Basic Skills in Vascular Surgery

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Basic Skills in Vascular Surgery

• Tim Brandys MD FRCSC

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Objectives

• Learn Basic Operative Skills involved with
• management of unexpected vascular injuries
• Proximal and Distal Control
• Primary Vessel Repair
• Patch Angioplasty
• Primary Anastomosis
• Decision making (Interposition Graft)
• Vessel Ligation

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Unexpected Bleeding

• Do Not Panic
• Communicate Early with anesthesia that you will
  have ongoing bleeding

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ASK FOR WHAT YOU NEED

• Group and cross match 6 units
• FFP,CRYO,PLTs
• Get appropriate sutures,clamps,retractors

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Call for Help

• Ask for help early rather than too late

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Think FIRST AID

• Apply direct pressure to the source of bleeding
  until you are ready to deal with it
• More diffuse bleeding pack off the area with LAP
  pads

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Change your Mind Set

• Switch from elective procedure to Trauma
  protocols.
• Extend incisions to get greater exposure.
• Consider packing the patient and carrying out
  temporary closure if profound coagulopathy ensues.

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Exposure,Exposure ,Exposure !

• Do I need to extend the incision ?

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Arterial Injury Basic Principles

• 1.Proximal /Distal Control
• 2.Avoid direct entry into hematoma
• 3.HeparinSystemic,Local, or None
• 4.Active Bleeding apply Direct pressure
• 5.Debride damaged arterial wall
• 6.Arterial defect gt 1/3 circumference,Do not do
  primary repair(Patch ,Resect Reanastomose,Interpos
  ition Graft)
• 7.Arterial Defect gt2cm long,Do not do primary
  anastomosis (Interposition Graft)

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Arterial Injury Continued

• 7.Remember possibility of through and through
  injury.
• 8.Suture Choice Non absorb. Monofilament
• 9.Interposition graftavoid prosthetic in
  contaminated field,consider extra anatomic bypass
• 10.Some arteries can be ligated (ext.
  carotid,int. iliac)

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Dissection
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Dissection
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Prox./Distal Control
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Proximal and Distal Control
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Primary Repair
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Primary Anastomosis
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End to End Repair
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Primary Anastomosis Pediatrics
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Patch Repair
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Patch Angioplasty Repair
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Fish Mouth
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Modified Fish Mouth
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Triangulated
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Interposition Graft Repair
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Venous Injury

• Avoid any repair that will narrow lumen by 50 or
  more
• Interposition grafts have poorer long term
  results.
• Vigorous dissection around veins and attempts to
  clamp can sometimes do more harm than good
• Proximal and Distal control of Cava try sponge
  sticks
• Some veins can be ligated without limb or life
  threatening consequences
• Prep. Leg for vein harvest

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Cava Repair
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Today

• Patch Angioplasty
• End to end Fish mouth Anastomosis