left infrageniculate to dorsalis pedis artery bypass with reversed saphenous vein
- left greater saphenous vein harvest from groin to mid-calfTYPE OF ANESTHESIA: General.
ESTIMATED BLOOD LOSS: 100mL.
COMPLICATIONS: None.
Brief findings:
- Vein of reasonable quality from groin to mid-calf with diameter 5mm proximally and distally with decrease to 3mm in mid-section in an area of pair vein
- Popliteal artery with some plaque but strong pulse and good lumen
- DP artery at the level of the proximal foot with open lumen of 1.5mm, area without severe calcification reasonable for clamp and suture
INDICATIONS FOR PROCEDURE: Pt is 54 yo man with progression of gangrene of the left foot in the setting of right leg amputation. He has cardiac and renal disease and revascularization was planned to allow for optimization as best as possible. Given slow progression of gangrene, we discussed need for pop-pedal bypas. Duplex demonstrated an open DP with occluded more proximal AT. The popliteal artery appeared to have reasonable flow and lumen. We discussed the risks and benefits of proceeding with surgery including possible inability to perform the bypass, MI, renal failure, limb loss, bypass occlusion, bleeding, infection and need for additional surgey. After discussion of the risks and benefits, informed consent was obtained.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed in supine position. General anesthesia was administered and the patient was prepared with chlorhexidine from the umbilicus to the toes on the left with the toes prepared with betadine and wrapped with gauze and ioban. After timeout was performed and appropriate antibiotics were administered, an incision was made over the area marked out with doppler demonstrating patent dorsalis pedis artery on the foot. This incision was extended through the soft tissues and fascia sharply with cautery as needed to expose the DP. The dissection continued to expose approximately 2-3 cm of artery circumferentially using care to preserve as many branches as possible.While thickened it appeared to have a reasonable clamping zone and lumen for sewing. The saphenous vein was isolated using skip incisions from the groin to the mid-calf. All branches were ligated using 3-0 and 4-0 silk ties and transected to free it circumferentially. Once the saphenous vein was fully freed, attention was turned towards the popliteal dissection. Through the below knee inicision, the gastrocnemius fascia was incised. The popliteal space was entered. The vein was dissected off of the artery and the artery was circumferentially dissected for a length of 4-5 cm. IT was thickened, but had a good pulse. Now with the proximal and distal targets obtained, a non-anatomic tunnel was created using a counter incision just lateral to the tibia near the ankle to swing the vein from the popliteal space along the medial calf, gently across the tibia and down into the dorsal foot. The patient was then anticoagulated with heparin. The saphenous vein was ligated distally with 2-0 silk ties and transected at a branch point. Proximally it was ligated at the saphenofemoral junction with 2-0 silk stick tie. The vein was inflated with heparinized saline and any branches were controlled with 7-0 prolene figure-of-8 sutures as needed. The popliteal artery was then clamped proximally and distally and all branches were controlled with potts wrapped vessel loops. A 2 cm arteriotomy was made and the vein was spatulated at a branch point and sewn in a reversed, end to side fashion using a running continuous 6-0 prolene suture. Prior to completion of the anastomosis, the artery was flushed and irrigated with heparinized saline and flow was restored distally with the bypass clamped. With full inflation, the minimal vein size was 3 mm with max vein 5mm in diameter. Once hemostatic, it was passed through the tunnels avoiding any kinks or twists. The dorsalis pedis artery was clamped proximally and distally with bulldog clamps. Branches were controlled with 2-0 silks. A longitudinal arteriotomy 1.5cm in length was made. The wall was diseased, but reasonable for sewing. There was good antegrade and retrograde flow in the artery when clamps were removed and it flushed well in both directions. The vein was cut to length, spatulated and sewn in place using a running continuous 7-0 prolene suture. Prior to completion, the artery and vein were flushed and irrigated with heparinized saline and flow was restored. Following, there was a strong signal at the DP beyond the bypass. Hemostasis of the soft tissues was obtained with help of cautery where needed. The more proximal leg wounds were closed in multiple layers of 2-0 and 3-0 vicryl sutures followed by running 3-0 nylon vertical mattress suture. The counter incision for the tunnel and the distal wound were both closed in one layer due to poor tissue compliance and inability to safely place a second layer. These layers were closed with multiple interrupted 3-0 nylon vertical mattress sutures. The wounds were then cleaned and dressed with 4 x 4's, kerlix and an ace wrap. At the conclusion of the case, the patient was extubated and transferred to the ICU in stable condition. Sponge, instrument, and needle counts were correct. I was present and scrubbed for all key portions of the case.
- left greater saphenous vein harvest from groin to mid-calfTYPE OF ANESTHESIA: General.
ESTIMATED BLOOD LOSS: 100mL.
COMPLICATIONS: None.
Brief findings:
- Vein of reasonable quality from groin to mid-calf with diameter 5mm proximally and distally with decrease to 3mm in mid-section in an area of pair vein
- Popliteal artery with some plaque but strong pulse and good lumen
- DP artery at the level of the proximal foot with open lumen of 1.5mm, area without severe calcification reasonable for clamp and suture
INDICATIONS FOR PROCEDURE: Pt is 54 yo man with progression of gangrene of the left foot in the setting of right leg amputation. He has cardiac and renal disease and revascularization was planned to allow for optimization as best as possible. Given slow progression of gangrene, we discussed need for pop-pedal bypas. Duplex demonstrated an open DP with occluded more proximal AT. The popliteal artery appeared to have reasonable flow and lumen. We discussed the risks and benefits of proceeding with surgery including possible inability to perform the bypass, MI, renal failure, limb loss, bypass occlusion, bleeding, infection and need for additional surgey. After discussion of the risks and benefits, informed consent was obtained.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed in supine position. General anesthesia was administered and the patient was prepared with chlorhexidine from the umbilicus to the toes on the left with the toes prepared with betadine and wrapped with gauze and ioban. After timeout was performed and appropriate antibiotics were administered, an incision was made over the area marked out with doppler demonstrating patent dorsalis pedis artery on the foot. This incision was extended through the soft tissues and fascia sharply with cautery as needed to expose the DP. The dissection continued to expose approximately 2-3 cm of artery circumferentially using care to preserve as many branches as possible.While thickened it appeared to have a reasonable clamping zone and lumen for sewing. The saphenous vein was isolated using skip incisions from the groin to the mid-calf. All branches were ligated using 3-0 and 4-0 silk ties and transected to free it circumferentially. Once the saphenous vein was fully freed, attention was turned towards the popliteal dissection. Through the below knee inicision, the gastrocnemius fascia was incised. The popliteal space was entered. The vein was dissected off of the artery and the artery was circumferentially dissected for a length of 4-5 cm. IT was thickened, but had a good pulse. Now with the proximal and distal targets obtained, a non-anatomic tunnel was created using a counter incision just lateral to the tibia near the ankle to swing the vein from the popliteal space along the medial calf, gently across the tibia and down into the dorsal foot. The patient was then anticoagulated with heparin. The saphenous vein was ligated distally with 2-0 silk ties and transected at a branch point. Proximally it was ligated at the saphenofemoral junction with 2-0 silk stick tie. The vein was inflated with heparinized saline and any branches were controlled with 7-0 prolene figure-of-8 sutures as needed. The popliteal artery was then clamped proximally and distally and all branches were controlled with potts wrapped vessel loops. A 2 cm arteriotomy was made and the vein was spatulated at a branch point and sewn in a reversed, end to side fashion using a running continuous 6-0 prolene suture. Prior to completion of the anastomosis, the artery was flushed and irrigated with heparinized saline and flow was restored distally with the bypass clamped. With full inflation, the minimal vein size was 3 mm with max vein 5mm in diameter. Once hemostatic, it was passed through the tunnels avoiding any kinks or twists. The dorsalis pedis artery was clamped proximally and distally with bulldog clamps. Branches were controlled with 2-0 silks. A longitudinal arteriotomy 1.5cm in length was made. The wall was diseased, but reasonable for sewing. There was good antegrade and retrograde flow in the artery when clamps were removed and it flushed well in both directions. The vein was cut to length, spatulated and sewn in place using a running continuous 7-0 prolene suture. Prior to completion, the artery and vein were flushed and irrigated with heparinized saline and flow was restored. Following, there was a strong signal at the DP beyond the bypass. Hemostasis of the soft tissues was obtained with help of cautery where needed. The more proximal leg wounds were closed in multiple layers of 2-0 and 3-0 vicryl sutures followed by running 3-0 nylon vertical mattress suture. The counter incision for the tunnel and the distal wound were both closed in one layer due to poor tissue compliance and inability to safely place a second layer. These layers were closed with multiple interrupted 3-0 nylon vertical mattress sutures. The wounds were then cleaned and dressed with 4 x 4's, kerlix and an ace wrap. At the conclusion of the case, the patient was extubated and transferred to the ICU in stable condition. Sponge, instrument, and needle counts were correct. I was present and scrubbed for all key portions of the case.