p o i n t i n t h e
pote nti a l space to t r u e l u m e n m o r e t h a n 7 0 % o f t h e t i m e
i n o u r expe rience. O rt h og o n a l v i ews a re h e l pf u l i n assess­
ing the trajectory of the loop and whether it i s p rog ress­
i n g toward the reentry site.
• Even if t h e reentry site i s ca l c ified, a w i re l o o p o r a stiff
w i re with catheter s u p po rt may reenter t h e true l u m e n
a n d it i s worth a n atte m pt . If t h i s a pp roach i s u n s u ccess­
f u l , sel ect a reentry catheter as the n ext step . T h i s saves
t i m e and the reentry site is best for s u ccess before too
m uc h m a n i p u l a t i o n h a s taken p l a ce .

REENTRY DEVICE Reentry into True Lumen

Reentry Device Placement • After t h e catheter is i n p l ace, a need l e in t h e t i p of t h e

• The s u b i nt i m a l w i re is exc h a n g e d for a stiff 0.0 1 4- i n
g u idewire.
• The ree ntry d evice i s adva n ced .
• If t h e proxi m a l p a rt of t h e s u b i nt i m a l space is too
t i g h t to a l low passage of a 6-Fr ree ntry catheter (ap­
proxi mately 2 m m), a l o n g , l ow-ca l i be r b a l l o o n may
be used to s l i g htly e n l a rg e the s u b i n t i m a l space.
Do not d i l ate t h e a rea i ntended for reentry. If the
s u b i n t i m a l space at t h e ree ntry site i s e n l a rged, it
p revents t h e reentry need l e from havi n g a d e q u ate
s u p p o rt to p u nctu re the t r u e l u m e n .
catheter i s a d v a n c e d i nto t h e t r u e l u m e n .
• A 0 .0 1 4- i n g u i d ew i re is adva n ced from t h e reentry cath­
eter i nto t h e t r u e l u m e n .
• The d i rect i o n of t h e need l e is o r i e nted using
f l u o rosco py.
• O rth o g o n a l v i ews a re obta i ned to l ocate t h e j u xta­
position of t h e t r u e and fa lse l u m e n s .
• The i m a g e i ntensifier is posit i o n e d so that t h e cath­
eter and a n acce pta b l e ta rget vesse l seg m e nt a re
vi ewed s i d e-by-s i d e .
• Rotate t h e catheter u n t i l t h e " L " s h a p e a p p e a rs at the t i p .
C h a pt e r 2 9 PERCUTAN E O U S F E M O RAL-POPLITEAL RECONSTRUCT I O N TEC H N I Q U E S : Ree ntry Devices 2065

A B c
FIG 4 • Use of a reentry cath eter. A. If t h e w i re loop does not pass i nto t h e t r u e l u m e n ,
c o n s i d e r a ree ntry d e v i c e . I n t h i s exa m p l e, t h e O utbackTM (Cord i s) d e v i c e i s used. T h i s is a
6-Fr catheter that is adva n ced in t h e s u b i nt i m a l space, a l o n g t h e s a m e cou rse where t h e
c h a n n e l was created by t h e catheter a n d g u idewire. The reentry catheter is o r i e nted s i d e ­
by-si d e with t h e t r u e l u m e n . The catheter i s rotated so that t h e " L " s h a p e at t h e t i p of t h e
ree ntry catheter i s p o i n t i n g toward t h e true l u m e n . B. The need l e is a d v a n c e d . I n t h i s case,
the tip of the need l e had passed beyo n d the true l u m e n and the w i re i s outs i d e the a rte ry.
C. The need l e is passed a g a i n , t h i s t i m e n ot q u ite so d e e p l y, a n d t h e w i re passes i nto t h e t r u e
l u m e n . After each t h row of t h e need l e, if it a p p e a rs to be g o i n g i n t h e correct d i rect i o n i nto
the true l u m en, the w i re is passed to exp l o re and see if the tip prog resses i nto the correct
l ocat i o n in the t r u e l u m e n .

• Adva nce t h e need l e i nto t h e t r u e l u m e n I V U S i m a g e a n d t h e catheter i s rotated t o face t h e t r u e

• M u lt i p l e need l e passes may be req u i re d . The r i s k of l u m e n . U s i n g co l o r u ltraso u n d , the t r u e a n d false l u m e n s
a need l e pass is l ow. can be d isti n g u ished a n d t h e w i re passed i nto true l u m e n .
• The need l e may o n ly req u i re a p a rt i a l adva ncement • After pass i n g t h e wi re, t h e need l e i s retracted a n d t h e
to get i nto t h e t r u e l u m e n . A fu l l adva ncement may reentry catheter i s rem oved ove r t h e wire.
g o through t h e t r u e l u m e n a n d i nto t h e wa l l o n t h e • S o m e co m m e rc i a l ly ava i l a b l e r e e n t ry cath eters a re
o p posite s i d e . l i sted i n Ta b l e 1 . Ree n t ry cat h eters m a y be g u i d e d by
• M u lt i p l e s m a l l adjust m e nts a re often req u i red be­ f l u o roscopy or I V U S , a n d r e e n t ry is a c h i eved by p a s s a g e
fore t h e t r u e l u m e n i s reentered, espec i a l l y if the of a n e e d l e, stiff w i re t i p, o r d r i l l . O rt h o g o n a l v i ews a re
reentry site i s d i seased . o bta i n ed to locate t h e j uxta posit i o n of t h e t r u e a n d
• The n e e d l e th row is o r i e nted with i nt ravasc u l a r u ltra­ fa l s e l u m e n s a n d t h e i m a g e i nt e n s i f i e r i s p o s i t i o n e d s o
so u n d (IVUS) when using the P i o n e e rrM catheter t h a t t h e catheter a n d a n acce pta b l e ta rget vesse l s e g ­
(Medtronic). The need l e i s at 12 o'clock position o n the m e n t a re v i ewed s i d e-by-s i d e (FIG 4) .

ALTERNATIVE REENTRY OPTIONS to p rovide leverage f o r t h e need l e passa g e i nto t h e

true l u m e n .
Reentry Device Cannot Be Used • Another option is t o consider a stra i g h t 0 . 0 3 5 - i n
• Use a catheter with a stiff t i p to b l u nt l y p u s h on t h e re­ G l i dewi rerM o r a stra i g h t 0.0 1 4 i n , o r 0 .0 1 8 i n C T O w i re

entry site o r use low-prof i l e b a l l o o n a n g i o p l asty to break a n d p u s h on t h e locat i o n desi red for reentry a n d see if it

u p t h e tissue m e m b r a n e i n hopes of a c h i evi n g a fen estra­ c a n be d r i l led i nto p l ace.

t i o n as s h ow n by a ctive b l ood ret u r n .

• T h i s a p p roach is sometimes s u ccessfu l but it e n l a rges
a n d occas i o n a l ly perforates t h e s u b i n t i m a l space at t h e
reentry site a n d w i l l r e n d e r t h e reentry cath eters l ess
effi cacious beca use they rely o n a t i g h t s u b i nti m a l space
Retrograde Approach
• Retro g ra d e p u n ct u re can be p e rformed o n a d i st a l a rte ry,
s u c h as a t i b i a l o r ped a l a rte ry. Retro g ra d e passa g e of
a w i re is ofte n poss i b l e, even w h e n a ntegrade passa g e
2066 P a rt 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

--
A B c D
FIG S • Retrog rade p u n ctu re u s i n g p e d a l a ccess. A. T h i s patient h a s a p e d a l g a n g re n e i n an a n g iosome that is perfused
by t h e a nterior t i b i a l a rte ry. Revascu l a rization of t h e a nterior t i b i a l a rtery u s i n g a tra d iti o n a l a ntegrade a p p roach was not
su ccessfu l . B. A road map of t h e d i st a l anterior t i b i a l a rtery was p e rfo r m e d . The a rte r i a l access need l e is adva n ced i nto the
d ista l a nterior t i b i a l a rtery u n d e r roa d m a p p i n g . C. After retro g r a d e a ccess, the g u i dewire i s passed i nto t h e a nteg rade sheath.
The a n g i o p l a sty b a l loon is t h e n i ntrod u ced t h r o u g h t h e a ntegrade sheath. D. After a n g i o p l a sty, t h e a nterior tibial a rtery
is patent.

a c ross t h e same lesion was not. This i s especi a l ly t h e case
for occl u s i o n s of t h e p o p l itea l a n d proxi m a l t i b i a l level
where t h e re a re col laterals that a n a ntegrade w i re tends
to fo l l ow b l i n d ly a l o n g a n d where reentry devi ces a re
n ot as a p p l i ca b l e .
• Contrast is a d m i n istered t h r o u g h t h e proxi m a l ac-
cess to o bta i n a road m a p of t h e d ista l p u n ct u re site
o r u ltraso u n d used to g u i d e t h e a ccess.
• A 4-cm 2 1 - g a u g e m i cropu ncture need l e is used.
• A V 1 8 w i re (B osto n S c i e ntific) i s i ntrod uced.
• S h eath placement is avo i d e d if poss i b l e to keep t h e
a rteriotomy s m a l l .
• If t h e retrograde w i re ca n n ot break i nto t h e t r u e
l u m e n , a coro n a ry b a l l o o n catheter i s p a s s e d ove r it.
• A b a l l o o n i ntroduced from t h e a ntegrade d i rect i o n a n d
t h e b a l l o o n i ntroduced retro g ra d e a re j u xta posed a n d
i nfl ated a n d a re u s u a l l y a b l e to s p l it t h e d i ssect i o n f l a p
to o p e n t h e t r u e l u m e n (FIG 5).

PEARLS AND PITFALLS

Stayi n g in true l u m e n
S u b i nt i m a l passage
O pt i m a l ree ntry site
Col l atera l s
Reentry cath eters more l i ke l y
• S h o rtest reco nstruct i o n
• Preservati o n of m ost co l l atera ls
• M a y i ncrease risk of e m b o l ization at time of reca n a l ization
• I nt ra l u m i n a l contents a re exc l u d e d .
• The s u b i nti m a l s p a c e ofte n can be converted to a smooth, l a rg e d i a m eter co n d u it. U s u a l ly,
t h e entry a n d reentry sites req u i re extra a n g i o p l asty or mech a n i c a l s u p po rt from i m p l a nts.
• M i n i m a l c a l cificati o n s
• H e a lthy t r u e l u m e n
• S h o rtest s u b i nt i m a l c h a n n e l
• Reenter as close to d i st a l reconstituti o n as possi b l e
• Typ i ca l ly l a rg e i n c o m i n g col latera l feed i n g reconstituted segment
• S u b i n t i m a l space (flow c h a n n el)-no c o l late r a l s a n d ca n fa i l s u d d e n ly
• C a l cified ree ntry site
• Worse d i sease m o r p h o l ogy
C h a pt e r 2 9 PERCUTAN E O U S F E M O RAL-POPLITEAL RECONSTRUCT I O N TEC H N I Q U E S : Ree ntry Devices
POSTOPERATIVE CARE
• Postoperative care involves standard care after endovascu­
lar procedures. True lumen recanalizations have collaterals,
whereas subintimal passages do not. The subintimal recana­
lization should be monitored with duplex because they may
fail suddenly in a manner similar to a bypass. We typically
perform duplex surveillance every 6 months.
OUTCOMES
• Loop reentry using standard technique is successful in about
70% to 8 0 % of cases. 1 •2
• Patients that failed loop reentry were treated with reentry
catheters and approximately 8 0 % of these were successful. 2
• Reentry success was 9 0 % successful in a study using the
OutbackTM ( Cordis) reentry catheter for all-comers.3
COMPLICATIONS
• Complications are similar to other endovascular proce­
dures.
2067
• Access site complications are the most common and include
bleeding, hematoma, pseudoaneurysm, and arteriovenous
fistulae.
• Embolism to the runoff may be slightly more common in this
patient population because it involves treatment of the most
complex infrainguinal lesions.
• Perforation may also occur with greater frequency because
angioplasty and manipulation in the subintimal space are
key maneuvers in this procedure. However, when perfora­
tion occurs, it is only rarely clinically significant.
REFERENCES
1. Bolia A, Brennan ], Bell PR. Recanalisation of femoro-popliteal occlu­
sions: improving success rate by subintimal recanalisation. Clin Radio/.
1989;40(3):325.
2. Setacci C, Chisci E, de Donato G, et al. Subintimal angioplasty with
the aid of a re-entry device for TASC C and D lesions of the SFA. Eur
J Vase Endovasc Surg. 2009;38(1):76-87.
3. Bausback Y, Botsios S, Flux ], et al. Outback catheter for femoropop­
liteal occlusions: immediate and long-term results. J Endovasc Ther.
2011;18(1):13-21.

Chapter 30
�
I
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
DEFINITION
• Overview: Femoral-popliteal revascularization, for indi­
cations of limb salvage or claudication, is performed using
open, endovascular, or hybrid approaches. Advanced open
surgical techniques are detailed elsewhere. Guidewire­
catheter combinations are particularly effective and
widely used to cross femoral-popliteal stenoses or occlu­
sions. Once across, reconstructions are performed with
any combination of angioplasty, stenting, stent grafting,
or atherectomy.
• Basic procedural goals: Improve functional status, quality
of life, and, in the setting of ischemic tissue loss, augment
wound healing and limb preservation.
• Challenges influencing long-term clinical success: ( 1 ) superfi­
cial femoral and popliteal artery movement during activities
of daily living, including flexion, compression, torsion, and
stretching; ( 2 ) compromised runoff; ( 3 ) the generally diffuse
nature of femoral-popliteal disease, requiring angioplasty of
long segments of diseased and stiffened artery; (4) complex
pathology, including ostial lesions, luminal thrombus accu­
mulation, and mural calcification.
• Indications for intervention:
Rutherford class 1, 2, and 3 ischemia-exercise ther­
apy and medical management are pursued as primary
intervention. 1
Rutherford class 4, 5, and 6 ischemia-rest pain, ischemic
ulcer, and gangrene warrant revascularization as initial
therapy.
• Technical approach: Utilization patterns are trending toward
percutaneous-first approaches to management of lnter-Societal
Consensus for the Management of Peripheral Arterial Disease
(TASC II) type A, B, and C lesions. 2 Full consideration of cur­
rent indications for open versus percutaneous interventions
is beyond the scope of this text; reference should be made to
most recent TASC updates.3
PATIENT HISTORY AND PHYSICAL
FINDINGS
• History includes a detailed description of ischemic symp­
toms pertaining to claudication, rest pain, or tissue loss.
The progression of symptoms and timeframe are helpful in
determining the urgency of therapy.
• The presence and severity of cardiovascular disease risk
factors should be assessed and managed to ensure opti­
mal perioperative and long-term clinical results, including
tobacco use, diabetes, hypertension, hyperlipidemia, renal
dysfunction, and sedentary lifestyle.
• Previous vascular or endovascular surgery procedures should
be reviewed in detail, including obtaining operative notes,
prior imaging and surveillance studies, and prior physiologic
testing results whenever possible.
2068
-
Percutaneous Femoral-Popliteal
Reconstruction Techniques:
Antegrade Approaches
·
F. Ga llardo Pedrajas Peter A. Schneider
• For claudicants, the potential presence and contribution of
nonvascular causes of leg pain with exercise should be con­
sidered; for example, neurologic claudication secondary to
lumbar radiculopathy and other degenerative spine diseases.4
• Physical examination should document peripheral pulses
at all levels, both lower extremities, including the strength
and quality of femoral pulses and skin integrity at potential
access sites.
• The severity and extent of ischemia, degree of existing tissue
damage, and presence of infection are documented prior to
initiating intervention.
IMAGING AND OTHER DIAGNOSTIC
STUDIES
• Physiologic vascular testing provides objective determina­
tion of the location and severity of disease, assists in pro­
cedural planning, and provides documentation of baseline
conditions.
Ankle-brachial index (ABI ) : ratio of the continuous wave
Doppler-determined blood pressure in the anterior or
posterior tibial arteries (whichever is higher) to the blood
pressure in the brachial artery ( > 0 . 9 normal; 0.5 to
=
0.9 = usually consistent with mild to severe claudication;
<0.5 = present in patients with very short distance clau­
dication, rest pain, or tissue loss)
Toe pressures: The ABI may be artifactually elevated in
diabetic patients with calcified tibial arteries. Toe pres­
sures may provide more reliable assessment of pedal
and forefoot perfusion when the ABI is greater than 1 .2 .
Hallux pressure less than 5 0 mmHg may predict delayed
or inadequate wound resolution, 50 to 80 mmHg is
indeterminant, and greater than 8 0 mmHg is generally
sufficient to promote healing.
Duplex arterial imaging: Direct insonation provides
insight into the location and severity of disease. The ratio
of the peak systolic velocities (PSV) obtained from the
most compromised location divided by PSV from the most
adj acent, proximal noninvolved segment provides addi­
tional guidance regarding the severity of disease; greater
than or equal to 2 . 5 : 1 usually identifies a stenosis greater
than 5 0 % (FIG 1 ) .
• Computed tomographic arteriography ( CTA ) : CTA has
assumed an increasing role in guiding peripheral vascular
intervention, particularly in regard to choosing appropriate
devices and optimal interventional approach (e.g., ipsilateral
antegrade vs. contralateral retrograde ) . This additional guid­
ance, however, comes at the cost of substantially more iodin­
ated contrast and radiation exposure than that provided by
catheter-directed, intraarterial contrast arteriography, aug­
mented by direct ultrasonic visualization and physiologic
testing ( FIG 2 ) .
 C h a p t e r 30 PERCUTA N E O U S F E M O RAL-POPLITEAL RECONSTRUCT I O N TECH N I Q U E S 2069

A B c

�-.
r
·:\*" Ml'• l J:IJ: .. l!l
't

D E
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l•· ' '· tJ I
l. "

F G H
FIG 1 • D u p lex eva l u a t i o n of lower extrem ity a rteries. A. D u p lex m a p p i n g was p e rformed on a patient with ve ry severe l eft lower
extrem ity c l a u d icat i o n . T h e re i s a l eft S FA occ l u s i o n with reconstituti o n of t h e d ista l S FA. B. D u p l ex i m a g e of p roxi m a l l eft S FA s h ows some
plaque formation and a p e a k velocity of 9 5 em p e r seco n d . C. T h i s d u p l ex image d e m o n strates n o flow i n t h e occ l u d e d s e g m e n t of t h e
S FA. D. The l eft d ista l S FA d u p l ex i m a g e s h ows t h e p o i n t of reco n stitution o f t h e a rtery with a p a t e n t d ista l a rtery a n d low velocity fl ow.
E. The m o re d ista l S FA i s a h e a l t h i e r a rtery with a reaso n a b l e l u m e n , but it has a l ow peak vel ocity of 32 em p e r seco n d . F. The a rte r i o g r a m
p e rformed o n t h e l eft l o w e r extrem ity of t h i s p a t i e n t at t h e t i m e of i nte rve ntion s h owed a p a t e n t but d iseased proxi m a l S FA. The C FA a n d
p rofu n d a fem o r i s a rte ry d o not h a v e s i g n ificant occ l usive d isease. G . There is a m i d-SFA occl u s i o n a s d e m o n strated by d u p l ex eva l u a t i o n .
H. T h e r e i s reconstitution of t h e l eft d i sta l S FA as i n d i cated by d u p l ex m a p p i n g .

• Magnetic resonance arteriography (MRA) : MRA may also
assist preoperative planning. Although MRA does not expose
patients to ionizing radiation, artifactual overestimation of
disease severity is common in low flow conditions. Also,
gadolinium contrast administration is contraindicated in
patients with a glomerular filtration rate of less than 30 mL
per minute due to risk of contrast-associated glomerulo­
sclerosis ( FIG 3 ) .
SURGICAL MANAGEMENT
• Overview-Success in percutaneous management of femoral­
popliteal occlusive disease has catalyzed a reciprocal decline
in the use of open bypass for definitive revascularization.
Key features of percutaneous management include detailed
preoperative planning, choice of access site and closure tech­
niques, and familiarity and facility with a wide range of com­
plementary intraluminal wire-guided devices.4
Preoperative Planning
• The operative plan includes access site selection, planned
method of crossing, and options for arterial reconstruction.
• Endovascular inventory: An essential element of endovas­
cular success is a robust and redundant device inventory. In
contrast to open reconstruction techniques, where similar
instruments will suffice for all lower extremity bypass con­
figurations, regardless of routing, a unique and task-specific
 2070 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY
A B
FIG 2 • CT a n g i o g ra p h y for i nfra i n g u i n a l occ l u s ive d isease. Vo l u m e r e n d e r i n g tech n i q u e . Preope rative study of p u nctu re zones in t h e
CFA i n a p a t i e n t with a l o n g r i g ht S FA occ l u s i o n . A. Eva l u a t i o n of i l i a c a rtery i nf l ow. B. Lo n g r i g ht S FA occ l u s i o n with reco n stitution of
t h e a b ove-the-knee p o p l itea l a rte ry. C. CT eva l u ation of t h e CFAs a n d fe m o ra l b i f u rcat i o n s p r i o r to access. D. Cente r l i n e m e a s u r e m e nts
perfo rmed to m e a s u re d i a m eters and p l a n for ste nt g raft p l acement in the r i g h t S FA.
repertoire is required for almost every endovascular ap­
proach. Procedural success requires that the necessary de­
vices, including guidewires, sheaths, catheters, angioplasty
balloons, stems, reentry devices, stem grafts, and atherec­
tomy catheters are identified and available before interven­
tion is attempted.
• Appropriate radiation protection must be available for all
individuals involved in interventional procedures. All team
members must conscientiously wear a radiation dosimeter,
submitted monthly for aggregate exposure documentation.
FIG 3 • M a g n et i c reso n a nce a n g i o g r a p h y as p reope rative
assess m e nt of l e s i o n l ocat i o n and seve rity. This patient h a s
extensive i l i a c a n d fe m o r a l a rtery occ l u s ive d isease. B o t h fem o ra l
a rtery p u nctu re sites a re c o m p r o m i sed . T h e re a re l o n g l e s i o n s i n
both su perfi c i a l fe m o ra l a rteries.
c D
Leadership ensures that all team members adhere to basic
radiation safety tenants, including limiting the length and
intensity of exposure to the minimum required for precision
imaging and intervention (the "as low as reasonably achiev­
able" [ALARA] principle ) . Safety principles, including dis­
tance from the radiation source, appropriate shielding and
optimal table height, and source-image intensifier distance,
must be understood and applied during every procedure.
• Antibiotic prophylaxis is administered prior to the initia­
tion of the procedure, whenever permanent implants are
considered.
• Percutaneous procedures are performed under local anes­
thesia with appropriate sedation. Care should be taken to
avoid oversedation to ensure that patients can cooperate
with instructions and imaging requirements during the
procedure. When hybrid open endovascular procedures
are contemplated, general anesthesia may facilitate more
rapid and accurate device deployment, with reciprocally
less radiation exposure for the patient, cath lab team, and
operator.
• An important initial consideration is the approach and
optimal puncture site. The common femoral artery ( CFA)
is the most frequent access site. The approach is typi­
cally either up and over the aortic bifurcation from the
contralateral femoral artery or ipsilateral antegrade femo­
ral puncture. The transbrachial, transthoracic approach
may also provide optimal antegrade access under certain
circumstances.
Positioning
• Surgeon position should provide forehand access, whenever
possible ( FIG 4) .
• Retrograde femoral puncture: This i s the most common
type of access for all endovascular procedures, including
femoral-popliteal revascularization ( FIG S) . The needle is
placed in the CFA and the guidewire is advanced retrograde
into the iliac artery.
• The femoral area is examined prior to puncture of the
artery. The inguinal ligament extends from the anterior su­
perior iliac spine to the pubic tubercle. The best puncture
 C h a p t e r 30 PERCUTA N E O U S F E M O RAL-POPLITEAL RECONSTRUCT I O N TECH N I Q U E S 2071

= head, the access attempt is aborted before larger devices

are inserted to minimize the risk of retroperitoneal hema­

il
FIG 4 • Pat i e n t positi o n i n g . The o p e rator works fore h a n d w h e n
poss i b l e . The r i g ht-h a n d e d o p e rator sta n d s o n t h e patie nt's
r i g h t s i d e fo r a retrog rade fe m o r a l p u nctu re of e i t h e r g r o i n . The
r i g ht- h a n d e d o p e rator sta n d s at t h e i nfe r i o r aspect of t h e l eft
a r m w h e n perform i n g a l eft b rach i a l p u ncture. The m o n itors a re
p l aced so that t h ey can be comforta b l y observed by t h e ope rator.
site is inferior to the inguinal ligament and at least a cen­
timeter superior to the femoral bifurcation. Ultrasound
provides useful guidance for arterial puncture ( FIG 6 ) .
Following needle insertion, spot fluoroscopy from a n ipsi­
lateral oblique angle is obtained to confirm position. If ar­
terial insertion is determined to be proximal to the femoral
toma formation due to inadequate compression or control
following the procedure. Common femoral access also en­
ables closure devices to be employed with confidence when
necessary.
• Closure devices: recommended for retrograde femoral access
site management following insertion of greater than or equal
to 6-French (Fr) sheaths. Sheath puncture less than 6 Fr is
best managed by compression for 10 to 15 minutes, with or
without adjuncts such as a thrombin-impregnated dressing
(e.g., D-stat® patch) .
• When pulses are not palpable a t the desired access site,
ultrasound or fluoroscopic guidance ( assisted by mural
femoral artery calcification) may provide valuable assis­
tance. Under these circumstances, bilateral femoral access
and ipsilateral iliac intervention may be required for proce­
dural success. Ideally, this eventuality is anticipated based
on the results of preprocedural examination and physi­
ologic testing. Fortunately, the pulseless femoral artery is
often palpable based on mural calcification alone. Patience
and spot fluoroscopic images to confirm needle and ar­
tery position following failed needle passes often ensures
ultimate success.
• Secondary puncture of the postoperative groin presents spe­
cial challenges. Whenever possible, scar tissue and anasto­
moses should be avoided. Access in native artery is preferable
to prosthetic or autogenous grafts. Considerable force may
be required for needle and micropuncture set access; consid­
eration should be given to using " stiff" 0 . 0 1 8-in wires and

A B

FIG 5 • Retro g rade fem o ra l p u n cture. A. The anato m i c relationsh i ps a re eva l uated. The l eft h a n d may be used to h e l p g u ide the needle. B.
The a ccess need l e is p laced i n the CFA i nfe rior to the i n g u i n a l l i g a m ent a n d superior to the femoral bifu rcat i o n . C. The need l e is advanced i nto
the CFA until a rte r i a l b l ood return is a p p a rent. D. In the i m a g e a prolongation of the g u id e inside the retrograde fem o ra l s h o u l d be i n c l u d ed,
i n order to u n d e rsta n d that with this a pproach a n d these needle a n g u lation the g u i d e s h o u l d never go to the SFA, or p rofu n d a a rtery.
2072 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

FIG 6 • U ltraso u n d-g u i ded p u n ct u re . A. In t h i s case, the

operator i s eva l u a t i n g t h e l eft CFA u s i n g the u ltraso u n d
p r o b e w i t h a l o n g i tu d i n a l o r i e ntat i o n . The m o n itor i s
p l aced i n a l o c a t i o n where the o p e rator can v i s u a l ize
t h e a rte r i a l p u ncture rea l time. B. I n t h e d rawing, the
operator i s prepa r i n g for a n a ntegrade femora l p u ncture
with u ltraso u n d g u i d a nce. C. I n this re n d e r i n g of an
u ltraso u n d image that is seen d u ri n g com m o n femora l
a rterial p u n ctu re, t h e co m m o n femora l ve i n is typica l ly
B m u c h l a r g e r in d i a m eter, l i es s i d e-by-si d e to t h e a rtery,
a n d t h e ve i n is typica l ly easily com p ress i b l e . The entry
n e e d l e ca n be v i s u a l ized as it enters the a rtery to e n s u re
t h e correct location of t h e p u nctu re.

micropuncture sets specifically manufactured to facilitate
difficult groin access.
• Antegrade femoral puncture: The femoral pulse and inguinal
ligament are carefully marked (FIG 7 ) . Needle placement is
directed proximal to the femoral artery bifurcation under
real-time ultrasound guidance.
• Guidewire placement into the superficial femoral artery
( SFA) requires patience and practice. Ultrasound imaging
in a longitudinal view may facilitate SFA wire intubation.
When using a micropuncture set with a " steerable " 0 . 0 1 8 -in
wire (e.g., one with a slight curve placed at the tip ) , fluoro­
scopic control may also be employed. If repeated attempts
result in deep femoral artery placement, the micropuncture
set should be exchanged for an 1 1 em 4- or 5-Fr sheath
over a standard multipurpose (e.g., Bentsen) wire. Once
safe antegrade deep femoral access is obtained, the 5 -Fr
sheath may be gradually withdrawn with sequential fluo­
roscopic contrast " puffs " of 1 mL or less performed until
the femoral bifurcation is imaged ( but while the sheath
tip is still in the CFA ) . At this j uncture, roadmapping or
last-image-hold digital subtraction angiography from an
ipsilateral oblique angle is performed to outline femoral
bifurcation anatomy, after which a steerable hydrophilic
guidewire and, ultimately, the 5 -Fr sheath is directed under
fluoroscopic imaging into the SFA.
• Antegrade femoral access should be avoided in the obese,
in patients with a short CFA, or in patients with extreme
proximal or orificial SFA disease. Although antegrade
access improves " pushability" across total occlusions and
enables usage of a wider inventory of guidewire-catheter
combinations, there is no option for inflow disease man­
agement using this approach. Also, the safety of cur­
rent generation closure device placement is uncertain in
antegrade approaches and should be avoided whenever
possible.
• Brachial puncture and transaortic sheath placement may
provide an alternative option for " antegrade " femoral ac­
cess. Upper extremity arteries are smaller, less forgiving,
more prone to spasm, and less predictably managed with
compression following access. Notoriously, small amounts
of arterial extravasation may catalyze debilitating and per­
manent neurapraxia, even when brachial access is obtained
well distal to the axillary fossa. Debilitating nerve injury
from " axillary" sheath hematomas may occur at any location
proximal to the antecubitum. In our practice, we minimize
this risk by defaulting to surgical exposure and direct arte­
rial puncture with suture closure for essentially all brachial
artery access procedures. Exposure is easily obtained with
local anesthetic in most patients.
• The longer guidewires and catheters required to access the
femoral and popliteal arteries are also less responsive to sur­
geon manipulation from a brachial approach and also limit
the available inventory of appropriate devices for femoral or
popliteal intervention.
• When brachial access is required, the level of access is
determined by the diameter of the largest sheath required
 C h a p t e r 30 PERCUTA N E O U S F E M O RAL-POPLITEAL RECONSTRUCT I O N TECH N I Q U E S 2073

A
B

c
FIG 7 • Anteg rade p u ncture. A. The needle p u nctu res the s k i n at the level of the i n g u i n a l l i g a ment or j u st su perior to that leve l . The a n g l e
o f trajecto ry o f the need l e wi l l permit the a rtery p u n ct u re to be p roxi m a l to the femoral bifu rcat i o n . B. T h e further p roxi m a l t o the femoral
bifurcation the a rtery p u nctu re i s located, the easier it is to stee r the w i re i nto the S FA. The best locat i o n for need l e p l acement is i nfe rior to
the i n g u i n a l l i gament but w e l l p roxi m a l to the femora l bifu rcati o n . C. The n e e d l e enters the CFA and when a rte r i a l return is a c h i eved, the
floppy-t i p g u i dewire i s advanced i nto the a rtery. D. The a rtery a n d the a n atomic b o u n d a ries a re p a l pate d . E. A clamp is used to assist with
f l u o rosco p i c i dentification of the desi red p u n ct u re locat i o n . F. The need l e is p l aced. G. Arter i a l return is achieved. H. A g u i d ewire is p l aced .
I. A sheath is adva nced.

to complete the procedure. For 6- or 7-Fr sheaths, the
segment immediately proximal to the antecubital fossa is
sufficient. For larger sheaths, access should be obtained
in the distal axillary artery, proximal to the bifurcation
of the deep brachial artery. The left arm should be used
whenever possible to minimize risk for embolic iatro­
genic stroke. D uring micropuncture access, even under
direct vision, back-bleeding may not be pulsatile due to
the smaller caliber of the brachial artery. Sheaths should
be managed with frequent flushing with 1 0 0 units/mL
heparin, as well as systemic anticoagulation once defini­
tive interventional sheaths (6 to 7 Fr, 55 to 90 em from
the arm) are positioned in the target artery, or whenever
sheaths appear to be occlusive. Intraarterial nitroglycerine
inj ection may reduce arterial vasospasm to the distal
extremity when necessary.

• Percuta neous femora l-pop l itea l revascula rization tech­ bifurcation to prevent kinking as wel l as sufficient length to
n i q ues include bal loon a n g ioplasty a lone, or self-expa n d i n g reach the treatment site without l i m iting d evice selectio n .
stent g raft i m p l a ntation as a n adju nct to a n g i o p lasty. These Sheath access a lso perm its seri a l a n g iogra p h i c i m a g i n g to
techniq ues req u i re p lacement of i nterventiona l-grade g u i d e device positioni ng, deployment, a n d confirm proce­
sheaths, bra ided when req u i red to cross the aortic a rch or d u ra l success.

SHEATH PLACEMENT • Decide on o pt i m a l s h eath positi o n i n g . U s u a l ly, p l a ce m e nt

i m m ed i ately adjacent to t h e ta rget l e s i o n maxi m izes the
• E n s u re t h a t t h e a p p ro p r i ate s h e a t h is s e l ected a n d a b i l ity to cross t h e l e s i o n , control t h e proce d u re, a n d
t h a t a lt e r n atives a re ava i l a b l e s h o u l d p l a n s o r n e e d s m i n i m ize contrast usage. I n m a n y c i rcu mstan ces, it may
change. n ot be poss i b l e o r practica l to advance t h e sheath past
2074 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY
t h e fe m o r a l b i f u rcat i o n w h e n a p proac h i n g from t h e con-
t ra l atera l fe m o r a l a rte ry.
Up and Over Approach
• Cross i n g t h e a o rt i c b i f u rcat i o n ( FIG 8 ) : T h ro u g h a con-
t r a l a t e ra l retro g r a d e p u nctu re, a n i nfrare n a l a o rtogram
is p e rfo r m e d to eva l u ate a o rt i c b i f u rcat i o n a n atomy
and locat i o n . U s u a l l y l ocated at t h e level of t h e i l i a c
c rest, vasc u l a r ca l cificat i o n s may o u t l i n e t h e b i f u rcat i o n
a n d g u i d e positi o n i n g . T h e a o rt i c b i f u rcati o n m u st b e
f r e e of occ l u s ive o r a n e u rysm a l d i sease to e n s u r e safe
sheath passa g e . Occa s i o n a l ly, i l i a c a rtery l e s i o n s m u st be
treated p r i o r to fe m o r a l i nte rve n t i o n to e n s u re o pt i m a l
o u tco m e .
A a n d extrava s a t i o n f r o m w i r e i nj u ry. S i m i l a r l y, w h e n
B e v e r s h e a t h s a re exc h a n g e d o r adva n ced-a rte r i a l pe rfo­
c Obes ity a n d excessive a b d o m i n a l p a n n u s may s i g n ifi­
FIG 8 • S h eath access. A. An exch a n g e g u i d ewire is p l aced
over t h e a o rt i c b i f u rcat i o n . T h e tip of t h e g u i dewi re i s
p l aced i n a l a rge, safe b r a n c h . I n t h i s exa m p l e, t h e p rofu n d a
f e m o r i s a rt e ry i s u s e d to a n c h o r t h e w i re . B. T h e s h e a t h i s
advanced over t h e stiff g u i d e w i r e . T h e a dva n c e m e n t of t h e
s h e a t h i s o b s e rved u n d e r fl u o rosc o p i c c o n t r o l to e n s u re t h a t
i t i s b e i n g p a s s e d safe l y. C. Aft e r s h e a t h p l a c e m e nt over
the a o rt i c b i f u rcat i o n , the stiff w i re i s rem oved and t h e
d i rect i o n a l w i re i s a d va n ce d a c ross t h e l e s i o n i n p r e p a r a t i o n
for treatment.
• S e l ective cath ete r i z a t i o n of the a o rt i c b i f u rcat i o n i s
p e rf o r m e d , fo l l owed by a nt e g r a d e cath ete r i z a t i o n o f
t h e contra latera l i l i a c a rt e ry syst e m , e i t h e r w i t h t h e
f l u s h o r p i gta i l c a t h e t e r used for t h e a o rtog r a m o r a n
exch a n g e c a t h e t e r a d v a n c e d at l e a st to t h e fe m o r a l
b i f u rcat i o n .
• T h e s h eath t i p is p l aced somewhere betwee n m id - i l i a c
a rtery a n d t h e m i d - to d i sta l S FA, d e p e n d i n g o n l e s i o n
l ocat i o n a n d i ntervent i o n a l i ntenti o n . A 6-Fr sheath may
be a d e q u ate for this p u rpose, but 7 F r may be req u i re d
for m a ny d e v i c e s ( r e a d t h e package i nsert). The a n g i o­
p l a sty catheter l e n gt h for prox i m a l S FA l e s i o n s is 7 5 to
80 em; for m o re d i sta l lesio ns, 90 to 1 1 0 e m .
• Access to t h e d e e p f e m o r a l a rtery m a y be req u i re d to
s a f e l y a d v a n c e t h e " u p a n d ove r " s h e a t h ove r a stiff
exc h a n g e w i re ( e . g . , R o s e n ® ) . Aft e r f l u s h i n g a n d d i l a ­
t o r p l a c e m e nt, e n s u r e t h a t t h e s h e a t h s i d e a rm stop­
cock i s t u r n e d to t h e " off" p o s it i o n . T h e skin i n c i s i o n
m a y n e e d to b e e n l a rg e d to fa c i l itate p l a ce m e nt . C o n ­
s i d e r s e r i a l d i l at o r exch a n g e s w h e n u p s i z i n g a s h e a t h
by t w o o r m o re F r e n c h s i z e s . Occa s i o n a l ly, d e p e n d ­
i n g o n t h e a n g l e of t h e a o rt i c b i f u rcat i o n , s h e a t h
p l a c e m e n t m a y b e fa c i l itated by p a s sa g e ove r a stiff,
exc h a n g e l e n gt h h y d ro p h i l i c w i r e . W h e n u s i n g hy­
d ro p h i l i c w i res f o r t h i s p u rpose, c a r e s h o u l d a l ways
b e t a k e n to keep the tip of the w i re in the i m a g e
s c r e e n f i e l d to p revent i n a dve rt e n t a rte r i a l p u n ct u re
c o n f r o n t e d by ext r e m e t o r t u o s ity i n t h e i l i a c a rte r i a l
syst e m , i nte rva l a d v a n c e m e n t of t h e s h e a t h i nto t h e
i nte r n a l i l i a c a rt e ry m a y b e req u i re d to g a i n a ccess t o
t h e c o n t r a l at e r a l i l i a c a rt e ry w i t h a seco n d o r " b u d d y "
w i re, fo l l ow i n g w h i c h , sta n d a rd c a t h e t e r a n d g u i d e ­
w i r e tech n i q u e s m a y b e u s e d to a d v a n ce t h e s h e a t h to
its u lt i m a t e d e s i red l o c at i o n .
• Reg a rd l ess of p roced u re or a ccess a p p roach, it is a lways
a dvisa b l e to keep the w i re tip in the i m a g i n g f i e l d w h e n ­
rat i o n a n d extravasat i o n may l i m it proced u r a l options,
or t h e a b i l ity to i n itiate syste m i c a nticoa g u lation, a n d
may i n crease c o m p a rtment p ressu res to t h e p o i n t of re­
q u i ri n g s u rg i ca l release i f not recog n i zed and m a n a g e d
prom ptly.
Ipsilateral Approach
• See p r i o r reco m m e n d at i o n s for sec u r i n g a ccess (Ta b l e 1 ) .
cantly l i m it t h e use of this a p p ro a c h . B efore i n iti at­
i n g treatme nt, o bta i n a n g i o g ra p h i c d o c u m e ntat i o n of
exist i n g i p s i l atera l a n atomy, including i nfra p o p l itea l
r u n off.
• S h o rter g u id ewi res a n d devices i m p rove the eff i c i e ncy of
the i ps i latera l a ntegrade a p p ro a c h .
• If b a l l o o n a n g i o p l asty a l o n e is p l a n n e d , 4 - o r 5-Fr sheath
c a n be used to treat i p s i l a te ra l S FA l e s i o n s . M o re com­
p l ex reco nstruct i o n s req u i re 6 Fr and occa s i o n a l l y
7 - F r sheaths.
 C h a p t e r 30 PERCUTA N E O U S F E M O RAL-POPLITEAL RECONSTRUCT I O N TECH N I Q U E S 2075

Table 1: Approach: U p and Over o r Ipsilateral Antegrade

Approach Antegrade Up and Over Brachial

P u n cture M o re c h a l l e n g i n g S i m p l e retrograde femoral Retrog rade brach i a l
Catheterization Prox i m a l femoral p u ncture a n d sel ective C h a l le n g i n g with tortuous a rteries, C h a l l e n g i n g , l o n g d i stance, d iseased aorta
catheters d i seased bifurcation
Easy to cathete rize S FA
Catheter control Exce l l e n t Fa i r Fa i r
Catheter i nve ntory Minimal M o r e s u p p l ies, l o n g catheters Specific materia l , long sheaths, catheters
U p and over sheaths
I n d i cations l nfra p o p l itea l , fe moropopl ite a l d isease Prox i m a l S FA disease Proxi m a l S FA, fe moropopl iteal disease
Lim itati ons Obesity, C FA d i sease, proxi m a l S FA d isease Contra l atera l d i sease, bifurcation d isease Aortic d i sease, i nfra p o p l iteal d isease

SFA, superficial femoral artery; CFA, common femoral artery.

CROSSING OCCLUSIVE LESIONS G u i d ewire l e n gt h s va ry from 1 45 to 300 e m . For

• G u idewire-catheter ski l l s form the basis of a l l e n d ovascu­
lar p roced u res. S u ccessf u l g u idewire positi o n i n g req u i res
fa m i l i a rity with a ra n g e of devices and g u i d ew i re-catheter
p a i rings. The g u i d ewire req u i red for cross i n g the lesion
co u l d not be a d e q u ate for worki n g o r deploying a stent
o r a stent g raft. Fa m i l i a rity with and access to a wide se l ec­
t i o n of wi res (depen d i n g o n l e ngth, d i a m eter, tip p ressu re,
and hydro p h i l i c q u a l iti es) i s essential for success (FIG 9) .
• G u i dewire featu res to be co n s i d e r e d :
• Le n g t h : M ust be a d e q u ate to cover t h e c u m u l ative
d ista nce, both i n s i d e and outs i d e t h e patie nt, to
perform the proced u re a n d s u p po rt the catheter.
a n i ps i latera l a ntegrade a p p roach, 1 45- to 1 80-cm
g u i d ewi res a re a d e q u ate, but for contra lateral or
brach i a l access, 260- to 300-cm l e n gths a re neces­
sa ry. As a g e n e r a l r u l e of t h u m b, g u i dewire l e ngth
m ust be at l e a st twice that of t h e coax i a l device to
be posit i o n e d over t h e w i r e .
• D i a m eter: M ost femora l-po p l itea l p roced u res a re
pe rfo rmed with 0 . 0 3 5 - i n g u i dewi res, but s m a l l e r
ca l i be r a n g i o p l asty is g e n e ra l ly p e rformed with
0 . 0 1 8-in o r 0 .0 1 4- i n g u i d e w i res.
• Stiffness: An i n n e r ste e l core confers d i fferent m a g ­
n itudes of stiffness o n t h e shaft of t h e w i r e . A stiffe r
w i re may h e l p to cross a ca lcified l e s i o n , but it is

A B c D
FIG 9 • Cross i n g t h e l e s i o n . A. I n t h i s case, a critica l stenosis is crossed. T h e i m a g e intensifier is a n g u l ated to get t h e best v i ew of
t h e pathway t h r o u g h t h e l e s i o n . B. Typ i c a l ly, a hyd ro p h i l i c w i re with a d i rect i o n a l t i p is used a n d t h e w i re t i p is steered t h r o u g h
t h e l e s i o n . C. I n t h i s case, a n occ l u s i o n i s crossed u s i n g s u b i n t i m a l tech n i q u e . The g u i d e w i re i s advanced a n d i s s u p p o rted b y a
catheter with an a n g led t i p . D. The g u i d ew i re is p o i nted toward t h e a rte r i a l wa l l at t h e b eg i n n i n g of t h e l e s i o n a n d is poi nted
away from t h e co l l ateral that fi l l s t h e segment and i s near t h e l ocat i o n where t h e l e s i o n b e g i n s . The w i re i s p u s h e d u n t i l an
e l bow forms and enters t h e s u b i n t i m a l space. (con tinued)
2076 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY
E F
a l so e a s i e r to i nj u re t h e vesse ls. I n wi res specifi ca l ly
d e s i g n e d to cross femora l-po p l iteal l e s i o n s, t i p p res­
s u re may a lso v a ry across w i res with s i m i l a r stiffness
a l o n g t h e majority of t h e i r l e n g t h .
• Coat i n g : Hydro p h i l i c g u i dewi res may reduce t h e co­
effi c i e n t of frict i o n . Typ i ca l ly, t h ey a re passed in con­
j u nction with p u rpose-specific cross i n g catheters.
• Cross i n g cath eters s u p p o rt g u i d e w i re passa g e a n d , de­
p e n d i n g o n d e s i g n , confer va ry i n g d e g rees of s u p p o rt
B ALLOON ANGIOPLASTY
• The a n g i o p l asty p rocess e n l a rges t h e l u m e n by com­
press i n g a n d r u ptu r i n g t h e p l a q ue, a s we l l a s stretc h i n g
a n d , i n s o m e cases, d a m a g i n g t h e m e d i a a n d adventitia
(FIG 1 0) .
• H e p a r i n is typ i ca l ly a d m i n istered, 50 to 1 00 u n its/kg fo l ­
l ow i n g sheath p l a c e m e nt a n d p r i o r to i nterve n t i o n .
• The b a l l o o n l e n gt h a n d d i a m eter a re typica l ly s e l ected
to treat the e n t i re l e s i o n , with m i n i m a l p roxi m a l o r d i sta l
ove r l a p, to restore o r i g i n a l d i a m eter as dete r m i n e d by
proxi m a l or d i sta l m e a s u re m ent. The b a l l o o n catheter i s
posit i o n e d o v e r t h e g u i dewire a n d i nflated to n o m i n a l
p ress u re t o a c h i eve t h e specified d i a m eter. Occa s i o n ­
a l ly, h i g h e r p ressu res may be req u i red to r e d u c e l e s i o n
" w a i st i n g . "
• I n f l ate slow ly. B a l l oo n i nflation is m a i nta i n ed for
2 m i n utes.
FIG 9 • (contin ued) E. The l o o p is adva nced. The l o o p
is m a i nta i n ed i n a n a r row confi g u ration by s u p po rt i n g it
closely with t h e cath eter. F. After t h e l o o p pops i nto the
patent d ista l seg m e nt, t h e catheter i s adva nced. The w i re
is re m oved a n d contra st is a d m i n i stered to confirm t h e
l ocati o n o f t h e catheter t i p i n t h e t r u e l u m e n .
a n d d i rect i o n a l ity. After t h e g u i d e w i re i s used t o cross
the l e s i o n , the catheter may be advanced so that t h e
cho ice wo r k i n g w i re may be p l aced . Cross i n g catheter
tech n o l ogy h a s a dvanced considerably in t h e l a st 5 to
1 0 yea rs. Options a b o u n d for tors i o n a l ity (bra i d ed or
u n b ra i d ed), tip taper, tip s h a pe, l e n gth, and d i a m eter.
Exa m p les i n c l u d e t h e Q u ick-Cross® a n d CTX® catheter
fa m i l i es. Some expe r i e nce i s req u i red to learn how to use
t h ese cath eters opti m a l l y i n m ost situations.
• Defl ate slow ly, a n d e n s u re fu l l deflation f l u o rosco p i ca l ly
before withd rawa l .
• T h e b a l l o o n a n g i o p l a sty catheter m a y be used repeat­
e d l y d u r i n g the s a m e proced u re; h owever, its capacity to
recover the p rede p l oyment d i a m eter fo l l ow i n g deflation
d e g ra d e s with seq u e n t i a l use.
• B a l l o o n d i a m eters r a n g e from 4 to 7 m m for t h e S FA and
3 to 6 m m i n t h e p o p l itea l a rtery.
• Conve n ti o n a l a n g i o p l asty is l i m ited somewhat by ta rget
a rtery d i ssect i o n . Not a l l d i ssect i o n s need fu rth e r treat­
m e nt. In g e n e r a l , o n ly flow- l i m it i n g d i ssect i o n s as j u d g ed
by seq u e n t i a l contra st i nject i o n s t h r o u g h t h e i nte rve n ­
t i o n a l sheath need a d d i t i o n a l t r e a t m e n t . D i ssect i o n s
may be m a n a g e d by p r o l o n g e d periods o f i nflation f o l ­
l owed by g r a d u a l d e f l a t i o n to " t a c k " t h e p l a q u e u p t o
t h e a rte r i a l wa l l . Persistent flow obstruction fo l l ow i n g
a n g i o p l asty i s t h e m ost co m m o n i n d icat i o n for su bse­
q u e nt seco n d a ry ste nti n g .
 C h a p t e r 30 PERCUTA N E O U S F E M O RAL-POPLITEAL RECONSTRUCT I O N TECH N I Q U E S 2077

A B c D E
FIG 1 0 • B a l l o o n a n g i o p l asty. A. The b a l l o o n catheter is adva n ced over t h e g u i d e w i re a n d i nto t h e lesio n . If poss i b l e, a n
a n g i o p la sty b a l l o o n is sel ected that i s a b l e t o treat t h e w h o l e l e s i o n l e n gth with a s i n g l e i nflati o n . B. T h e ba l l oo n i s i nfl ated a n d
t h i s i s observed u s i n g f l u o rosco py. A t very l ow p ressu re, t h e b a l l o o n w i l l i n f l ate freely i n t h e l ocat i o n s w h e r e t h e re is m i n i m a l
o r n o i m p i n g e m e n t o f t h e l e s i o n o n t h e b a l l o o n . C . U s u a l l y with 2 a t m o f pressu re, t h e waist o n t h e b a l loon becomes a p p a rent
and t h e l e s i o n beg i n s to y i e l d to t h e outward force exerted by t h e b a l l o o n . D. The b a l l o o n is i nfl ated g r a d u a l ly. T h i s h e l ps
to avo i d d e l ive r i n g m o re pressure to t h e a rtery t h a n is req u i re d . T h i s a lso a l l ows t h e l e s i o n to g ra d u a l ly g ive way. At h i g h e r
p ressu re, t h e waist becomes s m a l l e r. E. Press u re i n t h e b a l l o o n is g ra d u a l ly i ncreased u n t i l t h e ba l l oo n reaches its fu l l d i a m eter.
The ba l l oo n is typ i ca l ly i nfl ated for 2 to 3 m i n utes in situati o n s where t h e o p e rator is h o p i n g to use a n g i o p l asty as sta n d - a l o n e
t h e ra py.

STENTS
• Altho u g h a l l vascu l a r-compatib le, size-a ppropri ate, self­
expa n d i n g (nitinol) stents may be d e p loyed in the super-
ficial femora l or popl itea l a rteries as c l i n ica l l y i n d icated,
sel ect d evices h ave o bta i ned specific i n d ications for t h i s
a p p l icat i o n f r o m the U . S . F o o d a n d Drug Ad m i n istrat i o n .
The operator i s encouraged to fa m i l i a rize h i mself o r h e r-
self with t h i s designation a n d to use a p p l i cation-a p p roved
d evices whenever a p p ropriate to e n s u re opti m a l outcom e .
• Mate r i a l a n d c h a ra cte r i stics of peri p h e ra l stents have
evolved in recent yea rs. Self-exp a n d i n g n it i n o l ste nts a re
m ost a p p ro p r i ate for S FA a n d p o p l it e a l a p p l i cations. The
ideal ste nt should h a ve t h e a b i l ity to a d a pt to t h e vesse l
with a precise d e p l oyment a n d without k i n ki n g , co l l a ps-
i n g , o r fract u r i n g as we l l as l i m it l o n g-term a rte r i a l i nj u ry
a n d restenosis. M o re recently, d r u g - e l u t i n g stents have
been deve l o ped and a re a p p roved for use in t h e U n ited
States to l i m it c h r o n i c restenosis of the ste nt a rte r i a l
s e g m e n t fo l l ow i n g d e p l oyment. The pote nti a l c l i n i c a l
b e n efits d erived f r o m these d e v i c e s a re offset to a s i g ­
n ificant deg ree by t h e i r s u bsta nti a l i n c rease i n cost over
" ba re m eta l " ste nts.
• F e m o ra l-popl itea l stents may be p l aced routi n e l y o r se­
lectively. S e l ective ste nt p l acement may be c o n s i d e red
for s i g n ificant posta n g i o p l a sty d issect i o n , long l e s i o n s
(> 1 5 em), res i d u a l ste nosis posta n g i o p l a sty, p ress u re g ra ­
d i ent (> 1 0 m m H g ) after a n g i o p l a sty, r e c u r r e n t ste nosis,
occl u s i o n , or to prevent or l i m it posta n g i o p l asty e m b o l i ­
zati o n of p l a q u e .
• Loca l izati o n : A ste nt i s typ i ca l ly d e p l oyed to s p a n t h e
d i stance betwee n relatively hea lthy a rtery proxi m a l a n d
d ista l to t h e ta rget les i o n . " H e a lthy" i s a re l ative t e r m
i n t h i s s e n s e , a n d care s h o u l d be taken to l i m it ste nt
cove rage to t h e m i n i m a l d i stance req u i red to a c h i eve an
opti m a l res u lt. Long l e s i o n s in t h e S FA a re the m ost com­
m o n ly ste nted seg m e nt, but be aware that stents in the
d i st a l s u perfi c i a l femora l and p o p l itea l a rteries may be
d a m aged by stress from knee flexion (FIG 1 1 ) . Excessive
2078 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

A c D

FIG 1 1 • Stent p l acement. A. The patient represented by these

I
a rte r i o g r a m s p resented with a right foot Rutherford 5 g a n g re n e .
.
Arte r i o g r a p h y d e m o n strated seve r a l m i d-SFA ste noses. B. The d i sta l S FA
a n d p roxi m a l to m i d - p o p l itea l a rteries were occ l u d e d . C. T h e SFA ste noses
were treated with b a l l o o n a n g i o p l asty and t h e s h eath was adva n ced
d i sta l ly so that its tip was c l ose to t h e occl u s i o n . D. A c h r o n i c tota l
occ l u s i o n (CTO) catheter is used to s u p p o rt t h e g u i d ew i re in cross i n g t h e
l e s i o n a n d t h e l ocat i o n i n t h e t r u e l u m e n i s confi r m e d . E. After ba l l oo n
a n g io p l a sty, t h e re w a s a s i g n ificant d issect i o n a n d resi d u a l ste nosis. F. A
self-expa n d i n g n i t i n o l ste nt was p l a ced fo r mech a n i c a l s u p po rt of t h e
E F a rte r i a l wa l l a n d to e n h a nce i m m ed i ate patency of t h e reconst r u ct i o n .

stent cove rage may acce l e rate l o n g -term restenosis a n d
l u m i n a l comprom ise, reg a r d l ess o f t h e d e g ree of i n it i a l
success o r t h e type o r size of d e p l oyed ste nt.
• Sheath size: M ost stents for i nfra i n g u i n a l d e p l oyment
req u i re a 6- o r 7-Fr sheath. Refer to t h e i n d iv i d u a l i n st r u c-
t i o n s for use for each i n d iv i d u a l device.
• D e p l oyment: M ost infra i n g u i n a l n i t i n o l ste nts a re de­
p l oyed using a pin and p u l l m a n euver that retracts the
cover from t h e constra i n e d stent a n d the u n derlying man­
d r e l . A ratchet i n g mech a n ism may a lso be i nteg rated i nto
the d e p l oyment p rocess. Typ i c a l ly, these may be removed
for basic p i n/p u l l d e p l oyment if the ratch et becomes
j a m med o r d is a b l e d . After d e p l oyme nt, comp letion
a n g i o p l asty is perfo rmed to bring the stent to p rofi l e .
• Co m p l icat i o n s of stent d e p l oy m e nt:
• Acute: a rte r i a l d i ssect i o n , occ l u s i o n , r u ptu re, ste nt
m i g ration o r e m b o l ization, e m b o l i zation of athe ro­
s c l e rotic mate r i a l , t h ro m bosis
• Chronic: intimal hyperplasia, recu rrent ste n os i s,
i nfect i o n , ste nt d a m a g e , t h ro m bosis

STENT GRAFTS t h e p roce d u re is we l l u n d e rway. Agg ressive pred i l ata­

• N it i n o l -based, flexi b l e ste nt g rafts may be d e p l oyed ove r
l o n g a n d ca l cified S FA l e s i o n s as an a ltern ative to bare
m eta l o r d r u g -e l ut i n g ste nts. As a general rule of t h u m b,
t h e l o n g e r a n d m o re co m p l ex t h e ta rget l e s i o n (s) a n d
l e n gth o f req u i red cove rage, t h e m o re s u i ta b l e t h e i n d i -
cat i o n for covered stent p l acement.
• Stent g raft i n g may req u i re exc h a n g e of a 0.035-in wire
system for s m a l l e r g u i d ewi res (e.g., 0.025 i n o r 0.0 1 8 i n);
the operator is a g a i n cautioned to refe r to the i nstruc­
tions for use for each device co nsidered for p l acement.
Stent g rafts m ust be d e p l oyed ove r the specific g u ide­
w i re a d e q u ate for the ste nt g raft. S h eath u ps i z i n g may
a lso be req u i red, d e pe n d i n g on t h e d i a meter sel ected .
Choos i n g a l a rg e r s h eath a t t h e outset w i l l m i n i m ize the
need for awkwa rd o r i n efficient sheath exch a n g e after
tion i s a lso often necessa ry in order to create suffi cient
space for bulkier covered ste nt to pass the lesion prior to
d e p l oyme nt. S i m i l a r to ba re metal stents, covered stent
d e p l oyment i s u s u a l l y fo l l owed by co m p l etion a n g i o p l asty
to b r i n g the covered l u m e n to prof i l e (FIG 1 2) .
• R e l ative advantages o f ste nt g raft i n g , compa red to b a re
meta l stents, i n c l u d e t h e a b i l ity to create an e n t i re l y
new l i n i n g for a d isease a rte r i a l segment. T h i s cover­
age obviates the poss i b i l ity of i n -ste nt stenosis with i n
t h e g raft. H owever, experience h a s s h ow n t h a t u n l i ke
s u r g i ca l ly p l aced p rosthetic bypass g rafts, covered stents
in the s u p e rfi c i a l fe m o ra l and p o p l itea l a rteries tend to
i n cite reste nosis at the p roxi m a l e n d . Th u s, p l acement
u s u a l l y req u i res coverage u p to t h e o r i g i n of t h e S FA. Any
u n covered a rtery i n this reg i o n i s l i ke l y to deve l o p critica l
reste nosis. D i sadvantages i n c l u d e t h e n ecessa ry coverage
 C h a p t e r 30 PERCUTA N E O U S F E M O RAL-POPLITEAL RECONSTRUCT I O N TECH N I Q U E S 2079

A B c D

E F G H
FIG 1 2 • Stent g raft. A. T h i s patient h a s a l o n g S FA occ l u s i o n that was re l i ned with Vi a b a h n ® ste nt g raft. An a o rto i l i a c
a rte r i o g r a m was pe rfo rmed u s i n g contra l atera l access. B. T h e l eft S FA i s occ l u d e d . There i s a p a t e n t prox i m a l stu m p of S FA .
C. The p o i n t of reconstitution is t h e a bove-the-knee p o p l itea l a rte ry. D. The proxi m a l p o p l itea l a rte ry, exte n d i n g to t h e knee,
i s d iffusely d isease d . E,F. After reca n a l ization a n d a g g ressive ba l l oo n a ng io p l a sty, t h e a rtery is reco nstructed with Vi a b a h n ®
ste nt g raft p l a c e m e nt . G , H . The d ista l e n d o f the g raft i s fu l ly d i l ated a n d without f l o w l i m itation i n t h e stra i g h t leg a n d bent
knee positi o n s .

of a l l co l l atera l vesse l s encom passed i n t h e cove red s e g ­
m ent, as we l l as t h e i ncreased risk for g raft i nfect i o n
i n h erent i n fa b r i c-cove red m eta l ste nts. Al so, a l t h o u g h
some ste nt g rafts a re h e p a r i n-bonded, t h e t h ro m boge­
n i c ity of covered stents va ries d i rectly with t h e l e n gth of
seg m e nt cove red, such that co m p l ete S FA cove rage from
t h e o ri g i n to t h e a d d u ctor ca n a l n ecessitates l o n g -term
o r a l a nticoa g u lation t h e ra py i n patients treated i n o u r
practice. Anticoa g u l a t i o n i n t h i s c i r c u m stance i s d e s i g n e d
to l i m it t h r o m b u s exte n s i o n fo l l ow i n g f u t u r e g raft oc­
c l u s i o n rat h e r t h a n i n creas i n g l o n g -term g raft patency.
Anticoa g u l a t i o n does n ot typica l ly extend prosthetic
g raft patency i n t h e lower extremity, reg a r d l ess of open
o r e n d ovasc u l a r p l a c e m e nt .

PEARLS AND PITFALLS

I n d icat i o n s
Arte ry p u nctu re
Specific mate r i a l
Cross i n g t h e l e s i o n
C l o s u re
A com p l ete vascu l a r h i story is esse n t i a l to accu rate ly co nfirm t h e d i a g nosis. O bj ective e v i d e n c e o f isch e m i a i s
req u i red to j u stify i nte rvention a n d to prov i d e a base l i n e for f u t u r e co m p a ri s o n .
T h e p u nctu re is p l a n n e d p r i o r to t h e p roced u re . Access site issues a re t h e m ost co m m o n type of
co m p l icat i o n . A w e l l - p e rformed access w i l l set the p roced u re up for su ccess.
In p l a n n i n g the procedu re, check to m a ke s u re that all the n ecessa ry i nventory is ava i l a b l e prior to the proced u re .
Do n ot force t h e w i re a cross t h e l e s i o n .
C l o s u re d e v i c e s c a n s i m p l ify t h e proced u re a n d a l l ow for m o re patient comfort a n d e a r l i e r d i sc h a rge, b u t
accu rate CFA access s h o u l d be co nfirmed, typica l l y at t h e o utset of t h e proced u re, before therapeutic
sheaths a re p l aced .

F o l l ow-u p The patient is eva l u ated after the p roce d u re at 1 week a n d 1 month a n d then 6-month i nterva ls afte r that. We
typica l ly obta i n some assessment of perfusion (AB I ) . D u p lex m a p p i n g may a lso be perfo rmed for s u rve i l l a nce.
2080 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

POSTOPERATIVE CARE
• The patient should remain at bedrest for at least 6 hours
after the procedure. After use of a closure device, usually
2 hours of bedrest is required.
• Puncture site management: Obtaining hemostasis is made
safer and simpler when the arteriotomy site is carefully man­
aged during the procedure. Ensure the patient is comfortable
prior to removing the sheath.
• Holding pressure: After ipsilateral antegrade puncture, use
two hands to hold pressure, one is placed proximal to the
inguinal ligament to apply pressure over distal external
iliac artery to decrease the pressure flowing through the
puncture. The other hand applies pressure over the area of FIG 13 • Co m p l icat i o n s . H e m atoma i s the more com m o n access
arterial puncture j ust distal to the inguinal ligament. There site co m p l i cation and m ost com m o n co m p l icat i o n of e n d ovasc u l a r
are no approved closure devices for antegrade puncture. proced u res.
Following a retrograde puncture, digital pressure is held
at the location of arteriotomy, proximal to the skin punc­
ture site.
should incorporate a full range of postprocedural out­
• Closure devices: Closure devices are used whenever possible
comes, beyond arterial patency alone, in the assessment
to reduce risk of access site complications and limit patient
of procedural success. As such, consideration to postop­
immobility following the procedure. Newer generations of
erative ambulatory status, potential for independent liv­
closure devices are easier to use and are considered a good
ing, wound care requirements, and pain management is
option for closing the arteriotomy in puncture procedures
essential and comparable to the impact on graft patency
for 6 Fr and larger.
on long-term patient satisfaction and quality of life?
• The patient should be encouraged to
• A comparison of self-expandable stents versus femoral­
Avoid smoking
popliteal above-the-knee bypass had been published by
Walk daily
Kedora et a!., reporting similar limb salvage, with compara­
Follow best medical treatment
ble primary ( 73 . 5 % vs. 74.2 % ) and secondary patency rates
Follow-up with the vascular clinic
( 8 3 . 9 % vs. 8 3 . 7 % ) at 1 year with both techniques.8
• Others studies reported that despite the reduced primary
OUTCOMES
patency, limb salvage rates remain comparable to surgi­
• Patients with peripheral artery disease (PAD ) and critical cal bypass and range from 74% at 5 years to 8 4 . 7 % at
limb ischemia ( CLI) have a shorter life expectancy than the 8 years. 9
general population. The most effective method of revascu­ • Lower limb revascularization of diabetic patients affected by
larization that returns patients to their premorbid func­ intermittent claudication, in addition to improved walking
tional state in the shortest period of time, with the least performance, is associated with a reduction in the incidence
amount of surgical risk, is considered ideal. In this regard, of future major cardiovascular events when accompanied by
most centers have adopted a percutaneous-first approach increased physical exercise and improved glucose manage­
to lower extremity revascularization, when intervention is ment and weight control. 1 0
indicated.5 This rubric reserves open surgical reconstruc­
tion for patients who fail percutaneous intervention. More COMPLICATIONS
recently, controversy has arisen as to how many unsuc­
• Artery puncture: hematoma, occlusion, dissection, pseudo­
cessful secondary interventions constitute " failure . "
• Successful percutaneous revascularization i s considered aneurysm, arteriovenous fistula ( FIG 1 3 )
• Failure of recanalization: intimal dissection, branch oc­
equivalent to traditional standard management strat­
egy-that is, bypass surgery-in providing freedom from clusion, thrombosis, embolization, vessel rupture, remote
major and minor amputation, in patients with severe limb hemorrhage
• Stent/stent graft complications: stent embolization, stent will
ischemia, up to 2 years following revascularization. To
date, the Bypass versus Angioplasty in Severe Ischemia not expand lesion, stent kink, stent thrombosis
• Infection
of the Leg ( BASIL) trial remains the only randomized
prospective trial comparing the success of open surgical
bypass versus endovascular therapy for CLI. When life REFERENCES
expectancy extends beyond 2 years, bypass patency is 1. Hirsch AT, Haskal ZJ, Herrzer NR, et al. ACC/AHA 2005 guidelines
superior. 6 for the management of patients with peripheral arterial disease (lower
• Although percutaneous transluminal angioplasty (PTA) extremity, renal, mesenteric, and abdominal aortic): executive sum­
mary a collaborative report from the American Association for Vas­
provides superior limb salvage rate and assisted patency
cular Surgery/Society for Vascular Surgery, Society for Cardiovascular
rates than prosthetic bypass, care should be taken to avoid
Angiography and Interventions, Society for Vascular Medicine and
outcomes that limit future bypass options ( e . g . , inj ury or Biology, Society of lnterventional Radiology, and the ACC/AHA Task
occlusion of significant infrageniculate arteries that could Force on Practice Guidelines (writing committee to develop guidelines
serve as future bypass targets ) . Modern surgical practice for the management of patients with peripheral arterial disease) en-
 C h a p t e r 30 PERCUTA N E O U S F E M O RAL-POPLITEAL RECONSTRUCT I O N TECH N I Q U E S
dorsed b y the American Association of Cardiovascular and Pulmonary
Rehabilitation; National Heart, Lung, and Blood Institute; Society for
Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascu­
lar Disease Foundation. 1 Am Coil Cardiol. 2006;47:1239-1312.
2. Faglia E, Dalla Paola L, Clerici G, et al. Peripheral angio-plasry as the
first-choice revascularization procedure in diabetic patients with criti­
cal limb ischemia: prospective study of 993 consecutive patients hos­
pitalized and followed between 1999 and 2003. Eur 1 Vase Endovasc
Surg. 2005;29:620-627.
3. Norgren L, Hiatt WR, Dormandy JA, et al. lnter-Sociery Consensus
for the Management of Peripheral Arterial Disease (TASC II). ] Vase
Surg. 2007;45(suppl S):S5-S67.
4. Issack PS, Cunningham ME, Pumberger M, et al. Degenerative lumbar
spinal stenosis: evaluation and management. J Am Acad Orthop Surg.
2012;20(8):527-535.
5. Giugliano G, Perrino C, Schiano V, et al. Endovascular treatment of
lower extremity arteries is associated with an improved outcome in
diabetic patients affected by intermittent claudication. BMC Surg.
2012;12(suppl 1):S19.
2081
6. Nice C, Timmons G, Bartholemew P, et al. Retrograde vs. antegrade
puncture for infra-inguinal angioplasty. Cardiovasc Intervent Radio/.
2003;26:370-374.
7. Adam DJ, Beard JD, Cleveland T. Bypass versus angioplasty in severe
ischaemia of the leg (BASIL): multicentre, randomised controlled trial.
L ancet. 2005;366:1925-1934.
8. Kedora J, Hohmann S, Garrett W, et al. Randomized comparison of
percutaneous Viabahn stent grafts vs. prosthetic femoral-popliteal
bypass in the treatment of superficial femoral arterial occlusive dis­
ease. 1 Vase Surg. 2007;45:10-16.
9. Houbballah R, Raux M, LaMuraglia G. Trans-Atlantic debate: lower
extremity bypass versus endovascular therapy for young patients
with symptomatic peripheral arterial disease. Part two: against the
motion. Endovascular therapy is the preferred treatment for patients
< 65 years old with symptomatic infrainguinal arterial disease. Eur 1
Vase Endovasc Surg. 2012;44:116-119.
10. Conrad MF, Crawford RS, Hackney LA, et al. Endovascular
management of patients with critical limb ischemia. 1 Vase Surg.
2011;53:1020-1025.
 -

Chapter 31 Maximizing Vein Conduit for

Autogenous Bypass
r

·
r

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ·

Gregory J. La n dry
t

DEFINITION Alternative imaging modalities include computed tomog­

• Autogenous conduit is preferred for all lower extremity by­
passes when available. The greater saphenous vein ( GSV) is
the most frequently used conduit. Other options for native
conduit include the short saphenous vein, arm vein ( basilic,
cephalic, brachial) , and femoral vein.
DIFFERENTIAL DIAGNOSIS
• The majority of patients for whom autogenous vein bypass
is necessary will have atherosclerotic peripheral vascular
disease.
• Other conditions for which autogenous vein bypass may
be necessary include aneurysms (e.g., femoral, popliteal) ,
trauma, and vasculitis.
PATIENT HISTORY AND PHYSICAL
FINDINGS
• A history of cardiovascular risk factors should be elicited
in all patients undergoing lower extremity bypass, including
smoking history and history of cardiac and cerebrovascular
disease and history of diabetes, chronic kidney disease, hy­
perlipidemia, and chronic obstructive pulmonary disease.
• Upper and lower extremity pulse exam should be performed.
Because atherosclerosis is a systemic disorder, the following
pulses should be assessed bilaterally: carotid, brachial, ra­
dial, femoral, popliteal, dorsalis pedis, and posterior tibial.
Both the presence and strength of pulses should be recorded.
• If lower extremity pulses are absent, which is usually the case
in patients undergoing surgery for peripheral vascular dis­
ease, ankle-brachial indices should be measured. The high­
est ankle pressure is divided by the highest brachial pressure.
• Lower extremities should be evaluated for the presence of
ulcerations or gangrene.
• A history of prior vein use or removal should be elicited. Veins
may have previously been used for prior lower extremity or
coronary artery bypass. Patients with varicose veins may have
undergone prior vein stripping or ablation. Patients with
chronic kidney disease may have had prior upper extremity
arteriovenous fistula placement. In dialysis-dependent
patients, upper extremity veins should be used j udiciously as
they may be necessary for future arteriovenous access.
IMAGING AND OTHER DIAGNOSTIC
STUDIES
• All patients considered for lower extremity bypass should
undergo arteriography to define the proximal (inflow) and
distal (outflow) targets.
Digital subtraction angiography remains the gold stan­
dard and provides the greatest anatomic detail for opera­
tive planning.
raphy ( CT) and magnetic resonance (MR) angiography or
duplex ultrasonography.
• Duplex ultrasonography should be used for preopera­
tive vein mapping to identify suitable autogenous conduit
( FIG 1 ) . If the patient has good-quality GSV, no further vein
mapping is typically necessary. If the GSV is of poor qual­
ity or absent, small saphenous vein and arm vein should be
mapped ( FIG 2 ) .
Ideal conduit diameter i s 3 . 5 m m o r greater.
Vein should be easily compressible. Thick-walled
or noncompressible vein indicates prior superficial
venous thrombosis and vein is likely not suitable for
bypass.
Mapping should ideally immediately precede surgery with
vein course marked with an indelible marker on the skin.
This allows precise placement of incisions, which avoids
the creation of skin and tissue flaps that might impede
wound healing.
SURGICAL MANAGEMENT
• Preoperative planning
If not previously marked or if marks have faded, it is
useful to remark the intended venous conduit with ultra­
sound guidance prior to surgery (FIGS 3 and 4) .
Open foot lesions o r gangrene should be covered with
sterile adhesive to prevent contamination of sterile
incisions.
Prophylactic intravenous antibiotics should be adminis­
tered to reduce risk of perioperative infection.
Common femoral vein
Deep femoral G reater saphenous
vein vein
G iacom i n i vein
Small saphenous vein
FIG 1 • Lower extrem ity venous a n atomy.

2082
 C h a pt e r 3 1 MAXI M I Z I N G V E I N C O N D U I T FOR AUTO G E N O U S BYPASS
Cephalic vein
FIG 2 • U pp e r extremity ve n o u s a n atomy.
• O p e n v e i n h a rvest: GSV
• A l o n g it u d i n a l i n c i s i o n is m a d e d i rectly ove r t h e
m a rked ve i n . E it h e r a s i n g l e i n c i s i o n o r m u lt i p l e s k i p
i n c i s i o n s can be u s e d , with some e v i d e n c e of fewer
wo u n d i nfect i o n s with the l atter a p proach (FIG S).
• The necess a ry l e n gth of ve i n is u n roofe d . U s i n g
b l u nt a n d s h a r p d i ssect i o n w i t h M etze n b a u m scis­
so rs, t h e ve i n i s freed from su rrou n d i n g struct u res.
Side branches a re l i g ated and d iv i d e d with s i l k l i g a ­
tu res a n d h e m oc l i ps.
• The G SV is d ivided proxi m a l ly at t h e s a p h e n ofemo­
ra l j u nction (FIG 6), d i sta l ly accord i n g to t h e l e ngth
of v e i n needed.
FIG S • O p e n G S V h a rvest t h r o u g h s k i p i nc i s i o n s . T h e ve i n i s
e n c i rc l e d w i t h s i l a st i c vesse l loops.
2083
FIG 3 • Lower extrem ity ve i n m a p p i n g with m a rk i n g of G SV.
If arm vein is to be harvested, it is important to avoid
blood draws or intravenous lines in the intended arm ( s ) . If
veins from both arms are necessary, central venous access
may be necessary.
• Positioning
The maj ority of the procedures are performed with the pa­
tient supine. If small saphenous vein is the intended con­
duit, it is often easier to perform this part of the procedure
with the patient prone and then to reprepare and drape
with the patient supine.
If arm vein is to be harvested, the arms should be abducted
and placed on arm boards.
FIG 4 • U pp e r extrem ity ve i n m a p p i n g with m a rk i n g of the
ce p h a l i c and bas i l i c ve i n s .
• It is h e l pf u l d ista l ly to i d e ntify a b r a n c h p o i n t i n the
ve i n that ca n su bse q u ently be used for t h e p roxi m a l
a na stomosis if t h e g raft i s p l aced i n reversed con­
fig u ration (FIG 7A,B) .
• O p e n ve i n h a rvest: s m a l l sa p h e n o u s ve i n
• The s a m e tech n i q u e is used as fo r t h e GSV, except
typ i ca l ly with the patient prone.
• Prox i m a l ly, t h e ve i n is typica l l y d ivided at t h e s a p h e­
n o p o p l itea l j u n ct i o n . Some patie nts w i l l have con­
t i n u a t i o n of t h e s m a l l sa p h e n o u s v e i n i n t h e t h i g h
(G iacom i n i ve i n ) w h i c h a l l ows h a rvest i n g a d d i t i o n a l
l e n gth of ve i n i n t h e t h i g h .
FIG 6 • G SV m o b i l ized p roxi m a l l y to saphe nofemoral j u ncti o n .
S i d e branches l i gated w i t h s i l k l i g atu res.
2084 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY
A d i ssection, this n e rve ca n be preserved (FIG 9) .
B •
FIG 7 • A.B. D ista l G SV d ivided at b r a n c h p o i n t to p rovi d e
sta rt i n g s p o t f o r prox i m a l a na sto mosis of reversed ve i n g raft.
• O p e n ve i n h a rvest: a r m ve i n
• Both t h e cep h a l ic a n d basi l i c v e i n s c a n be h a rvested
t h r o u g h l o n g it u d i n a l arm i nc i s i o n s . The s a m e tech­
n i q u e is used a s for l e g ve i n ; h owever, care m u st be
taken as t h e a r m ve i n s tend to be m o re thin wa l l ed
and fra g i l e t h a n l e g ve i n .
• The ce p h a l i c ve i n ca n freq uently be h a rvested as a
s i n g l e co n d u it from t h e wrist to t h e d e ltopecto r a l
g roove (FIG SA-C) . A s i n g l e segment is freq uently
a d e q u ate for a femora l-po p l itea l o r fe m o ra l to
p roxi m a l t i b i a l bypass.
• The basi l i c vei n tends to be larger i n d i a mete r than the
cep h a l i c ve i n , a lt h o u g h often, only a short segment
i n the u pper a rm is ava i l a b l e . The basi l i c ve i n i s wel l
FIG 8 • A. Cep h a l ic v e i n h a rvested t h e
fu l l l e n gth of t h e a r m with s k i n b r i d g e a t
a ntec u b i t a l fossa . B. U p p e r a r m cepha l i c
ve i n . C. Cepha l i c ve i n h a rvested m e d i a l l y t o
d e ltopecto r a l g roove. B c
su ited for use as an exte nsion g raft when revision of
a previously p laced bypass i s n ecessa ry. When used as
a new bypass, a com posite g raft com posed of two o r
m o re vei n seg m ents is freq u e ntly necessa ry.
• The basi l i c vei n often has l a rg e branches that com m u ­
n i cate m e d i a l l y w i t h the brach i a l vei n . These branches
a re often broad based a n d a re bette r l igated with a
r u n n i n g m onofi l a ment sutu re t h a n s i m p l e l i g at i o n .
• The m e d i a n a ntebrach i a l cuta neous n e rve freq uently
i nterd i g itates with the basi l i c ve i n . With meticu l o u s
• B rach i a l ve i n i s i nti mately associated w i t h both t h e
brach i a l a rtery a n d m e d i a n n e rve. T h i s ve i n can a l so
be h a rvested as co n d u it, but g reat care needs to be
taken to avo i d i nj u ry to adjacent structu res (FIG 1 0) .
O p e n h a rvest: fe m o ra l ve i n
• Alth o u g h typica l ly used for l a rg e r vesse l reconstruc­
tion, fe m o ra l vein ca n be used for a utog e n o u s lower
extrem ity bypass if n ecessa ry.
• Proxi m a l fem o ra l ve i n is h a rvested m e d i a l to S a rto-
r i u s m usc l e . Ve i n i s adjacent to s u perfi c i a l fe m o r a l
a rte ry. Ve i n can be h a rvested p roxi m a l ly u p to t h e
p rofu n d a fem o ra l ve i n .
• D i sta l l y, t h e fe m o r a l ve i n is e a s i e r to h a rvest with
t h e S a rto r i u s m uscle reflected poste r i o rly. The ve i n
c a n e a s i l y b e h a rvested as fa r as t h e a d d u ctor ca n a l .
• If a longer seg m e nt is needed, the ve i n can be further
ha rvested ca u d a l to the add uctor tendon i nto the
popl iteal fossa .
• E n d osco p i c h a rvest: G SV
• E n d osco p i c h a rvest works best for ve i n s with i n
t h e sa p h e n o u s fasc i a l envelope (FIG 1 1 A) . It i s
tech n i c a l l y m o re d iffi c u l t i n c a s e s where t h e v e i n
l eaves t h i s fasci a l envelope a n d i s situ ated more
 C h a pt e r 3 1 MAXI M I Z I N G V E I N C O N D U I T FOR AUTO G E N O U S BYPASS 2085

FIG 9 • B a s i l i c ve i n h a rvested i n u p pe r arm. M e d i a n

a ntebrach i a l cuta n e o u s n e rve adjacent to a n d i nterd i g itati n g
with ve i n .

B
FIG 1 1 • A. G SV (ma rked by cursors) with i n t h e sa p h e n o u s
fasc i a l e n v e l o p e s u ita b l e f o r e n d osco p i c ve i n h a rvest.
B. S u bcuta n e o u s G SV outside of sa p h e n o u s fasc i a l enve l o pe,
less s u i ta b l e for e n d oscopic h a rvest.

FIG 10 • B rach i a l ve i n h a rvest with ve i n adjacent t o m e d i a n

n e rve. B rach i a l a rtery d e e p to n e rve.

su p e rfi c i a l ly o r i n t h e s u bcuta n e o u s fatty tissue

(FIG 1 1 B) .
• Ava i l a b l e h a rvest i n g systems a re described in Ta b l e 1 .
• A 2-cm i n c i s i o n is m a d e at t h e l evel of the knee a n d
t h e G SV d issected free at t h i s site a n d e n c i rcled with
a s i l astic vesse l l o o p (FIG 1 2) . FIG 12 • A 2-cm incision at the level of the knee t h r o u g h
• The vei n is d issected from the knee to the saphenofem­ which G SV (enci rcled w i t h s i l astic loop) d i ssected f o r e n d osco p i c
oral j u nction using a conical dissecting tip (FIG 1 3). C02 ha rvest.
i nsufflation is performed through a n i nflata b l e troca r.
• The ve i n is h e l d i n p l a ce with t h e C-r i n g or V-lock
mech a n ism a n d s i d e b r a n c h es a re d iv i d e d with bi­
polar e l ectroca utery o r h a rm o n i c scissors d e p e n d i n g
o n t h e m a n ufact u r e r (FIG 1 4) .
• H a rvest i n g can a lso be performed in the calf; however,
t h i s is more techn ica l ly cha l l e n g i n g d u e to m u lt i p l e
genicu late venous branches, s u bcuta neous position o f
vei n , a n d close a p p roxi mation w i t h sa phenous n e rve.
• If an i n c i s i o n i n t h e g ro i n is g o i n g to be m a d e for
t h e p roxi m a l a n asto mosis of the g raft, the i n c i s i o n
c a n be m a d e at t h i s p o i n t to co m p l ete t h e prox i m a l
h a rvest. If a n i n c i s i o n i s n ot g o i n g to be m a d e i n t h e FIG 13 • C o n i ca l d i ssect i n g tool m o u nted o n c a m e ra used
g r o i n , a sta b i n c i s i o n i s m a d e i n t h e g r o i n a n d t h e to i s o l ate G SV. O p e rator sta n d i n g o p posite screen d e p icti n g
ve i n g rasped u n d e r d i rect v i s i o n with a tonsi l c l a m p . e n d osco p i c i m a g e .

Table 1 : Endoscopic Vein Harvesting Systems

Manufacturer Device Dissecting Tool Vein Securing Side Branch Ligation

M a q uet Vasoview Conical tip C·ring Bipolar l i gating forceps

M a q uet Vasoview H e m o p ro Conical tip C·ring Thermostatic cut and seal
Te rumo Vi rtu o S a p h Conical tip V-lock Bipolar cut a n d coa g u lation
2086 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY
FIG 1 4 • GSV h e l d in p l astic c ra d l e w h i l e s i d e b r a n c h l i gated
and d ivided with b i p o l a r e l ectroca utery.
The ve i n is t h e n p u l l e d t h r o u g h t h e i n c i s i o n a n d
l i gated a n d d ivided w i t h s i l k l i g a t u res.
• After p rox i m a l d ivision, t h e ve i n c a n be p u l l e d out
o f t h e t u n n e l t h r o u g h t h e k n e e i nc i s i o n .
• A b e l ow-knee i n c i s i o n c a n be m a d e to h a rvest t h e
d ista l ve i n if t h i s i n c i s i o n i s a l ready i ntended for the
d ista l a n a stomotic site.
• B a ck-ta b l e ve i n p r e p a ration
• H a rvested ve i n s a re p r e p a red on a back ta b l e
(FIG 1 5). Ve i n s a re d i stended w i t h t h e s u rg e o n 's
s o l u t i o n of choice. The a ut h o r p refers u s i n g c h i l l ed,
h e p a r i n ized a ut o l o g o u s b l ood, a lt h o u g h h e p a r i n -
i z e d sa l i n e is a lso suffi cient.
• Any s i d e branches not l i g ated d u r i n g t h e i n it i a l h a r­
vest a re l i g ated with s i l k l i g at u res or, if too s m a l l o r
s h o rt, with 7 - 0 polypropy l e n e s u t u r e .
• F o r e n dosco p i c a l l y h a rvested ve i n s, beca u se t h e
s i d e b r a n c h e s a re not l i g ated d u r i n g t h e i n it i a l
h a rvest, t h ey a re l i g ated at a b a c k ta b l e w i t h s i l k
l i g a t u res o r 7 - 0 p o l y p ropyl e n e s u t u re after ve i n
remova l .
A
FIG 1 6 • A. D i a g ra m d e p i ct i n g ve i n s p l i c i n g . B. S p l i c i n g of
a rm ve i n s to create s i n g l e cond u it. Ve i n s spatu l ated with Potts
scissors. C. A 7-0 polypropy l e n e suture p l a ced to a p p roxi m ate
the heel and toe of the two ve i n s . D. Ve n oven ostomy performed
with ru n n i n g sutu re. E. F i n a l spat u l ated venoven ostomy.
FIG 1 S • B a c k-ta b l e prepa rat i o n of h a rvested ve i n .
• Com posite g raft creation
• A ven ove nostomy c a n be pe rfo rmed with two (or
m o re) ve n o u s seg m e nts to create a s i n g l e co n d u i t of
a d e q uate l e n g t h . The ve i n of l a r g e r d i a m eter s h o u l d
be p l a ced p roxi m a l ly. The ve i n s a re spatu l ated a n d
sewn e n d -to-e n d w i t h r u n n i n g 7 - 0 polypropy l e n e
s u t u r e (FIG 1 6A-E). Additi o n a l ve i n seg m e nts c a n
be a d d e d a s n ecessa ry with t h e s a m e tech n i q u e t o
create a co n d u i t of a d e q u ate l e n g t h .
• G raft t u n n e l i n g
• G rafts a re best t u n n e led u s i n g a h o l l ow t u b e t u n ­
n e l e r, s u c h as a Sca n l a n t u n n e l e r, i n order to avo i d
u n n ecessa ry t e n s i o n o n t h e ve i n as it is p u l l e d
t h r o u g h t h e s u bcuta neous tissue. T h i s i s p a rti c u l a rly
i m p o rtant i n a com posite g raft where suture l i n e
d isruption c a n potent i a l l y occ u r.
• Tu n n e l i n g p e rformed after t h e proxi m a l a n a sto­
mosis a l l ows the g raft to be passed u n d e r p ressu re,
D
E
 C h a pter 31 MAXI M I Z I N G V E I N C O N D U I T FOR AUTOG E N O U S BYPASS 2087

Profu nda
femoral Common
artery femoral
artery
Profu nda
femoral
to peroneal H"''l l-
. ------- Superficial
FIG 17 • Anato m i c t u n n e l t h r o u g h p o p l itea l fossa f o r
artery femoral
fe m o ra l to b e l ow-knee p o p l itea l a rtery bypass. artery
bypass ---7--- -+-1.11

Laterally
w h i c h lessens t h e l i ke l i h ood of twist i n g or k i n k i n g
tunneled
d u ri n g t u n n e l i n g . 1 '-----;---- Medially
g raft to
• In a fi rst-t i m e bypass, t u n n e l i n g anato m i c a l l y through tunneled
anterior tibial
g raft to
the popl itea l fossa for b e l ow-knee ta rgets p rovides artery ----�-�
anterior
the m ost d i rect route to maxi m i ze ve i n l e n gth
tibial artery
(FIG 1 7). I n redo p roce d u res i n which p revio u s g rafts
were t u n n e l ed through the popl iteal fossa, a s u bcu­
;:1--.U...-7------ Popl iteal
taneously t u n n eled g raft may be n ecessa ry.
artery
• Two options exist for g rafts t u n n e l e d to t h e a nte­
rior t i b i a l a rtery. For g rafts based o n the c o m m o n
fe m o ra l a rte ry, a l atera l, su bcuta neously t u n n e l e d
g raft i s t h e m ost stra i g htfo rwa r d . For g rafts based
f u rt h e r d i sta l ly o n the s u p e rfi c i a l fe m o r a l o r p ro­
Anterior
f u n d a fem o r a l a rteri es, an a n ato m i c t u n n e l t h r o u g h tibial artery ------:-----cCII
t h e p o p l itea l fossa a n d i nterosseous m e m b r a n e i s
II--'----- Posterior
more d i rect a n d maxi m i zes ve i n l e n g t h . T h e i nte ros­
tibial artery
seous m e m b r a n e s h o u l d be d i rectly v i s u a l ized a n d
Fibula -----
a cruciate i n c i s i o n m a d e t o p revent g raft stricture.
G rafts to t h e poste r i o r tibial o r pero n e a l a rtery a re
t u n n e led e i t h e r t h r o u g h t h e p o p l itea l fossa or m e d i ­
a l ly a n d s u bcuta neously (FIG 1 8) . FIG 1 8 • D i a g ra m d e p i ct i n g t u n n e l i n g opti o n s for t i b i a l
• C h o i ce o f p roxi m a l a n asto motic site g rafts.
• The c h o i ce of p roxi m a l a n a stomotic site d e p e n d s o n
t h e a n atomy a n d ve i n l e n gth a n d q u a l ity. For patients req u i r i n g t i b i a l o r p e d a l bypasses
If a d e q u ate ve i n l e n gt h is p resent, an a n a sto­ with i nsufficient ve i n l e n gth, the s u p e rfi c i a l
mosis to the co m m o n fe m o r a l a rte ry i s g e n e r­ fe m o ra l a rtery can be treated w i t h a n g i o p l asty
a l ly p refe rred. with or without ste n t i n g to p rovide i nflow for
If ve i n l e n gth i s i n suffi c i e nt, t h e g raft ca n be a g raft based o n t h e a bove- o r b e l ow-knee
based o n either t h e s u perfi c i a l o r p rofu n d a p o p l itea l a rte ry. This is i d ea l ly p e rformed e i t h e r
fe m o r a l a rte ry. For patients w i t h athe roscle­ i n a hybrid operat i n g room ( O R ) su ite o r i n a
rot i c lower extre m ity a rte r i a l occ l u s ive d isease, sta n d a rd OR with C-a rm f l u o rosco py.
t h e p rofu n d a fe m o r a l a rtery i s m o re l i kely to • C h o i ce of d ista l a n asto motic site
be better p rese rved t h a n the s u p e rfi c i a l femo- • In g e n e r a l , t h e s h o rtest bypass confi g u ration that
ra l a rte ry, which i s m o re l i kely to be affected by provides a d e q u ate d ista l flow is chose n .
atherosclerosis (FIG 1 9A,B) . I f d i rect runoff to the foot can b e achieved through
I n t h e presence o f c o m m o n fem o r a l o r proxi­ a bypass to the poplitea l artery, this is preferred .
mal p rofu n d a fe m o r a l a rtery ste nosis, a com­ If t h e pop l iteal a rtery is occ l u d ed a n d a t i b i a l
m o n a n d/o r p rofu n d a fe m o ra l e n d a rterectomy a rtery se rves as t h e d ista l ta rget, a d i rect a n g io­
with p l a c e m e nt of a ve i n o r p rosthetic patch some revasc u l a rization s h o u l d be chosen if pos­
(Linton patch) c a n prov i d e a d e q u ate i n f l ow for sible i n cases of foot u l cers o r isch e m i a . For rest
t h e g raft, with t h e p rox i m a l a n asto mosis to the p a i n o r c l a u d ication, the d o m i n a nt t i b i a l vessel
d i st a l end of t h e patch (FIG 20) . s h o u l d be chose n .
I n patients w i t h patent su p e rfi c i a l fe m o r a l • Prox i m a l a n asto mosis
a rteries a n d m o re d i sta l t i b i a l a rtery d i sease, as • Proxi m a l a n d d i st a l a rte r i a l c o n t r o l is o bta i n ed
is often seen i n patie nts with d i a betes, g rafts w i t h atra u m at i c vasc u l a r c l a m ps, s i l a st i c l o o ps, o r
may be based o n e i t h e r the a bove- o r b e l ow­ F o g a rty cath eters a s n e e d e d a n d p e r s u rg e o n 's
knee p o p l itea l a rte ry. choice.
2088 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

FIG 1 9 • A. Common, s u pe rfi c i a l , a n d p rofu n d a

femora l a rteries d i ssected for p roxi m a l a n astomosis.
Vessels enci rcled with s i lastic loops. B. Proxi m a l
a n astomosis t o p rofu n d a femora l a rtery i n patient
with i n a d e q u ate vei n length to base g raft o n
co m m o n femora l a rtery. N ote t u n n e l i n g d evice i n
A subsarto r i a l posit i o n .

• The a n asto motic a rteriotomy is m a d e with a n o . 1 1

sca l pe l a n d exte n d e d with Potts scissors. The a rte­
r i otomy l e n gt h s h o u l d be a bout 1 . 5 to 2 t i m e s t h e
d i a m eter of t h e ve i n .
• The p roxi m a l a n asto mosis is i d ea l ly performed u s i n g
a ve i n b r a n c h as t h e h e e l i n order to avo i d h e e l stric­
t u re (FIG 2 1 ) . The ve i n i s spatu l ated t h ro u g h the
heel (FIG 22A-C) .
• T h e a n asto m o s i s is pe rfo r m e d with ru n n i n g po ly­
p r o py l e n e r u l e . As a r u l e of t h u m b, s u t u re d i a meter
i s 4-0 i n t h e i l i a c a rte ry, 5-0 f e m o ra l , 6-0 p o p l i te a l ,
Occluded
superficial a n d 7 - 0 t i b i a l (FIG 23) .
• D i st a l a n a stomosis
femoral
artery ---lit-": • T h i s is p e rformed in s i m i l a r fas h i o n to t h e p roxi m a l
a n a stomosis, a lt h o u g h spatu l a t i o n t h r o u g h a s i d e
b r a n c h i s g e n e ra l ly n ot possi b l e a n d l e s s n ecessa ry as
for t h e proxi m a l a n asto mosis, beca use t h e g raft toe
g e o m etry i s more i m po rta nt for patency than t h e
h e e l g e o m etry i n t h e outflow (FIG 24) .
• I ntraope rative a ssessment
• A u g m e ntati o n of D o p p l e r s i g n a l s at t h e a n k l e with
t h e g raft o p e n compa red to the g raft occ l u d e d
g e n e ra l ly i n d i cates g raft pate n cy w i t h i m p roved
FIG 20 • D i a g ra m of Li nton patch on co m m o n a n d p rofu n d a a rte r i a l perfus i o n . I ntraoperative d u p l ex or
fe m o r a l a rteries f r o m w h i c h proxi m a l a n a stomosis of bypass a rte r i o g r a p h y s h o u l d a lso be c o n s i d e red to r u l e out
i s based. tech n i c a l problems with t h e g raft.
 C h a pt e r 3 1 MAXI M I Z I N G V E I N C O N D U I T FOR AUTO G E N O U S BYPASS 2089

Spatulate Spatulate
without through
branch point branch point

! !
Relative No
anastomotic anastomotic
stenosis stenosis
FIG 21 • The v e i n is spatu l ated
t h r o u g h a branch point to avoid
a stricture at t h e heel of the
proxi m a l a n a stom osis, which can
occ u r if a side branch i s n ot used.

FIG 22 • A. Preparation of ve i n for

prox i m a l a n a stomosis. If poss i b le, s i d e
b r a n c h i s c h o s e n for h e e l of p roxi m a l
a n asto mosis t o p revent a n asto motic
strict u re . B. Ve i n spatu l ated with
Potts scissors t h r o u g h branch p o i nt.
C. Spat u l ated ve i n p repa red for
prox i m a l a n asto mosis. B c

FIG 23 • D i a g ra m d e m o nstrati n g p roxi m a l

g raft a n a stomosis.
2090 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

FIG 24 • D i st a l a n a stomosis to b e l ow-knee p o p l itea l a rte ry.

PEARLS AND PITFALLS

Open ve i n h a rvest
E n dosco p i c ve i n h a rvest
Ve i n preparation
G raft t u n n e l i n g
Anastomotic placement
• Preope rative v e i n m a p p i n g i s i m p o rtant to loca l i z e t h e site of t h e i nc i s i o n to avo i d tissue flaps that
c a n l e a d to poor w o u n d h ea l i n g .
• Ve i n b r a n c h es s h o u l d n o t be l i g ated f l u s h with t h e ve i n as " d i m p l i n g " c a n occ u r w h e n t h e ve i n i s
d i st e n d e d . It i s g o o d t o l i g ate t h e ve i n b r a n c h at l e a st 1 m m away from t h e v e i n t o a l low proper
ve i n expa n s i o n (FIG 2S) .
• A r m v e i n s t e n d to b e m o re frag i l e t h a n leg ve i ns, req u i ri n g g e n t l e r h a n d l i n g d u ri n g h a rvest.
• Avo i d h a rvest i n g ve i n s that a re s u bcuta n e o u s o r not e n c l osed with i n a fasc i a l envelope as these a re
tech n ica l ly m o re d iffi c u l t to h a rvest a n d t h e refore m o re prone to i nj u ry.
• Avo i d ove r d i ste n d i n g t h e ve i n d u ri n g p r e p a rat i o n . A good tech n i q u e is to i nject a s m a l l a m o u nt of
fl u i d i nto t h e ve i n a n d t h e n m a n u a l ly d i ste n d i n g t h e ve i n i n segme nts rat h e r t h a n tryi n g to i nflate
t h e vein with t h e syri n g e .
• Pass i n g t h e g raft w h i l e d iste n d e d red u ces t h e risk of twi st i n g o r k i n k i n g .
• U s i n g a ste r i l e m a rk i n g p e n , a l i n e can be d rawn o n t h e a nterior s u rface o f t h e ve i n to h e l p orient
t h e g raft d ista l ly a n d prevent twi st i n g .
• Seve rely d i seased vesse l s t e n d to d e l a m i n ate w h e n h a n d l e d . G reat c a r e m ust be taken to i n c l u d e
a l l layers i n t h e a n asto m o s i s to p revent d i ssect i o n .
• I n seve r e l y ca l c i f i e d vess e l s, vesse l l o o p s m a y n ot p rovi d e a d e q u ate c o n t r o l a n d vasc u l a r
c l a m ps m a y c a u s e a c r u s h i n j u ry. I n t h e s e cases, F o g a rty b a l l o o n s m a y b e n e e d e d f o r a rte r i a l
c o n t ro l .

Nond istended vein

Tie at
appropriate Tie too
distance close to vein
from vein

FIG 25 • " D i m p l i n g " ca n occu r with g raft d iste ntion if s i d e

Distended vein b r a n c h t i e i s too c l ose to ve i n .
 C h a pt e r 3 1 MAXI M I Z I N G V E I N C O N D U I T FOR AUTO G E N O U S BYPASS
POSTOPERATIVE CARE
• Patients should be monitored postoperatively in either an in­
tensive care unit or a surgical ward. Hourly vascular checks
should be performed with continuous wave Doppler.
• Early ambulation, generally on the first postoperative day,
is encouraged, particularly in patients with claudication or
rest pain. Patients with ulcers or gangrene may require a lon­
ger period of non-weight bearing if lesions are on a weight­
bearing surface.
OUTCOMES
• Anticipated 3 -year primary patency rates for reversed saphe­
nous vein grafts are 70 % to 8 0 % for femoral-popliteal and
60% to 75 % for femoral-tibial. Comparable patency rates
for arm vein bypasses are 60% to 70 % and 5 0 % to 6 0 % ,
respectively, and for prosthetic grafts, 45 % t o 65 % and
20% to 3 0 % , respectively. Anticipated 5-year limb salvage
in patients with critical limb ischemia is 8 0 % to 9 0 % , with
5-year survival in 4 0 % to 70 % . 1 -5
• Reversed and in situ vein grafts have been shown to have
comparable patency rates in multiple studies.6
• Ambulatory function and independent living status is pre­
served in the maj ority of patients who undergo successful
revascularization.
• 6. Harris PL, Veith FJ, Shanik GD, et al. Prospective randomized com­
Quality of life measures are improved in the maj ority of
patients who undergo successful revascularization.7
• Up to 20% of patients will develop vein graft stenoses
requiring either open or endovascular revision during
follow-up.
2091
• Data on patency rates of open versus endoscopically har­
vested vein grafts are mixed, making definitive recommenda­
tions on the preferred approach difficult.
COMPLICATIONS
• Wound infection
• Seroma
• Hematoma
• Graft occlusion
• Myocardial infarction
REFERENCES
1. Chew DK, Owens CD, Belkin M, et al. Bypass in the absence of ipsilat­
eral greater saphenous vein: safety and superiority of the contralateral
greater saphenous vein. 1 Vase Surg. 2002;35(6):1085-1092.
2. Curi MA, Skelly CL, Woo DH, et al. Long-term results of infragenicu­
late bypass grafting using all-autogenous composite vein. Ann Vase
Surg. 2002;16(5):618-623.
3. Faries PL, Arora S, Pomposelli FB, et al. The use of arm vein in lower­
extremity revascularization: results of 520 procedures performed in
eight years. 1 Vase Surg. 2000;31(1):50-59.
4. Gentile AT, Lee RW, Moneta GL, et al. Results of bypass to the pop­
liteal and tibial arteries with alternative sources of autogenous vein.
1 Vase Surg. 1996;23(2):272-279.
5. Taylor LM J�; Edwards JM, Porter JM. Present status of reversed vein by­
pass: five-year results of a modern series. 1 Vase Surg. 1990;11(2):193-206.
parison of in situ and reversed infrapopliteal vein grafts. Br 1 Surg.
1993;80(2):173-176.
7. Nguyen LL, Moneta GL, Conte MS, et al. Prospective multicenter study
of quality of life before and after lower extremity vein bypass in 1404
patients with critical limb ischemia. 1 Vase Surg. 2006;44(5):977-983.

Chapter 32
1
I
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
DEFINITION
• Endovascular tibial intervention is a minimally invasive,
endoluminal revascularization of the infrapopliteal vessels.
It is an accepted treatment of critical limb ischemia ( CLI) in
patients with tibial occlusive disease. It is usually performed
from a transfemoral access ( antegrade approach) and, in
selected cases, from transpedal or tibial access (retrograde
approach) .
• Therapeutic interventions performed i n tibial arteries include
balloon angioplasty, drug-eluting balloon angioplasty, stent­
ing, and atherectomy.
• Procedures are most commonly performed under local anes­
thesia with moderate conscious sedation in a fixed-imaging
hybrid operating room or in the interventional angiography
suite. Portable imaging systems may also provide sufficient
resolution for precise, image-guided intervention depending
on circumstances.
DIFFERENTIAL DIAGNOSIS
• Neuropathic pain is commonly described as burning sen­
sation, stabbing, or aching pain that is commonly accom­
panied by numbness or hypoesthesia. Diabetic neuropathy
is probably most common and is frequently nocturnal as
well. The symptom complex of diabetic neuropathy may
be confused with ischemic rest pain or metatarsalgia, given
the similar dermatomal distribution and overlapping risk
factors.
• Venous ulcers are associated with skin pigmentation, indura­
tion from chronic venous hypertension, and inflammation.
They develop primarily in the perimalleolar region of the
ankle and usually do not involve the forefoot.
• Musculoskeletal pain resulting from mechanical etiology,
stress fracture, arthritis, and plantar fasciitis
• Soft tissue infection and malperforans ulcers in diabetic
patients with advanced sensory neuropathy and/or Charcot
deformity of the foot
• Chronic, nondiabetic peripheral neuropathies such as dorsal
foot paresthesias and dysesthesias following long saphenous
vein harvest
PATIENT HISTORY AND PHYSICAL
FINDINGS
• Patients with infrainguinal occlusive disease present with
symptoms of claudication ( Rutherford ischemia classifica­
tion categories 1, 2, and 3 ), ischemic rest pain, or tissue
loss ( Rutherford categories 4, 5, and 6 ) . When the ath­
erosclerotic disease is limited to the infrapopliteal arterial
segments, pain is mainly located in the forefoot. Advanced
2092
-
Tibial Interventions:
Tibial-Specific Angioplasty
Considerations and
Retrograde Approaches
·
Georges E. AI Kh oury Rabih A. Cha e r
A B
FIG 1 • A. Patient with t i b i a l occ l u s ive d i sease a n d i sc h e m i c
r i g h t fi rst t o e u l cerati o n . Rutherford c l ass 5 . B. Patient with
severe m u l t i l evel occl usive d i sease with g a n g re n e of t h e l eft fi rst
toe a n d u l cerations on t h e dorsum of t h e foot. Rutherford class 6 .
arterial insufficiency c a n also lead t o ischemic ulceration,
gangrenous changes, and nonhealing wounds. This constel­
lation of symptoms represents CLI and typically occurs when
the ankle pressure is less than 50 mmHg, the ankle-brachial
index (ABI) is less than 0.4, and the great toe pressure is less
than 3 0 mmHg ( FIG 1 A, B) .
• CLI with tissue loss often occurs i n the setting o f multilevel
arterial occlusive disease. In the case of isolated diabetic tibial
occlusive disease, femoral, and frequently popliteal, pulses
remain palpable. In either circumstance, limb-threatening
ischemia may ensue. In the latter circumstance, multilevel
approaches to complete revascularization, either staged or
simultaneous, should be pursued.
• Neurovascular exam, with particular focus on the wound
location and the extent of tissue loss, should be evaluated
and documented. Probably, the most deterministic variable
is the extent of tissue loss-Wagner wound classification, the
presence and severity of osteomyelitis, exposure or involve­
ment of the calcaneus bone, residual intact skin on either the
dorsal or plantar foot. These conditions all impact decision
making and clinical outcome.
• Patient functional capacity also plays an important role
in the therapeutic strategy. Options and outcome goals
vary substantially between ambulatory and nonambulatory
patients.
IMAGING AND OTHER DIAGNOSTIC
STUDIES
• Pulse volume recordings (PVRs) ( FIG 2 )
• Duplex ( FIG 3 )

A
c
FIG 3 • A. D u p l ex 8-mode i m a g e shows the calcified t i b ioperoneal
tru n k bifurcation i nto the posterior t i b i a l a rtery a n d peroneal
a rtery. B. D u p l ex of the t i b ioperoneal tru n k bifurcation shows flow
i nto the posterior t i b i a l a rte ry. C. D u p lex of the proxi m a l posterior
tibial a rtery shows normal triphasic Doppler waveform.
C h a p t e r 3 2 T I B IAL I NT E RVE N T I O N S 2093
FIG 2 • PVR o n a p a t i e n t with severe r i g h t t i b i a l
occ l u s ive d isease a n d n o n h ea l i n g t o e u l ce r. The
tra c i n g s a re p u lsati l e at t h e calf l evel consistent
with a d e q u ate femoropo p l itea l fl ow; h owever,
t h e wavefo rms a re fl at, d ista l ly s u g g estive of
t i b i a l occ l u s ive d i sease.
• Computed tomography ( CT) and magnetic resonance (MR)
angiograms can be obtained; however, their diagnostic use
in planning tibial interventions is frequently limited by the
imprecision of bolus timing with distal extremity cross­
sectional imaging techniques, heavy medial calcification
frequently present in target arteries, and the diminutive size
of reconstituted target arteries, which may be present in the
peri- and inframalleolar regions.
• Catheter-directed, intraarterial angiography remains the gold
standard imaging study for tibial occlusive disease for both
diagnostic and therapeutic purposes ( FIG 4) .
SURGICAL MANAGEMENT
• Technical skills, careful planning, and knowledge of the rel­
evant arterial anatomy determine tibial revascularization
strategies for limb salvage. Current controversies include the
potential value of restoring patency in more than one tibial
vessel to optimize blood flow and maximize the chances of
FIG 4 • S e l ective l eft leg a n g i o g r a m s h ows patent p o p l itea l
a rte ry, patent t i b i o p e r o n e a l tru n k, co m p l ete occl u s i o n of t h e
a nterior t i b i a l a rte ry, a n d co m p l ete occ l u s i o n of t h e peronea l
a rte ry.
2094 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

wound healing. Proponents of this approach reference the

" angiosome " concept of the foot or the idea that specific skin
regions derive primary perfusion from end-arterioles arising
primarily from either the dorsal pedal or posterior tibial arter­
ies as they cross the ankle. This practice is pursued in marked
contradistinction to the open surgical imperative to restore
in-line flow to the foot in the single largest, most continuous
crural artery. The many advantages of endovascular recon­
struction techniques in tibial reconstruction include restoring
partial flow in multiple target arteries as compared to a single
artery following surgical bypass, as well as opportunities to re­
peat procedures with relatively simple outpatient interventions
as needed, to maintain patency and skin integrity. Treatment
decisions regarding revascularization strategy in individual
circumstances should be guided by patient-specific anatomic
considerations, arterial runoff into the foot, patient habitus
and ambulatory status as well as patency and feasibility con­
siderations related to either open or endovascular options.
• Currently available endovascular technology facilitates suc­
cessful treatment of complex occlusive lesions at and below
the malleolar level. Technical limitations remain, however, FIG 6 • A n g i o g r a m f r o m s h e a t h sh ows t h e catheter i n t h e
highlighted by risks of arterial perforation ( FIG 5 ) , difficulty s u b i nt i m a l p l a n e afte r reca n a l ization of poste r i o r t i b i a l (PT) w i t h
in true lumen reentry in complete occlusions ( FIG 6) , proce­ reco nstituti o n of d i sta l P T a w a y f r o m t h e catheter.
dure-related distal arterial embolization, and limited pedal
vessel outflow in certain circumstance.
• The retrograde or SAFARI ( SubintimAl Flossing with Preoperative Planning
Antegrade-Retrograde Intervention) tibial intervention tech­
• Preoperative vein mapping prior to the diagnostic angiogram
nique may improve technical results in challenging lesions,
is helpful in handicapping potential surgical alternatives and
particularly those resistant to ipsilateral antegrade access,
determining the extent to which interventional alternatives
including flush occlusions at the origin of the target artery or
to be pursued.
with large collateral arteries adj acent to the occluded origin.
• Patients should be medically optimized prior to their proce­
In nearly every circumstance, even chronic and recalcitrant
dure: Preventive strategies are advised to reduce the risk of
occlusions may be crossed more easily from the retrograde
kidney inj ury in patients at risk for contrast nephropathy;
rather than antegrade approach; this is true regardless of the
smoking cessation is encouraged as well as antiplatelet and
chronicity of the lesion in question, degree of calcification,
statin therapy.
or length of occlusion.
• Tibial interventions can entail significant radiation expo­
sure. Protective shields, lead glasses, and j udicious use of
fluoroscopy are recommended to protect all participants in
the procedure. Ultrasound-guided access can minimize radi­
ation exposure, particularly for pedal access; needle extend­
ers allow the operator to puncture remotely and minimize
hand exposure.
• Micropuncture and pedal access kits are essential access tools.
• Sheaths: 5 and 6 Fr, braided, 90 em or 1 1 0 em from contra­
lateral femoral access; 45- to 55-cm sheath from the ipsilat­
eral transfemoral access
• Wires: 300-cm, 0 . 0 1 4-in or 0 . 0 1 8 -in wires; 260-cm, 0.035-
in floppy Glidewire™
• Catheters: 1 5 0- to 1 70-cm catheters and balloons
• Medications: heparin ( or other anticoagulant) , clopidogrel,
nitroglycerin, papaverine, alteplase, and calcium channel
blockers. Consider preprocedural perioperative antibiotics
prior to procedures potentially requiring prosthetic implants.

Positioning

• The patient is placed supine on the angiographic table with

both groins prepped and draped. Consider preparing the
FIG 5 • A n g i o g r a m s h ows extravasat i o n from d i st a l poste r i o r foot and the leg in anticipation for retrograde approach if
t i b i a l a rtery i n a n atte m pt to cross a tota l occ l u s i o n with a needed. Stockinette can be placed over the involved foot and
catheter a n d w i re . the leg is covered with the angiographic drape ( FIG 7 ) .
 C h a p t e r 32 T I B IAL I NT E RVE N T I O N S 2095

F I G 7 • Patient i s p l aced i n t h e s u p i n e position o n t h e a n g i o g ra p h i c

ta b l e; t h e g ro i n s a n d l ower extrem ity a re prepped a n d d ra ped i n
a nt i c i pat i o n o f a nteg rade a n d retrog rade a p p roaches.

ANTEGRADE TIBIAL REVASCULARIZ ATION

First Step: Femoral Access and Anticoagulation

• Contra latera l fe m o r a l access with sta n d a rd up a n d ove r

tech n i q u e is o u r rout i n e a p p roach for d i a g n osti c a rteria­
g r a m s a n d m ost t i b i a l i nterve n t i o n s .
• Ante g r a d e fe m o ra l a p p roach h a s d i st i n ct advantages for
t i b i a l o r pedal i nte rve n t i o n s, espec i a l ly in t h e sett i n g of
a host i l e a n d n a rrow a o rt i c bifu rcati o n o r occ l u d ed or
seve rely d i seased contra latera l i l iofe m o r a l syst e m . An­
teg rade access g e n e ra l ly provides e a s i e r p u s h a b i l ity a n d
red u ced r a d i a t i o n t o t h e patient a n d proced u r a l tea m .
• U ltraso u n d-g u i d e d access may m i n i m i ze risk for a ccess
site co m p l icat i o n s .
• D i a g n ostic a rte r i o g r a m to i m a g e t h e i nflow is p e rfo r m e d .
• A 5- or 6-Fr sheath is adva nced over a stiff w i re to t h e
p o p l it e a l a rte ry, posit i o n e d as close as possi b l e to t h e
t i b i a l trifu rcat i o n . (S h e a t h : 90 to 1 1 0 em f r o m t h e contra­
l atera l fe m o r a l access and 45 to 5 5 em from t h e i p s i l at­
e ra l fe m o ra l access) (FIG 8) .
• Sheath t i p posit i o n i n g c l ose to t h e ta rget vesse l maxi­ FIG 8 • After obta i n i n g fe m o ra l access, the sheath i s
m i zes p u s h a b i l ity across tota l occ l u s i o n s . A l so, i m p roved advanced to t h e p o p l itea l a rtery f o r t h e i nterve n t i o n . It a l l ows
better visu a l ization of the t i b i a l vesse l s a n d faci l itates the
v i s u a l ization of t i b i a l vesse l s i s a c h i eved with reduced
p u s h a b i l ity a n d t h e a b i l ity to cross tota l occ l u s i o n s .
contra st vo l u mes.
• Anticoa g u l at i o n is esta b l i s h e d using u nfract i o n ated h e p ­
a r i n o r oth e r a lternatives to a c h i eve a n activated c l ott i n g
t i m e (ACT) o f m o re t h a n 2 5 0 seco n d s . espec i a l ly d i st a l to exte n d e d o r seri a l occl u s i o n s . D e l ayed
v i ews ( p ro l o n g e d d i g it a l s u btract i o n a n g i o g r a p h y [DSA]
Second Step: Selective Angiogram t i m e) may i m p rove o pacificat i o n of patent t i b i a l o r p e d a l
vesse ls d i st a l to occ l u d ed s e g m e nts (FIG 9) . Withd raw­
• I m a g i n g of the t i b i a l outflow is obta i n ed from sheath
ing the sheath to the femora l b i f u rcat i o n may u ncover
i njections o r through d i a g n ostic catheters (5- to 1 0- m l
reconstitution of d i sta l t i b i a l a rtery seg m e nts t h r o u g h
power o r h a n d i njection). To reduce contrast l o a d , contrast
exte n d e d d e e p fe m o r a l a rtery co l l atera l pathways.
may be d i l uted 50% for a l l but the most d i stal arterial beds.
• Anteroposte r i o r or i p s i l atera l a nte r i o r o b l i q u e p roj ect i o n s
T hird Step: Crossing the Occlusion
a re o bta i n e d to visu a l ize t h e p o p l itea l "trifu rcat i o n " a n d
sepa rate t h e t i b i a a n d f i b u l a . Tru e l atera l o b l i q u e p rojec­ • A n g l e d cath eters a n d g u i d ewi res a re typ i ca l ly used to
t i o n s a re o bta i n e d to v i s u a l ize p e d a l o utfl ow. sel ect the respective t i b i a l a rteries.
• Arte r i o g ra p h i c i m a g e s m ust be ca refu l ly exa m i ned to • The catheter/g u i d ewire co m b i n a t i o n is advanced i nto t h e
o pt i m ize o utcome; m u lt i p l e p roj ect i o n s may be req u i red ta rget t i b i a l a rtery p roxi m a l to t h e occ l u s i o n o r stenosis.
to suffi c i e ntly opac ify tibial and ped a l vascu l a r a n ato my, • Anatomy is confirmed with m a g n ified a rteriog ra p h i c views.
2096 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

Pop
Pop

TPT
AT ...... ,/
.--­
TPT

Per FIG 9 • A. D i a g n ostic a n g i o g r a m from t h e p o p l ite a l

s h eath d e m o n strates patent r i g h t p o p l itea l a rte ry,
AT occ l u d ed a nterior t i b i a l a rte ry, a n d occ l u ded d i sta l
-
--- t i b i o p e ro n e a l tru n k with reco nstituti o n of pero n e a l
Per
a rte ry. The poste r i o r t i b i a l a rtery a p pe a rs to be
occ l u d e d . B. A n g i o g r a m with d e l ayed DSA t i m e
i d e ntifies a patent d iseased poste r i o r t i b i a l a rtery
d ista l to t h e occ l u d ed t i b i o p e ro n e a l tru n k a n d patent
A B peroneal a rte ry.

• " Road m a p p i n g " may i m p rove g u i d a nce across occ l u ­
s i o n s . The w i re leads t h r o u g h t h e occl u s i o n , fo l l owed by
the cross i n g catheter (e . g ., Q u ick-Cross1M o r Cook CXI1M,
0 .0 1 4 in o r O. D 1 8 in) (FIG 1 0) .
• Tra n s l u m i n a l passa g e i s preferred to s u b i nt i m a l access,
because ree ntry i nto t h e t r u e l u m e n may be u n p re d i ct­
able and cha llenging.
• Soft-t i p ped hydro p h i l i c g u i dewi res a re used to n e g otiate
and trave rse t i b i a l ste nosis with t h e s u p p o rt of cross i n g
cath eters u n d e r m a g n ified r o a d m a p g u i d a n ce.
• Heavier weig hted t i p, c h ro n i c tota l occ l u s i o n s (CTO)
g u i dewi res (e i t h e r 0.0 1 4- i n o r 0 . 0 1 8-in p l atfo rms) a re
d e s i g n e d to p rovide i m p roved p e rforma nce a n d p e n etra­
tion across tota l occl u s i o n s .
• For l o n g e r occ l u s i o n s, l e a d i n g with a 2 - m m pe rcuta n e o u s
transl u m i n a l a n g i o p l a sty (PTA) b a l l o o n a s a n a ltern ative
to l ow-p rofi l e cross i n g cath eters (e.g., Q u i c k-Cross1M o r
CXI1M) ca n i m p rove a ccess by exte n d i n g o r reesta b l i s h i n g
t h e reca n a l ization p l a n e d u r i n g transit.
Fourth Step: Reentry into the True Lumen
• Reenter i nto t h e t r u e l u m e n u n d e r road m a p g u id a nce
(FIG 1 1 ).
• Adva nce t h e cath eter ove r t h e w i re i nto t h e true l u m e n
beyo n d t h e ta rget l e s i o n a n d rem ove t h e wire.
• Aspi rate to check for back-bleed i n g and s u bsequently
perform a sel ective a n g io g r a m through t h e catheter to
confi rm t h e proper i ntra l u m i n a l positi o n (FIG 1 2) .

j
r�
'
t -­

\
cath

-
PT

FIG 1 0 • Reca n a l i zation of occ l u d ed PT. U n d e r road m a p

g u i d a nce, t h e P T w a s sel ected, a n d u s i n g a w i re a n d s u p po rt FIG 1 1 • Angiogram from catheter in PT d u r i n g reca n a l ization
catheter, t h e occ l u s i o n was crossed. of occluded PT.

FIG 12 • A n g i o g r a m f r o m catheter i n t h e p l a nt a r a rtery t o
confirm t h e proper i ntra l u m i n a l position afte r reca n a l ization
of PT.
• Adva nce a stiff w i re with l o n g , soft t i p i nto t h e ta rget
vesse l as d ista l as possi b l e (FIG 1 3) .
• Remove the catheter carefu l l y u n d e r f l u o roscopic g u id a nce
w h i l e m a i nta i n i n g wire access i nto the d ista l patent a rtery.
• Reentry devices ca n be used to sel ect t h e t r u e l u m e n from
a d i ssect i o n p l a n e . Alternatively, if fa i l u re to reenter the
true l u me n persists desp ite t h e use of reentry devices o r
b a l l o o n a n g io p l a sty to d i s r u pt t h e d issect i o n m e m b r a n e,
access i nto t h e d i sta l t r u e l u m e n ca n be reatte m pted in a
sta ged futu re sett i n g .
A B
FIG 1 4 • A. B a l l oo n a n g i o p l asty of d ista l PT with 2 - m m b a l loon for 2-m i n ute i nflation t i m e . B. B a l loon a n g i o p l asty of PT with
3 - m m ba l l oo n for 2-m i n ute i nflation t i m e .
C h a p t e r 32 T I B IAL I NT E RVE N T I O N S 2097
FIG 1 3 • Placement of w i re i nto t h e p l a nt a r a rtery p r i o r to
a n g i o p l asty of t h e occ l u d e d PT.
Fifth Step: Treatment with Balloon Angioplasty
• The p roxi m a l a n d d ista l e n d s of t h e l e s i o n a re d e m a r­
cated by a repeat contrast i nject i o n t h r o u g h t h e sheath.
The use of radiopaque a d h esive r u l ers a p p l ied o n the
affected l e g may help with measurement a n d device
s e l ecti o n .
• D e l iver the a p p ropriate s i z e ba l l oon (typica l ly 2 t o 3 . 5 m m
i n d i a meter) t o t h e ta rget lesion a n d perform t h e b a l loon
a n g i o p lasty for 2- to 3-m i n ute inflation t i m e (FIG 1 4).
2098 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY
FIG 1 5 • A n g i o p l a sty of PT with l o n g b a l l o o n .
• S i n g l e i n f l a t i o n u s i n g a l o n g b a l l o o n d e c re a s e s t h e
p roced u r a l t i m e a n d red u ce s t h e r i s k of p o sta n g i o ­
p l a sty d i ssect i o n req u i ri n g r e i n t e rve n t i o n (FIG 1 5) .
Ta p e r e d b a l l o o n s c a n h e l p treat l e s i o n s a c ross vess e l s
of va r i a b l e s i z e .
• H e p a r i n fl ush, conti n u o u s or i nterm ittent, t h r o u g h the
sheath i s reco m m e n d e d d u r i n g b a l l o o n i nflation a n d
t h r o u g h o u t t h e p roced u re .
• Sel ective i nject i o n of i ntraarte r i a l n itrog lyce r i n t h r o u g h
t h e s h e a t h w i l l m i n i m ize t h e effects of spasm at o r d i st a l
to t h e i nterve n t i o n .
Sixth Step: Angiogram Post-Balloon Angioplasty
• The treatm ent b a l l o o n is retracted back ove r t h e w i re to
t h e p o p l itea l a rtery l eve l .
• The co m p letion a rte r i o g r a m is pe rfo rmed from a sheath
i nject i o n to assess t h e a n g i o p l asty outcome and pedal
r u n off (FIG 1 6) .
• Reco i l or d issect i o n s a re treated with s u sta i n e d reinfla­
t i o n of t h e b a l l o o n for 3 to 5 m i n utes o r by upsizing the
b a l l o o n , fo l l owed by m o re g ra d u a l defl a t i o n .
• F l ow- l i m it i n g d i ssect i o n s in t h e proxi m a l t i b i o p e r o n e a l
tru n k a n d prox i m a l t i b i a l a rteries may be resolved with
ste nt p l a ce m e n t w h e n n ecessa ry.
• D i stal embol ization can be ma naged by aspiration through
the exist i n g catheter or aspiration with a p u rpose-specific
catheter such as the ExportrM
• Other m o d a l ities may be usef u l in resto r i n g patency, s u c h
as atherectomy d evices a n d c a n be used a s sta n d - a l o n e
t h e ra py o r as a dj u n cts to b a l l o o n a n g i o p l asty.
• T h e r o ut i n e u s e of t i b i a l ste nti n g is not a dvocated at
t h i s sta g e . A l th o u g h t h e re is s o m e evi d e n c e to s u g g est
PT ----
Plantar
--- -
FIG 1 6 • A n g i o g r a m from sheath postreca n a l ization a n d
a n g i o p l a sty o f P T s h ows g o o d flow without a n y flow- l i m it i n g
d i ssect i o n .
t h a t d ru g - e l u t i n g stents m a y res u l t i n i m p roved d u ra ­
b i l ity, t h e s e a r e s u bj ect to cost rest r i ct i o n s, reg u l at o ry
a p p rova l s, a n d ava i l a b i l ity d e p e n d i n g on t h e cou ntry of
practice.
Seventh Step: Reconstruction of Another
Tibial Vessel
• The u lt i m ate g o a l is to reesta b l i s h d i rect, i n - l i n e a rte­
rial flow to t h e isch e m i c p a rt of t h e foot. A seco n d a ry
g o a l is to o pt i m ize flow by reco nstruct i n g m o re t h a n o n e
occ l u d ed t i b i a l a rte ry, w h e n poss i b l e .
• The w i re is redi rected i nto a n oth e r t i b i a l vessel a n d
reca n a l ization i s p e rformed a s described e a r l i e r (FIG 1 7) .
• W h e n t h e pero n e a l a rtery is t h e s o l e outflow vesse l,
revasc u l a rization to t h e level of t h e pero n e a l col latera l s
at a n kl e i s n e e d e d .
• Osti a l l e s i o n s at t h e b i f u rcati o n of a nterior t i b i a l a rtery
a n d t i b ioperonea l tru n k can be treated with kissi n g
b a l l o o n tech n i q u e to p revent p l a q u e s h ifti n g .
Eighth Step: Completion Angiogram and
Hemostasis
• If t h e co m p l et i o n a n g i o g r a p h y is satisfacto ry (FIG 1 8),
the sheath i s p u l led back to the co m m o n femora l a rtery
a n d i nject i o n from that level is reco m m e n d ed to r u l e
out a n y co m p l icat i o n s i n the femoropo p l itea l s e g m e n t
re l ated to sheath positi o n .
• T h e s h e a t h i s r e m oved a n d h e m osta s i s i s o bta i n ed
at t h e a ccess s i t e e it h e r by u s i n g c l o s u r e d e v i c e o r
m a n u a l c o m p re ss i o n w i t h o u t h e p a r i n reve rsa l u n l ess
necessa ry.
 C h a p t e r 32 T I B IAL I NT E RVE N T I O N S 2099

-­
Wire ---
-

F I G 1 7 • A. A n g i o g r a m f r o m t h e sheath a t
t h e t i m e o f reca n a l ization o f a nterior t i b i a l (AT)
a rtery with a w i re a n d catheter. The pero n e a l
a rtery is patent a n d reconstitutes a d ista l a nterior
AT tibial a rtery. B. Angiogram from t h e sheath
posta n g i o p l asty of t h e AT with 3 - m m ba l l oo n ,
s h ows p a t e n t AT without a n y d issect i o n o r fl ow­
A B l i m it i n g ste nosis.

-
PT
......
AT

FIG 1 8 • A. Co m p l et i o n a n g i og ra m from t h e
s h e a t h postreca n a l ization of occ l u d e d AT a n d PT
s h ows patent vesse l s with good flow m a i n ly in t h e
AT w i t h o u t a n y s i g n ificant d i ssect i o n . The p e ro n e a l
a rtery reconstituted i n a retro g r a d e fas h i o n f r o m t h e
A B AT. B. Patent d i st a l AT a n d P T r u n off i nto t h e foot.

RETROGRADE TIBIAL RECANALIZATION • Access to t h e poste r i o r t i b i a l a rtery is o bta i n ed i n the

First Step: Retrograde Access
• Ante g ra d e access is o bta i n ed fi rst as described e a r l i e r.
T h i s is used for i n it i a l i m a g i n g a n d d e l ivery of treat m e n t
devices.
• Retrog rade t i b i a l a rte r i a l access is pe rfo rmed u n d e r
u ltraso u n d o r f l u o roscopic g u i d a nce u s i n g a m icropu nc-
t u re 2 1 - g a u g e n e e d l e ; a 300-cm, 0 . 0 1 8-i n or 0 .0 1 4- i n
w i re; a n d ba l l oo n o r s u p p o rt catheter. An i ntrod ucer d i -
l ator, a l t h o u g h potent i a l ly u sefu l, is not essent i a l .
• Sedation s h o u l d be m a n a g e d to m i n i m ize m ove ment
w h e n road m a p p i n g i s used to i d e ntify ta rget a rteries.
• Local a n esthesia is i nfi ltrated at the i ntended p u n ct u re site.
reg i o n of t h e m e d i a l m a l l e o l u s . Dorsifl exi o n a n d/o r ever·
sian of t h e foot may fa c i l itate a ccess.
• Access to t h e a nterior t i b i a l a rte ry i s obta i n ed o n the
d o r s u m of the foot o r t h e d i st a l a spect of t h e leg a nteri·
orly, where t h e ta rget a rtery may be l a rg e r. Do rsa l i s pedis
access i s fac i l itated by p l a nt a r flexion of t h e foot.
• The peroneal a rtery s h o u l d be a p proached l atera l ly
t h ro u g h t h e i nte rosse o u s m e m b r a n e .
• M o re proxi m a l access to t h e poste r i o r o r a n t e r i o r t i b i a l
a rteries m a y be o bta i n e d w i t h r o a d m a p g u i d a nce w h e n
n ecessa ry.
• I n a dvertent venous p u n ct u re may occ u r d u r i n g atte m pts
at retrog rade access, and w h e n it does, c o n s i d e r l eavi n g
2 1 00 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

FIG 1 9 • Retro g ra d e a p p ro a c h : a ccess to PT u n d e r u ltraso u n d

( U S ) g u i d a n ce.

t h e w i re in p l a c e to h e l p g u i d e f u rt h e r attem pts at a rte­ FIG 20 • A. Retro g ra d e access to AT with a d e q u ate a rte r i a l

rial access. back-bleed i n g f r o m t h e m ic ro p u nctu re need l e . B. Need l e i n AT
• U ltraso u n d-assisted retro g ra d e access, as an adju n ct to a n d w i re adva n ced proxi m a l ly u n d e r f l u o rosco p i c g u i d a nce .
road map g u i d a nce a l one, may h e l p to defi n e the th ree­
d i m e n s i o n a l o r i e ntat i o n of the need l e in re l a t i o n to t h e
ta rget a rtery (FIG 1 9) . T hird Step: Recanalization o f Tibial Occlusion
• I m a g e q u a l ity is o pt i m ized by i n co rporat i n g a suff i c i e nt
• Ante g r a d e sheath a rte r i o g r a p h y is used to d e l i neate t h e
d e l a y fo l l ow i n g contra st i nject i o n to maxi m i ze opaci­
extent of t h e ta rget l e s i o n .
ficat i o n of t h e ta rget a rte ry. S e l ective use of i ntra a rte­
• The occ l u s i o n i s crossed u s i n g 0 . 0 1 8-i n o r 0. 0 1 4- i n w i res,
r i a l vasod i l ators t h r o u g h the a ntegrade may reduce
s u p p o rted by a cross i n g catheter or l ow-profi l e a n g i o­
t h e seve rity of access-rel ated vasospasm, w h e n p rese nt,
p l a sty b a l l o o n (FIG 23) .
d i st a l ly.
• The w i re a n d cross i n g catheter co m b i n a t i o n i s adva n ced
• The C-a rm is adjusted to best a l i g n the need l e to the tar­
from d i sta l to proxi m a l and i nto t h e p o p l itea l a rtery if
g et vessel, typ i ca l l y u s i n g an i p s i l atera l o b l i q u e project i o n .
poss i b l e . The w i re i s rem oved .
• S u r g i c a l exposu re may b e c o m e necess a ry to e n s u re
• F o l l ow i n g a s p i rat i o n to confi rm l u m i n a l position, a
a d e q u ate a ccess for retro g ra d e t i b i a l reco nstruct i o n .
sel ective a rteriogram is pe rfo rmed from t h e retrograde
Retro g r a d e a ccess may a l so be o bta i n ed concom itant
catheter.
with p l a n ned tra n s m etata rsa l a m p utation by i d e ntify i n g
a n d ca n n u l a t i n g t h e o p e n e n d of transected d i sta l d o rs a l
p e d a l a rte ry.

Second Step: Retrograde Angiogram

• O n ce good back-bleed i n g is ach i eved, t h e w i re is a d ­

va n ced u n d e r f l u o roscopic g u i d a nce (FIG 20), fo l l owed
by a n a p propriately sized s u p p o rt catheter, b a l loon, o r
t h e i n n e r d i l ator of t h e 4 - F r m i crosheath.
• I n m ost cases, retro g ra d e sheaths a re g e n e ra l ly not de­
p l oyed to m i n i m i ze tra u m a to t h e p u n ct u re site a n d d i s­
ta l ta rget a rtery (FIG 21 ) . W h e n sheaths a re req u i red, use
of a ra d i a l access s h eath w i l l fa c i l itate atra u m at i c access.
• I nt ra l u m i n a l posit i o n is co nfirmed by retrograde a n g i og ­ FIG 21 • Retrog rade a ccess: w i re a n d i n n e r d i lator of t h e
ra phy t h r o u g h t h e catheter o r d i l ator (FIG 22) . m i crosheath.
 C h a p t e r 32 T I B IAL I NT E RVE N T I O N S 2 1 01

Antegrade
Wlr�

Peroneal

Retrograde -..J
I
dilator

F I G 22 • Retro g ra d e access o f t h e peroneal a rtery

a n g i o g r a m from t h e i ntrod ucer confi rms t h e i nt ra l u m i n a l
posit i o n .

Fourth Step: Exteriorization o f the Wire from the • D i st a l i ntra l u m i n a l positi o n is confirmed with a rteriog ra­
Femoral Access Site phy t h r o u g h t h e cross i n g catheter.
• Next, t h e t h r o u g h a n d t h r o u g h w i re is rem oved from t h e
• N ext, an atte m pt is m a d e to advance t h e g u i d e w i re i nto
a nteg rade s h e a t h , l eavi n g t h e cross i n g catheter across
the a ntegrade s h eath .
the l e s i o n . The wire i s exc h a n g e d for a 300-cm work i n g
• W h e n t h i s p roves d iffi c u l t on its own, a s n a re is d e p l oyed
wi re, adva n ced d i sta l ly t h r o u g h t h e a ntegrade cross i n g
t h ro u g h t h e a nteg rade sheath to capture and exte r n a l ­
catheter.
ize t h e d i st a l retro g ra d e w i re (FIG 24) . • The retrog rade a ccess catheter or m i c ro p u n ctu re 4-Fr
• F o l l o w i n g s u ccessf u l exte r n a l ization of t h e retro g ra d e
access d i l ator i s su bse q u ently removed from t h e d i s­
wi re, " w i re access" i s ava i l a b l e f r o m b o t h e n d s .
ta l ta rget a rte ry. H e m ostas i s is obta i ned a n d m a i n ­
• A cross i n g catheter is t h e n advanced from t h e antegrade
ta i n ed b y m a n u a l pressu re at t h e access s i t e (FIG 25),
access site ove r t h e w i re to t h e patent tibial vessel d ista l
the a p p l icat i o n of a b l ood p ress u re cuff across the site
to t h e occ l u s i o n .

- AT

Pop

--

AT

TPT

...._
.... ... . __.
.

-- Wiro
-

A B c
FIG 23 • A. A n g i o g r a m from antegrade sheath. Wi re cross i n g t h e occ l u d e d PT. B. A n g i o g r a m confi rm i n g e ntry of t h e w i re
i nto t h e t i b i o p e r o n e a l tru n k (TPT) . C. A n g i o g r a m s h ows t h e retro g r a d e w i re a n d catheter across t h e occ l u s i o n i nto t h e p o p l itea l
a rtery p roxi m a l ly.
2 1 02 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

-
-

-
PT
l
Extomal
BP Cun

FIG 26 • A n g i o g r a m of PT a ccess site with b l ood pressu re

FIG 24 • S n a r i n g t h e retro g ra d e w i re i nto t h e prox i m a l cuff used for h e m ostas i s ( i m a g e o n the r i g h t of the screen).
sheath.

(FIG 26), or a rad i a l co m p ress i o n device (Dstat T M R a d i a l Antegrade-Retrograde Approach

H e m ostat B a n d ) .
• If t h e retrog rade w i re is not a b l e to cross t h e l e s i o n a n d
• Remov i n g a l l devices f r o m t h e retro g ra d e access s i t e as
q u ickly a s poss i b l e red u ces i nstr u m e ntati o n time a n d reg a i n access to t h e t r u e l u m e n , a n antegrade-retrog rade

potenti a l f o r a rte r i a l i nj u ry a n d d i st a l t h ro m bosis. a p proach m a y be used to create adjacent s u b i nt i m a l

• I nflati n g a ba l l oo n adva n ced from t h e a ntegrade a ccess p l a nes i n o p posi n g d i rect i o n s (FIG 29) .
• The d i ssect i o n f l a p separat i n g t h e adjacent s u b i nt i m a l
sheath across the retrograde access site (FIG 27) may
affect h e m ostas i s but can a lso i ncrease tra u m atic i nj u ry spaces m a y be d i sru pted b y s i m u lta neous i nflation i n

a n d access site b l e e d i n g a n d is t h a n kfu l ly rarely n e e d e d . both d i rect i o n s .

• T h i s a l l ows visu a l i zation a n d reca n a l ization of t r u e

Fifth Step: Treatment with Balloon Angioplasty l u m e n from e i t h e r o r b o t h d i rect i o n s . The t w o PTA b a l ­
l o o n s sel ected f o r t h i s m a n e uver s h o u l d be s i z e d a p p ro­
• The i nterve n t i o n is t h e n performed in t h e sta n d a rd fash­ priately to m i n i m ize risk for ta rget a rte r i a l r u pt u r e .
i o n from t h e a ntegrade a p p roach (FIG 28) .

�
I

FIG 2S • H e m ostas i s w i t h m a n u a l c o m p ress i o n postretro­ FIG 27 • A n g i o g r a m s h ows extravasation from retrograde

g rade PT access. pero n e a l access site postreca n a l ization of TPT.

 C h a p t e r 32 T I B IAL I NT E RVE N T I O N S 2 1 03

/
- ::""'
TP'T

... .;4dlf ...,.

I
=- �
L� J
-...
PT

FIG 29 •
Retro g ra d e/a nteg rade PTA to d is r u pt t h e m e m b r a n e
between t w o s u b i nt i m a l p l a nes.
A B

FIG 28 • A. B a l l o o n a n g i o p l asty of the occ l u d ed PT post­

retrog rade reca n a l ization a n d exte riorization of the w i re
from t h e antegrade sheath. B. Co m p l et i o n a n g i o g r a m sh ows
good f l ow i nto the PT without any d issect i o n .

PEARLS AND PITFALLS

G o a l s for p e rcuta neous t i b i a l
reva scu l a rization
Contra latera l o r antegrade fe m o r a l
access
U ltraso u n d -g u i d ed a ccess
Retro g ra d e a p p roach
Sheath l ess retro g ra d e tech n i q u e
Cross i n g tota l occ l u s i o n s
B a l l oon-assisted reca n a l ization
K i ss i n g balloon tech n i q u e
Anticoa g u l a t i o n
Va sod i l ators
• Ach i eve d i rect i n - l i n e flow to t h e i sc h e m i c foot a n d, when poss i b l e, opti m i ze p e d a l
perfu s i o n by reca n a l i z i n g m o re t h a n o n e occ l u d ed t i b i a l a rte ry.
• C h o i ce based on i nflow a n atomy a n d ta rget l e s i o n . Adva n c e m e n t of t h e a ntegrade
sheath t i p i nto t h e p o p l itea l a rtery i s key for s u ccessf u l t i b i a l revasc u l a rizat i o n .
• Can h e l p access t h e a nterior wa l l of t h e vessel i n a rel atively d isease-free s p o t a n d m i n i ­
m i ze access site co m p l icat i o n s . It i s reco m m en d e d i n a nteg rade fe m o ra l access a n d retro­
g ra d e p e d a l a ccess.
• S h o u l d not b e regarded as the fi rst option for t i b i a l i nte rve ntions. It i s s e l ectively consid­
ered after fa i l ed atte m pts at a nteg rade access a n d i n t h e sett i n g of f l u s h occ l u s i o n s of
t h e a nteg rade a rtery with l a rge, adjacent co l l atera l s .
• I s p referred to m i n i m ize t i b i a l a rtery access co m p l icat i o n s s u c h as d issect i o n a n d t h ro m ­
b o s i s . Reca n a l ization is a c h i eved with a w i re a n d s u p p o rt catheter. H e m ostas i s w i t h
m a n u a l c o m p ress i o n i s u s u a l ly suffi cient.
• The i nt ra l u m i n a l plane i s atte m pted fi rst with a stiff w i re a n d cross i n g catheter.
The proper catheter positi o n s h o u l d be confirmed with a sel ective a rteriog ra p h y p r i o r to
defin itive a n g i o p l asty.
• I nflation of a 2 - m m b a l l o o n may assist with the reca n a l ization of l o n g ca l cified
occl u s i o n s .
• I s s o m e t i m e s needed to t r e a t t h e ost i a l l e s i o n s at t h e o r i g i n of t h e a nterior t i b i a l o r pos­
terior t i b i a l a rte ry, d e p e n d i n g o n t h e a m o u nt of p l a q u e in t h e adjacent p e ro n e a l a rtery
or t i b i o p e ro n e a l t r u n k .
• M a i nta i n a n ACT of g reater t h a n 250 secon d s t h r o u g h o u t t h e interve n t i o n . Cont i n u o u s o r
i nterm itte nt f l u s h i n g o f t h e p o p l itea l s h e a t h w i t h h e p a r i n ized sol ution i s recom m e n d e d .
• A r e u s e d f r o m t h e a nteg rade s h e a t h a n d at t h e p e d a l access s i t e to p revent vasospasm
and to a l low better v i s u a l ization of t i b i a l vesse l s d ista l to t h e occ l u s i o n
2 1 04 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY
A p ress u re .
POSTOPERATIVE CARE
• Following the procedure, the patient is observed in the
recovery unit with serial postarterial intervention, neurovas­
cular exams, and intravenous and oral hydration.
• A clopidogrel loading dose (usually 300 mg) is administered
when the patient is not already on dual antiplatelet therapy.
Dual anti platelet therapy is recommended for at least 3 months;
longer when stems are used.
• Clinical follow-up is obtained 2 to 4 weeks after the procedure
is performed, including vascular lab studies (usually PVRs,
segmental pressures, and Duplex arterial insonation) (FIG 30) .
• Close follow-up is essential t o ensure optimal symptom reso­
lution and limb salvage.
OUTCOMES
• Tibial balloon angioplasty carries a relatively low primary
patency rate but can greatly augment long-term limb sal­
vage rates. The minimally invasive nature of the procedure
is especially advantageous in high medical risk patients.
One year primary patency rates in experienced hands range
from 3 0 % to 4 0 % ; secondary patency rates approach 6 0 % ,
with ultimate limb salvage greater than 70 % . 1•2
• Use of a drug-eluting balloon may improve patency rates.
• Primary stenting does not appear to offer any advantage over
tibial angioplasty alone.3 There may be some patency advantage
associated with drug eluting, as compared to bare metal stents.4
Stenting under all circumstances should be considered as a " bail­
out, " used to improve suboptimal results of angioplasty alone.5
• Patients with significant tissue loss and gangrene should
be followed very closely after successful tibial angioplasty.
Lesional restenosis rates trend higher in patients at increased
risk for limb loss.6
• Multilevel interventions, when necessary, are associated with
improved limb salvage rate and wound healing compared to
isolated tibial interventions. 2
• Postangioplasty arterial restenosis may portend less clinical
significance once healing is achieved in the distal limb or
forefoot. The temporary increase in blood flow following
angioplasty is often sufficient to heal small ulcerations?
• There is some evidence of improved patency with drug­
eluting stems and drug-eluting balloons.4•8
COMPLICATIONS
• Access site complications (hematoma, bleeding, pseudo­
aneurysm) are more common with the ipsilateral antegrade
femoral approach.
FIG 30 • A. D u p l ex of the a nterior t i b i a l a rtery
postreca n a l i zation and a n g i o p l asty s h ows
patent vesse l with relatively n o r m a l D o p p l e r
fl ow. B. Fol low- u p PVRs postreca n a l i zation a n d
a n g i o p l asty o f t h e r i g h t a nterior t i b i a l a rtery a n d
r i g h t poste r i o r t i b i a l a rtery d e m o n strates n o r m a l
PVR wavefo r m s i n t h e foot w i t h a d e q u ate toe
• Contrast-induced nephropathy can be avoided by sufficient
preoperative, intraoperative, and postoperative hydration as
well as j udicious use of contrast at all times.
• Vessel thrombosis can be avoided by maintaining a therapeu­
tic anticoagulation level throughout the procedure. The use
of nitroglycerin can help prevent vasospasm and a low-flow
state. Dual antiplatelet therapy is recommended to avoid early
postprocedural target artery thrombosis.
• Outflow embolization may be successfully treated with aspi­
ration embolectomy or alteplase if needed.
• Retrograde access site bleeding, dissection, and vessel throm­
bosis are described after the retrograde pedal access. Using
ultrasound-guided access, sheathless technique and the use
of local vasodilators may minimize the risk of retrograde
access site complications.
• Compartment syndrome may develop either from reper­
fusion inj ury following successful intervention or, more
commonly, perforation of tibial arteries in the deep compart­
ments of the leg.
• Limb loss may result from failed intervention, iatrogenic
vessel thrombosis, distal arterial occlusion following embo­
lization, and compartment syndrome.
REFERENCES
1. Fernandez N, McEnaney R, Marone LK, et al. Predictors of failure
and success of tibial interventions for critical limb ischemia. J Vase
Surg. 2010;52:834-842.
2. Fernandez N, McEnaney R, Marone LK, et al. Multilevel versus iso­
lated endovascular interventions for critical limb ischemia. J Vase
Surg. 2011;54:722-729.
3. Randon C, Jacobs B, De Ryck F, et al. Angioplasty or primary stent­
ing for infrapopliteal lesions: results of a prospective randomized trial.
Cardiovase Intervent Radial. 2010;32:260-269.
4. Bosiers M, Scheinert D, Peeters P, et al. Randomized comparison of
everolimus-eluting versus bare-metal stents in patients with critical
limb ischemia and infrapopliteal arterial occlusive disease. J Vase Surg.
2012;55:390-398.
5. Donas K, Torsello G, Schwindt A, et al. Below knee bare nitinol stent
placement in high-risk patients with critical limb ischemia is still
durable after 24 months of follow-up. J Vase Surg. 2010;52:356-361.
6. Sagib NU, Domenick N, Cho JS, et al. Predictors and outcomes of
restenosis following tibial artery endovascular interventions for criti­
cal limb ischemia. J Vase Surg. 2013;57(3):692-699.
7. Schmidt A, Ulrich M, Winker B, et al. Angiographic patency and
clinical outcome after balloon-angioplasty for extensive infrapopliteal
arterial disease. Catheter Cardiovase Interv. 2010;76:1047-1054.
8. Schmidt A, Piorkowski M, Werner M, et al. First experience with
drug-eluting balloons in infrapopliteal arteries: restenosis rate and
clinical outcomes. ] Am Coli Cardia/. 2011;58;1105-1109.

Chapter 33
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - r - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Geetha Jeya b a /a n
DEFINITION
• Perimalleolar bypasses are defined by the anatomic location
of the distal target outflow vessel. Perimalleolar bypasses
refer to any bypass in which the distal target vessel of re­
vascularization is the posterior tibialis, anterior tibialis, or
peroneal arteries at the level of the ankle. The pedal vessels
(dorsalis pedis, posterior tibialis, lateral or medial plantar
artery) are also target vessels in some patients with very
distal disease.
• These bypasses are performed in patients with advanced
critical limb ischemia (CLI), which includes tissue loss, or is­
chemic rest pain for which there is not a durable or feasible
endovascular option. With the advent of advanced endovas­
cular techniques, the indications for perimalleolar or tibial by­
passes are evolving. The inflow vessel and conduit chosen are
tailored to individual patients and their anatomic limitations.
DIFFERENTIAL DIAGNOSIS
• The three major etiologies of lower extremity ulceration in­
c! ude ischemic, neuropathic, and venous stasis disease. Al­
though all of these can have poor perfusion as a primary
contributing factor, the diagnostic workup and management
may be slightly different. Arterial ulcerations typically have
a punched-out dry appearance and usually occur on the dis­
tal forefoot and toes, whereas neuropathic ulcerations often
occur on pressure points and are associated with calluses.
Venous stasis ulcerations are typically located on the medial
or lateral malleolus and have associated skin changes and
brawny induration in addition to serous drainage.
PATIENT HISTORY AND PHYSICAL
FINDINGS
• Patients with CLI typically present with ischemic rest pain
and/or tissue loss or forefoot gangrene. Most of these pa­
tients have significant comorbid conditions such as diabetes
mellitus, coronary artery disease, hyperlipidemia, and hy­
pertension that will be important for risk stratification and
in deciding between different revascularization modalities.
Additionally, managing and optimizing these risk factors
are keys to successful outcomes following lower extremity
revascularization, regardless of the technique used. As
such, optimizing lipid profile, glycemic control, smoking
cessation; minimizing renal dysfunction; and managing
hypercoagulable states are all essential components to the
perioperative medical management, in addition to manag­
ing any concomitant coronary disease. The majority of pa­
tients are already followed by a team of physicians for their
comorbidities (primary care physician, cardiologist, endocri­
nologist, nephrologist), whereas the surgical team is evaluat­
ing the peripheral vascular disease. It is imperative that these
consultants remain actively involved in the perioperative
I
Perimalleolar Bypass and
Hybrid Techniques
-..
Rabih A. Cha e r
period for both the short-term and long-term success of limb
salvage and overall survival. The age of the patient, func­
tional status, and comorbidities guide the vascular surgeon's
decision making in terms of the type of revascularization of­
fered to the patient.
• Most patients presenting as outpatients will have a history
of symptoms of disabling claudication, rest pain, or tissue
loss. Taking a careful history noting duration of symptoms,
level of pain/claudication, areas of tissue loss, and history
of traumatic neuropathic ulceration will guide the workup.
Young patients, younger than 60 years of age, or patients
with multiple arterial/venous thromboses should undergo a
thrombophilia evaluation. Physical examination should in­
clude a thorough peripheral vascular examination, includ­
ing assessment of the potential presence of a palpable aortic
aneurysm on abdominal exam. The quality and symmetry of
pulses and/or handheld Doppler signals between both legs at
the femoral, popliteal, and pedal levels assist in determining
the anatomic level of disease. Wound documentation, when
present, should note location, depth, presence of infection,
bone exposure, and extent of soft tissue defects. Neuropathic
deformities of the foot should also be taken into careful con­
sideration for offloading purposes. If there is gross purulence
or systemic signs of infection, a debridement of the affected
area is required prior to revascularization, even if the area is
malperfused, for source sepsis control.
• The location and appearance of ulcerations will often as­
sist in differentiating ischemic, neuropathic, or decubitus
wounds. Location of the ischemic wound is important in
determining which target vessel will be chosen for revascu­
larization. If the history and physical examination suggest
peripheral vascular disease as the primary diagnosis, then
noninvasive vascular testing is the next step in determining
need for revascularization and level of disease.
IMAGING AND OTHER DIAGNOSTIC
STUDIES
• After a thorough history and physical examination, the
diagnostic workup of patients with ischemic ulcerations,
rest pain, or significant claudication involves noninvasive
vascular testing. This involves calculation of ankle-brachial
indices and pulsed volume recordings in addition to duplex
imaging of the extremity. An ankle-brachial index (ABI) of
less than 0.4 is typically seen in patients with CLI ( FIG 1 ) .
Toe pressures o f less than 40 mmHg suggest inadequate
perfusion for wound healing. In cases of severely calcified
vessels, it is important to obtain associated pulsed volume
recordings and toe pressures because ABis can be falsely
elevated due to vessel incompressibility. Transcutaneous
oxygen tension (TcP0 ) measurement can also be used
2
to determine the severity of ischemia and probability of
wound healing.
21 05
2 1 06 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

Ankle
1 90
mm
Hg
A no
1 90

FIG 2 • D i g ita l s u btract i o n a n g i o g r a p h y with catheter p l a ced i n

t h e c o m m o n fe m o ra l a rtery to fi l l c o l late r a l s from t h e p rofu n d a
to m o re d i st a l ta rget vesse ls.
FIG 1 • Seve rely reduced A B I a n d fl atte ned d i sta l p u l sed vo l u m e
record i n g s ( PVRs) .

bypass typically have multilevel disease. As such, it is criti­

cally important to image the runoff with the catheter placed
• Once the history, physical examination, and noninvasive proximal to the profunda origin, as the distal runoff will
testing are complete, the surgeon must determine the next likely be filling from profunda collaterals that are commu­
step in imaging, which may be both diagnostic and thera­ nicating with geniculate collaterals. With common femoral
peutic. The patient's functional status, cardiac risk profile, or profunda disease, the catheter will need to be placed in
and other comorbidities (ambulatory status, etc . ) will all the common iliac artery to evaluate internal iliac collaterals
play an important role in determining whether any revascu­ that are in communication with the profunda and more dis­
larization attempt is even feasible. If femoral pulses are not tal collaterals. Performing magnified, time-delayed digital
palpable on physical examination and noninvasive testing is subtraction angiography will assist in revealing which tibial
also suggestive of inflow disease, computed tomography ar­ vessels are patent and filling through collateral networks. It
teriography ( CTA) may be instrumental in evaluating the ex­ is also essential to identify the primary named crural artery
tent of aortoiliac disease, taking into account renal function that is in continuity to the foot that will perfuse the tissue
and risk of contrast-induced nephrotoxicity. Alternatively, affected by ischemic ulceration ( FIG 3) .
aortography obtained from contralateral femoral access or • Using full-strength contrast, magnified proj ections o f the
upper extremity arterial access may suffice. General manage­ foot will help delineate which pedal vessels are patent, which
ment approaches to aortoiliac versus infrainguinal disease fill the tarsal and plantar branches, and confirm the status of
are discussed elsewhere in this book. the plantar arch. Occasionally, there are situations in which
• Once the clinical determination is made that the level of dis­ no suitable target (e.g., " named" artery) is identifiable and
ease is infrainguinal, digital subtraction angiography is an
excellent diagnostic test and provides access for therapeutic
intervention as well. This chapter focuses on patients with
multilevel infrainguinal disease who, presumably, have either
failed endovascular revascularization, prior open bypass, or
who have no endovascular options for revascularization.
Therefore, the primary goal of diagnostic angiography is to
assess the caliber and quality of inflow vessels and bypass
targets.
• The contralateral femoral artery is accessed and an aorta­
gram with oblique pelvic views is obtained to rule out the
presence of inflow disease that may need treatment prior to
evaluating the infrainguinal segment. An ipsilateral oblique
magnified projection will be helpful in determining if there
is any significant common femoral or profunda femoris ste­
nosis, which is especially important if these vessels are to be
chosen as the source of inflow for an open bypass ( FIG 2 ) .
• Deciding o n which type o f intervention t o perform, endovas­
cular versus open, and how aggressive to be about either ap­
proach is determined by multiple considerations as outlined FIG 3 • M a g n ified o b l i q u e p roject i o n of the foot d e m o n strati n g
earlier and elsewhere in this section. Patients requiring open a patent p l a nt a r a rch a n d d i g ita l vesse ls.
 C h a p t e r 33
exploration of a tibial vessel at the time of operative interven­
tion may be required. This exercise is fraught with risk, how­
ever, especially in the setting of a desperately ischemic foot,
and should rarely be undertaken without conclusive pre- or
intraoperative arteriography. Duplex ultrasonography may
assist in further defining quality, caliber, and patency of
tibial vessels in these situations. Choosing a patent posterior
tibialis or anterior tibialis artery in direct continuity with
the pedal arteries is preferred over a peroneal artery as a
distal target when the former is available, especially in cases
of forefoot wounds; however, peroneal arteries are perfectly
suitable and serviceable in this situation in the absence of
other alternatives.
• The decision to proceed with open perimalleolar bypass is
made in the context of the patient's overall clinical func­
tional status, cardiopulmonary and renal comorbidities,
presence of autogenous saphenous vein conduit, and op­
tions for endovascular revascularization. Preoperative au­
togenous conduit assessment is best performed by detailed
ultrasonographic imaging along the length of the vein.
Preference is always given to a single segment of greater sa­
phenous vein ( GSV) from the ipsilateral leg that is at least
2 .5-3 mm in diameter, compressible, and free of thrombus
throughout. Assessment of the contralateral GSV is useful
in case ipsilateral vein is found to be of poor quality during
operative exploration.
• Inflow artery selection is usually based on length of available
conduit and location of proximal disease. The common, su­
perficial, or deep femoral or popliteal arteries may all serve
as suitable inflow arteries in circumstances where minimal
or insignificant occlusive disease is present proximally. This
determination is best made during diagnostic angiography.
The need for concomitant inflow endarterectomy should
also be evaluated at this time.
A B
FIG 4 • A. Positi o n i n g of t h e leg i n g e n t l e exte r n a l rotati o n to fa c i l itate exposure of t h e G SV m e d i a l l y. B. I d e ntify i n g a n d m a r k i n g t h e
GSV u n d e r u ltraso n o g r a p hy.
P E R I MALLEOLAR BYPASS A N D H Y B R I D TECH N I Q U E S 2 1 07
SURGICAL MANAGEMENT
Preoperative Planning
• Type of anesthesia to be used is determined by the type of
cardiopulmonary comorbidities and the anatomic level of
arterial occlusive disease. Preoperative consultation with
anesthesiology and cardiology is customary in this patient
population to assess the appropriate amount of surgical
risk. General anesthesia, peripheral nerve block, and spinal
anesthesia are all potential options in this group of patients.
Intraoperative fluid administration should be used j udi­
ciously and preoperative preparation should include blood
type determination and crossmatching as necessary. It is our
practice to hold therapeutic anticoagulation for at least a
few days prior to the procedure, but most patients remain on
antiplatelet agents through the day of surgery and continue
through the perioperative period.
Positioning
• Any lower extremity bypass might require intraoperative
angiography and, as such, all such procedures should be
performed on a radiolucent table. The patient is positioned
supine, with the leg slightly abducted and externally rotated
to provide optimal exposure of the ipsilateral GSV harvest
site ( FIG 4 ) . It is our practice to localize the GSV by ultra­
sound to assist in incision planning. This also helps deter­
mine whether the contralateral leg should also be prepped as
an alternative site for vein harvesting.
• Other items that should be available in the room include a sterile
pneumatic tourniquet and surgical bump. Both are useful when
the below knee popliteal artery or tibioperoneal trunk is used
for arterial inflow for the graft. Open forefoot wounds are ex­
cluded from the operative field with adhesive or Ioban drapes.
- - - - -
- - ...
2 1 08 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

PERIMALLEOLAR BYPASS TO THE DISTAL

POSTERIOR TIBIALIS ARTERY
First Step: Exposure of the Posterior Tibialis Artery
at the Ankle

• S i m u lta n eous d i ssection of the i nflow a n d o utfl ow ta rg ets

i ncreases the effi ciency of the operative a p p roach. The
d i stal i n cision is m a rked by p a l pating poste rior to the me­
dial m a l leol us, taking care to avo i d i nj u ry to adjacent GSV
(FIG S). D issection i s carried sharply t h r o u g h skin and sub­
cuta neous tissues a n d t h rou g h the flexor ret i nacu l u m . The
tendons of the flexor d i g itorum longus m uscle a n d flexor
h a l l ucis l o n g u s pass a nteriorly and poste riorly, respec­
tively, to the n e u rovasc u l a r b u n d l e at this leve l . The p a i red
t i b i a l ve i n s a re often seen fi rst as overlying the a rtery. The
t i b i a l n e rve trave ls posterior to the a rtery and may n ot be
seen clearly d u r i n g this exposu re . The t i b i a l a rtery does
n ot need to be d i ssected c i rcu mferent i a l l y if a p n e u m at i c
tou r n i q u et is d e p l oyed for prox i m a l contro l . Use of a to u r­
n i q uet m i n i m izes risk for venous i nj u ry at the d i ssection
FIG 6 • I n c i s i o n for t h e exposu re of t h e fe m o ra l b i f u rcat i o n
site a n d tra u m a to the a rte r i a l e n d oth e l i u m from vesse l
a n d sta rt of t h e G S V h a rvest i n c i s i o n .
loops a n d vasc u l a r c l a m ps. For exposure of the med i a l a n d
l atera l p l a ntar a rteries, the s a m e i n cision is typ i ca l ly ca r­
ried f u rt h e r d i sta l ly onto the m e d i a l aspect of the foot. s h o u l d be d ivided to l i m it the a n g l e f r o m which the g raft
o r i g i n ates from the a rte r i a l a n astomosis. If the below knee
Second Step: Exposure of the Inflow Artery popl itea l a rtery i s to be used as the infl ow, which m i g ht be
• Concu rrent d i ssection of the a rte r i a l i nflow s h o u l d be the case i n d i a betic patients with severe t i b i a l d i sease n ot

performed w h i l e the t i b i a l ta rget is b e i n g exposed . If the a m e n a b l e to e n d ovascu l a r revasc u l a rization, t h i s exposu re

com m o n femoral a rtery is chosen, then a l o n g itu d i n a l ver­ is best obta i ned t h r o u g h a med i a l calf i n c i s i o n .

tica l i n cision j u st below the i n g u i n a l l i g a m e nt w i l l a l low

for s i m u ltaneous expos u re of the fem o r a l bifu rcation in
a d d it i o n to the saphenofemoral j u nct i o n for d i ssection of
the GSV (FIG 6) . If the deep femora l a rtery i s to be used
as i nfl ow, then d ivision of the l atera l femoral c i rcumflex
ve i n may be h e l pf u l in contro l l i n g the fi rst-order branches
past the orig i n . If the deep femoral o ri g i n is truly deep, the
m uscle be l l ies of the a d d uctor longus a n d vastus m e d i a l i s
T hird Step: Harvest and Preparation of Autogenous
Vein
• The cou rse of the G SV is m a rked on t h e s k i n p r i o r to
p re p p i n g . The s h o rtest s e g m e n t of s u it a b l e ca l i be r a n d
q u a l ity G S V i s h a rveste d . I n c i s i o n p l acement is p a rt i a l ly
determ i n e d by t h e location of t h e a rte r i a l access i n c i s i o n s .
Care s h o u l d be taken to avo i d creat i n g s k i n f l a ps d u ri n g

---;.--,--- Flexor digitorum longus muscle

Soleus muscle
a;-r.-- Posterior tibial artery

Tibial nerve

Flexor retinaculum

I plantar artery

Flexor hallucis
brevis muscle Abductor hallucis muscle
FIG 5 • I nc i s i o n for exposure of t h e poste r i o r t i b i a l i s a rtery at t h e m e d i a l m a l l e o l u s .
 C h a p t e r 33 P E R I MALLEOLAR BYPASS A N D H Y B R I D TECH N I Q U E S
Completely open technique
Saphenous vein
harvest com plete
FIG 7 • Preparation of the G SV.
ve i n expos u re . H a rvest i n g ve i n t h r o u g h s k i p i n c i s i o n s
may h e l p to m i n i m ize wo u n d com p l icat i o n s but i s n o t
n ecessa ry for a good res u l t . M i n i m a l ve i n m a n i p u lation,
with care b e i n g taken to accu rate ly l i g ate s i d e branches
with 4-0 b r a i d e d p e r m a n e n t sutu re (or s i l k), is i m porta nt.
M i n i m a l d issect i o n of t h e ve i n is typica l l y req u i red w h e n
i n situ bypass i n p l a n n e d . The ve i n can be l eft i n i t s bed,
with l i m ited d i ssect i o n of t h e a n asto motic s e g m e nts.
Skip i n c i s i o n s p rovide access to l i g ate l a rg e side b r a n c h es.
• After a n adeq u ate l e n gth of saphenous is exposed, it is
removed from its bed for bypass p l acement o r transposed
i nto position after va lve lysis for i n situ bypass. When
Reversed
Common
femoral artery
A B
FIG 8 • A. A valvu l otome b e i n g used to lyse va lves in a n o n reve rsed ve i n u n d e r d iste n s i o n . B. Tu n n e l i n g with h o l l ow t u n n e l i n g
device t h ro u g h t h e su bcuta n e o u s tissues away from s a p h e n ectomy site.
2 1 09
removed a n d repositioned, we g e n e ra l ly try to use the
l a rgest d i a meter segment for bypass. The saphenofemo­
ra l j u n ct i o n i s oversewn or suture l i gate d . The vei n is then
reversed and d istended gently with h e p a r i n ized sa l i n e
o r p l a s m a lyte solution. Oth e r ve i n p reservative solutions
can be used at the d i scretion of the surgeon. Any u ntied
branches a re ca refu l l y c l a m ped a n d tied with silk suture.
S m a l l tears o r h o l es a re oversewn i n a l o n g i tu d i n a l fas h i o n ,
ta k i n g c a r e n ot to n a rrow the ve i n , u s i n g 7 - 0 polypropyl­
e n e suture (FIG 7) . Depend i n g o n i n stitut i o n a l expertise,
e n d ovei n ha rvest is an a lternative method to m i n i m i ze i n ­
c i s i o n a l length a n d potential w o u n d com p l ications.
• Once prepa red, ve i n s ca n be used i n reversed o r n o me­
ve rsed confi g u rations. We g e n e ra l ly p refer reversed as to
m i n i m a l ly d i s r u pt the endothe l i u m . If the d i st a l porti o n of
the ve i n i s s i g n ificantly s m a l l e r a n d concern exists regard­
ing size m i s m atch at either e n d , t h e n ve i n s may be posi­
tioned i n a n o n reversed fas h i o n by lys i n g t h e valve. To
lyse t h e ve i n va lves, a valvu l otome is gently passed u p t h e
ve i n after the p rox i m a l a n astomosis i s co m p l ete a n d t h e
ve i n is perfused a n d d iste n d e d . It is critica l ly i m po rta nt
to have the fi rst assista nt p rovid e gentle cou ntertract i o n
o n t h e ve i n as t h e valvu l otome i s hooked o n t h e va lves
in order to lyse them (FIG SA) . C a re m u st a l so be taken
to not hook the va l v u l otome o n a n y l i g ated branches to
avo i d tea r i n g the ve i n . Other c o m m e rc i a l ly ava i l a b l e va l ­
v u l otomes ca n be u s e d at t h e d i scret i o n of t h e s u r g e o n .
• Tu n n e l i n g t h e ve i n : The t u n n e l i s created u s i n g a h o l l ow
t u n n e l e r (e . g ., G o re, Sca n l a n, J e n k n e r) with a b l u nt a p ­
propriately s i zed t i p (6 m m at least) i n a s u bcuta n e o u s
p l a n e a w a y f r o m t h e s a p h e n ecto my i nc i s i o n , if poss i b l e,
to avo i d wo u n d co m p l i cations. The ve i n is ca refu l ly i n ­
spected at t h e entry a n d exit s i t e o f t h e t u n n e l to e n s u re
it is in a l oose p l a n e a n d n ot constra i n e d by fasc i a l o r
m u sc u l a r b a n d s (FIG SB) .
Sartori us muscle
21 1 0 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

• After syst e m i c a nticoa g u lation is a c h i eved with u nfrac­

t i o n ate h e p a r i n , the p roxi m a l a n asto mosis i s p e rformed
after contro l l i n g t h e i nflow a rtery with vesse l loops o r
vasc u l a r c l a m ps. The loops o r c l a m ps a re released a n d t h e
a n asto mosis is confi rmed to be h e m ostatic. O n ce t h i s i s
assu red, t h e ve i n i s perfused a n d d i stended, t h e valves
a re lysed if a p p l i ca b l e, and the vein i s m a rked for ori­
entat i o n . It i s t h e n passed through t h e t u n n e l e r to exit
t h e d i sta l i n ci s i o n and c l a m ped proxi m a l ly with a n atra u ­
matic b u l l d o g c l a m p o r Yasa rg i l c l i p . The l e n gt h of v e i n
needed i s dete r m i n ed afte r t h e ve i n h a s a l ready been
t u n n e l ed and d iste nded, with t h e l e g i n a maxi m a l l y ex­
tended positio n . The leg can be m a n i p u l ated in va r i o u s
pos i t i o n s with knee flexion to m a ke s u re a n y excess o r re­
d u n d a n t ve i n i s a p p ro p r i ately t r i m m e d p r i o r to e m b a rk­
ing o n t h e d ista l a n asto mosis.

Fourth Step: Distal Anastomosis Creation

• If a tou r n i q uet is to be used for d i sta l control, t h e n the

l ower l e g i s exsa n g u i nated using a n E s m a rch b a n d a g e .
The to u r n i q uet i s p l aced a r o u n d t h e t h i g h if t h e i n f l ow
is at t h e level of t h e co m m o n fe m o r a l , profu n d a femo r i s,
or proxi m a l s u p e rfi c i a l fe m o r a l a rteries. It is i nfl ated to FIG 9 • Ta rget a rtery i s i d e ntified and a n a sto m o s i s is created

250 to 300 m m H g . T h e ta rget is t h e n i d e ntified. Care i s i n an e n d -to-s i d e tech n i q u e .

taken to i d e ntify t h e a rtery i n stead of t h e ve i n beca use
t h ey ca n a p p e a r dece ptive ly s i m i l a r when exsa n g u i nated
is taken to avo i d i nj u ry to t h e sa p h e n o u s n e rve. At t h e
u n d e r to u r n i q uet h e m ostasis. The d ista l a n astomosis i s
a n k l e a n d a r o u n d p o i nts of f l e x i o n , s u c h a s t h e k n e e , i t
created u s i n g a 6 - 0 , 7 - 0 , o r 8 - 0 polypropy l e n e suture de­
is usefu l to use vertical m attress n y l o n sutu re. It i s a lso
pen d i n g o n t h e size of t h e ta rget a rte ry. Lo u p e m a g n ifi­
i m po rtant to close t h e a n k l e i n c i s i o n fi rst before reperfu­
cat i o n is h e l pf u l and g e n e ra l ly m a n d atory i n this sett i n g .
s i o n e d e m a m a kes tension-free c l o s u re c h a l l e n g i n g . It i s
The fi rst assistant s h o u l d s i t beside t h e operati n g s u r­
often d iffi c u l t to g et m o re t h a n o n e l ayer of s u bcutane­
g e o n to m a i nta i n s u t u re t e n s i o n a r o u n d t h e a n asto mosis
o u s tissue ove r t h e bypass and d i st a l a n asto m o s i s at t h e
a n d s u ct i o n away b l o o d a n d d e b r i s from t h e ope rative
peri m a l l e o l a r l e v e l (FIG 1 0) .
f i e l d (FIG 9) .
• The patency o f t h e bypass i s assessed i ntraoperative ly
• If t h e to u r n i q uet fa i l s to m a i nta i n suffi cient h e m ostasis
by m u lt i p l e pote n t i a l methods. Fee l i n g a stro n g bypass
d u e to m e d i a l ca l cificat i o n i n t h e l a rg e r p roxi m a l a rter­
p u l se in t h e t u n n e l and in the ta rget vesse l d i st a l to the
ies, oth e r opti o n s for h e m ostas i s i n c l u d e vessel loops a n d
a n asto mosis i s reassu r i n g . Liste n i n g with a h a n d h e l d
vasc u l a r c l a m ps f o r t i b i a l control, u s e o f vesse l sto p p e rs,
D o p p l e r to assess t h e q u a l ity o f t h e D o p p l e r s i g n a l of
o r use of a carbon d i ox i d e (C0 2 ) b l ower s u ct i o n device.
the a rtery d ista l to the d i sta l a n asto mosis i s a l so h e l pfu l .
C i rc u mferent i a l t i b i a l a rtery d issect i o n m u st be d o n e
A m u l t i p h asic stro n g D o p p l e r s i g n a l that a u g m e nts s i g ­
w i t h ca re to a v o i d i nj u ry to t h e adjacent p a i red t i b i a l
n ificantly w h e n t h e g raft i s fi rst com p ressed a n d t h e n re­
vei ns, o r ve n a e com ita ntes, t h a t g ive off seve ra l cross­
l eased i s s u g g estive of a patent bypass. In the a bsence of
ing branches a b ove and below the ta rget a rte ry. Newer
strong c l i n i ca l s i g n s of g raft patency (e . g . , p a l p a b l e d i st a l
d isso l v i n g e n d o l u m i n a l occ l u s i o n gels a re ava i l a b l e for
t e m p o r a ry h e m ostas i s as we l l and may p rovide a less
t ra u matic method of control in s m a l l e r a rteries.
• P r i o r to co m p l et i o n of t h e a n a stomosis, t h e t o u r n i q uet
i s deflated and f l u s h e d . T h e prox i m a l g raft c l a m p or
b u l l d o g i s r e l e a se d and t h e a n asto m o s i s i s t h o ro u g h l y
f l u s h e d p r i o r to tyi n g d o w n a n d co m p l et i n g t h e a n as­
tomosis. To p i c a l a g e nts such a s t h ro m b i n/G e l fo a m ,
S u r g i ce l ®, o r F l osea l ® may be h e l pf u l i n obta i n i n g he­
m osta s i s fo l l owi n g reve rsa l of a nticoa g u l a t i o n with
prota m i n e .
• Wo u n d c l o s u re is a key c o m p o n e n t of t h e operat i o n .
M ost of t h e m o r b i d ity f r o m these p roced u res a r i ses from
wo u n d co m p l icat i o n s . The ve i n h a rvest bed s h o u l d be i r­
rig ated, i ns pected for h e m ostas i s, a n d c l osed i n m u lt i p l e
l ayers o f r u n n i n g o r i nterru pted a bsorba b l e sutu re. Care FIG 10 • C l os u re of t h e sa p h e n o u s h a rvest s i t e .
 C h a p t e r 33 P E R I MALLEOLAR BYPASS A N D H Y B R I D TECH N I Q U E S 21 1 1

p u l se), a n i ntraoperative c o l o r f l o w d u p l ex scan m a y b e

used to i d e ntify pote nti a l flow l i m it i n g d efects, such a s
reta i n e d valves, foca l vel ocity e l evat i o n s, a n d l ow f l ow i n
t h e g raft itself. H owever, i ntraoperative d u p l ex sca n n i n g
i s n o t ava i l a b l e i n a l l o p e rat i n g rooms with sufficient res­
o l ution to recog n ize these d efects. F i n a l ly, o n -ta b l e a rte­
riography a lso provides usef u l d eta i l regard i n g potenti a l
p r o b l e ms, i n c l u d i n g t h e stat u s o f t h e a n astom oses, t u n ­
n e l i n g issu es, a n d t h e p resence o f reta i n e d va lves, if
a ny. C o m p l et i o n a rteriography can be pe rfo rmed either
through a n u p- a n d -ove r a p p roach from t h e contra late ra l
fe m o ra l a rtery o r with a p u n ct u re i n t h e i ps i late r a l i n ­
f l o w a rtery j ust a bove t h e p roxi m a l a n asta mosis (FIG 1 1 ) .
S o m e deg ree o f s p a s m may be s e e n at t h e site o f c l a m p
p l a c e m e n t o r vesse l l o o p m a n i p u lati o n . W h e n t u n n e l ­
i n g concerns a rise, dyn a m i c a rte riography w i t h t h e l e g
fl exed a n d exte n d e d i n v a r i o u s positions can be h e l pf u l
t o prevent k i n k i n g of t h e bypass i n t h e e a r l y posto pera­ FIG 1 1 • O n -ta b l e a n g iography to assess the bypass fo l l owi n g
tive p e r i o d . com p l etion o f the a n a stom oses.

PERIMALLEOLAR BYPASS TO THE DISTAL t e n d o n s often e a s i l y i d e ntify t h i s g roove in w h i c h the a r­

tery r u n s . The exte nsor reti n a cu l u m is d iv i d e d at t h e m a l ­
ANTERIOR TIBIALIS ARTERY l e o l u s a n d t h e vasc u l a r b u n d l e s h o u l d be e a s i l y i d e ntified
First Step: Exposure of the Anterior Tibialis Artery at t h i s l evel l y i n g a l o n g t h e anterior su rfa ce of t h e t i b i a
at the Ankle (FIG 1 2) .

• S i m u lta neous d i ssect i o n of t h e ve i n a n d prox i m a l i nflow
a rtery s h o u l d occ u r w h i l e t h e d ista l bypass ta rget is i d e n ­
t i f i e d a n d contro l led as described e a r l i e r. The d i st a l expo­
s u re of t h e a nterior t i b i a l a bove t h e a n kl e i s p e rformed
by identify i n g t h e tendon of t h e exte nsor h a l l u cis l o n g u s
a n d creat i n g a n i n c i s i o n j u st latera l to t h i s a n d m e d i a l
t o t h e t i b i a l i s a nterior te n d o n . P l a nt a r flexi n g t h e a n k l e
a n d p a l pati n g t h e space that o p e n s between t h e two
Second Step: Tunneling the Vein t o the Anterior
Tibialis Artery
• The G SV is h a rvested a n d e i t h e r reversed or used i n a
n o n reversed fash i o n d e p e n d i n g on factors described
e a r l i e r. T h e t u n n e l from t h e i n flow a rtery to t h e a nte­
rior t i b i a l c a n be m a i nt a i n e d i n a s u bcuta n e o u s p l a n e
a cross t h e a nt e r i o r s u rface o f t h e t i b i a m e d i a l to t h e

FIG 1 2 • Expos i n g t h e a nterior

t i b i a l i s a rtery at t h e a n k l e .
21 1 2 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

exposu re site. A c o u n t e r i n c i s i o n m a y be n e e d e d at t h e
a n k l e to a l low for a g e n t l e r c u rvature of t h e ve i n g ra ft
towa rd t h e d o rsu m of t h e foot. If t h e re is concern a b o u t
pote n t i a l c o m p ress i o n of t h e ve i n g raft i n t h i s reg i o n
b e c a u s e of i t s s u p e rfi c i a l natu re, t h e a lternative i s t o
t u n n e l t h r o u g h t h e i nte rosse u s m e m b ra n e . T h i s t u n n e l
i s created h i g h e r i n t h e c a l f betwee n t h e d e e p poste­
rior and a nt e r i o r co m p a rt m e nts (FIG 1 3) . B e c a u se t h e
G SV h a rvest i n c i s i o n i s a l ready o n t h e m e d i a l ca lf, t h e
d i ssect i o n c a n b e exte n d e d d e e p e r by retract i n g t h e g a s­
troc n e m i u s m u scles poste r i o rly a n d p a rt i a l ly d iv i d i n g
t h e s o l e u s to reach t h e poste r i o r t i b i a l vesse l s . These a re
p rotected a n d g e ntly retracted poste r i o r l y w h i l e t h e fi­
bers of t h e t i b i a l i s poste r i o r m uscle a re sepa rated a n d
t h e t u n n e l e r i s b l u ntly passed t h r o u g h t h e i nte rosse u s
m e m b ra n e h e r e . O n ce t h e ve i n g raft i s i n t h e a nt e r i o r
co m p a rt m e nt, it c a n be t u n n e l e d i n a s u bcuta n e o u s o r
s u bfasc i a l p l a n e to reach t h e exposed a nt e r i o r t i b i a l i s
a rtery j u st a bove t h e a n k l e .

T hird Step: Exposure o f the Dorsalis Pedis Artery

• If t h e d o rs a l p e d a l a rtery is t h e ta rget vesse l , t h e n t h e

exposure d i sta l ly i s o n t h e d o r s u m of t h e foot a n d the
t u n n e l i n g tech n i q u es re m a i n s i m i l a r to what i s outl i n e d
e a r l i e r for t h e a nterior t i b i a l a rtery at t h e a n k l e . An i n -
c i s i o n i s created o n t h e d o r s u m of t h e foot j ust late r a l
to t h e exte nsor h a l l uc i s l o n g u s tendon and carried down
through t h e fasc i a . T h e dorsal p e d a l a rtery l i es late ra l to
the deep peronea I n e rve h e re (FIG 1 4) .
F I G 1 3 • Tu n n e l i n g t h r o u g h t h e i nteross e u s m e m b r a n e a t
t h e m i dcalf.
• Care s h o u l d be taken to n ot l eave se lf-reta i n i n g retrac­
tors in for too long in these s m a l l e r d i st a l i n c i s i o n s to
avo i d t e n s i o n o n the w o u n d edges and pote n t i a l s k i n
necrosis.

Su perficial peroneal nerve,

medial dorsal branch ----c:----

Lateral tarsal artery

Deep peroneal nerve --,.--=1PI\�

Extensor hall ucis

brevis muscle ---"�=��=��tW

FIG 1 4 • Exposure of t h e d o rsa l i s p e d i s a rte ry.

 C h a p t e r 33 P E R I MALLEOLAR BYPASS A N D H Y B R I D TECH N I Q U E S
EXPOSURE OF T H E PERONEAL ARTERY AT
THE ANKLE
First Step: Peroneal Artery Anatomy
• The p e r o n e a l a rtery comes off t h e t i b i o p e r o n e a l t r u n k at
t h e u p pe r c a l f a n d t h e n d i sta l ly branches i nto two per­
forati n g b r a n c hes, termed a nterior a n d poste r i o r perfo­
rat i n g p e ro n e a l a rteri es, w h i c h s u p p l y the a nterior a n d
lateral co m p a rt m e nts a n d com m u n icate with t h e a nte­
rior t i b i a l a rtery and some ta rsa l branches.
Second Step: Exposure of the Distal Third of the
Peroneal Artery
• Because t h e proxi m a l segment of t h e peroneal a rtery
c a n be accessed e a s i l y from a m e d i a l a p p roach, t h e peri­
m a l l e o l a r o r d i sta l t h i rd of t h e a rtery needs to be ap­
proached from a lateral a p p roach a n d req u i res resect i o n
of a p o rt i o n of t h e fi b u l a . An i n c i s i o n i s created a l o n g
the l atera l b o r d e r of t h e f i b u l a a n d d issect i o n i s carried
down through t h e fascia to t h e fibula after w h i c h t h e
peri oste u m is clea red p roxi m a l ly a n d d ista l ly (FIG 1 5) .
The peroneal a rteries are in c l ose prox i m ity to t h e f i b u l a
m ed i a l ly a n d ca re s h o u l d be taken to avo i d i n j u ry to
the vasc u l a r b u n d l e w h e n c l e a r i n g t h e b o n e med i a l ly
(FIG 1 6) . The b o n e can t h e n be excised a n d t h e peroneal
a rtery i s i d e ntified behind t h e i nterosseus m e m b r a n e .
The b o n e c a n be transected u s i n g a G i g l i saw o r osc i l ­
lati n g power saw. The a dvantage o f e i t h e r a trad i t i o n a l
FIG 1 5 • C l e a r i n g the f i b u l a r a n d resect i o n for exposure of the d ista l pero n e a l a rte ry.
21 1 3
b o n e cutter or power saw is that t h e b o n e d oes n ot nec­
essa r i l y have to be c i rcu mferenti a l ly d i ssected .
• T h e peronea l a rtery c a n a lso b e exposed poste r i o rly, b u t
t h i s i s somewhat c h a l l e n g i n g t o d o w h e n t h e patient i s
s u p i n e . An i n c i s i o n j u st a bove t h e a n k l e postero l atera l ly
betwee n t h e t e n d o n s of t h e flexor h a l l uc i s l o n g u s a n d
t h e fl exor d i g it o r u m l o n g u s reve a l s t h e a rtery i n its m ost
d ista l seg m e nt (FIG 1 7) . T h i s a p p roach is favored w h e n
the s m a l l sa p h e n o u s ve i n w i l l a l so be h a rvested for t h e
g raft c o n d u it.
T hird Step: Additional Procedure: Spliced Vein
• D e s p i t e ca refu l preoperative p l a n n i n g a n d effo rts t o
fu l ly i nterrog ate a d e q u ate c o n d u it, t h e g reater s a p h e ­
n o u s ve i n may p rove to be u n s u ita b l e for t h e i ntended
p u rpose once expose d . I f l e n gth of ve i n i s a concern, then
ca refu l c o n s i d e ration should b e g iven to e i t h e r m ovi n g
t h e i n f l ow a n a stomosis m o re d i sta l ly o r m ovi n g t h e ta r­
get a rtery m o re p roxi m a l ly. An a d d i t i o n a l a lternative i s
to create a s h o rter t u n n e l , h a rvest t h e g reater s a p h e n o u s
ve i n f r o m t h e contra late r a l l e g , o r h a rvest a r m ve i n w h e n
o t h e r opti o n s a re not ava i l a b l e o r advisa b l e .
• Occa s i o n a l ly, if n o s u i ta b l e autogenous ve i n c o n d u i t
exists (espec i a l ly i n t h e c a s e of r e d o bypass); c o n s i d e r­
ation may be g iven to cadaveric c ryo p rese rved ve i n o r
prosthetic bypass with ve i n cuffs o r patches d i st a l ly.
The l i m itat i o n s of these n o n a uto g e n o u s options m u st
be w e i g h e d a g a i n st t h e known patency l i m itat i o n s of
s p l i ce d ve i n or a r m ve i n g rafts.
21 1 4 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY
Flexor dig itorum
longus muscle
PEARLS AND PITFALLS
Preoperative p l a n n i n g
Placement o f i n c i s i o n
Tu n n e l i n g
I ntraoperative a ssessment
of bypass
FIG 16 • Exposure of the d ista l t h i rd of
the peroneal a rte ry.
longus m uscle
FIG 1 7 • Poste r i o r a p p roach to t h e d ista l t h i rd of t h e pero n e a l
a rte ry.
• The bypass ta rget i s chosen to p rovi d e t h e best option fo r d i rect i n - l i n e perfusion to a rea of
tissue loss o n the forefoot.
• U s i n g u ltraso u n d in the ope rati n g room to i d e ntify the GSV in relation to the p roxi m a l and d ista l
i n c i s i o n s can h e l p avo i d ra i s i n g flaps or creat i n g posto pe rative w o u n d co m p l icat i o n s .
• Use of a to u r n i q uet a b ove t h e knee can assist i n avo i d i n g u n n ecessa ry m a n i p u l a t i o n a n d
potenti a l i nj u ry to d ista l t i b i a l vesse ls.
• Tu n n e l i n g t h e bypass away from t h e ve i n h a rvest incision c a n help p rotect t h e bypass from
exposu re a n d i nfect i o n i n case of wo u n d co m p l icat i o n s a n d w o u n d d e h iscence posto p e ratively.
• M a n i p u l a t i n g t h e leg i n s l i g htly d iffe rent posit i o n s can assist with eva l u ati n g t h e cou rse of t h e
ve i n bypass i n t h e t u n n e l d u r i n g i ntraoperative assess m e n t w i t h o n -ta b l e a n g i og ra p hy.
 C h a p t e r 33 P E R I MALLEOLAR BYPASS A N D H Y B R I D TECH N I Q U E S 21 1 5

Wo u n d c l o s u re • Avo i d l eavi n g self- reta i n i n g retractors in d i sta l i n c i s i o n s for p r o l o n g e d periods to avo i d s k i n e d g e

Posto pe rative care
necrosis.
• C l o s u re of d i st a l wounds is best acco m p l ished with n y l o n suture i n a vertica l m attress fas h i o n
i n o r d e r to avo i d t e n s i o n o n t h e wo u n d . Wo u n d s ove r t h e d o r s u m of t h e foot c a n be c l osed
with h o rizontal m attress sutu res. Occa s i o n a l ly, a counte r i n c i s i o n may be n ecessa ry to p rovi d e
a d e q u ate cove rage o v e r t h e exposed a rtery at t h e a n k l e .
• A gently p l aced soft cast c a n p revent s i g n ificant l ower l e g edema and s u bse q u ent wo u n d
breakdown i n t h e i m med iate posto perative p e r i o d .
• Pred ischarge d u p l ex assessment of t h e g raft i s i m p o rtant if i ntraoperative a ssess m e n t of t h e
bypass was not perfo rmed with a n g i og ra p h y o r d u p lex.

POSTOPERATIVE CARE
• Because of the length and location of incisions for inflow,
vein harvest, and distal anastomosis, the patient will un­
doubtedly have significant edema postoperatively through­
out the affected leg. To prevent blistering and potential
wound breakdown, the foot, ankle, and lower leg may be
wrapped in a soft cast consisting of an inner layer of Webril®
and outer layer of gently compressive Cohan®. Care needs
to be taken to minimize external compression on the vein
graft itself, especially in the areas around the ankle. The soft
case is changed on postoperative day 3. The patient can am­
bulate starting on postoperative day 1, but the leg should
be elevated when the patient is sitting or in bed. Patients
are left on antiplatelet therapy perioperatively. There is some
data supporting therapeutic anticoagulation in patients with
high-risk vein bypasses (poor runoff, suboptimal conduit,
etc . ) ; however, this must balanced against the risk of bleed­
ing in individual patients.
• For perimalleolar bypass patients who did not get an intra­
operative assessment of their bypass with an on-table angi­
ography, a predischarge duplex is performed to document FIG 18 • S u rve i l l a nce d u p l ex of ve i n bypass.
patency and pedal perfusion. If a significant abnormality is
identified on duplex (significantly low flows in the bypass or
focally high velocities), then this should be addressed prior
to discharge with angiography or exploration of the area
with appropriate intervention. COMPLICATIONS
• Once discharged, patients either return weekly for a change
• Early complications of distal bypasses include bleeding,
of their soft cast until their edema has sufficiently resolved
wound infection/breakdown, and graft occlusion. Late
or follow-up at the 1 -month interval for formal duplex inter­
complications include graft stenosis, limb swelling, graft
rogation of the bypass. Certainly, more frequent visits may
occlusion, and aneurysmal degeneration of the vein bypass.
be warranted in patients with wound concerns.
Most patients with CLI have concomitant coronary disease
• Surveillance duplex of vein bypasses is obtained at the
and the rate of perioperative myocardial infarction can be
3 -month, 6-month, 9-month, and 1 2-month postoperative
as high as 5 % . It is very important to maintain patients on
time points with both ABI and graft duplex ( FIG 1 8) . After
their cardiac medications in the perioperative period and
the 1 -year time point, provided everything is stable clinically
manage fluids j udiciously to avoid precipitating coronary
with the patient and there are no previous abnormalities
events.
on postoperative imaging, the surveillance can be moved to
once a year. Occasionally, the surveillance interval is short­
SUGGESTED READINGS
ened for high-risk bypasses or prosthetic tibial bypasses.
1. Cronenwett JL, Johnston KW, Rutherford BS, eds. Rutherford's Vas­
OUTCOMES cular Surgery. 7th ed. Philadelphia, PA: Saunders/Elsevier; 2010.
2. Wind GG, Valentine RJ, eds. Anatomic Exposures in Vascular Sur­
• Primary patency of perimalleolar vein bypasses can be as high gery. Philadelphia, PA: Lippincott Williams & Wilkins; 2013.
as 77% at 1 year, and limb salvage rates up to 8 5 % at 1 year as 3. Zarins CK, Gewertz BL. Atlas of Vascular Surgery. 2nd ed. New York,
NY: Churchill Livingstone; 2005.
well. Given the significant comorbidities in many patients with
4. Netter FH. Atlas of Human Anatomy. 5th ed. Philadelphia, PA:
CLI, the rate of hospital readmission and poor functional out­ Saunders/Elsevier; 2010.
come can be very high. Wound healing is adversely impacted 5. Zwiebel WJ, Pellerito JS. Introduction to Vascular Ultrasonography.
by the presence of diabetes mellitus and renal failure. 5th ed. Philadelphia, PA: Saunders; 2005.

Chapter 34
I
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - � - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
DEFINITION
• Acute iliofemoral occlusion is defined as complete or partial
thrombosis of any part of the iliac vein and/or the common
femoral vein ( CFV), with or without associated femoropop­
liteal thrombosis, in which symptoms have been present for
14 days or less or for which imaging indicates that thrombo­
sis has occurred within the past 1 4 days or less. 1 Acute ilio­
femoral occlusion may occur de novo following unprovoked
deep vein thrombosis (DVT) or may occur (or reoccur) in
the setting of prior ipsilateral DVT or external compression
(May-Thurner syndrome or neoplasia) . Treatment options
include ( 1 ) systemic anticoagulation alone; (2) open surgi­
cal venous thrombectomy; or ( 3 ) percutaneous intervention,
including catheter-directed thrombolysis, pharmacomechan­
ical thrombectomy, and stenting of intrinsic or extrinsic
obstructive lesions or masses.
DIFFERENTIAL DIAGNOSIS
• Iliofemoral DVT most commonly presents with unilateral leg
swelling and pain. Although patient history and simple diag­
nostic testing can generally distinguish from other causes, dif­
ferential diagnoses include cellulitis or worsening of chronic
conditions such as venous insufficiency or lymphedema.
PATIENT HISTORY AND PHYSICAL FINDINGS
• There are three objectives in the treatment of iliofemoral
thrombotic occlusion: ( 1 ) Prevent propagation of DVT and
subsequent pulmonary embolism (PE), (2) provide symptom­
atic relief for the patient, and ( 3 ) prevent the development of
postthrombotic syndrome (PTS ) .
• A thorough history must be obtained prior t o treatment be­
cause decisions regarding choice of treatment modality are
impacted by severity of symptoms as well as the patient's
overall functional status.
• Specific risk factors that merit individualized questioning in­
clude history of trauma, current or past episodes of DVT or
PE, history of thrombophilia, history or current diagnosis
of cancer, and a history of tobacco or substance use. Family
history of DVT or PE is important to ascertain. A thorough
investigation of current medications should be undertaken,
making note of any contraceptive therapy, hormone re­
placement therapy, or use of anticoagulation (i.e., warfarin,
enoxaparin, etc . ) .
• Symptoms o f iliofemoral occlusion can range from nonde­
script mild symptoms to severe disabling symptoms, and
manifestations of symptoms can vary widely. Commonly
reported symptoms of iliofemoral occlusion include limb
21 1 6
-
Acute I liofemoral Deep Vein
Thrombosis and May-Thurner
Syndrome: Surgical and
lnterventional Management
·
Sha ron C. Kia ng Bria n G. DeRubertis
edema, heaviness, pain, lifestyle-limiting venous claudi­
cation, stasis dermatitis, and in advanced cases, venous
ulcerations.2 Duration of symptoms and consideration of in­
citing events at the time of symptom development will help
differentiate acute occlusion from exacerbation of chronic
disease.
• Symptom severity is an important differentiating variable
in the management rubric of acute iliofemoral occlusion;
severe and persistent symptoms, especially those continuing
following the initiation of therapeutic anticoagulation, in­
crease the likelihood of long-term disabling sequelae. The
more severe and persistent the symptoms, the more j ustified
the indication for aggressive thrombus removal.
• A detailed physical examination is essential. Conditions that
produce symptoms mimicking those associated with iliofem­
oral occlusion should be excluded. A thorough abdominal
and lower extremity pulse examination, with noninvasive
physiologic testing if necessary, will exclude possibility of
arterial insufficiency. Comprehensive assessment of periph­
eral motor and sensory nerve function and of the spine and
lower limb j oints can rule out these confounding etiologies.
• The affected limb(s) should be examined for evidence of
chronic venous insufficiency and/or stasis dermatitis, as well
as signs and symptoms of acute DVT. Signs of acute iliofemo­
ral occlusion may include pain, swelling, and bluish discol­
oration. Extensive thrombus propagation throughout the
ipsilateral venous system may lead to phlegmasia alba dolens,
characterized by profound painful swelling and a pale, milk­
like skin hue. Further thrombus propagation from the deep to
the superficial venous system increases outflow obstruction to
the point of impeding arterial inflow, precipitating phlegmasia
cerulea dolens, limb threat, and tissue loss.
• In patients with either acute or chronic venous disease, objective
evaluation and prognostic stratification is best accomplished by
using the CEAP ( Clinical, Etiology, Anatomy, Pathophysiology)
system and venous clinical severity score (VCSS).3•4
• Because multiple interventions may be required to optimize
outcome in acute iliofemoral disease, patients' expectations
should be managed accordingly. In addition, iliac and femoral
venous intervention commonly requires extended periods of
postoperative anticoagulation (warfarin and/or low-molecular­
weight heparin) to ensure long-term procedural success. The
likelihood of patient compliance thus represents an additional
important prognostic indicator.
• Long-term functional outcomes are discouraging for patients
who refuse interventional management of acute iliofemoral
occlusive disease. Forty-four percent of patients treated with
medical therapy alone will experience venous claudication,
and up to 60% will develop PTS within 2 years. 5-7
 C h a p t e r 34 ACUTE I L I O F E M O RAL D E E P V E I N T H R O M B O S I S A N D MAY-T H U R N E R S Y N D R O M E
IMAGING AND OTIIER DIAGNOSTIC STUDIES
• Imaging provides important prognostic and interventional
guidance to surgical management of acute iliofemoral
occlusive disease. Current modalities include duplex ultra­
sonography; catheter-based contrast phlebography; and
reconstructed, cross-sectional, contrast-based whole body
(computed tomography [CT] and magnetic resonance [MR] )
imaging.
Duplex Ultrasonography
•
In experienced hands, duplex ultrasonography (US) provides
extremely sensitive and specific information regarding the
chronicity and extent of infrainguinal venous obstruction.
Diagnostic accuracy in the iliocaval venous system is less
predictable due to the presence of overlying bowel gas and
abdominal adiposity.
•
Duplex-derived criteria for acute venous occlusion in­
clude incompressibility under direct vision, partial luminal
obstruction within the normally echo-free lumen, and absent
or abnormal venous flow characteristics with respiration or
following a Valsalva maneuver or distal compression. 8
• The primary advantages o f duplex imaging include its nonin­
vasive nature, avoidance of ionizing radiation or nephrotoxic
contrast agents, easy reproducibility, portability, and accessi­
bility in the outpatient setting. Additionally, substantial cost
savings are realized compared to other imaging modalities.
Other advantages include the ability of duplex scanning to
differentiate hematomas, lymphatic system obstruction, su­
perficial thrombophlebitis, and other soft tissue abnormal­
ities from deep venous obstruction. Thus, duplex scanning
is the initial imaging modality of choice in all patients with
suspected iliofemoral DVT. When sufficient imaging parame­
ters are met, definitive therapeutic intervention may be safely
performed based on duplex-derived anatomic and diagnostic
imaging alone.
Computed Tomography Venography
• CT phlebography is frequently ordered for assessment of
limb swelling in the inpatient setting. Advantages of this
modality include nearly universal availability day or night,
less reliance on skill and experience of the technical staff
performing the procedure, outstanding spatial resolution,
reproducibility and sensitivity throughout the entire venous
system, the simultaneous ability to image pulmonary arterial
flow and lung perfusion, freedom from limb pain induced
by direct probe compression during ultrasound examina­
tions, and the ability to incidentally diagnose concurrent
conditions (such as solid organ neoplasia) that may influ­
ence thrombogenicity or suitability for treatment with open
versus endovascular techniques.
• The modern helical CT phlebogram provides a diagnostic
sensitivity and a specificity of nearly 1 0 0 % per year and was
found to detect previously unsuspected venous thrombosis
at a prevalence of 1 . 1 % . 9•1 0
• CT phlebography also provides useful information regard­
ing thrombus density (and thus chronicity) , the presence of
residual luminal patency in obstructed veins, and the na­
ture and severity of extrinsic iliac vein compression when
present.
21 1 7
• The applicability of CT phlebography to the diagnosis of
venous obstruction is limited by the volume of iodinated in­
travenous contrast required to obtain optimal spatial reso­
lution in target vessels, as well as considerable whole-body
radiation exposure inherent in CT imaging. On average,
the radiation dosage delivered by diagnostic CT phlebogra­
phy is equivalent to that of over 1 ,200 chest x-rays or over
10 years environmental exposure at sea level ( dosage equiv­
alents courtesy of Radiation Physics Department, Stanford
Hospital & Clinics ) . This is particularly true in patients
with reduced creatinine clearance, women of childbearing
age who may be pregnant, or in children. For many rea­
sons, including the considerable expense associated with the
study, CT phlebography should not be considered a first-line
study but rather reserved for patients in whom duplex scan­
ning does not provide sufficient anatomic guidance or where
additional diagnoses (e.g., pulmonary embolization, solid
organ malignancy, or external iliac vein compression, etc . )
merit evaluation or exclusion.
Magnetic Resonance Venography
• MR phlebography shares many of the advantages and dis­
advantages of CT-derived cross-sectional imaging, including
the ability to obtain high-quality, high-resolution images of
surrounding soft tissues and delineate the extent of accom­
panying lymphadenopathy, soft tissue sarcomas, venous an­
eurysms, malformations, and compression syndromes that
may influence treatment and long-term management consid­
erations. MR phlebography also provides a sensitivity and
specificity of nearly 1 0 0 % , respectively, in the diagnosis of
acute iliofemoral venous occlusion. 1 1
• However, unlike computed tomography venography ( CTV) ,
magnetic resonance venography (MRV) can be used during
pregnancy and provide reduced risk of nephrotoxicity in
patients with reduced creatinine clearance (although gadolin­
ium is contraindicated in patients with an estimated glomeru­
lar filtration rate [eGFR] of more than 60 mL per minute) .
• Contraindications for MR-based venous imaging include the
presence of implantable pacemakers/defibrillators/infusion
systems or other ferromagnetic devices and surgical clips/
endografts, as well as claustrophobia in affected patients.
MR studies are also expensive compared to duplex US, and
dedicated personnel and equipment are less widely available
than are modern, multirow-detector CT imaging capabili­
ties. Thus, MR phlebography is considered most appropri­
ate as a secondary examination in the absence of suitable
duplex imaging or in the presence of contraindications to
CT phlebography. MR phlebography may be particularly
useful in the evaluation of coexisting or complicating ipsilat­
eral or central venous vascular malformations.
Catheter-Based Contrast Phlebography
• Despite continuing improvements in the quality and wide­
spread availability of noninvasive imaging, catheter-based
contrast phlebography remains the gold standard for ilio­
femoral venous evaluation. Sensitivity and specificity are
also nearly 1 0 0 % , and in addition to anatomic information,
physiologic venous pressure and flow information are also
provided throughout the iliocaval system when accessed in a
retrograde fashion from the CFV.
21 1 8 P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY
• Typical fluoroscopic findings include abrupt vessel cutoff in
the case of total occlusion or visualization of a filling defect
with residual luminal flow around the margins, a phenom­
enon known as "tram tracking. "
• A n obvious limitation i s the relatively high degree of
operator dependency, both in terms of physician and facility
capabilities. Catheter-based contrast phlebography may be
nondiagnostic in up to 1 8 % of cases due to misinterpreta­
tions, artifacts, or superimposition of overlying structures. 12
Thus, experience and suitable infrastructure are necessary to
ensure accuracy and precision.
•
Other major drawbacks include the inherent invasiveness
of the procedure and attendant procedural risk, radiation
and contrast exposure (although significantly less than that
required for CT imaging) , and cost. Thus, contrast phle­
bography is also inappropriate as the initial diagnostic mo­
dality for most patients and best employed in conj unction
with planned interventions directed at active thrombus
removal.
Intravascular Ultrasound
• Intravascular ultrasound (IVUS ) with the 9F Volcano IVUS
catheter (Volcano Corporation, San Diego, CA) provides
direct intraluminal visualization during catheter-based phle­
bographic assessment and intervention.
• IVUS-based imaging allows for precise measurement of cross­
sectional area and maximum and minimum lumen diameter.
Flow within the residual lumen may be determined, as well
as precise analysis of residual luminal irregularities. The
superior two-dimensional imaging characteristics of IVUS
compared to contrast phlebography make this modality the
PERCUTANEOUS MANAGEMENT OF
ILIOFEMORAL DEEP VEIN THROMBOSIS
( +/- VENOUS COMPRESSION SYNDROMES)
Duplex-Guided Femoral Vein Access
• Access site is chosen based on d u p l ex US f i n d i n g s, proxi­
mal (pe r i p h e r a l ) to t h e site of th rom botic occ l u s i o n . T h i s
may be t h e C F V i n patie nts with isol ated i l i a c DVT o r t h e
p o p l itea l o r t i b i a l ve i n s i n patie nts with i l iofe m o r a l DVT.
• U n d e r u ltraso u n d g u i d a nce, a 0 . 0 1 8 - i n m i cropu ncture
set is used to access t h e ta rget ve i n . In t h e sett i n g of
proxi m a l o bstruct i o n , t h e ve i n i s typ i ca l ly l a rg e and e a s i l y
i d e ntifi e d . Wi re a n d catheter exch a n g e d i s pe rfo rmed t o
u psize to a 5-Fr i nterve n t i o n a l s h eath .
Baseline Phlebography
• The i n it i a l p h l e bo g r a m is p e rformed e i t h e r t h r o u g h t h e
i nterventi o n a l s h e a t h o r t h r o u g h a d i a g n ostic catheter
adva n ced to the s u spected site of occl u s i o n . When u s i n g
d i g ita l s u btract i o n a n g i o g r a p hy, a m ixtu re o f 5 0 % Visi­
paque and 5 0 % sa l i n e provides a d e q u ate vo l u m e a n d
visua l i zation w h i l e m i n i m iz i n g contrast l o a d .
• The ease with which g u idewire passa g e is acco m p l ished,
as w e l l as h isto rical i nformation reg a rd i n g d u ration
of sym ptoms, i nfo rms i nte rventi o n a l decision m a k i n g .
measurement instrument o f choice when assessing extrinsic
iliac vein compression from tumors or overlying iliac arteries
(e.g., May-Thurner syndrome) .
INTERVENTIONAL AND SURGICAL
MANAGEMENT
Preoperative Planning
• Serologic and hematologic evaluation should include the
basic metabolic panel {to assess renal function and concomi­
tant electrolyte abnormalities) , complete blood count, and a
coagulation profile. It is also important to ascertain the sta­
tus of anti platelet or anticoagulation therapies when present
(e.g., dose, dosing frequency, prior complications, etc . ) .
• Prior t o operative intervention, the index treatment limb
should be marked as required for World Health Organiza­
tion's preoperative checklist and "time-out" requirements
and extent and severity of edema " baselined" for future
comparison.
• When appropriate access requires multiple sites (e.g., bilat­
eral femoral and/or internal jugular vein approaches) , those
should be marked and initialed as well.
Positioning
• Patients can be placed supine or prone depending on the
site necessary for access . On the operating table, the pa­
tient should be placed supine, with their arms secured at
the side to facilitate ancillary access from the groin or
neck. When popliteal access is required, prone positioning
is required.
Pati ents with sym ptoms of l ess than 7 days d u ration a re
freq uently co n c l usively treated with s i n g l e-sessi o n p h a r­
macomech a n ical t h rom bectomy, whereas patie nts with
longer d u ration w i l l m o re freq uently req u i re p retreat­
ment with m u ltiday cou rses of catheter-d i rected t h rom­
bo lytic t h e ra py. The i n it i a l p h l e bogram is i nstru mental in
d eterm i n i n g the cou rse of therapy i n t h i s reg a r d . Regard­
l ess of a p p roach, the g o a l of thera py i s to a c h i eve rapid
thrombus remova l, m i n i m ize venous o bstruction, reduce
the l i ke l i h ood of ve nous valvu l a r d a m a g e, u n cover u n d e r­
lying ve nous com p ress i o n syn d ro mes, a n d at l east theo­
retica l ly, reduce l i ke l i hood of symptomatic recu rrence.
Catheter-Directed T hrombolysis
• U nt i l rece ntly, catheter-d i rected t h ro m bolysis h a s been
t h e m a i nstay of i nte rve nt i o n a l m a n a g e m e n t fo r i l i o­
femora l DVT. F o l l o w i n g g u i d ewire traversa l of t h r o m b us,
treatment length i s dete r m i ned via i nsert i o n of a m a rker
catheter. S u bsequently, an a p p ro p r i ately sized side­
hole i nfusion catheter i s positi o n e d ove r t h e occl u d i n g
t h r o m b u s . I nfusion catheters co m e w i t h i nfusion (pe rfo­
rated segment l e n gths) ra n g i n g from 5 to 50 em o r l o n ­
g e r, a n d i nfusion segment l e n gt h s h o u l d be sel ected t o
d i rect i nfusate specifica l l y i nto l u m i n a l t h r o m b u s o n ly­
for exa m p l e, not i nto patent l u m i n a l seg m e nts w h e re it
w i l l be r a p i d l y d issi pated i nto the ven o u s and syste m i c
 C h a p t e r 34 ACUTE I L I O F E M O RAL D E E P V E I N T H R O M B O S I S A N D MAY-T H U R N E R S Y N D R O M E
c i rcu l a t i o n . P r i o r to i n itiati n g i nfusion, t h e m u lt i p u rpose
g u i dewire used to position the catheter i s exc h a n g e d fo r
a p u rpose a n d cath ete r-specific e n d -occ l u s i o n wi re, w h ich
typica l ly forces the i nfusate to exit th roug h t h e s i d e holes
rath e r t h a n l e a k out coaxi a l l y along the g u idewire l u m e n .
• O n ce proper positi o n i n g is o bta i n ed, a conti n u o u s i nfu­
sion of tissue p l a s m i n o g e n activator (tPA o r a lt e p l ase,
G e n e ntech, San F r a n c i sco, CA) i s i n iti ated at t h e rate
of 0 . 2 5 to 1 .0 m g per h o u r, d e p e n d i n g o n the extent of
t h r o m b u s b u r d e n a n d pe rceived c h r o n i city. A c o n c u r­
rent, coaxi a l h e p a r i n i nf u s i o n (400 to 700 u n its per h o u r)
is a d m i n istered t h r o u g h the sheath to p revent t h r o m b u s
accu m u l a t i o n a r o u n d t h e i nfusion syste m .
• M o n ito r i n g i n a ste p-down o r i ntensive care environment
i s a n essenti a l safety req u i rement during exte nded peri­
ods of catheter-di rected i ntravenous throm bolysis outs i d e
of the c a t h l a b . F i b r i n o g e n l evels, coa g u l ation p rofi l e, a n d
hem atocrit a re assessed every 4 t o 6 h o u rs. Typical ly, tPA
infusion is h a lted if/when fibrinogen levels d ro p below
200 mg/d l or evi dence of bleed i n g i s p resent. Repeat p h le-
bography i s perfo rmed eve ry 12 to 24 h o u rs to assess t h e r­
a peutic prog ress a n d res i d u a l thrombus l o a d . As thrombus
b u rd e n recedes, replacement catheters with s h o rter infu-
s i o n segme nts a re typica l ly chosen to concentrate drug
d e l ivery with i n the rem a i n i n g c l ot. I nfusion rarely cont i n ­
ues beyo n d 48 h o u rs reg a r d l ess o f p rog ress, as experie nce
has d e m o n strated that com p l icat i o n rates va ry d i rectly
with tota l tPA dosage and length of infusion. Also, infu­
s i o n rates may be reduced when s i g n ificant prog ress is
n oted d u ri n g periodic p h l e bo g ra p h i c assessment, a g a i n
to red u ce risks o f dosage-rel ated b l eed i n g com p l ications
while sti l l p u rs u i n g co m p lete d isso l ution of clot.
• U ltraso u n d -assisted t h r o m b o lysis u s i n g t h e E KOS i n ­
f u s i o n catheter ( E KOS Corporation, Both e l l , WA) may
A B
FIG 1 • A. The 6-Fr A n g ioJet t h r o m bectomy catheter i s usefu l i n t h e treatment of DVT. T h i s catheter i s advanced t h r o u g h a
sheath situated i n t h e p o p l itea l or fe m o ra l ve i n ove r a 0 . 0 3 5 - i n g u idewire. The catheter h a s rad i a l l y o r i e nted i nfusion s i d e h o l e s
that d e l iver sa l i n e a n d t PA d i rectly i nto t h e t h r o m b u s (B) a n d a s p i ration po rts that rem ove d issolved t h r o m b u s a n d d e b ri s .
21 1 9
reduce the d u ration of i nfusion a n d tota l t PA dose. T h i s
6-Fr catheter is a l so ava i l a b l e i n m u lt i p l e i nfusion l e n g t h s
a n d conta i n s a c o r e w i re prod u c i n g u ltraso u n d e n e rgy
that may d i s r u pt f i b r i n bonds and i n crease t PA d iffu s i o n
with i n t h r o m b u s . C l i n i c a l stu d ies h ave d e m o nstrated
e q u iva l e n t c l i n ica l o utcomes with red u ced i nfusion t i m e s
u s i n g t h e E KO S syste m .
Pharmacomechanical T hrombectomy
• P h a rmacomech a n ic a l t h ro m bectomy (P MT) uses m e c h a n ­
i c a l forces to assist t PA d i spersion with i n t h e t h r o m b us,
typica l ly d u ri n g a s i n g l e treatm ent sess i o n . Concu rrent
a s p i ration capa b i l ities h e l p rem ove th rom b u s fra g m e nts
d u r i n g treatment sess i o n s . Devices cu rrently used for t h i s
p u rpose i n t h e ve n o u s system i n c l u d e t h e A n g i oJet cath­
eter ( M E D RAD, Wa rre n d a le, PA) and Tre l l is (Covi d i e n ,
M a nsfi e l d , M A ) i nfusion systems.
• The A n g ioJet systems comprise an i nfusion catheter a n d
ded i cated reusa b l e d rive u n it . Rad i a l ly o r i e nted i nfusion
p o rts g e n e rate h i g h - p ress u re j ets to d is p e rse h e p a ri n i zed
sa l i ne, with o r without t PA, i nto t h e t h r o m b u s and an
adjacent a s p i rat i o n p o rt to export fra g m e nts and d e b r i s .
• The A n g i oJ et catheter i s m ost co m m o n l y used i n a cute
i l iofe m o r a l occ l u s i o n in the " power p u l s e " mode; in t h i s
sett i n g , t h e a s p i rat i o n f u n ct i o n of t h e catheter is tem po­
r a r i l y d is a b l e d , whereas t PA p u l sation i s d e l ivered d i rect ly
i nto t h e t h r o m b u s . Typ i c a l ly, 6 to 8 m g of t PA i s d e l ivered
i n this fas h i o n at t h e beg i n n i n g of a treatm ent sess i o n .
W i t h power p u lse activated, t h e catheter is repeate d l y
advanced a n d withd rawn t h r o u g h t h e t h r o m b u s over
t h e g u idewire (FIG 1 ) . After a l l o w i n g t h e t PA to dwe l l
f o r 1 0 t o 1 5 m i n utes, t h e a sp i ration f u n ct i o n i s activated
and t h r o m b u s rem oved to the g reatest extent poss i b l e .
2 1 20 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

FIG 2 • The Tre l l is p e r i p h era l i nfusion system is an 8-Fr

catheter with a s i n g l e-use d isposa b l e d rive u n it . The catheter
h a s co m p l i a n t occ l u s i o n b a l l o o n s that a re i nfl ated o n e i t h e r
s i d e of the t r e a t m e n t z o n e afte r adva n c i n g t h e catheter ove r
t h e g u i d e w i re t h r o u g h t h e t h r o m b u s . The treatment z o n e
of t h e catheter (e i t h e r 1 5-cm o r 3 0 - c m l e n gth) conta i n s both
i nfusion side h o l e s and a s p i ration p o rts. ( F i g u re cou rtesy of
Covi d i e n , © 2 0 1 4.)

FIG 3 • Once the Tre l l is catheter is i n position, t h e g u i d ew i re

• The Tre l l is system is com posed of an i nf u s i o n catheter is re p l aced by t h e mech a n i c a l d ispersion wi re, w h i c h i s
of either 1 5- o r 30-cm i nfusion l e n gth, with co m p l i a nt attached to t h e d rive u n it a n d e n a b l es t h e t r e a t m e n t p o rt i o n
occ l u s i o n b a l l o o n s at e i t h e r e n d of t h e i nfusion po rts of t h e catheter to osci l l ate back a n d forth (arrow) to fac i l itate
t PA d is p e rs i o n . D u r i n g the 1 0-m i n ute treatment t i m e, t PA is
(FIG 2) . F o l l o w i n g p l acement ove r the g u i dewi re, t h e
i nfused t h ro u g h the i nfusion p o rt at a rate of 1 m g ( 1 m l) per
e n d occ l u s i o n b a l l o o n s a re i nfl ated i n o r d e r to i s o l ate
m i n ute, and fo l l owi n g treatme nt, the d i ssolved t h r o m b u s a n d
the a rea of p l a n ned p h a rmacomech a n i c a l t h ro m b o lysis
re m a i n i n g t PA i s a s p i rated t h ro u g h t h e a s p i rat i o n p o rt.
(FIG 3) . A s i n u s o i d a l d i spers i o n w i re i s then advanced
t h r o u g h t h e core of t h e catheter and attached to a d is­
posa b l e d rive u n it, w h i c h w h e n activated uses m e c h a n i ­
fo rmation, or foca l exte r n a l c o m p ress i o n may become
c a l forces to d i sp e rse t h e t PA t h r o u g h t h e t h r o m b u s .
a p p a rent o n co m p l et i o n p h l e bograp hy. These lesions
After a n i nfusion o f 6 m g of t PA o v e r t h e s p a n of 1 0 m i n ­
should be a d d ressed during t h e s a m e treatment sess i o n
utes, a s p i ration of t h r o m b u s a n d d e b ri s i s p e rformed
to m i n i m ize the risk of recu rrence. IVUS may be p a rticu­
from t h e t reated segment. The occ l u s i o n b a l l o o n s con­
l a rly usef u l i n t h i s reg a r d .
centrate tPA with i n t h e treatment seg m e nt, e n a b l i n g
• Alth o u g h f i x e d ste noses may occ u r t h ro u g h o ut the
m u lt i p l e i nfusion a n d d is p e rsa l sess i o n s d u ri n g t h e s a m e
ve n o u s system, t h e m ost co m m o n location for ext r i n s i c
proced u re w i t h m i n i m a l syste m i c d e l ivery o f t h ro m bo­
c o m p ress i o n occu rs at t h e p o i n t w h e re t h e l eft c o m m o n
lyt i c agent (FIG 4) .
i l i a c ve i n passes b e n eath t h e ove r l y i n g r i g h t c o m m o n
i l i a c a rtery (RC IA) (FIG S). After recog n i z i n g t h i s c o m ­
Stenting o f Underlying Venous Stenoses o r Venous
p ress i o n a n d su ccessf u l remova l o f t h r o m b u s p roxi m a l o r
Compression Syndromes
d ista l to t h i s lesion, t h e ste nosis may be safely resolved
• F o l l o w i n g c l e a rance of acute t h r o m b u s from the i l iofem­ with ste n t i n g (FIG 6) . This i s best perfo rmed by u p s i z i n g
oral system, u n d e r l y i n g ve n o u s lesions that p rovoked DVT t h e i ntervent i o n a l s h e a t h to at l e a st 1 0 F r fo l l owed b y

FIG 4 • Patient w i t h l eft i l iofemoral ven o u s t h rom bosis

B c
seco n d a ry to M ay-T h u r n e r syn drome. N ote the extensive
thrombus with i n the i l iac and femoral ve i n s (A). B,C. The
patient is b e i n g treated i n the prone position t h r o u g h
popl itea l vei n access. The Tre l l i s catheter h a s been i nserted
and advanced t h r o u g h the thromb us, and the occl usion
b a l l oo n s a re i nfl ated o n either side of the treatment
zone (arrows). N ote the osc i l lati n g d ispersion wire that
i m p roves tPA d e l ivery d u r i n g infusion.
 C h a p t e r 34 ACUTE I L I O F E M O RAL D E E P V E I N T H R O M B O S I S A N D MAY-T H U R N E R S Y N D R O M E
FIG S • I ntravasc u l a r u ltraso u n d i s t h e m ost sens itive
assessm ent tool for d etect i n g M ay-Th u rn e r co m p ress i o n of
t h e l eft c o m m o n i l i a c ve i n . A. The RCIA i s lyi n g d i rectly over
and c o m p ress i n g t h e l eft common i l i a c ve i n (betwee n yellow
arrows). B. F o l l o w i n g stenti n g of the l eft co m m o n i l i a c ve i n ,
t h e re i s co m p l ete reso l ut i o n o f t h e c o m p ress i o n b y t h e RCIA.
d e p l oyment of a se lf-exp a n d i n g , braided, sta i n l ess stee l
Wa l l stent (B oston Scientific, Watertown, M A ) . I n con­
j u n ct i o n with co m p l et i o n ve n o g r a p hy, IVUS i s t h e n used
to q u a ntify t h e extent of resi d u a l c o m p ressi o n .
• Stent d i a m eter i s chosen based o n IVUS-obta i n e d mea­
s u re m e nts, b u t d i a m eters com m o n ly chosen for co m m o n
FIG 6 • Ste n t i n g o f t h e l eft c o m m o n i l i a c ve i n f o r M ay­
T h u r n e r syn d ro m e i s pe rfo rmed with a b ra i ded self-expa n d i n g
sta i n less ste e l stent, u s u a l ly i n d i a meters ra n g i n g from 1 6 to
20 m m .
OPERATIVE MAN AGEMENT O F
ILIOFEMORAL DEEP VEIN THROMBOSIS
Iliac Venous T hrombectomy
• For m ost c l i n ic a l sce n a r i os, o p e n ve n o u s t h r o m bectomy
has l a rg e l y been s u p p l a nted by the i ntervent i o n a l ,
i m a g e -g u ided tech n i q ues descri bed i n t h e p reced i n g
sect i o n s . I n patie nts w i t h l i m b-th reate n i n g p h l e g m a s i a
ceru l e a n d o l e n s o r t h o s e with contra i n d icat i o n s to lytic
t h e ra py o r contrast a d m i n i strat i o n , o p e n s u rg i c a l t h ro m -
bectomy re m a i n s a n effective a n d n ecessa ry treatment
m o d a l ity.
• W h e n ever poss i b le, s u r g i c a l t h r o m bectomy is pe rfo rmed
under general a nesthesia with positive pressu re ve nti l a ­
t i o n to r e d u c e t h e risk of i ntra o p e rative P E .
• A vertica l i n g u i n a l i n c i s i o n is m a d e to a l l ow expos u re
a n d control of t h e C FV, fe m o r a l ve i n , s a p h e nofe m o r a l
j u nction, a n d t h e prof u n d a fe m o r i s ve i n . O n ce these
2121
i l i a c ve i n p l a ce m e n t i n M ay-T h u r n e r patients r a n g e from
1 6 to 20 mm. In this a p p l ication, it i s i m p o rtant to c h oose
l o n g e r stents that p rovi d e a d d i t i o n a l su rface a p position
i n t h e com m o n o r even exte r n a l i l i a c ve i n s to present
ste nt d is l o d g e m e n t and m i g ra t i o n . Wa l l stents a re p a r­
t i c u l a rly a p p ro p r i ate i n t h i s reg a rd as t h ey w i l l s h o rten o r
exte n d i n p ro p o rt i o n to t h e u lt i m ate treatm ent d i a m eter
and featu re exposed wi res at either e n d to o pt i m ize ve i n
wa l l e n g a g e ment.
• O n ce a p propriately sited a n d d e p l oyed, poststent d i l a ­
t i o n i s n ecessa ry to e n s u re opti m a l d e p l oyment a n d
m i g ration resista nce. S o m e d i scomfo rt w i l l be expe r i ­
e n ced by t h e " a w a k e " patient d u ri n g these p roced u res,
a n d ste n t i n g m o l d i n g s h o u l d be g u i d e d by patient t o l e r­
a n ce u n d e r these c i r c u m stances.
Completion Imaging
• Co m p l et i o n p h l e b o g r a p h y d o c u m e nts reso l ut i o n of
target ste n o s i s a n d rec i p roca l r e d u ct i o n i n co l l atera l
ve n o u s fl ow.
• The presence of p e rs i stent co l l atera ls s u g g ests res i d u a l
ven o u s ste nosis o r c o m p ression; I V U S s h o u l d be reper­
formed in t h i s c i rc u msta nce to confi rm wa l l a p position
and ste nt expa n s i o n . Repeat b a l l o o n d i l a t i o n may be
n ecessa ry i n these c i rc u m st a n ces until s uffi cient expa n ­
s i o n i s a c h i eved .
Closure of the Femoral Vein Access
• F o l l owi n g sheath rem ova l, m a n u a l pressu re is h e l d over
the ve n o u s p u nctu re site. C l o s u re devi ces a re not a p p ro­
p r i ate o r i n d icated for m a n a g e ment of ve n o u s a ccess.
• Patients need to re m a i n s u p i n e for at l east 1 h o u r fo l l ow­
i n g sheath re m ova l .
• Therapeutic i ntrave n o u s a nticoa g u l a t i o n with u nfrac­
t i o n ated h e p a r i n i s i n iti ated at the co m p l et i o n of t h e
p roced u re . M a i nt e n a n ce of fu l l a nticoag u l at i o n w i t h o u t
i nterruption t h r o u g hout t h e early posto pe rative p e r i o d
i s i m pe rative to p roced u r a l s u ccess.
ve n o u s structures h ave exposed, the patient i s syste m i ­
ca l l y a nticoa g u l ated w i t h 1 00 u n its/kg o f i ntrave n o u s
hepa rin.
• A l o n g itud i n a l ve n otomy is m a d e i n t h e CFV, a n d a n o . 8
or n o . 1 0 ve n o u s t h r o m bectomy catheter is t h e n passed
up to t h e level of t h e com m o n i l i a c ve i n and t h ro m ­
bectomy is perfo r m e d . Attem pts a re m a d e to c l e a r t h e
majo rity of t h e i l i a c t h r o m b u s before pass i n g t h e t h ro m ­
bectomy catheter i nto t h e ve n a c a v a i n order to reduce
t h e l i ke l i hood of p u l m o n a ry e m b o l izat i o n .
• Back-bleed i n g may n o t be p resent d u e to com petent
i l i a c ve i n va lves, o r back-bleed i n g c a n occ u r from t h e hy­
pogastric ve i n even without c l e a ra n ce of the t h r o m b u s
with i n t h e c o m m o n i l i a c ve i n . The refo re, back-bleed i n g
s h o u l d n ot be u s e d a s a n i n d icator o f effective t h ro m ­
b u s c l e a ra nce a n d ve n o g ra p h y s h o u l d be pe rfo rmed
as a rout i n e afte r c o m p letion of i l i a c a n d i nfra i n g u i n a l
t h r o m bectomy.
2 1 22 P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY
Infrainguinal Femoral Venous T hrombectomy
• F o l l o w i n g i l i a c ve n o u s t h r o m bectomy, h e p a r i n ized sa l i n e
s h o u l d be used t o f l u s h t h e i l i a c v e i n , t h e prox i m a l exter­
n a l i l i a c ve i n (or d i st a l C FV) s h o u l d be c l a m ped, a n d t h e n
a n y t h r o m b u s at t h e prox i m a l (pe r i p h e ra l ) a spect of t h e
venotomy s h o u l d be extracted with forceps.
• l nfra i n g u i n a l t h r o m b u s ca n t h e n be removed by m a n u a l
m a ssage o r b y exsa n g u i nati n g t h e l e g w i t h a n Esm a rch
b a n dage, seq u e n ti a l ly a p p l ied from t h e foot to the
groin, with s uffi cient ove r l a p to prov i d e conti n u o u s com­
p ress i o n (FIG 7) . C l ot i s d e l ivered t h ro u g h t h e ve n otomy
at t h e g ro i n .
• B a l loon t h rom bectomy can be performed using a no. 3
t h rom bectomy catheter passed from t h e venotomy i n the
CFV i n a retrograde fash ion down toward the poplitea l and
tibial ve ins. Following t h rom bectomy, the i nfra i n g u i n a l ve-
nous circulation should be flushed vigorously with heparin-
ized sa l i ne before closure of the venotomy.
• I f i nfra i n g u i n a l t h r o m b u s persists after t h ro m becto my,
a d d it i o n a l tech n i q ues for t h r o m b u s rem ova l i n c l u d e
o n -ta b l e t PA a d m i n istrat i o n . For o n -ta b l e tPA a d m i n ­
i strati o n , 6 m g o f a lt e p l ase i n 2 0 0 m l s a l i n e i s i nfused
retrog rade i nto t h e fe m o ra l ve i n t h r o u g h t h e ve n otomy
i n t h e CFV, t h e n t h e ve i n i s c l a m ped and the solution i s
a l lowed to d we l l for 1 0 to 30 m i n utes.
• If t h e i nfra i n g u i n a l ve n o u s t h rom bectomy is not s uccess­
ful d u e to c h r o n i c t h r o m b u s in the fe m o r a l ve i n , the fem­
o ra l ve i n is then l i gated b e l ow t h e p rofu n d a , and ba l l oo n
t h r o m bectomy i s t h e n p e rformed o n t h e p rofu n d a ve i n
a n d its branches.
FIG 7 • Acute t h r o m b u s can g e n e ra l ly be extracted d u r i n g
o p e n s u r g i c a l t h r o m bectomy b y exsa n g u i nati n g t h e l e g
w i t h a n e l a st i c E s m a rch t o u r n i q uet. After perfo r m i n g t h e
venotomy i n t h e C FV i n t h e g r o i n , t h e to u r n i q uet i s wra pped
from t h e foot u p to t h e groin, expe l l i n g thrombus t h ro u g h
t h e ven otomy.
• After o p e n t h ro m bectomy is com p l ete, t h e ve n otomy i s
c l osed with r u n n i n g conti n u o u s m o n ofi l a m ent sutu re,
avo i d i n g postcl o s u re str i ctu re of the CFV by p recis i o n
s u t u r e p l acement. I f n a rrow i n g i s a p p a rent, ve i n o r
bov i n e pericard i a ! patch a n g i o p l asty may be p e rformed
as n ecessa ry to restore l u m i n a l d i a m eter.
Adjunct Arteriovenous Fistula Creation
• Rates of ret h ro m bosis fo l l owi n g s u r g i c a l t h r o m bectomy
can be a s h i g h a s 80 % . Creat i o n of an a rteri ove n o u s fis­
tula (AVF) may s i g n ificantly reduce this r i s k and a re i n co r­
porated i n t h e p roced u re by m ost s u rg e o n s .
• T h e s a m e g r o i n i n c i s i o n may be e m p l oyed for AVF cre­
ation, transposi n g t h e proxi m a l segment of t h e i ps i l at­
e r a l g reater s a p h e n o u s ve i n to the su p e rfi c i a l fe m o r a l
a rtery (FIG 8) .
• S u rg i c a l l i gation or i nterventi o n a l occ l u s i o n of the AVF i s
u lt i mately req u i red for opti m a l l o n g-term outcome, usu­
a l ly e m p l oyed with i n 6 weeks fo l l owi n g t h e p roced u re .
Docu m e nted pate n cy of the ven o u s system s h o u l d be
d e m o n strated o n fo l l ow-u p d u plex i m a g i n g . Fa i l u re to
close t h i s fistu l a may resu lt in s i g n ificant l o n g-term l i m b
a n d card i ovascu l a r com p l i cations, a n d fo l l ow-u p i s essen­
tial to e n s u re that t h i s p a rt of t h e proce d u re i s com p l eted.
• O p e n t h ro m bectomy p roced u res by their n a t u re a re
associated with s i g n ificant b l o o d l oss from t h e centra l
ve n o u s syste m, a n d p r e p a rations s h o u l d be m a d e both
to crossmatch and bank s uffi c i e nt packed red b l ood ce l l s
(RB Cs), as w e l l a s e m p l oy ope rative scave n g i n g systems t o
recycl e a n d rei nfuse l ost b l ood to e n s u re t h a t a p p ro p r i ate
FIG 8 • Pate n cy rate fo l l owi n g o p e n s u r g i ca l t h r o m bectomy
i s s i g n ificantly i m p roved by creati o n of an AVF. F o l l o w i n g
t h ro m bectomy of t h e i l i a c a n d fe m o r a l vei ns, t h e ve n otomy
i s c l osed with r u n n i n g m o n ofi l a m ent s u t u re and an e n d -to­
side a n a stomosis i s created betwee n the sa p h e n o u s ve i n a n d
s u p e rfi c i a l fe m o r a l a rte ry.
 C h a p t e r 34 ACUTE I L I O F E M O RAL D E E P V E I N T H R O M B O S I S A N D MAY-T H U R N E R S Y N D R O M E
h e modyn a m i c co n d it i o n s may be m a i nta i n e d t h r o u g h ­
out t h e p roced u re .
Completion Imaging
• Co m p l et i o n ve n o g ra p h y of t h e i l i a c ve n o u s system s h o u l d
be p e rformed fo l l owi n g o p e n s u rg i ca l t h ro m bectomy t o
assess t h e a d e q u acy o f t h e t h ro m b ecto my.
• F o l l o w i n g closure of t h e venotomy a n d reesta b l i s h m e n t
of ve n o u s flow t h r o u g h the i l iofe m o r a l ven o u s system,
a n 1 8- g a u g e access needle and g u i dewire can be used to
p u n ctu re the CFV and p l ace a 5-Fr sheath. Contrast i nj ec­
t i o n d i rectly t h r o u g h t h i s sheath is pe rformed to eva l uate
POSTOPERATIVE CARE
• Following open surgical thrombectomy, full therapeutic
anticoagulation is imperative to prevent rethrombosis. An
intravenous heparin infusion is immediately initiated and
maintained for 24 to 48 hours before the patient is transi­
tioned to oral anticoagulation with a low-molecular-weight
heparin bridge prior to discharge.
• Ambulation should begin on the first postoperative day.
Patients may usually be discharged within 48 to 72 hours
following thrombectomy.
• On discharge, the patient should be placed in elastic com­
pression stockings ( 3 0- to 40-mmHg ankle gradient) , and
the importance of compression should be stressed to the
patient in the discharge instructions.
OUTCOMES
Endovascular Intervention
• Pharmacomechanical venous thrombectomy provides clinical
success rates of 70% to 1 0 0 % and may reduce the incidence of
the PTS, although this latter conclusion remains controversial.
• Following successful procedures, long-term venous patency
is reported at 8 4 % in 5 years.
• Valvular competence is preserved at 8 0 % in 5 years and
56% in 10 years in recent series.
Surgical T hrombectomy
• to deep venous thrombosis. Which technique? Clin Chest Med.
Surgical thrombectomy provides long-term iliac venous pa­
tency, with rates approaching 80% when combined with in­
clusion of a temporary AVE
• At 5 years, over one-third of patients can be expected to be
symptom free and have retained valvular competence.
2 1 23
the i l ia c ve i n s and assess for resi d u a l t h r o m b u s . F o l l o w i n g
ve n o g r a p hy, the sheath i s rem oved, a n d a s i n g l e m o n o­
f i l a m e n t stitch can be used to close the p u n ctu re site.
Wound Closure
• A ca refu l sea rch for a ny transected l y m p h at i cs s h o u l d be
con d u cted prior to wound closure.
• A closed suction d ra i n s h o u l d be p l a ced in t h e g r o i n
wo u n d to p revent sero m a form ati o n .
• The wo u n d is t h e n closed with m u lt i layered r u n n i n g
a bsorba b l e s u t u res f o r h e m ostat i c a n d lym p h ostat i c
closure.
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