mindyanna
Networker
I am very green when it comes to Vascular surgery and I feel so lost on where to begin. They are so complex and from what I remember in school, they could have multiple codes for one surgical case. I have listed one of the operative reports below in hopes that someone could explain to me in laymen terms what it all means. I am actively seeking some sort of course to help me better understand the vascular world but in the meantime I was hoping I could draw off the experts to get me started.
PROCEDURE PERFORMED: Right suprageniculate popliteal artery to anterior tibial artery bypass using nonreverse saphenous vein in an anatomic tunnel.
INDICATIONS: Patient is a 60-year-old nursnig home resident who presented with profound ischemic rest pain in the right lower extremity. Angiography demonstrated severe infrspopliteal trifurcation occlusive disease with reconstitution of anterior tibial artery. He had pre-op vein mapping which demonstrated adequate caliber saphenous vein; however, pre-op cardiac stress test suggested reverible defect and he had pre-op cardiac cath which demonstrated adequate coronaries and he presents now for right lower extremity distal bypass.
PROCEDURE: We began the procedure by making vertical incision midway between the tibial crest and the fibula along the middle third of the right leg and carried the dissection down through the deeper issues with the aid of Bovie electrocautery. The patient had extensive subcutaneous venous varicosities and these were either ligated or clipped as they were encountered. Following this we were fianlly able to identify the anterior tibial vessels through the musculature and the anterior tibial artery was skeletonized from appropriate length distally and proximally and encircled with vessel loops. It appeared to be a soft compliant vessel and would accept an outflow anastomosis. We then turned our attention to the medial aspect of the right lower extremity and via three incisions, two in the medial right leg and one in the distal medial thigh, the entire length of required saphenous vein was dissected free and skeletonized and harvested. Following this the incisions in the proximal medial calf and in the distal medial thigh were deepened and the infrageniculate popliteal fossa and suprageniculate popliteal fossa were entered respectively. The supragenculate popliteal artery was identified and had a palpable pulse and it was skeletonized for an appropriate length and encircled distally and proximally with vessels. Following this an anatomical tunnel was created from the suprageniculate popliteal fossa to the infrageniculate popliteal fossa after which a tunnel was created from infrageniculate popliteal fossa to the anterior tibial exposure through the interosseous. The patient was then systematically heparinized and then we transected the harvest segment of saphenous vein and ligated the remaining stumps with 3-0 Ploysorb ties. We then flushed through the vein ensuring that we had clipped and/or ligated all branches. I decided not to reverse the vein because of the probable size mismatch to the outflow artery. After adequate circulation time of heparin, vascular clamps were applied on the exposure suprageniculate popliteal artery and a longitudinal arteriotomy was created. Examination of the lumen demonstrated atheromatous plaque but I decided not to do an endarterectomy at this level as there appears to be adequate lumen and decent pulse. The proximal end of the nonreversed saphenous vein graft was spatulated and tailored to match the length of the popliteal arteriotomy and we proceed to sew our proximal anastomosis using 6-0 Prolene suture. Following this flow was then reestablished to the vein graft and as expected there was no flow distally because of retained valves. Then a LeMaitre valvulotome was introduced to the distal aspect of the nonreversed saphenous vein graft and passed a total of three times which resulted in excellent pulsatile outflow through the distal end of the graft after which he was flushed with heparinized saline and clamped off for later use. I then marked the saphenous vein graft under arterial tension and passed it though our previously created tunnel in the retropopliteal orientation and also through the interosseous until it was at the level of the anterior tibial exposure and once again checked the flow and it was excellent and pulsatile and I was comfortable that it was not twisted or kinked. Following this I then turned my attention to the exposed anterior tibial artery and vascular control was established and a longitudinal arteriotomy was created. I then spatulated the distal end of the nonreversed saphenous vein graft and proceeded to sew the outflow anastomosis using 7-0 Prolene suture. Just prior to tying down the final suture I flushed in a retrograde antegrade fashion as well as heparinized saline prior to tying down the final suture. Flow was then reestablished and there was excellent palpable pulse in the outflow anterior tibial artery as well as in the dorsalis pedis artery in the foot as well as excellent Doppler signal.
I appreciate any help you can offer. Thanks!
PROCEDURE PERFORMED: Right suprageniculate popliteal artery to anterior tibial artery bypass using nonreverse saphenous vein in an anatomic tunnel.
INDICATIONS: Patient is a 60-year-old nursnig home resident who presented with profound ischemic rest pain in the right lower extremity. Angiography demonstrated severe infrspopliteal trifurcation occlusive disease with reconstitution of anterior tibial artery. He had pre-op vein mapping which demonstrated adequate caliber saphenous vein; however, pre-op cardiac stress test suggested reverible defect and he had pre-op cardiac cath which demonstrated adequate coronaries and he presents now for right lower extremity distal bypass.
PROCEDURE: We began the procedure by making vertical incision midway between the tibial crest and the fibula along the middle third of the right leg and carried the dissection down through the deeper issues with the aid of Bovie electrocautery. The patient had extensive subcutaneous venous varicosities and these were either ligated or clipped as they were encountered. Following this we were fianlly able to identify the anterior tibial vessels through the musculature and the anterior tibial artery was skeletonized from appropriate length distally and proximally and encircled with vessel loops. It appeared to be a soft compliant vessel and would accept an outflow anastomosis. We then turned our attention to the medial aspect of the right lower extremity and via three incisions, two in the medial right leg and one in the distal medial thigh, the entire length of required saphenous vein was dissected free and skeletonized and harvested. Following this the incisions in the proximal medial calf and in the distal medial thigh were deepened and the infrageniculate popliteal fossa and suprageniculate popliteal fossa were entered respectively. The supragenculate popliteal artery was identified and had a palpable pulse and it was skeletonized for an appropriate length and encircled distally and proximally with vessels. Following this an anatomical tunnel was created from the suprageniculate popliteal fossa to the infrageniculate popliteal fossa after which a tunnel was created from infrageniculate popliteal fossa to the anterior tibial exposure through the interosseous. The patient was then systematically heparinized and then we transected the harvest segment of saphenous vein and ligated the remaining stumps with 3-0 Ploysorb ties. We then flushed through the vein ensuring that we had clipped and/or ligated all branches. I decided not to reverse the vein because of the probable size mismatch to the outflow artery. After adequate circulation time of heparin, vascular clamps were applied on the exposure suprageniculate popliteal artery and a longitudinal arteriotomy was created. Examination of the lumen demonstrated atheromatous plaque but I decided not to do an endarterectomy at this level as there appears to be adequate lumen and decent pulse. The proximal end of the nonreversed saphenous vein graft was spatulated and tailored to match the length of the popliteal arteriotomy and we proceed to sew our proximal anastomosis using 6-0 Prolene suture. Following this flow was then reestablished to the vein graft and as expected there was no flow distally because of retained valves. Then a LeMaitre valvulotome was introduced to the distal aspect of the nonreversed saphenous vein graft and passed a total of three times which resulted in excellent pulsatile outflow through the distal end of the graft after which he was flushed with heparinized saline and clamped off for later use. I then marked the saphenous vein graft under arterial tension and passed it though our previously created tunnel in the retropopliteal orientation and also through the interosseous until it was at the level of the anterior tibial exposure and once again checked the flow and it was excellent and pulsatile and I was comfortable that it was not twisted or kinked. Following this I then turned my attention to the exposed anterior tibial artery and vascular control was established and a longitudinal arteriotomy was created. I then spatulated the distal end of the nonreversed saphenous vein graft and proceeded to sew the outflow anastomosis using 7-0 Prolene suture. Just prior to tying down the final suture I flushed in a retrograde antegrade fashion as well as heparinized saline prior to tying down the final suture. Flow was then reestablished and there was excellent palpable pulse in the outflow anterior tibial artery as well as in the dorsalis pedis artery in the foot as well as excellent Doppler signal.
I appreciate any help you can offer. Thanks!
