Perioperative management - Aortofemoral bifurcation bypass (Y-graft) in peripheral arterial occlusive disease stage IIb-III

According to the TASC criteria, therapeutic treatment options can be derived depending on the length of the local occlusion/stenosis. The length of the stenosis and the regions of its localisation determine the choice of therapy: endovascular or open vascular surgery.

TASC criteria for aortoiliac vascular occlusions

Video example:

Clinically the patient presents with Fontaine PAOD IIb–III and the preoperative angiogram demonstrates: occlusion of the right common and external iliac artery, subtotal stenosis of the left external iliac artery including bilateral stenosis of the femoral bifurcation

-> TASC D, thus recommendation for open reconstruction

Classification of PAOD according to the Fontaine stages and Rutherford categories

• Serious cardiopulmonary risks (e.g. NYHA IV, COPD GOLD stage IV)
• Acute or chronic inflammatory abdominal processes (e.g. florid ulcerative colitis, recurrent sigmoid diverticulitis)
• History of multiple extensive abdominal procedures ("hostile abdomen")
• Cirrhosis
• Advanced malignancy

Medical history

• Claudication
• Walking distance
• Risk factors -> nicotine, arterial hypertension, coronary heart disease, heart failure, diabetes mellitus, manifest renal failure with/without dialysis dependence, coagulopathies

Inspection

• Skin changes
• Muscular abnormalities
• Orthopaedic deformities
• Skin colour
• Hair
• Trophic changes
• Swelling, oedema, mycosis, phlegmon, ulcera cruris etc.

Palpation with contralateral comparison

• Pulse status
• Skin temperature

Auscultation of the limb arteries with contralateral comparison

Ankle-Brachial Index (ABI)

• ABI = systolic BP of posterior tibial artery / systolic BP of brachial artery

• An ABI of < 0.9 is considered diagnostic of significant PAOD.
• Determination of the Ankle-Brachial Index (ABI) by non-invasive measurement of the Doppler occlusion pressure is a suitable test for demonstrating PAOD.
• For the diagnosis of PAOD, the ABI with the lowest ankle artery pressure is decisive.
• A pathological ankle-brachial index is an independent risk indicator for increased cardiovascular morbidity and mortality.

Colour-coded duplex sonography

• Carotid arteries, abdominal aorta, limb arteries
• Localisation of stenoses and occlusions in almost all vascular regions except the thoracic region
• Quantification of the degree of stenosis and assessment of plaque morphology possible
• Sensitivity and specificity approximately 90%
• Well suited as a screening method

CT angiography

• Multi-slice computed tomography (MS-CT) using non-ionic contrast medium
• Broad range of indications: traumatic vascular lesion (especially trunk), vascular dissection/rupture, aneurysm, arterial thrombosis/embolism, portal vein/mesenteric vein thrombosis, pulmonary artery embolism, PAOD, vascular tumours
• Advantages: quickly performed; detection of relevant concomitant diseases; visualisation of peripheral arteries; sensitivity and specificity each approximately 90%
• Disadvantages: exposure to radiation and contrast media, allergies (approximately 3%), no functional assessment

Cardiac check-up

• Resting ECG
• Exercise ECG
• Echocardiography

Chest radiograph

Possibly spirometry

Laboratory tests

• Full blood count
• Electrolytes
• Coagulation
• Renal function
• Liver enzymes
• Blood lipids
• Blood group

• Enema the evening before surgery
• Trimming of hair in the surgical field
• Packed red blood cells ordered and available
• Indwelling bladder catheter
• Perioperative antibiotic prophylaxis 30 minutes before the start of surgery (see KRINKO, Robert Koch Institute recommendations)

General surgical risks

• Major bleeding; blood transfusions; hepatitis/HIV transmission from allogeneic blood units
• Allergy/intolerance
• Wound infection
• Thrombosis/embolism
• Injury to skin, vessels and nerves, e.g. due to positioning
• Keloids
• Incisional hernia

Specific surgical risks

• Thrombosis of the vascular graft and possibly adjacent vascular segments, possibly leg ischaemia, amputation
• Graft infection with bleeding from suture sites; sepsis, leg ischaemia, amputation
• Injury to adjacent organs such as the ureter, bladder, spleen, liver; intestinal ischaemia -> resection, stoma formation
• Paraplegia with a low origin of the arteria radicularis magna
• Nerve lesions -> paraesthesia, pain, paralysis of the abdominal wall and thigh musculature
• Peritoneal adhesions -> chronic pain, mechanical ileus
• Lymphatic fistula
• Secondary bleeding
• Impotence
• Anastomotic/graft aneurysm
• Compromised renal function due to intraoperative angiography