Reconstruction/ bypass procedures

Endoluminal Procedures

Basic steps
- Obtain arterial access
- Perform initial аrtеriоgrарhy and determine whether to proceed with the intervention.
- Anticoagulate the patient and monitor to maintain an adequate level.
- Identify target lesions and place a sheath through which wires, catheters, and other devices are delivered.
  - Then, cross stenoses and occlusions and treat the diseased segment to achieve a patent lumen, followed by completion аrtеriοgraрhy.
  - For multilevel disease, the goal of treatment is to establish in-line flow to the foot in a patient with tissue loss, and typically, the lesions are treated from proximal to distal in sequence.
    - In-line flow is an important concept
- Remove devices and manage the access site.
Options
- Balloon angioplasty
- Stents
- Athrectomy
- Embolectomy/lysis
  - Beneficial in acute ischaemia due to emboli (e.g. AF)
Complications
- Puncture site problems: Bleeding / haematoma (3%), pseudoaneurysm, AV fistula, nerve damage, vascular stenosis / occlusion
- Bleeding and pseudoaneurysm:
  - Digital pressure usually effective
  - Occasionally thrombin injection, stent or surgery
- Arterial dissection/arterial perforation
  - Dx by arteriogram after angioplasty/ stenting.
  - Tx with tamponade with balloon then covered stent
- Embolisation and thrombosis
  - More common in occlusive disease and CLI
  - Depends on nature of emboli – thrombus responds to thrombolytic agents, plaque needs suction thrombectomy ~ occasionally require surgery
- Stent occlusion/infection
  - Generally tx with surgery
- Contrast problems: allergy, renal impairment
- Fracture or loss of guidewire

Surgical Procedures

Work up
- Vascular evaluation
  - Vein mapping for autogenous conduit
  - Arteriography - procedure planning
Graft options
- Vein graft - typically GSV
- Prosthetic - typically ePTFE for lower extremity and Dacron for the Aorta
Options
- Endarterectomy
- Bypass
- Amputation
- Sympathectomy
- Endarterectomy
Bypass steps
- Arterial exposure and control
- Vein exposure/harvest
- Systemic аոtiϲοаgulatiοո
- Proximal anastomosis
- Graft tunneling
- Distal anastomosis
- Completion imaging
Options
- Aortoiliac disease
  - Aorto-bifemoral Bypass
    - Expose both femoral vessels first and control them, if profundaplasty is needed do it now, then form retroperitoneal tunnel on anterior surface of external iliacs under inguinal ligament
    - Aorta – transperitoneal versus lateral retroperitoneal
      - Transperitoneal – right visceral rotation – mobilise SB, incise ligament of Treitz, mobilise duodenum, mobilise up to renal vein level, down to IMA
    - Potential to damage ANS
    - Complete retroperitoneal tunnels
    - Anticoagulate – 5000 IU heparin
    - Clamps; infra-renal, supra-IMA
    - End-to-end anastomosis (dividing distal aorta) – 3/0 Prolene
      - (can do end-to-side if some patent flow distally to IMA/internal iliacs)
    - Re-site clamp to end of graft
    - Anastomose to CFA
    - Can close retroperitoneum over an end-to-end
  - Extra-anatomical bypass
    - No danger to nerves but prone to late occlusion & infection
    - Indications
      - Re-operation for aortobifemoral occlusion
      - Contraindication to transabdominal reconstructive approach (co-morbidities or intra-abdominal pathology)
      - Aorta is no good in first place
    - Axillofemoral Bypass
      - Find axillary artery with least evidence of disease (if equal use right as has less risk of developing subclavian occlusive disease
      - Axillary artery exposed via transverse incision over deltopectoral groove – deep to vein, inferior to brachial plexus, occasionally dividing pectoralis minor tendon helps
      - Expose femoral arteries
      - Use tunnelling device – midaxillary line, superficial to EOA, medial to ASIS to prevent kinking, make Extrafascial suprapubic tunnel between the two sides
      - Anticoagulate
      - Use 6 or 8mm externally supported PTFE graft
      - Anastomosis
        
        Axilla
        
        Ipsilateral femoral
        
        Contralateral femoral
    - Femorofemoral bypass
      - Requires 1 functioning iliac
      - Tunnel as above
    - Unilateral Iliofemoral Bypass
      - Indication:
        
        Ext disease in EIA with failure to respond to endovascular tx or disease extends beyond CFA
      - Often have to do combined CFA endarterectomy and patch
      - Retroperitoneal approach to CIA
      - Tunnel created above/below inguinal ligament – with care to avoid injuring femoral vein
- Common femoral
  - Femoral endarterectomy with patch angioplasty ensuring adequate flow into the deep femoral artery can be performed concomitantly with an inflow procedure (eg, iliac stenting),
  - Femoropopliteal bypass
  - Femoral-tibial bypass
- Femoropopliteal artery disease
  - Distal Popliteal/ Posterior Tibial or mid-peroneal
Issues
- Beware reperfusion injury - metabolic acidosis, hyperkalaemia, myoglobulinemia & pulmonary dysfunction (respiratory failure due to activated white cells)
- Always do a 6 week USS to assess graft and determine if ongoing graft surveillance required. If shows low flow rate may salvage with long term anticoagulants.
- NB: Prevalence of thrombophilia in PVD pts (≈27%) is higher than general population
  - Pts can be tested pre-op & considered for post-op warfarin, if requiring high-risk bypass / anastomosis
- Poorly controlled glucose perioperative in DM pts → Poorer outcomes after bypass
Sympathectomy
- Lumbar Chemical Sympathectomy – Phenol injected under radiological guidance
- Side Effects: Lateral thigh pain - can last 2 -6 weeks (Post-sympathectomy Neuralgia)
- Complications: 1/5000 risk of motor/sensory deficit
- Useful in pts not suitable for surgery (multilevel disease / no remaining surgical options) and Buerger’s
- Not effective in Mx of gangrene of toes/feet and doesn’t usually prevent amputation
- Main indication is for complex regional pain disorder (pain, swelling and vasomotor dysfunction)
Other Possible Treatments
- Hyperbaric oxygen therapy
- Intermittent pneumatic compression – 3x 2hr sessions per day required long-term

Arterial anastomosis

End-to-end anastomosis
- Two ends of arteries of similar size are sutured directly together
- Used when vessel length permits and no size mismatch
- Common in primary vessel repair or grafts with equal calibre
End-to-side anastomosis
- End of one artery sutured to the side of another
- Used in bypass grafts or when preserving flow to distal native artery
- Helps reduce tension and allows flow to continue beyond the anastomosis
Side-to-side anastomosis
- Sides of two parallel arteries opened and sutured together
- Less commonly used, but may be seen in some AV fistulas or bypasses
- Allows mixing of flow between two vessels
Techniques
- Typically performed with fine monofilament (e.g. 6-0 or 7-0 prolene)
- Interrupted or continuous sutures depending on location and surgeon preference
- Use of atraumatic clamps or vessel loops to control flow
- Ensure good intima-to-intima apposition, no inversion or eversion of edges
- Flush vessels before final sutures to remove air and debris
- Avoid tension or twisting at the anastomosis
Considerations
- Size match, tension-free alignment, haemostasis, and patency are key goals
- May use magnification or loupes for precision
- Check distal pulses or flow intraoperatively (e.g. Doppler, flush test)

Arteriotomy closure

Direct primary closure
- Used when the arteriotomy is short and there’s no narrowing risk
- Typically done with continuous or interrupted 5-0 or 6-0 polypropylene suture
- Care taken to avoid purse-stringing or narrowing the lumen
- Often used in small vessels or during embolectomy
Patch angioplasty
- Used when direct closure would narrow the artery or if arteriotomy is long
- A patch (usually synthetic like Dacron/PTFE or autologous vein) is sewn to the arteriotomy edges
- Increases lumen diameter and reduces turbulence
- Common in carotid endarterectomy or femoral artery exposure
Technique considerations
- Arteriotomy edges should be cleanly incised and not ragged
- Intima should be handled delicately to prevent dissection or thrombosis
- Heparinised saline flush used before closure to remove debris
- Clamp time minimised and distal perfusion checked afterwards
Post-closure check
- Palpate pulse or use Doppler to confirm patency
- Watch for bleeding from suture line or patch edges
- Reversal of heparinisation may be done based on context (e.g. trauma vs elective)

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Contents

Operative management of peripheral vascular disease

Reconstruction/ bypass procedures

Endoluminal Procedures

Surgical Procedures

Arterial anastomosis

Arteriotomy closure

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