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Step by Step®

Step by Step®

Piush Choudhry MBBS MS

General Surgery
Indraprastha Apollo Hospital
All India Institute of Medical Sciences
Indian Spinal Injuries Center
Fortis Hospital
New Delhi, India


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Step by Step ® Arterial Surgery

First Edition: 2013
ISBN :   978-93-5090-510-4
Printed at
Dedicated to
My children, Nitika and Dhruv

In this whirling of life, the human body, since time immemorial,

has been subjected to the inevitable process of trauma whether
it is accidental or iatrogenic. The recent innovations in the
field of medical sciences coupled with the gamut of surgical
specialties that have burgeoned in the last few decades, the
management of the patient is now inexcusable.
It has been the work of many committed surgeons to
provide quality care to these patients notwithstanding the
limitations of surgical approach some have at their hospitals.
Often the complexity and consequences of the presenting
scenario undermine the capacity of the most deserving
surgeon. These are times when we revert to our experience.
These illustrations with texts are an expression of approach
in these situations.
Piush Choudhry

I would like to thank the Department of Anatomy, King George

Medical College, Lucknow, Uttar Pradesh, India, for creat­ing
concepts that have been etched into our minds and Depart­
ment of Surgery, MS Ramaiah Medical and Teaching Hospital,
Bengaluru, Karnataka, India, for effectively placing these con­
cepts into practical use that I have been able to cherish safely
over 10 years of my practice with some of the best surge­ons in
our field.
I hope, this book will be useful guide for the aspiring and
practicing surgeons. Most of the vessels have been covered to
generate a practical approach to the subject.

1. Vascular Trauma 1
• Mechanism of Injury in a Vascular Trauma  1

2. Neck 5
• Carotids   5
• Anatomical Structures to be Dissected  5
• Subclavian Artery  9
• Axillary Artery  12

3. Upper Limb 14
• Brachial Artery  14
• Radial Artery  18
• Ulnar Artery  19

4. Abdomen 21
• Abdominal Aorta  23
• Hepatic Injuries  25
• Splenic Injuries  27
• Hepatic Portal System  29
• Portal Vein  29
• Testicular Arteries and Ovarian Arteries  31
• Superior and Inferior Mesenteric Arteries  31
• Inferior Mesenteric Artery  33
• Marginal Artery  34
• Kidneys, Adrenals and Gonads  35
• Salient Features  35
• Vasculature of the Pelvis  37
• Relations  37
• Myopectineal Orifice of Fruchaud  39
xii  Step by Step Arterial Surgery

5. Lower Limb 41
• External Iliac Artery  41
• Relations  41
• Femoral Artery  43
• Popliteal Artery  49
• Posterior Tibial Artery  51

6. Arterial Suturing 54

Bibliography 63

Index 65

Vascular Trauma 1
Severe vascular injuries constitute less than 3 percent of major
trauma. Persistent arterial bleeding, rapidly expanding hematoma
and unexplained hypotension following accidents declare the
presence of a major vessel injury. The leading causes of arterial injury
are urban violence, automobile accidents and iatrogenic. Medicine is
now a high risk industry, like aviation. But, the chance of dying in an
aviation accident is one in two million while the risk of dying from a
medical accident is 1 in 200.
Iatrogenic injuries are now seen in laparoscopic surgeries. Vascular
injuries are a major cause of death from laparoscopy with a reported
mortality rate of 15 percent. The cause is the close proximity of the
anterior abdominal wall to the retroperitoneal structures especially
in thin individuals. It occurs during insertion of the Veress needle
during insufflation. Though the distal aorta can be involved, the
right common iliac artery is prone as it takes off directly below the
umbilicus. The most common minor vascular injury is to the inferior
epigastric artery. These injuries can become significant for conversion
to the open procedure.

Mechanism of Injury in a Vascular Trauma

It can be either:
• Blunt
• Penetrating
• Compression
• Stretch

Types of Arterial Injuries

• Laceration or incomplete transaction
• Transection
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• External compression
• Contusion, intimal damage and thrombosis
• Contusion and spasm
• Contusion and aneurysm
• Pulsating hematoma, false aneurysm
• Arteriovenous fistula.

Completely Severed Artery

Bleeding caused by knives, missiles, and surgical instruments usually
arrests spontaneously with the clot forming like a cork in a wine bottle.
The clot propagates distally until the collateral circulation develops.
Disruption of the artery causes immediate cessation of the distal
flow with complete disappearance of the pulse, this being the basis
for the usual diagnosis of the condition. The severity of the ischemia
following complete severance depends on the site of interruption,
size and condition of the collateral vessels and demand of the tissues.

Partially Severed Artery

This injury produces serious or recurrent bleeding and is the precursor
of both false aneurysms and arteriovenous fistulas. This injury may be
caused by knives, missiles, drill points, needles and catheters.
The most common examples of arterial injury complicating
fractures and dislocations are:
• Injury to the axillary artery in dislocation of the shoulder
• Injury to brachial artery from supracondylar fracture of the
humerus or dislocation at the elbow.
• Injury to the popliteal artery from dislocation of the knee or
displaced fracture of the upper end of the tibia.
The vessel may be torn across, it may be occluded by thrombosis or it
may be sealed temporarily by spasm. The effects may lead to:
1. Traumatic aneurysm
2. Impairment of the blood supply in the territory of the damaged
vessel with consequent gangrene, ischemic paralysis of the nerves
or ischemic contracture of the muscles called as Volksmann
ischemic contracture. Vascular occlusion may also be caused by
tissue edema within a closed fascial compartment of the forearm
Vascular Trauma  3

or leg in case of compartment syndrome or by an overtight plaster

or bandage especially in the first two or three days after an injury
or operation when swelling reaches its peak.
In detecting the presence of acute ischemia the rule of ‘P’ is a
useful start.

Sudden or gradual in outset, usually continuous rest pain suggests
critical ischemia. In the upper extremity, the intensity of pain may be
reduced due to the good collateral supply near the shoulder. In the
lower extremity, the pain is usually in the distal foot, made worse by
lying down or elevation of foot and somewhat relieved by hanging
the foot out of the bed.

Loss of sensation, especially to light touch, feeling of numbing and
tingling. Impairment of supply to sensory nerves usually causes a
stocking or a glove like loss of sensation in the involved skin. It is
important to rule out a neurological cause in absence of color changes.

Loss of motor nerve function can cause varying degrees of paralysis.

Pallor or Perishingly Cold

For most of the major extremity injuries skin at some point distal to
the injury is pale or mettled in color and cool to touch when compared
with the uninvolved side.

The other signs of ischemia are not always immediately apparent
and may not develop until propagation of distal clot obliterates large
collateral, therefore, the loss of distal pulses is the earliest and at times
the only sign of this type of arterial injury.
Recent studies show more urgent admissions with threatened
limbs. There is definitely a significant change of acceptance to arterial
surgery and its importance to life-threatening conditions. The arterial
4  Step by Step Arterial Surgery

repair in damage control surgery hinges on a sharp distinction

between simple and complex vascular repair techniques.
Simple repair includes lateral repair, ligation and temporary
intralu­minal shunt insertion while complex vascular reconstructions
include end-to-end anastomosis and graft interposition. Though the
decision to apply damage control techniques maybe different owing
to the inherent complexity and frequent association with multiple
injuries, the decision to abbreviate the initial operation before the
physiological reserves of the patient has been exhausted is of vital
Partial vascular lacerations may be directly sutured after trimming
the damaged edges. Lateral repair is often performed in larger
vessels of the trunk and extremities, in the absence of the complete
transection or devitalization of their vessel walls. Thus the flow of
blood is restored.
Ligation is a technical valid option for the critically injured patient
who is rapidly approaching his or her physiological limits . Ligation
of the bleeding vessel is possible in certain cases without irreversible
ischemia such as in radial or ulnar arteries when either one is patent.
There is a significant risk of critical limb ischemia following ligation
of the iliac, common femoral and superficial femoral arteries. In most
patients the subclavian artery can be ligated if no major soft tissue
destruction has occurred around the shoulders. Although the external
carotid artery can be ligated, the internal carotid ligation as a life saving
maneuver can be attempted with a reasonable chance of neurological
recovery. Fasciotomy is amenable in case of ligation of a major limb
artery because early compartmental syndrome is difficult to diagnose
in the early postoperative period. This fasciotomy, if not caused by
trauma itself should always be open because closed fasciotomy may
result in a compartment hematoma or the edematous skin itself may
be a source of constriction elevating intracompartmental pressures.

Neck 2
Indications for Exposure
1. Minimally invasive endovascular intervention
2. Carotid endarterectomy
3. Delayed post-traumatic rupture
4. Arterial dissection
• Severe violent trauma
• Trivial trauma such as vomiting, scuba-diving, chiropractor
manipulation, visit to hair dresser.
Spontaneous as in connective tissue disorders
5. Congenital agenesis, aplasia and hypoplasia
6. Carotid-cavernous sinus thrombosis
7. Saphenous interposition vein grafting for internal carotid artery
8. Pseudoaneurysm following irradiation for nasopharyngeal
9. Epistaxis.

Anatomical Structures to be Dissected

• Skin
• Superficial fascia
• Platysma
• Deep fascia
• External jugular vein in superficial fascia
• Retraction of sternocleidomastoid outwards and omohyoid
• Superior and middle thyroid veins
• Descendens hypoglossi
6  Step by Step Arterial Surgery

• Carotid sheath incised

• Common carotid artery exposed (Fig. 2.1).
Superior belly of omohyoid muscle crosses the artery in front at
the level of the cricoid cartilage. Below this artery is deep seated while
above this the artery is superficial and chosen for exposure.
The common carotid divides into the internal and external carotid
arteries at the upper border of thyroid cartilage. At the termination
of the common carotid artery the internal carotid is related to the
posterior border of the neck of the mandible and enters the skull
through the carotid canal, first posterolateral then deep to the external
carotid artery and enclosed in the carotid sheath (Figs 2.2 to 2.4).
Avoid injury to the hypoglossal nerve (Fig. 2.5) which crosses in
front of internal carotid artery and external carotid artery just above
the tip of greater cornu of the hyoid bone (Fig. 2.6).

Figure 2.1  Common carotid bifurcation and its relation to the

posterior belly of digastric muscle
Neck  7

Figure 2.2  Floor of the submandibular triangle

Figure 2.3  Sternomastoid and its landmarks

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Figure 2.4  Branches of external carotid artery

Figure 2.5  Ansa cervicalis, its roots and branches to infrahyoid muscles
Neck  9

Figure 2.6  Pharyngeal and laryngeal branches of vagus with

the carotid artery

Subclavian Artery
The incision is made half inch above clavicle from sternal head of
sternomastoid to anterior border of trapezius (Figs 2.7 to 2.9).

Indications for Exposure

1. Subclavian endarterectomy
2. Reconstructive surgery as for carotid to subclavian bypass,
repositioning of subclavian artery, axilloaxillary and subclavian
artery aneurysm.

• Skin
• Superficial fascia
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• Platysma
• Deep fascia
• External jugular vein receiving suprascapular and transverse
cervical veins.

Above and lateral

• Upper and middle trunks of brachial plexus
• Inferior belly of omohyoid muscle.

Figure 2.7  Arteries and veins at the root of neck

Neck  11

Figure 2.8  The triangle of the vertebral artery (base 1st part of subclavian
artery). The sympathetic trunk, ganglia and branches at root of the neck, the
trunk throws ansa around three arteries, the inferior thyroid, vertebral and
subclavian (ansa subclavia)

Figure 2.9  Subclavian artery, clavicle bone at root of neck

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Scalenus medius and 1st rib with lowest trunk of brachial plexus.
All the lesions of subclavian artery and aortic arch are localized
until thrombosis occurs in which case the occlusions extend to the
first distal major branch. Occlusions of subclavian artery proximal to
origin of vertebral artery may result in the retrograde flow down the
vertebral artery down to the subclavian artery, a ‘subclavian steal’. Arm
motion may accentuate the flow. Significant occlusion of innominate
artery may result in similar retrograde flow in right common carotid
artery and vertebral artery. Embolization from ulcerating lesion of
innominate or common carotid artery produce symptoms such as
transient ischemic attacks, ipsilateral amaurosis fugax, dysphasia
or contralateral hemipariesis. Symptoms related to exercise usually
occur in the presence of multiple lesions with decreased perfusion.
Carotid distribution area symptoms may consist of unilateral visual
loss, dysphasia, hemipariesis.

Axillary Artery
The artery extends from outer border of first rib to lower margin of
teres major under cover of pectoralis major above and subcutaneous
below. The surgical exposure of the artery is same as that of infra­
clavicular brachial plexus.

Indications for Exposure

1. Arterial reconstructive surgery as in axillofemoral bypass graft,
subclavian artery aneurysm
2. Surgical repair of lacerated artery.
The incision is made just below the clavicle, medial thirds to the
mid-point of the clavicle along deltopectoral groove. The incision can
be extended proximally across the clavicle to the posterior border of
sternocleidomastoid to expose the subclavian artery or distally along
the medial border of biceps for brachial artery (Fig. 2.10).
Neck  13

Figure 2.10  The right brachial plexus and the axillary artery

Relations of Axillary Artery

Medial root of median nerve.

Radial and circumflex nerves lie posterior.

Lateral root of median nerve, musculocutaneous nerve.

Between it and axillary vein lies medial cutaneous nerve of forearm
in the anterior plane and ulnar nerve in the posterior plane. Medial
cutaneous nerve of arm also lies medial.

Upper Limb 3
Brachial Artery
The artery extends from the lower border of teres major ending
distally 1 cm below the elbow joint dividing into the radial and
ulnar arteries.

• Muscular
• Nutrient artery to the humerus
• Profunda brachii with anterior and posterior descending branches
(Fig. 3.1)
• Arterial anastomosis around the elbow formed by profunda
brachii and its branches and the ulnar collateral and supratrochlear
arteries, branches of the brachial artery (Figs 3.2 and 3.3).

Figure 3.1  Four types of variations in origin of posterior humeral circumflex

and profunda brachii artery in 2.9% arteries were otherwise irregular

Indications for Exposure

1. Repair of lacerations of the artery
2. Incision for brachiocephalic fistula
3. Saphenous vein transplant fistulas (Fig. 3.4)
4. Thrombosis after coronary angiography
5. Displaced supracondylar fractures of the humerus
Upper Limb  15

Figure 3.2  Arteries of the arm and elbow region

Figure 3.3  Superficial veins of the arm

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Figure 3.4  Brachiocephalic fistulas and saphenous vein transplant fistula

where distal artery is unavailable

Figure 3.5  Surface markings and incisions: a—for third part of axillary artery, b
and c—for brachial artery, d, e and f—for radial artery, g and h—for ulnar artery

The incision extends along the medial border biceps from the
axilla above and just distal to the elbow (Figs 3.5 and 3.6).
Upper Limb  17

Figure 3.6  Exposures for arteries of the upper limb

Along its course the artery lies along the medial head of triceps,
the insertion of corcacobrachialis and brachialis. In the upper arm
the artery is medial to the median nerve (Fig. 3.7) but after the
nerve crosses it anteriorly, the artery becomes lateral to the nerve.
Proximally, the ulnar nerve and the medial cutaneous nerve of the
forearm are medial to it before the ulnar nerve passes through the
medial intermuscular septum into the posterior compartment of
the arm.
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Figure 3.7  Developmental explanation of variable relationship of median

nerve to brachial artery

Antecubital Fossa
Exposure of the brachial artery which is directly lacerated, an anterior
lazy S incision is preferred. The brachial artery is a midline structure,
it lies on the brachialis and is medial to the biceps tendon and lateral
to the median nerve and divides at the neck of the radius into radial
and ulnar arteries.
High bifurcation of the brachial artery or high origin of the radial
artery from the brachial artery is the most frequent arterial variation
of the upper extremity.

Radial Artery
Indications for Exposure
1. Repair of laceration
2. Graft in cardiac bypass surgery
Upper Limb  19

Course of the Radial Artery

The radial artery extends from the neck of radius to the styloid process
of the radius and can be approached in its proximal third between
the pronator teres and the brachioradialis as it lies on the supinator.
Then the artery lies on the radial origin of flexor digitorum superficialis,
flexor pollicis longus, pronator quadratus and the lower end of the
radius. Its first major branch is the radial recurrent artery which passes
between the posterior interosseous nerve and the superficial terminal
radial nerve. This artery anastomoses with anterior descending branch
of profunda brachii artery. Distally the radial artery is lateral to flexor
carpi radialis and medial to the tendon of brachioradialis.
The radial artery enters the wrist deep to the tendons of abductor
pollicis longus and extensor pollicis brevis and runs deep to the
tendon of extensor pollicis longus in the anatomical snuff box. The
dorsal metacarpal artery, branch of dorsal carpal artery arising from
the radial artery in the snuff box, supplies the scaphoid. Operations
on the scaphoid can result in a postoperative hematoma. The arteria
princes pollicis branch of the radial artery as is it enters the palm is
the volar artery to the thumb while the arteria radialis indicis supplies
the radial side of index finger.

Ulnar Artery
The incision is made on the anterior surface of the forearm over the
tendon of the flexor carpi ulnaris proximal to the wrist and crosses
60 degrees to the distal transverse crease between the little and ring
fingers to the hypothenar eminence.

The brachioradialis and pronator teres muscles are laterally and the
flexor digitorum sublimis medially. The ulnar nerve lies medial to
the ulnar artery. At level of the wrist crease the ulnar nerve passes
into the Guyon’s space. The ulnar artery runs with the nerve in
the Guyon’s space and turns radially and becomes the superficial
palmar arch. The deep branch of the ulnar artery accompanies the
20  Step by Step Arterial Surgery

Figure 3.8  Median and ulnar nerves in the forearm

Figure 3.9  Radial and axillary nerves

deep branch of the ulnar nerve (Figs 3.8 and 3.9) and becomes the
deep palmar arch.

Abdomen 4
Injuries to major abdominal vessels are uncommon but can
be lethal and hemorrhage can be the most important cause
of early death. Intra-abdominal vascular injuries are associated
with extremely rapid rates of blood loss and pose challenges
of exposure during laparotomies. Essential to the successful
management of these injuries is familiarity with the anatomy of
intra-abdominal vascular structures (Figs 4.1 and 4.2) the tech­
niques of control of the hemorrhage combined with selected
application of ligation, primary repair or bypass procedures.

Figure 4.1  Primary retroperitoneal structures, also spleen and colon

22  Step by Step Arterial Surgery

Figure 4.2  Abdominal innervation and vasculature

The anatomic distribution of the vessels have been defined

• Midline supramesocolic hemorrhage or hematoma (super­
ior to the transverse mesocolon) from an injury to the
suprarenal aorta, celiac axis, proximal superior mesenteric
artery, or proximal renal artery.
• Midline inframesocolic hemorrhage or hematoma from
infrarenal aorta or inferior vena cava (IVC) injury.
• Lateral perirenal hematoma or hemorrhage from injury to
the renal vessels or kidneys.
• Lateral pelvic hematoma or hemorrhage from injury to the
iliac artery, iliac vein, or both.
• Hepatoduodenal ligament hematoma from injury to the
portal vein, hepatic artery, or both.
Abdomen 23

In major abdominal vascular injuries, the most lethal injuries are

in the retrohepatic vena cava, visceral aorta and the main portal
vein. Blunt trauma usually involves the venous system.

Exposure of the Vessels

Visceral rotation is valuable for the operative exposure of major
intra-abdominal vascular wounds.
Left peritoneal reflection is carried for midline and left
supramesocolic hematomas. The mobilization of the left aspect
of the colon, spleen, stomach, distal pancreas in a plane deep
to the pancreas the adequate exposure of the suprarenal aorta,
celiac axis, proximal superior mesenteric artery and left renal
vessels is obtained.
Right sided supramesocolic hematomas reflection of the
ascending colon, duodenum and pancreatic head provides a
view of the infrahepatic vena cava, portal venous system and
right renal vessels.
Proximal vascular control of inframesocolic or pelvic bleed­
ing is better obtained by right visceral rotation.

Abdominal Aorta
The injuries of the abdominal aorta (Fig. 4.3) should be con­
trolled by lateral arteriorrhaphy where feasible. Large wounds
require autologous vein patching. For complete transection,
synthetic graft interposition can be used even in contamination
(Fig. 4.4).
Extensive damage to the celiac trunk (Fig. 4.5) can be con­
trolled by ligation because of the rich collateral circulation,
however, occlusion of superior mesenteric artery proximal
to middle colic branch requires reconstruction either as an
interposition autologous vein graft or bypass from aorta to
superior mes­enteric artery.
24  Step by Step Arterial Surgery

Figure 4.3  Collateral branches of the abdominal aorta to the paired

glands, suprarenal, renal and testicular arteries

Figure 4.4  Abdominal viscera and vessels

Abdomen 25

Figure 4.5  Celiac trunk

Hepatic Injuries
The liver is the most commonly involved intra-abdominal organ
and more than 85 percent of the wounds can be managed by
simple hemostatic measures like gauze packaging. For conti­
nued sup­er­­ficial bleeding though argon beam coagulation is
Pringle’s maneuver which is the temporary occlusion of the
porta hepatis, the portal vein, hepatic artery and common bile
duct significantly reduces blood loss (Fig. 4.6). Packs, if applied,
should be removed early within 24 hours as they increase
intra-abdominal pressure which may compromise splanchnic
and renal circulation and are an important source of bacterial
proliferation. If bleeding does not stop, it is probably an
indication of hepatic vein and retrohepatic vena caval tear or
aberrant derivation of lobar hepatic artery. As these accessory
lobar arteries do not lie in the porta hepatis they have to be
occluded separately (Fig. 4.7).
26  Step by Step Arterial Surgery

Figure 4.6  The epiploic foramen and the peritoneal reflection

Figure 4.7  Vascular supply to liver and gallbladder

Abdomen 27

Mobilization of the Liver

This is done by dividing falciform ligament to the diaphragm,
incising peritoneal attachments between left and right lobe
of liver and diaphragm and incising right and left triangular
ligaments. The gastrohepatic ligament and retroperitoneum is
incised to expose the retrohepatic vena cava on the left.
Selective hepatic artery ligation is performed if the above
attempts are not successful. Retrohepatic vena caval shunts
have been used but have a high mortality. Hepatic lobectomy
carries a mortality of 50 percent, the immediate indication
being retrohepatic vena cava injury in adults as in a child the
confluence of the major hepatic veins and vena cava is more

Splenic Injuries
Spleen salvage following injury should be done when the risk
of complications of splenorrhaphy do not exceed the risk of
total splenectomy. Overwhelming sepsis is an complication
which needs to be considered in favor of splenic salvage.
The grade of injury can be determined by the splenic injury
Grade 1
• Hematoma, subcapsular with less than 10 percent surface
• Laceration, capsular tear less than one cm of parenchymal
Grade 2
• Hematoma, subcapsular 10 to 50 percent surface area
intraparen­chymal less than 5 cm diameter
• Laceration, 1 to 3 cm parenchymal depth that does not
involve a trabecular vessel.
28  Step by Step Arterial Surgery

Grade 3
• Hematoma, subcapsular with greater than 50 percent sur­­
face area or expanding ruptured subcapsular or paren­
chymal hematoma, intraparenchymal hematoma greater
than 5 cm or expanding.
• Laceration, greater than 3 cm depth or involving trabecular
Grade 4
• Laceration involving segmental or hilar vessels producing
major devascularization up to 25 percent of spleen.
Grade 5
• Laceration, completely shattered spleen.
• Vascular, hilar vascular injury that devascularizes spleen.
The splenic artery (Fig. 4.8) in 85 percent of the cases
divi­des into two primary branches supplying the superior and
inferior lobes. The lobar arteries further divide into cephalic
and caudal segments.

The spleen is freed from its phrenicolienal and lienorenal avas­
cular peritoneal attachments. The inferior lienocolic ligament

Figure 4.8  Vasculature of pancreas and spleen

Abdomen 29

may contain vessels and should be ligated first. The plane

posterior to the pancreas is developed for dissection.
The splenic injury can be managed using:
• Wrapping of spleen in a absorbable compression bag
• Cotton or Teflon pledget
• Microfibrillar collagen
• Thrombin
• Fibrin biological glues
• Argon beam coagulator or electrocautery for small cap­
sular avulsions
• Splenorrhaphy.
Deep parenchymal lacerations require ligation of individual
vessels. Segmental arterial ligation produces demarcation at
the avascular intersegmental plane.
Splenectomy is valid for life-threatening conditions. Auto­
transplantation of splenic tissue into muscles, omentum and
retroperitoneal tissue restores some of the immune functions
lost with splenectomy though postoperatively such patients
require the polypneumococcal vaccine.

Hepatic Portal System

The inferior vena cava wounds should be primarily repaired
even if the luminal diameter is compromised, though vein
patch may be required for extensive injuries. Inferior vena
caval ligation can be done for massive tissue loss. The abrupt
occlusion of suprarenal cava can cause renal impairment from
venous hypertension and reconstruction can be done by
saphenous vein interposition or synthetic grafting.

Portal Vein
The bleeding in the postal vein (Fig. 4.9) can be controlled by
temporarily by digital pressure but a definitive repair of the
30  Step by Step Arterial Surgery

Figure 4.9  Hepatic portal system

superior mesenteric and splenic veins will require the division

of the pancreas. In severe injuries the portal vein may be
ligated, portosystemic shunting should be done if bowel is
The portal anastomosis is formed by:
1. Esophageal:
• Left gastric
• Azygos
• Hemiazygos
2. Caput madusae:
• Periumbilical veins in falciform ligament
• Superior and inferior epigastric
3. Hemorrhoids:
• Superior rectal and middle rectal
• Middle rectal and inferior rectal
4. Veins of Retzius: Veins of the secondary retroperitoneal
structures anasto­mose with dorsal body wall forming veins
of Retzius. May profusely bleed when these structures are
mobilized surgically otherwise they are quiet.
Abdomen 31

Testicular Arteries and Ovarian Arteries

They arise below the renal artery on either side and descend in
the retroperitoneal tissue on the psoas fascia to deep inguinal
ring. In females, it enter pelvis crossing the ureter. The right
artery crosses the inferior vena cava.

The third part of the duodenum, right colic and ileocolic vessels,
end of ileum or cecum.

The forth part of the duodenum, inferior mesenteric vein, left
colic and sigmoid vessels and the sigmoid colon.

Superior and Inferior Mesenteric Arteries

Superior Mesenteric Artery
The superior mesenteric artery arises (Figs 4.10 and 4.11) from
the aorta anterior to vertebra L1 and usually 1 cm caudal to the
celiac axis. It travels under the neck of the pancreas and the
splenic vein.

The artery passes over the left renal vein, the third part of the
duodenum and the uncinate process of the pancreas.
As it passes over the left renal vein, the compression by this
artery can lead to the nutcracker syndrome. This syndrome is
also called the renal vein entrapment syndrome, or mesoaortic
compression of the left renal vein. It is characterized by pain in
the left flank region, testicular pain and hematuria. Occasionally,
32  Step by Step Arterial Surgery

Figure 4.10  Superior and inferior mesenteric artery

Figure 4.11  Superior mesenteric artery distribution

Abdomen 33

varicocele, varices in the lower limbs, nausea and vomiting due

to compression of the splanchnic veins can be seen.
The posterior relation to the third part of the duodenum
can cause the superior mesenteric artery syndrome characterized
by early satiety, bilious vomiting, postprandial pain, abdominal
distension and can be the the cause of severe malnutrition.
The origin of the superior mesenteric artery can be exposed
through a transverse or vertical incision in the peritoneum
lateral to the spleen or the colon.

1. Inferior pancreatoduodenal arteries
• Anterior
• Posterior
2. Jejunal and Ileal branches
3. Ileocolic artery
• Anterior and posterior cecal
• Appendicular
• Ascending colic
• Ileal
4. Right colic (frequently missing)
5. Middle colic.

Inferior Mesenteric Artery

The artery (Fig. 4.12) originates from the aorta distal to the liga­
ment of Treitz, is typically smaller than the superior mesenteric
artery and is more likely to be involved in the atherosclerotic
process in the older patient.
1. Left colic
2. Sigmoidal
3. Rectosigmoid
4. Superior hemorrhoidal rectal artery
34  Step by Step Arterial Surgery

Figure 4.12  Inferior mesenteric artery distribution

The intestinal angina and the colicky pain in the distribution

of the superior mesenteric artery is referred to the umbilicus
while the colicky pain is referred to inguinal regions and
anterior thigh from the inferior mesenteric artery.

Marginal Artery
The anastomosis between superior mesenteric artery and the
inferior mesenteric artery form an arterial trunk (Drummond)
and lie in the mesentery close to the border of the large
intestine running from the ileocecal valve to the rectosigmoid
junction. There are several critical points where the marginal
artery may not provide collateral supply. The arch of Riolan
provides strong anastomotic connections between inferior
mesenteric artery and left branch of middle colic artery. The
Abdomen 35

connections between lowest sigmoid and upper rectal branch

of superior rectal (hemorrhoidal) artery is sometimes by a
very small vessel incapable of providing adequate collateral
circulation in vicinity of Sudeck’s critical point.

Kidneys, Adrenals and Gonads

Renovascular trauma is infrequent and kidney salvage
following complete renal artery occlusion is poor though revas­
cularization should be attempted even after prolonged delay.
A thrombosed renal vessel should be resected and reana­s­
tomosed or an aortorenal bypass graft should be used.

Salient Features
Renal Arteries
The origin of renal arteries (Fig. 4.13) is at level L1L2 below
superior mesenteric artery. Right renal artery passes posterior
to inferior vena cava.

Figure 4.13  Renal artery with its extra and intrarenal branches
36  Step by Step Arterial Surgery

Extrarenal Branches
Inferior suprarenal artery, numerous twigs to the ureter, occa­
sional gonadal artery, occasional inferior phrenic artery.

Intrarenal Branches
1. The segmental arteries
• Renal vascular segments
• Renal divisions anterior and posterior
The avascular segment, Brodie White Line
2. Interlobar arteries, the interlobular arteries, the afferent
glomerular artery.

Vascular Variations
Aberrant or supernumerary segmental arteries are common,
there is a fetal lobulation pattern with failure of renal arterial
segments to fuse into single renal artery.

Aberrant Segmental Artery

• Hilar (from renal artery)
• Polar (from aorta)
Polar arteries are larger, the lower ones pass anteriorly to the
ureter and may cause compression leading to hydronephrosis.
Ligation of a supernumerary renal artery almost produces
necrosis of renal segment.

Renal Vein
The right renal vein enters the inferior vena cava at lower point
than the left, no significant tributaries. Left renal vein is longer,
passes anterior to the aorta and receives the left gonadal
vein, left suprarenal vein, the left inferior phrenic vein and
communicates with azygos vein. In renovascular trauma the
right renal vein should be reconstructed while a left renal vein
can be ligated medially to a patent gonadal vein.
Abdomen 37

Multiple renal veins are less common than supernumerary
artery, the most common variation is doubling of the renal vein.

Vasculature of the Pelvis

Internal Iliac Artery
The internal iliac arteries arise from the common iliac arteries
at the L5S1 intervertebral disc divides at the upper margin of
the greater sciatic foramen into the anterior and the posterior
trunks. Internal Iliac arteries are paired and about 3 cm from the
line joining the aortic bifurcation to mid-inguinal point.
In two-thirds of a large number of cases, the length of the
internal iliac varied between 2.25 and 3.4 cm; in the remaining
third it was more frequently longer than shorter, the maximum
length being about 7 cm the minimum about 1 cm. The place
of division of the internal iliac artery varies between the upper
margin of the sacrum and the upper border of the greater
sciatic foramen.
The internal iliac artery (Fig. 4.14) is twice the size of the
external iliac artery in the fetus becoming the umbilical arteries,
when the placental circulation ceases the pelvic portion of
the umbilical artery remains patent giving rise to the superior
vesical artery, the remainder obliterates to form the in the solid
fibrous cord called as the medial umbilical ligament containing
the obliterated hypogastric artery extending from the pelvis to
the umbilicus.

Anteriorly: Lies the ureter
Posteriorly: Internal iliac vein, the lumbosacral trunk and piri­
formis muscle.
38  Step by Step Arterial Surgery

Figure 4.14  Arteries of the pelvis

Laterally: External iliac vein, psoas muscle and the artery is

above the obturator nerve.

1. Visceral branches:
• Umbilical
• Superior Vesical
• Inferior vesical
• Middle rectal
• Uterine and vaginal in females
2. Branches to the limb and perineum:
• Superior gluteal
• Inferior gluteal
• Obturator
• Internal pudendal
Abdomen 39

3. Somatic segmental branches:

• Iliolumbar
• Lateral sacral
4. Internal pudendal artery:
• Inferior rectal artery
• Superior perineal artery
– Transverse perineal
– Posterior scrotal
– Labial branch
• Deep perineal artery
– Dorsal artery of penis
– Deep (central) artery for erectile tissue
– Bulbar artery of bulb of penis.
– The lengths of the common iliac and internal
iliac arteries bear an inverse proportion to each
other, the internal iliac artery being long when the
common iliac is short.

Myopectineal Orifice of Fruchaud

By the arching fibers of the internal oblique and transversus
abdominus muscles.

By the rectus abdominus muscle and its fascial rectus sheath.

Cooper’s Ligament

Iliopsoas muscle: The inguinal ligament divides the orifice
into internal inguinal ring above where the internal inguinal
40  Step by Step Arterial Surgery

hernia occurs. Medial to the internal ring, is the Hesselbach’s

triangle. This is the location through which a direct hernia
develops. Below the inguinal ligament lies the femoral triangle
containing the femoral vein medially and the femoral artery
laterally. Medial to these vascular structures is the femoral
canal through which the femoral hernia occurs.

Lower Limb 5
External Iliac Artery
The artery (Figs 5.1 and 5.2) extends from the medial margin
of the psoas major to mid-inguinal point. It is represented by
lower two-thirds of a line drawn from a point about a finger
breath to the left and below the umbilicus to the mid-point
between anterior superior iliac spine and the pubic symphysis.

Peritineal cavity and its contents:
• in the beginning, it is crossed by the ureter and ovarian
vessel in females
• at the termination, it is crossed by genital branch of
genitofemoral nerve, deep circumflex iliac vein, testicular
vessels, ductus deferens in the males and round ligament
of uterus in females.

The artery is separated by psoas major by iliac fascia.

Extraperitoneal Exposure
For exposure (Fig. 5.3) the incision is made about 3 inches
above the inguinal ligament. The skin and two layers of the
superficial fascia are incised and the aponeurosis split along
the line of incision.
42  Step by Step Arterial Surgery

Figure 5.1  The common iliacs, external and internal arteries and veins

Figure 5.2  side wall of male pelvis seen on coronal section

Lower Limb  43

Figure 5.3  Extraperitoneal exposure

Inferior epigastric artery giving rise to cremastric, pubic, peri­
toneal, muscular and cutaneous branches.
Deep circumflex iliac artery giving rise to large ascending
branch between internal oblique and transversus.

Intraperitoneal Exposure
Lower paramedian incision is made. Aorta and iliac vessels
exposed, the overlying peritoneum is incised. Peritoneum
lateral to pelvic mesocolon should be divided.
The external iliac arteries should be repaired and the proxi­
mal hypogastric artery may be transposed to external iliac for

Femoral Artery
The femoral artery (Fig. 5.4) runs in the femoral or the Scarpa’s
triangle which is bounded proximally by the inguinal ligament,
44  Step by Step Arterial Surgery

Figure 5.4  Inguinal triangle viewed from behind

medially by the pectinus and the adductors and laterally by the

medial border of the sartorius. It is enclosed in a femoral sheath
(Fig. 5.5) which is the extension of the extraperitoneal fascia
about 2.5 cm distal to the inguinal ligament. The artery runs
at the mid inguinal point, obliquely and downwards medially
through the femoral triangle and subsartorial canal of hunter.
It ends by passing through an opening in adductor magnus to
become popliteal artery.

Indications for exposure

1. Vascular access for angiography, angioplasty and stentings
2. Embotectomies, control of the artery
3. Traumatic arterial lesions

Exposure at Scarpa’s Triangle

The incision (Fig. 5.6) is made over the arterial pulsation. If there
are no pulsations then incision is made from the midpoint to
Lower Limb  45

Figure 5.5  femoral sheath

Figure 5.6  Different incisions

46  Step by Step Arterial Surgery

the adductor tubercle curving towards the medial border of

the sartorius muscle.
The superficial circumflex iliac vein is divided for access
and deep fascia divided along the medial border of sartorius to
reach the femoral sheath. The artery is identified with its epi­gas­
tric and superficial circumflex iliac branches and mobilized distal
to the origin of profunda femoris. The saphenous vein (Fig. 5.7)
can be dissected medially by retracting the lymphatic tissue.

Exposure of Superficial Femoral

Artery in the Hunter’s Canal
The incision (Fig. 5.8) is given from about eight inches above
the adductor tubercle in line of the artery and then about four
inches along the posterior border of tibia (Fig. 5.9). The long
saphenous vein is pre­served and held aside. The underlying

Figure 5.7  The contents of the femoral triangle

Lower Limb  47

Figure 5.8  Exposure of superficial femoral artery in the

hunter’s canal

Figure 5.9  Deep dissection, the pro­

funda femoris arises posterior and lat­
eral aspect of common femoral artery
48  Step by Step Arterial Surgery

Figure 5.10  vasculature of the thigh

fascia is divided to expose the femoral vessels. The saphenous

nerve is retracted. The descending genicular artery should be
preserved (Fig. 5.10).

Skin, superficial fascia, fascia lata, anterior layer of femoral
sheath is derived from fascia transversalis.

Psoas major, pectineus and adductor longus separated from
upper part of femoral sheath derived from fascia iliaca.
Lower Limb  49

Popliteal Artery
The artery is (Fig. 5.11) crossed from the lateral to the medial
side by medial popliteal nerve and popliteal vein, the former
being most superficial and artery being the deepest.
The popliteal artery can be considered to consist of two
segments. The proximal which lies of the femur and the
distal which lies on the tibia. These two segments can be
approached either medially or posteriorly. The lateral approach
is made for exposure of the arch of anterior tibial artery and
endarterectomies of the distal polpliteal artery and its three
branches under direct vision.

Indications for Exposure

Reconstructive vascular surgery for localized lesions.

Figure 5.11  exposure of the popliteal artery medial approaches

upper, lower and posterior
50  Step by Step Arterial Surgery

Femoropopliteal Junction, Limited Medial Approach

The incision is made along the anterior border of sartorius and
the long saphenous vein preserved. The saphenous nerve is
preserved which lies below the sartorius and the saphenous
artery. the incision is made along the adductor tendon and
the vastus medialis is retracted. The lower end of the femoral
artery, the adductor hiatus and insertion of the tendon are
exposed. The hiatus is divided. The advantage of this approach
is the ease of exposure of the artery.

Distal Popliteal Artery, Limited Medial Approach

The incision is made along the posterior medial border of upper
third of tibia for 8 to 10 cm and can be extended proximally for
exposure of the entire vessel.
The long saphenous vein and the saphenous nerves are
preserved. The gracilis and semitendinosus are identified and
the latter cut, the plane between soleus and medial head of
gastronemius made and gastronemius retracted exposing
soleus and the vessels. The artery is in particular crossed by
many small venous branches which require careful ligation.

Popliteal Artery, Extended Medial Approach

This approach is useful in exposures required for fractures and
dislocations of the popliteal artery as it exposes the artery
entirely. The incision is made over distal third of thigh anterior
to sartorius and extends over the posteromedial border of the
knee along to the tibia.

Popliteal Artery, Posterior Approach

In this approach the muscles and tendons need not be exposed
and the neurovascular structures are relatively superficial. The
popliteal bifurcation can be exposed by splitting the soleus. The
Lower Limb  51

incision begins adjacent to tendons of the semimembraneous

and semitendinosus to the popliteal crease and extending to
the lateral head of the gastronemius. The short saphenous
vein identified with the posterior cutaneous nerve of the
thigh. The vein is dissected proximally and the popliteal vein
identified. The diamond shaped popliteal space is created by
separating the biceps femoris from the semimembraneous and
semitendinosus proximally and the two heads of gastronemius
distally. The sural and the sciatic nerves are identified. After
opening the sheath the popliteal artery is seen lying deep and
medial to the vein. This incision is not suitable for approach in
case of orthopedic injuries.

Fat covering lower part of femur, back of the knee joint, fascia
over popliteus.

Semimembraneous, medial condyle of femur above and
medial head of gastronemius below.

Biceps femoris, lateral condyle of femur above and lateral head
of gastronemius below.

Posterior Tibial Artery

This is the most important artery of the leg (Fig. 5.12). It is often
injured in the injuries around the knee joint. Ligation and repair
of the artery are the common indications. The approaches
include the extended medial approach to the posterior distal
artery as described and the posterior approach by splitting the
52  Step by Step Arterial Surgery

Figure 5.12  Vascular supply to the posterior and lateral crural

compartments and plantar foot

Posterior Tibial Artery, Medial Approach to

the Distal Segment
The incision is made longitudinally in the distal thirds of the
leg just behind the posteromedial aspect of the tibia and can
be extended proximally and distally. The medial border of the
soleus is identified and released from the deep aponeurosis.
The posterior tibial vessels are deep to the aponeurosis.

Anterior Tibial Artery

The anterior tibial artery comprises of two segments, the
origin and the arch and the distal two-thirds. For the proximal
segment, in the anterior approach the incision is made on the
medial aspect of the fibular head to the lateral aspect of the
tibialis anterior tendon at the ankle. The deep fascia between
Lower Limb  53

the extensor digitorum longus and the tibialis anterior is

incised and the neurovascular bundle is identified. Distally the
artery is approached by the extension of the incision and the
tendon of the tibialis anterior and the extensor hallucis longus
are retracted exposing the neurovascular bundle. Both the
medial branch of the superficial peroneal nerve in the incision
and the deep peroneal nerve in the neurovascular nerve need
to be preserved.
The lateral transfibular approach is the best approach for
the origin and the arch of the anterior tibial artery.

Dorsalis Pedis Artery

indication for exposure
• microvascular tissue transfer
• ligation or repair
It is the continuation of the anterior tibial artery lying on the
capsule of the ankle joint, the talus, navicular and intermediate
cuneiform between the extensor hallucis longus medially and
extensor digitorum longus laterally. It dips in the first web
space to join the lateral plantar artery completing the plantar

The incision is made medial to the extensor hallucis longus
distal to the superficial extensor retinaculum. The superficial
peroneal nerve is preserved.

Arterial Suturing 6
Arterial suturing includes following steps:
1. Arterial wall: longitudinal incision after embolectomy or
thromboendartectomy in large or medium sized vessels. A
full thickness continuous stitch (lateral suture). The needle
should pass through all layers of the arterial wall with the
intima turned outwards (Fig. 6.1).

Figure 6.1  Arterial wall

2. Resection and anastomosis or

grafting. Ovoid or rectangular patch should be used rather
than sharp pointed elliptical patch which narrows the
vessel. This technique can be used to widen the lumen
of a vessel that has become stenosed. For smaller vessels
autologous vein (Fig. 6.2).
Arterial Suturing  55

Figure 6.2  Loss of arterial tissue

3. End-to-end anastomoses by modified carrel method: Ends of

vessels to be anastomosed are to be cleared of adventitia
as its inclusion in suture line may promote thrombus
formation. Everting horizontal mattress sutures. Three
sutures are placed, the first deep posterior and the other
two equally spaced (Fig. 6.3).
4. Simple continuous sutures are placed along anterior
aspects at interval of 1 to 2 mm according to size of the
artery. The suture must not be too tight to cause a purse
string anastomosis.
5. Rotation of the anastomoses so that the posterior half can
be seen and sutured. If difficulty in rotation then single
stitch method as near bifurcations. It is useful in artery
which does not allow blalock suture to pull-up (Fig. 6.4).
56  Step by Step Arterial Surgery

Figure 6.3  End-to-end anastomoses by modified Carrel method

Figure 6.4  blalock suture to pull-out

Arterial Suturing  57

Figure 6.5  continuous suture placed anterior and posterior

6. Everting mattress suture is given where second continuous

suture is intended for hemostasis as in healthy aorta. Two
everting mattress sutures are placed with a loop on the
adventitia, i.e. healthy aorta. A continuous suture is then
placed anterior and posterior (Fig. 6.5).
7. Where growth of anastomosis is to be allowed for as in
coarctation of aorta as in children, interrupted everting
mattress sutures may be used (Fig. 6.6).
8. Blalock’s suture is used for normal or thinned walled arteries
where access to the posterior aspect of the anastomosis
cannot be obtained by rotation. Used in coarctation,
Blalock’s and Potts operations, portocaval anastomosis and
in bypass type of arterial grafts. Continuous everting sut­
ure of polypropylene fibers are placed in posterior half of
anatomosis with loops of adventitia. The ends are not tied
and drawn together with steady traction and the edges
everted. It is then completed as a normal continuous ever­
ting stitch maintaining the tension in stitch throughout.
The suture is finally tied to the free end (Fig. 6.7).
58  Step by Step Arterial Surgery

Figure 6.6  interrupted everting mattress sutures

Figure 6.7  Blalock’s suture used for normal or thinned walled arteries
Arterial Suturing  59

9. Suturing diseased artery, in a densely sclerotic or calcified

vessel: Care must be taken so that the suture is not cut by
sharp plague, the needle should be passed from within the
lumen to the outside of the arterial wall in order to pin-
back loose plaques and suture should be passed from graft
to artery. A second finer suture for hemostasis. The lower
limit of arteriotomy or endarterectomy should be firmly
sutured by several mattress sutures throughout the vessel
wall which lies on the outer aspect (Fig. 6.8).

Figure 6.8  Suturing diseased artery in a densely sclerotic or

calcified vessel

Kunlin suture: the risk of intimal flap dissection remains

in case of endar­terectomy, to eliminate this risk, sutures
are inserted to secure the intima. the needle passes from
outwards to inside the lumen through the endartere­
ctomised part and then from within outwards and tied
60  Step by Step Arterial Surgery

The sutures can be buttressed using pads of dacron for

friable arterial vessels.
10. Include plagues in end-to-end suture. The needle should
be placed from within outwards to avoid loosening the
plaques (Fig. 6.9).

Figure 6.9  plaques in end-to-end suture

11. Including plaques in lateral suture. It is often necessary to

suture a synthetic graft to the side of the diseased artery,
i.e. femoral. Secure plaques at the distal end where it may
become easily loose with interrupted sutures. Beginning
at proximal corner of anatomosis a continuous suture
of polypropylene is inserted from within the lumen. This
effectively completes the approximation of plague to
arterial wall and graft.
12. Cloth or vein graft also may be sutured within the lumen
or a diseased vessel using a continuous everting mattress
suture. The blood flow then tends to dilate the diseased
vessel reducing tendency to strip plaques by longitudinal
pressure (Fig. 6.10).
While the artery is clamped the peripheral vessels
are constricted. Early recovery of the circulation can be
Arterial Suturing  61

Figure 6.10  sutured within the lumen or a vessel diseased

promoted by instillation of a vasodilator into the distal

vessel before completing the anastomosis. The lower
clamp is released first, this allows the air in the vessel to
be expelled. Normally the bleeding that occurs can be
stopped after pressure for few minutes. One should wait for
other sutures as further stitch holes increase hemorrhage.
In case of persisting hemorrhage the circulating heparin
is to be considered and reversal of heparin levels can be
done. Rarely reinforcement sutures are required.

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Page numbers followed by f refer to figure

A Axillary artery 12
Axillofemoral bypass graft 12
Abdomen 21
aorta 23 B
innervation and Back of knee joint 51
vasculature 22f Blalock’s suture 57, 58
viscera and vessels 24f Brachial artery 14, 16f, 18f
Aberrant segmental artery 36 Brachiocephalic fistula 14, 16
Adductor tubercle 46 Branches of external carotid
Ansa cervicalis 8f artery 8f
Antecubital fossa 18 Bulbar artery of bulb of penis 39
layer of femoral sheath 48 C
tibial artery 52 Caput madusae 30
Aplasia 5 Carotid 5
Argon beam coagulator 29 cavernous sinus thrombosis 5
Arterial endarterectomy 5
dissection 5 sheath incised 6
reconstructive surgery 12 Celiac
suturing 54 axis 22
wall 54, 54f trunk 25f
Arteries of Collateral branches of
arm and elbow region 15f abdominal aorta 24f
pelvis 38f Common
upper limb 17f carotid
Arteriovenous fistula 2 artery exposed 6
Ascending colic 33 bifurcation 6f
66  Step by Step Arterial Surgery

femoral artery 47f jugular vein

iliac, external and internal in superficial fascia 5
arteries and veins 42f receiving suprascapular
Congenital agenesis 5 and transverse cervical
Contents of femoral triangle 46f veins 10
Control of artery 44 Extraperitoneal exposure 41, 43f
Cooper’s ligament 39 Extrarenal branches 36
Cotton or teflon pledget 29
Course of radial artery 19
D lata 48
Deep over popliteus 51
artery for erectile tissue 39 transversalis 48
fascia 5, 10 Femoral
perineal artery 39 artery 43
Delayed post-traumatic sheath 45f
rupture 5 vessels 48
Displaced supracondylar Femoropopliteal junction 50
fractures of humerus 14 Fibrin biological glues 29
Distal popliteal artery 50 Floor of submandibular
Dorsal artery of penis 39 triangle 7f
Dorsalis pedis artery 53

Glomerular artery 36f
Embotectomies 44 Graft in cardiac bypass surgery 18
Epiploic foramen and peritoneal
reflection 26f
Exposure of H
superficial femoral artery in Hematoma 28
Hunter’s canal 46, 47f Hemorrhoids 30
vessels 23 Hepatic
External artery 22
compression 2 injuries 25
iliac artery 41 portal system 29, 30f
Index 67

Hepatoduodenal ligament 22 L
Hypoplasia 5
Laceration 28
I pelvic hematoma 22
Ileocolic artery 33 perirenal hematoma 22
Iliac root of median nerve 13
artery 22 Loss of arterial tissue 54, 55f
vein 22 Lower limb 41
Iliopsoas muscle 39
Inferior M
belly of omohyoid muscle 10 Major abdominal vascular
mesenteric artery 33 injuries 23
distribution 34f Marginal artery 34
pancreatoduodenal arteries 33 Mechanism of injury in vascular
rectal artery 39 trauma 1
thyroid 11f Medial root of median nerve 13
vena cava injury 22f Median and ulnar nerves in
Infrahyoid muscles 8f forearm 20f
Infrarenal aorta 22 Microfibrillar collagen 29
Inguinal triangle 44f Microvascular tissue transfer 53
Interlobar arteries 36 Midline inframesocolic
Interlobular arteries 36 hemorrhage 22
Internal Minimally invasive
iliac artery 37, 39 endovascular intervention 5
pudendal artery 39 Mobilization of liver 27
Interrupted everting mattress Modified Carrel method 55, 56f
sutures 58f Musculocutaneous nerve 13
Intraperitoneal exposure 43
Intrarenal branches 36 N
Nasopharyngeal carcinoma 5
J Neck 5
Jejunal and ileal branches 33 Nutcracker syndrome 31

Kunlin suture 59 Ovarian arteries 31
68  Step by Step Arterial Surgery

P Repair of laceration 18
of artery 14
Paralysis 3
Retraction of
Partially severed artery 2
sternocleidomastoid outwards
Perishingly cold 3
and omohyoid downwards 5
Periumbilical veins in falciform Retrohepatic vena cava 23
ligament 30
Right brachial plexus and
Pharyngeal and laryngeal axillary artery 13f
branches of vagus with
Root of neck 11f
carotid artery 9f
Platysma 5, 10 S
Popliteal artery 49, 50
Portal vein 22, 23, 29
interposition vein grafting for
internal carotid artery
belly of digastric muscle 6f stenosis 5
tibial artery 51, 52 nerve 48
Primary retroperitoneal vein 46
structures 21f transplant fistula 14, 16f
Pringle’s maneuver 25 Scarpa’s triangle 43, 44
Profunda Sciatic nerves 51
brachii artery 14 Severe violent trauma 5
femoris 47 Side wall of male pelvis seen
Proximal on coronal section 42f
renal artery 22 Simple continuous sutures 55
superior mesenteric artery 22 Somatic segmental branches 39
Pulsating hematoma 2 Splenic injuries 27
Splenorrhaphy 29
Subclavian artery 9, 11f
R aneurysm 12
Radial Superficial
and axillary nerves 20f circumflex iliac vein 46
artery 16f, 18 fascia 5, 9, 48
Relations of axillary artery 13 veins of arm 15f
Renal Superior
arteries 35 and inferior mesenteric
vascular segments 36 arteries 31, 32f
vein 36 and middle thyroid veins 5
Index 69

hemorrhoidal rectal artery 33 U

mesenteric artery
Ulnar artery 16f, 19
distribution 32f
syndrome 33
and middle trunks of brachial
perineal artery 39 plexus 10
Suprarenal aorta 22 limb 14
Surgical repair of lacerated
artery 12 V
Suturing diseased artery 59
Vascular trauma 1
Vasculature of
T pelvis 37
Testicular arteries 24f, 31 thigh 48f
Thrombosis after coronary Veins of Retzius 30
angiography 14 Visceral aorta 23
Traumatic arterial lesions 44 Volksmann ischemic
Triangle of vertebral artery 11f contracture 2
Types of
arterial injuries 1
variations in origin of Wrapping of spleen in
posterior humeral absorbable compression
circumflex 14f bag 29