Chapter 23: Peripheral Vascular Surgery; Short Answer: Vascular Surgery

Using your medical dictionary, define claudication.

"To cramp" and is brought on by exercise and relieved by rest.

What type of graft must be preclotted prior to the aorta being incised? How is this accomplished?

A bifurcated knitted Dacron graft. Blood is drawn from the vena cava for preclotting. Using a 20-23 gauge needle on a 20mL syringe, graft placed in metal bowl for saturation of blood.

What device is used to remove the valves from an autograft saphenous vein?

A cartier valvulotome

What is arteriosclerosis obliterans?

A common disorder of the arteries characterized by thickening and loss of elasticity of the arterial walls. This results in a decreased blood flow to the organs that the arteries supply.

Describe DVT. How can it be life threatening?

A disorder involving a thrombus in one of the deep veins of the body. If the thrombus becomes an embolus, it is likely to enter the lungs causing a P.E.

What examination may be performed to identify a lesion of the common carotid artery?

A history and physical examination, arteriography, and a CT scan.

During an angioscopy, the vessel is irrigated with an irrigation solution for visualization. How is the irrigation pump set up and pressurized?

A pneumatic pressure cuff is placed around the bag of Ringer's solution and inflated to a pressure between 200 and 300 mm Hg.

When completing an angioplasty, what implant can be used to hold the vessel in the open position after the balloon angioplasty? What is the potential complication?

A stent can be placed in conjunction with the balloon angioplasty. A balloon that is too large can result in dissection of the vessel.

What additional instruments will be needed for an aortofemoral bypass that you did not need for the AAA?

A tunneling device (surgeon preference), sarot clamp, uterine dressing forceps, or specialty cardiovascular tunneler.

What can be used to aid in the visualization of small suture for loading?

A white paper towel is laid between the Mayo stand and the operative site or on the Mayo stand itself, which helps visualize blue suture. Needles should be returned from the surgeon directly to the ST because they are small and easily lost.

Why is a partial occlusion clamp such as a Satinsky or Cooley used during a femoropopliteal or femorotibial bypass graft?

Allows blood flow to continue through the vessel because the clamp is applied to only the top portion of the vessel.

What is plaque?

An atherosclerotic lesion that appears within the artery and causes the intima to obstruct the lumen.

Identify three types of treatments for embolism.

Anticoagulants (heparin); enzymes (urokinaseor); embolectomy (balloon or open).

What can be used to patch any leaks found in the anastomosis?

Any leaks in the proximal anastomosis are patched with interrupted, pledgeted prolene sutures.

What are the four types of vessel anastomosis that can be done?

Artery side to vein side, artery end to vein side, artery end to vein end, and vein end to artery side.

Vascular grafts are available in several materials. Identify at least two.

Autografts or autogenous, synthetic, and composite.

There are several types of emboli. Identify at least two.

Blood, fat, air, and cellular debris such as tumor portions.

If pledgets are used, how are they loaded?

By carefully folding the pledget in half with one hand and placing the needle (loaded on a needle holder) through the top half of the fold.

What are the signs and/or symptoms associated with a TIA?

Contralateral weakness worsens with a series of TIA's; the patient may exhibit confusion and/or speech difficulty that may resolve shortly after the episode.

The introducer kit is advanced and the IVC filter is deployed. Where is it usually placed?

Distal to the renal vein.

What is used to confirm normal blood flow in a vessel?

Doppler ultrasound to confirm the reestablishment of normal blood flow within the vessel.

What is used to remove the plaque?

Elevated with a Freer elevator or Penfield #4 dissector. Remaining pieces are removed with DeBakey forceps and mosquito clamp. Tenotomy scissors may also be used.

Why is an arteriovenous shunt or fistula completed?

Established for vascular access for patient's who require long term renal dialysis.

Identify three hemostatic agents that are typically used during peripheral vascular surgical procedures.

Gelfoam, topical thrombin, surgicel, and avitene.

What are the priorities for a ruptured AAA?

Have draping materials, a knife, cautery, Cell Saver suction, laparotomy sponges, and (Balfour) retractors ready to go. A Foley catheter with a 30 mL balloon may be used for hemorrhage control. A large aortic cross-clamp, such as a Fogarty aortic clamp, will be needed.

What medications can be used during an angioplasty?

Heparin: prevent clots; Nitroglycerin: eliminate vasospasms; Contrast dye: visualize the vessels and lesions.

What are the treatments for a thrombus occlusion? What catheter is used for an embolectomy?

High dosages of anticoagulants such as heparin allow the patient's own fibrinolytic system to lyse the occluding clot. A Fogarty embolectomy catheter is used.

For a carotid endarterectomy, why is it important for the surgical technologist to remain sterile and keep the back table and Mayo stand intact until the patient has been transported to the PACU?

In case the patient has to be put back on the table for hemorrhaging or other problems.

Using knowledge previously gained, identify why you think time is critical once the aortic and angled DeBakey clamps are applied to the vessels. What is given just prior to the application of the clamps to prevent some of the possible complications? What can you do to prevent the time from being lengthy?

Ischemia time, so the vessel does not die; heparin is given to prevent clots; anticipate and be prepared.

Using previous knowledge gained, explain why the peritoneum must be incised again. Where is the aorta located? Which artery is isolated to protect it prior to the incision being made?

Located in the retroperitoneal space. The inferior messenteric artery is isolated.

Critically analyze the situation using previous knowledge gained: Once the abdomen is entered, exposure of the abdominal aorta is the next step. The surgeon must pack the bowel away from the site. What do you think will be used for packing? What precautions will the surgical technologist perform foreign body retention?

Moist lap sponges are used for packing. Count laps first to verify count as a precaution.

Once the abdomen is opened and the small bowel is displaced, why do you think it is important to use warm wet towels or a bowel bag?

To prevent drying out and desiccation of the tissue, which causes tissue damage that must be repaired using the patient's resources, increases the chances of post-op adhesions.

Why is an IVC filter such as a Greenfield filter or a venal caval clip such as the Miles clip used?

To prevent the embolus from reaching the pulmonary circuit.

What is the primary indication for carotid endarterectomy?

Transient cerebral ischemia.

Describe varicose veins. What causes them to develop?

Veins that have become elongated, dilated, and tortuous. They can be primarily or secondarily due to DVT or venous stasis.

In what situation will contrast solution (e.g., Conray, Hypaque) be needed on the sterile field?

When an intraoperative arteriogram is anticipated.

What is the cause of a transient ischemic attack (TIA)?

When small pieces of plaque break away from the common carotid or internal carotid artery and are flushed upstream to lodge in small cerebral vessels, temporarily blocking blood flow to that particular area of the brain.

During carotid endarterectomy, is the use of a shunt necessary? Why or why not?

Yes, if something happens it is there as a backup to divert cerebral blood flow there as a precaution.

What are the most likely vessels to be used for an arteriovenous shunt?

radial artery and the cephalic vein in the wrist region.

How is the genitalia isolated from the groin? Why do you think this is important?

Prepped and draped separately because an arterial femoral line may have to be inserted for monitoring or if cannulation for CPB becomes necessary.

What types of precautions will be needed during this procedure?

Radiation precautions due to fluoroscopy. Care will be used to limit bumping of the OR bed during the procedure.

Ligation of vessels is important, what can be used as a carrier for the ties?

Schmidt tonsil clamps, sarot clamps for deeper ligation; right angle clamps to get around larger vessels.

How is a vein graft prepared for use?

Stored in heparin and checked for holes; remove valves with valvulotome or arrowhead catheter, and used as bypass conduit.

Where does atherosclerosis involvement tend to begin?

The 2 main areas are the aortic bifurcation and the superficial femoral artery.

What instruments are typically used to perform an arteriotomy?

The artery is grasped with a DeBakey forceps, entered with an #11 blade on a #7 handle, then extended with Potts-smith scissors.

Describe the size and characteristics of the suture for closure of the arteriotomy.

The common carotid is sutured with a 6-0 polypropylene double-armed sutures swaged on a taper needle.

Once the plaque and the thrombus material are removed, why is irrigation performed prior to beginning the anastomosis?

The jet action of the 20mL syringe/heparin needle combination with heparinized saline forces small pieces of thrombus from the aortic wall.

When trying to locate the subclavian catheter, what can occur as a result of the needle perforation? If a guidewire enters the ventricle, what can it cause?

The needle can cause a pneumothorax or a hemorrhage; the guidewire can cause dysrhythmias.