Carotid Endarterectomy

Definition

Excision of plaque from the intima (inner lining) of the carotid artery.

Discussion

Plaque that forms on the intima of arteries is caused by arteriosclerosis. Fragments of (inflamed) plaque or adherent blood clots migrating distally can cause transient ischemic attacks (TIA) or complete blockage of the larger carotid artery branches, resulting in stroke/cerebrovascular accident (CVA). Carotid endarterectomy (CEA) restores carotid arterial blood flow, enhances cerebral circulation, and often prevents CVA. In postendarterectomy patients, “restenosis” may result from radiation therapy.

Procedure

An incision is made along the anterior border of the sternomastoid muscle. The carotid sheath is exposed and incised. Care is taken to identify and prevent injury to cranial nerve branches (X, XI, and XII) and ansa cervicalis. Proximal and distal control of the carotid artery and its bifurcation is achieved with vascular clamps and/or umbilical tapes and vessel loops. Arteriotomy is made with a #11 blade and continued with Pott’s scissors. At this time, if a shunt is to be placed, it is passed proximal and distal to the arteriotomy and secured by tapes (or Rummel tourniquet). Plaque is freed from the arterial wall by blunt dissection. Care is taken to extract all plaque and debris to prevent subsequent embolization. A bypass graft patch is applied from the common carotid artery to the internal carotid artery. If an intimal flap has developed, it is tacked to the vessel wall with fine sutures to prevent dissection when blood flow is restored. The arterial lumen is flushed with a heparinized saline solution. The arteriotomy is closed, or if the lumen appears stenotic, a patch graft (autogenous, e.g., saphenous vein graft or synthetic graft) may be employed. Prior to placement of the final sutures when a shunt has been used, the shunt is removed and the arterial lumen is flushed once again with heparinized saline solution to remove any residual debris or air bubbles. Hemostasis is assured. The wound is closed in layers. A drain may be employed.

Preparation of the Patient

A forced-air warming blanket may be used when requested. Centralvenous pressure (CVP), arterial, and venous pressure lines are placed. Continuous electroencephalography (EEG) to monitor brain activity and transesophageal echocardiography is employed to monitor cardiac function. When an autograft will

not be taken, antiembolitic hose and a sequential compression device with disposable leg wraps may be employed. The disposable leg wraps are applied over the Antiembolitic hose. The patient may receive a local block or general anesthesia via endotracheal intubation. Prior to the arteriotomy, systemic heparinization may be requested. The patient is in supine position with the neck slightly extended; a rolled towel may be placed transversely between the scapulae. The head is supported by a padded headrest (doughnut) and turned toward the unaffected side. Excessive rotation of the head and extension of the neck is avoided because this significantly decreases blood flow to the carotid and vertebral arteries. Arms may be extended on padded armboards (that permit vascular access). A pillow may be placed under the knees to avoid strain on back muscles and for comfort. All bony prominences and areas prone to skin and neurovascular pressure or trauma are padded. Foley catheter is not routinely placed. An electrosurgical dispersive pad is applied.

Skin Preparation

When a synthetic graft “patch” is used, before starting the prep, place a cotton ball in the patient’s ear on the affected side. Towels or lap sponges may be placed at the sides of the neck to prevent prep solution from pooling under the neck. Begin at the neck on the affected side, extending from just above the infra-auricular border to just below the level of the axilla (include the axilla), and prep down to the table at the sides.

Circulator should remove the towels or lap sponges very carefully; the lap sponges are part of the count.

For an autologous “patch” graft, in addition to prep above, both legs are usually prepared; a second prep tray is needed. Two people are required to prepare the legs (front and back), including the feet, or one person can prep using a leg holder and sterile towels, as necessary.

Equipment

Forced-air warming blanket, optionalSequential compression device with disposable leg wraps, as requestedLeg holder (for autograft), optionalPadded headrest (e.g., doughnut)Electrosurgical unit (ESU)SuctionHeadlight and fiber-optic light source (optional)Doppler box (with coupling gel), optional

Scales (2) to weigh sponges (available)Magnifying loupes or microscope (e.g., Olympus, optional)Power source for Hall drill

Instrumentation

Basic/minor procedures and shunt traysSelf-retaining retractor, e.g.,Weitlaner (without teeth)Ligating clip appliers, e.g., Hemoclip® appliers, short (small and medium)Rummel tourniquet, optionalDoppler probe and cord, optionalHigh-speed drill, e.g., Hall oscillating endarterectomy valvutomeMicroscopic instruments:Micro tissue forceps, curved smooth forceps (2), curved tying forceps,micro-dissector and Castroviejo needle holder (optional)

Supplies

Antiembolitic hose (if synthetic graft is used)CVP and vascular pressure line accessories to anesthesia providerImpervious stockinettes or gloves to cover the feet (for autograft)Basin setBlades, (2) #10, (1) #15, (1) #11Electrosurgical pencil and cord with holder and scraperSuction tubingUmbilical tapes, vessel loops (for retraction)Dissectors (e.g., peanut)Heparin (interferes with blood clotting mechanism) administered intravenously (IV) (to anesthesia provider) or diluted with normal saline for irrigation.Antibiotics IV or diluted for irrigationProtamine sulfate (heparin antagonist, reverses action of heparin)Sterile labels, marking pen, and medicine cupsGraduate and disposable syringes, including bulb for heparinized salineHemostatic agents (e.g., Gelfoam, Hemopad, Helistat, Avitene, Surgicel™, Oxycel,Thrombin, or fibrin glue)Ligating clips, e.g., Hemoclips (small, medium) Shunt (e.g., Javid or polyvinyl tubing may be customized to fit), availableDrain, e.g., closed-suction, Hemovac™

Abdominal Aortic Procedures (Abdominal Aortic Aneurysmectomy, Abdominal Aortic Endarterectomy) with Aortoiliac Graft

Definitions

Aortic Aneurysmectomy is the excision of an attenuated (dilated and weakened) widening of the aorta (aneurysm).

Aortic Endarterectomy is the removal of plaque from the intima (lining) of the aorta.

Aortic Bypass is the anastomosis of an aortic graft directly to iliacor femoral vessels bypassing any blockage or stenosis in the aorta.

Discussion

In patients with abdominal aortic aneurysm (AAA), the aortic wall has weakened and dilation has occurred. A thrombus may fill most of the increased lumen, creating a potential source of embolus; the aneurysm may rupture freely with massive bleeding into the retroperitoneal space, or may rupture intramurally and produce a dissection with significant bleeding and obstruction of aortic branches.These latter presentations constitute an extreme surgical emergency. In abdominal aortic aneurysmectomy, the diseased portion of the aorta is excised and a tubular graft (synthetic) is inserted to reestablish vascular continuity.When the iliac arteries are involved, aortoiliac bifurcated Y-graft is employed.Aortic and iliac “extender cuffs” are available for use, as necessary. Suitable veins are not always available for use as grafts. Dacron or PTFE grafts are employed for bypass. Dacron grafts are available coated with protein (collagen/albumin) that reduces blood loss and antibiotics that prevent graft infection. Impregnated grafts are considerably more expensive than the noncoated grafts. PTFE grafts are often preferred by the surgeon, as they are composed of Teflon velour with a smooth inner surface and are less thrombogenic than the Dacron grafts. Neointimal hyperplasia that may occur at the distal anastomosis is reduced when a segment of vein is incorporated as either a Millar Cuff or Taylor Patch. Complications that arise from using synthetic grafts include occlusion or infection and the formation of true or false aneurysms at the graft site, embolization of plaque fragments, and erosion of the graft into adjacent structures, e.g., aorto-enteric fistulae.

Patients with AAA frequently have concomitant coronary artery disease that can lead to myocardial infarction following surgery. AAA occurs more frequently in men and is often detected by routine chest xray. AAA does not usually rupture spontaneously but may dissect acutely (as noted above) with severe

symptoms (such as back pain, hypotension, etc.).When surgery is appropriate, it is most often done as an elective procedure under controlled circumstances. Should the aneurysm rupture during surgery, the most important factor is controlling the hemorrhage. Postoperatively, patients are at risk for renal damage.

Procedure

The open procedures are described. AAA is approached by a long midlineincision.The intestines are mobilized, protected, and packed out of thefield. The posterior parietal peritoneum is incised, and the aorta isexposed. Care is taken to identify and protect the inferior vena cava,renal artery, and ureters. When AAA involves the inferior mesentericartery, the artery may be sacrificed (or preserved if backflow is brisk).Proximal and distal control is obtained with vascular forceps (e.g.,DeBakey). The aneurysm is opened, endarterectomy is performed, the vessel is flushed with heparinized saline, and clot(s) are evacuated. The lumbar vessels are sutured, leaving the posterior portion of the aneurysm in situ. The common iliac arteries (when involved) are transected and anastomosed to the aorta utilizing a bifurcated graft/prosthesis (autologous or synthetic) for the bypass. If the aneurysm is located higher in the abdomen, a tubular graft/prosthesis is employed. When appropriate, the inferior mesenteric artery (distally) or renal artery (proximally) may require reimplantation. When the graft has been sewn into place, the vascular control clamps are removed and the anastomoses are tested for leakage. The shell of the aneurysm may be sutured about the graft for “reinforcement.” Hemostasis is assured. The abdomen is closed in the usual manner.

When a section of the aorta is bypassed, a graft is anastomosed from a location on the aorta (according to the level of patency) directly to iliac or femoral vessels, bypassing any blockage or stenosis, and the need for extensive endarterectomy is eliminated. In endarterectomy of the aorta and iliac vessels, the vessels are incised, plaque and clots are removed, and the vessels are repaired (with or without patch graft).Various combinations of these techniques can be employed. Local anticoagulation with heparinized saline is used prior to closure of the anastomoses; blood clots are flushed out by the transient release of the control clamps. The posterior peritoneum is closed, and the wound is closed.

Preparation of the Patient

A forced-air warming blanket may be requested. Antiembolitic hose are applied when the graft used is synthetic; antiembolitic hose cannot be used when an autograft (using the saphenous vein) is performed. The anesthesia provider, assisted by the circulator, inserts lines to monitor arterial, central venous, and

pulmonary artery pressures. Continuous transesophageal echocardiography is employed. The patient is placed in supine position; a pillow may be placed under the knees to avoid strain on the back muscles and for comfort. Arms may be extended on padded armboards (that permit venous access). All bony prominences and areas prone to skin and neurovascular pressure or trauma are padded. Consult with the surgeon regarding insertion of a Foley catheter. Apply electrosurgical dispersive pad.

Skin Preparation

Begin at the midline, extending from axilla to mid-thighs and to the table at the sides.

Equipment

Forced-air warming blanket, when requested

Sequential compression device with disposable leg wraps, optional

CVP or Swan-Ganz, and vascular pressure line accessories to anesthesia provider

Cell-saver, optional

ESU

Suctions (2)

Scales (2) for weighing sponges

Headlight and fiber-optic light source, optional

Doppler box with coupling gel, optional.

Instrumentation

Major procedures tray

Abdominal and thoracic vascular procedures tray

Sterile Doppler probe, optional

Self-retaining retractors, e.g., Bookwalter (large) and Weitlaner

(2 small)

Harrington retractors (2)

Extra towel clips for draping

Ligating clip appliers, e.g., Hemoclip appliers (various sizes and

lengths)

Sterile Doppler probe and cord, optional

Supplies

Antiembolitic hose

Foley catheter and continuous drainage unit

Sterile, plastic adhesive drapes (2), optional

Basin set

Blades, (2) #10, (1) #15, (1) #11

Needle magnet or counter

Suction tubings (2)

Electrosurgical pencil and cord with holder and scraper

Penrose drains, umbilical tapes, vessel loops (for retraction)

Dissectors (e.g., peanut)

Hemostatic agent (e.g.,Avitene, Surgicel,Thrombostat)

Needle, 18-gauge (to vent the vena cava, to prevent air embolus)

Ligating clips, e.g., Hemoclips (all sizes)

Sterile marking pen with indelible ink, labels, and medicine cups and syringes

Heparin (anticoagulant) diluted to surgeon’s preference is added to normal saline for heparinized saline

Graduated pitcher and assorted syringes, including bulb (for heparinized saline)

Protamine sulfate (heparin antagonist, reverses action of heparin)

Antibiotic (intravenous or for irrigation), optional Shunt graft may be autologous or synthetic, sterilized, e.g., Dacron “patch” or collagen-impregnated graft

Endovascular stent graft, e.g., AneuRX, Acculink, Guidant, or SMART (shape memory alloy recoverable technology), etc.

Femoropopliteal BypassDefinition

The restoration of arterial circulation to the leg by interposition of agraft to bypass an occluded segment of the femoral artery.

Discussion

Patency of the popliteal artery is determined prior to surgery by ultrasound and later confirmed by angiography.When the popliteal artery is occluded, shunting the blood flow to a more distal artery becomes necessary; the exploration of tributary vessels (e.g., posterior tibial artery) may require use of a microscope. The graft may be autologous (e.g., saphenous vein) or a synthetic prosthesis, e.g., Dacron.Woven Dacron grafts are available coated with protein (collagen/albumin) that reduces the blood loss and antibiotics that prevent graft infection. Impregnatedgrafts are considerably more expensive than the noncoated grafts.

Risks associated with the surgery are bleeding, stroke, myocardialinfarction, pulmonary embolus, and infection. If bypass fails, amputationmay become necessary.

Procedure

A vertical incision is made in interrupted segments over the course of the femoral artery, from the inguinal area along the medial aspect of the thigh to below the knee; there may be several interruptions in the incision. The common femoral artery and its bifurcation are exposed.The distal popliteal artery is exposed, retracting the gastrocnemius and soleus muscles (posteriorly) and adductor muscles (anteriorly). The posterior tibial nerve is protected. A tunneling instrument is used to make a passage from the femoral triangle to the popliteal space under the sartorius muscle. For an autograft, the saphenous vein is harvested and its multiple branches are divided and ligated. The segment is flushed with heparinized saline, tested for leakage, and set aside in an emesis basin. The femoral artery, controlled by vascular clamp, is flushed with heparinized saline. The autograft (saphenous vein segment) is sutured to the common femoral artery in reversed anatomical position to avoid the action of the valves, or the valves are removed. Endarterectomy and “patch” angioplasty may be performed at the origin of the deep femoral artery. The autograft is passed through the tunnel (avoiding kinking

or tension) and anastomosed to the popliteal artery. Prior to placing the final sutures, the graft is flushed with blood and controlled by pressure or further sutures. Intraoperative angiography may be performed.The incisions are closed. If vessels distal to the popliteal artery are used, similar maneuvers are performed.

Vein harvesting may be performed as an endoscopic procedure.

Preparation of the Patient

An antiembolitic stocking may be applied to the unaffected leg. Epidural or spinal block anesthetic or general anesthesia may be employed.The patient is supine with the affected hip and thigh slightly externally rotated and abducted, and the knee is flexed.A pillow or roll may be requested to maintain the patient’s position. Arms may be extended on padded armboards. All bony prominences and areas prone to skin and neurovascular pressure or trauma are padded. Check with the surgeon regarding insertion of Foley catheter (usually requested).Apply electrosurgical dispersive pad.

Skin Preparation

The entire abdomen is routinely prepared for the harvesting of saphenous vein(s); when in doubt, consult with surgeon. The genital area is excluded from the prep by covering it with a towel folded in thirds.

Unilateral. Begin at the groin on the affected side, extending from the umbilicus to the toes (including front and back of thigh, leg, and foot). Prepare down to the table on both sides, including to midthigh on the unaffected side.

Bilateral. Prepare both groin regions, extending from the umbilicus to the toes (including front and back of thighs, legs, and feet).Two persons are required to complete the preparation, or one person may prep using a leg holder and sterile towels, as necessary.

Equipment

Pillows or rolls

Leg holder, optional

ESU

Suction

Doppler and cord with coupling gel (not sterile) used prior to prep, if requested

C arm for x-ray angiography

Magnifying loupes, optional

Instrumentation

Basic/minor tray

Peripheral vascular procedures tray

Tunneling instrument

Ligating clip appliers, e.g., Hemoclip appliers, short, medium

Self-retaining retractors, e.g.,Weitlaner or Gelpi

Sterile Doppler probe and cord, optional

Valvutome, e.g., Mills, to excise valves from saphenous vein (optional)

Doppler and cord with coupling gel (sterile)

Supplies

Antiembolitic hose (for unaffected leg)

Foley catheter, optional

Basin set

Blades, (2) #10, (1) #15, (1) #11

Suction tubing

Electrosurgical pencil and cord with holder and scraper

Umbilical tapes, Penrose drains, vessel loops for retraction

Needle magnet or counter

Dissectors (e.g., peanut)

Ligating clips, e.g., Hemoclips (small, medium, and large)

Hemostatic agents, e.g., Gelfoam, Surgicel, Thrombostat, Collastat, Oxycel, and/or Avitene, etc. (available)

Synthetic graft (according to surgeon’s choice of type and size)

Heparin and heparinized saline (diluted to surgeon’s preference)

Graduate pitcher and bulb syringe

Protamine sulfate (heparin antagonist, reverses action of heparin)

Medicine cups and syringes

Sterile labels and marking pen

Contrast media for angiography, optional

Antibiotic (intravenous or for irrigation), optional

Greater Saphenous Vein Ligation and Stripping

Definition

Excision of the greater saphenous vein and its tributaries.

Discussion

This procedure is indicated to treat severe varicose vein disease secondary to venous valvular incompetence. Another indication is superficial thrombophlebitis of the lower extremities. The lesser saphenous vein system may also be excised, as indicated. When the condition is less severe, varicose veins may be treated by endovenous laser (EVLT), endoluminal radio-frequency ablation (ERFA), or high-frequency electrocoagulation. Sclerotherapy, usually performed as an outpatient procedure, may be employed for small cutaneous varices (e.g., “spider” veins). Subfascial endoscopic perforator vein surgery (SFPS) is an additional surgical modality.

Procedure

An oblique incision is made in the groin overlying the saphenofemoral junction. The superficial fascia is incised and the proximal portion of the saphenous vein is mobilized, divided, and ligated close to the saphenofemoral junction. Tributaries are divided and ligated as indicated. A transverse incision is made over the saphenous vein distally anterior to the medial malleolus; tributaries are exposed, divided, and ligated.The probe end of the internal stripper is inserted into the distal end of the saphenous vein and threaded proximally.A ligature is tied about the distal end, securing the vein about the acorn end of the stripper. The surgeon withdraws the stripper proximally (with vein attached) through the femoral incision, as the assistant applies pressure over the course of the vein with a folded towel. The vein may be removed segmentally, or sections of it may be removed

with external strippers. Saphenous vein branches and perforating veins (usually marked by the surgeon preoperatively) are stripped, excised, or ligated using external strippers. This might entail numerous small incisions. The lesser saphenous vein (posterior aspect of the leg) may require similar treatment. All incisions are closed and dressed. The leg(s) are wrapped with cotton batting (optional) and an elastic bandage.

Preparation of the Patient

Epidural or general anesthesia is administered. The patient is supine with the thigh on the affected side externally rotated and abducted, and the knee is flexed. For a bilateral procedure, the legs are slightly apart, i.e., abducted. Arms may be extended on padded armboards. The patient is secured to the table with the safety belt fastened over the unaffected thigh. All bony prominences and areas prone to skin and neurovascular pressure or trauma are padded. When the procedure is bilateral, the safety belt is fastened about the waist; care is taken not to interfere with respiration. Foley catheter is not routinely inserted. Electrosurgical dispersive pad is applied.

Skin Preparation

Unilateral. Begin at the groin on the affected side, extending from the umbilicus to the toes (including front and back of thigh, leg, and foot). Prep down to the table on the affected side and well beyond the midline on the opposite side proximally.

Bilateral. Prepare both groin regions, extending from the umbilicus to the toes (including front and back of thighs, legs, and feet).Two persons are required to prep, or one person can prep using a leg holder and sterile towels, as necessary.

Equipment

Leg holder

ESU

Suction

Instrumentation

Basic/minor tray; peripheral vascular procedures tray, optional

Internal and external vein strippers

Weitlaner (sharp) or Gelpi retractor

Skin hooks (2), small sharp rakes (2)

Ligating clip appliers, e.g., Hemoclip appliers, short (small, medium, large)

Supplies

Basin set

Marking pen (indelible)

Blades, (2) #10, (1) #15

Needle magnet or counter

Suction tubing

Electrosurgical pencil and cord with holder and scraper

Ligating clips, e.g., Hemoclips

Cotton batting, optional, and elastic bandages, e.g., Ace

Portosystemic Shunt

Definition

Diversion of portal venous blood to the systemic venous system.

Discussion

This procedure is performed to relieve elevated portal venous pressure (portal hypertension), which can result in bleeding from esophageal or gastric varices, ascites, and hepatic failure. Preoperative angiography (splenoportagram) is useful for diagnosis.The primary cause is cirrhosis. The portal blood may be shunted into the inferior vena cava from the portal vein (end to side or side to side), from the splenic vein (with splenectomy), from the distal splenic vein (retaining the spleen), or mesocaval shunt from the superior mesenteric vein (with or without an interposing prosthetic graft). An additional procedure is a distal splenorenal shunt, in which the splenic vein is anastomosed to the left renal vein. The particular type of shunt is determined by the patient’s condition and the surgeon’s preference.

Procedure

Portacaval Shunt is described. A right subcostal incision is made, extending across the midline as necessary. Less often, a thoracoabdominal incision may be employed. Careful dissection is performed because even minor vessels may bleed

significantly. The duodenum is reflected, exposing the inferior vena cava. The hepatoduodenal ligament is incised; the common bile duct and hepatic artery are protected. The portal vein is exposed from the porta hepatis to the superior border of the pancreas. Portal pressure is measured (for a reference) by manometry through a needle inserted in a small mesenteric vein. Partial occlusion of the vena cava and the portal vein are obtained with vascular clamps. Anastomosis is made side to side after excising a generous window in either vein. For end-to-side anastomoses, the portal vein is transected at the porta hepatis, ligating the (hepatic) stump securely. The distal end is anastomosed to the side of the vena cava. Repeat manometry is performed. The wound is closed in layers.

Preparation of the Patient

Antiembolitic hose are applied. Following the administration of general anesthesia with endotracheal intubation, the patient is in supine position with the right side elevated. Anesthesia provider inserts a nasogastric tube and CVP line. A folded sheet or roll is placed under the right shoulder to facilitate visualization. The table may be positioned in Trendelenburg position. Arms may be extended on padded armboards. All bony prominences and areas prone to skin and neurovascular pressure or trauma are padded. Foley catheter is inserted and connected to drainage unit. Apply electrosurgical dispersive pad.

Skin Preparation

Begin at the right subcostal region, extending from the axillae to the upper thighs and down to the table at the sides.

Equipment

Forced-air warming blanket, optional

Sequential compression device with disposable leg wraps, as requested

ESU

Suction

Spinal manometer (for measuring portal pressure)

Blood pump and blood warmer

Scales for weighing sponges (2)

Cell-saver (optional, check with surgeon)

Instrumentation

Major procedures tray

Abdominal and thoracic vascular procedures tray

Long instruments tray

Ligating clip appliers, e.g., Hemoclip appliers (assorted sizes and lengths)

Supplies

Antiembolitic hose

N/G tube to the anesthesia provider

Basin set

Foley catheter and drainage unit

Extra lap sponges

Blades, (2) #10, (1) #15, (1) #11

Electrosurgical pencil and cord with holder and scraper

Suction tubing (2)

Needle magnet or counter

Three-way stopcock, polyethylene tubing (e.g., angiocath), and syringe

Ligating clips, e.g., Hemoclips (assorted sizes)

Arteriovenous Shunt or Arteriovenous (Bridge) FistulaDefinition

Establishment of a direct connection between an artery and a vein.

A communicating prosthetic loop between an artery and a vein

(shunt) or a direct communication between an artery and vein (fistula).

Discussion

The procedure is performed to provide easy access for venipuncture with a large-bore needle for purposes of renal dialysis or infusion chemotherapy.

Arteriovenous (AV) shunts or arteriovenous (bridge) fistulas involve the creation of a connection between an artery and a vein. When patients are in the late stages of renal disease, an arteriovenous shunt (Cimino shunt) is created for them in anticipation of their receiving dialysis. An anastomosis of the artery and vein form an internal connection (side to side, side to end, or end to end).The anastomosis on the venous side bulges under the greater pressure from the artery. The site of the venous dilatation formed at the anastomosis site thickens over the period of a few weeks. When the walls of the vein become thick (like arteries), the vein is strong enough to endure the repeated venipuncture required by dialysis. Bridge fistulas are the creation of a connection between an artery and a vein by means of a bridge. A bridge may be created from a saphenous vein graft, an umbilical vein graft, or a bovine artery prosthesis (usually enzymatically treated) or PTFE (Teflon) graft. A modification of the PTFE graft has tapered ends. The size of the bridge, whether straight or curved, depends upon the proximity of the vessels to each other.

Procedure

Arteriovenous shunt or arteriovenous bridge fistula is performed following injection of local anesthetic.An incision is made over a selected artery and adjacent vein (often the radial artery and cephalic vein of the proximal forearm). Use of the nondominant forearm is preferable; lower extremities can be used if forearm sites cannot be used (e.g., previous surgery).Vascular clamps or bulldogs are used to control the vessels. An incision is made into the lumen of the artery (arteriotomy). The artery is usually dilated with coronary artery dilators. The venous side is ligated distally. A shunt (e.g., saphenous vein graft, umbilical vein graft, or bovine artery prosthesis) is anastomosed to the artery and to the vein.When these vessels are inadequate, a synthetic PTFE graft may be positioned between the artery and the vein. Usually a loop fistula is created in the antecubital fossa by interposing a bridge between the brachial artery and the cephalic or basilic vein. Heparin solution is instilled into the shunt. Alternatively, a fistula may be created in the arm between the brachial artery and the axillary vein. The wound is closed, and a protective dressing is placed.

Preparation of the Patient

Antiembolitic hose may be applied. The patient is supine; a small pad may be placed under the lumbar spine and/or a pillow may be placed under the knees to avoid straining back muscles and for comfort. The affected forearm is extended on a padded hand table; the other arm may be extended on an armboard or padded and tucked in at the patient’s side. All bony prominences and areas prone to skin and

neurovascular pressure or trauma are padded. Apply electrosurgical dispersive pad.

Skin Preparation

Begin at the proposed site (e.g., nondominant forearm), extending from 3′′ to 4′′ above the elbow to include the entire hand (fingers, nails, and interdigital spaces).

Equipment

ESU

Hand table

Sitting stools (2) for surgeon and scrub person

Loupes, optional

Instrumentation

Shunt tray

Coronary artery dilators

Supplies

Antiembolitic hose, optional

Small basin

Electrosurgical pencil with needle tip and cord

Needle magnet or counter

Blades, (1) #15, (1) #11

Shunt, e.g., PTFE cannulas (2) or surgeon’s preference

Shunt connector

Heparin

Heparinized saline (diluted to surgeon’s preference)

Graduated pitcher and syringe

Shunt clamps (2)