Vascular Surgery Survival Guide

Updated March 2018

Team structure:
Students (sometimes), Intern, Senior Resident (4th year), Fellow

Schedule
 Thurs AM conference at 7:30am until 10am in CCD 7750. Lecture, then case
discussions of recent patients.
o The first Thursday of the month is usually Journal Club and
o The fellow will assign who is presenting which patients

General info to know for Vascular patients (consults/clinic/OR):

 When seeing clinic appointments, review previous clinic note and vascular labs.
 Previous vascular procedures: LOOK AT THE OP NOTE - get the details!
o exact location of proximal and distal anastomoses:
(e.g. “common femoral artery to below-knee pop” instead of “fem-pop” or
“SFA-to-PT” instead of “fem-distal”
o type of bypass
 what type of prosthetic graft: Dacron? PTFE?
 what type of vein bypass: reversed, non-reversed, in-situ
 Non-invasive tests (duplex, ABIs, vein mapping if planning vein graft)
o Most recent relevant duplex result and how they have changed from
previous v-lab encounter(s) Results under Procedures Tab
 Angios (CT or OR angios)
 PAD symptoms:
o Claudication, rest pain, non-healing ulcer, tissue loss or gangrene?
o Claudication
 Quantify distance (# of blocks or steps)
 Previous procedures (often they will have previous stents/plastys)
o Claudication and rest pain
 Characterize muscle group: hip/buttock, thigh, calf, foot
(this gives you an idea of level of occlusion: aortoiliac,
femoropoliteal, or infrapoliteal – usually the symptoms are one
level below the level of the problem)
 Pulse exam: palpable pulses or Doppler signals- Be specific with terminology-
Pulses are palpable, you are able to Doppler signals, biphasic/monophasic
 If pre-op: cardiac status (recent echo/cath), DM (how well controlled)
o We frequently consult cards, endo and HTN service
 Anticoagulation: if patient is currently on Coumadin, aspirin, Plavix or other oral
anticoagulation, need to plan If and When patient is to stop those medications
 GFR < 60: May need hydration pretreatment for renal protection
 Dialysis
 o Are they currently on HD? What days? What are they dialyzing through?
Previous AV Fistulas or Grafts? Are they right or left handed?
o Review Vein mapping- usually need 3mm vein for autogenous fistula
o Perform Allen’s test
 Carotid Stenosis
o Previous Procedures? Previous Strokes? Territory of strokes?
o Current symptoms- Amaurosis fugax (shade coming over eye), unilateral
weakness, difficulty finding words or with speech, stumbling
o Document baseline before OR to differentiate any stroke concerns postop

General Inpatient stuff to know:

 Vascular attendings like to communicate via text messages on their cell phone.
 Attendings like to round in between or after their OR cases. They will often just
text you to round.
 It is important to see Consults promptly and let senior resident/fellow know asap.
If everyone is in the OR, just come to the OR to staff the consult.
 Use the shared list please (the fellow or attendings will add you: add patients to it
(every admit, surgery, consult, etc) & never ever delete them
 Review daily lab values. Replete electrolytes to K>4.0, Mg>2.0, Phos>2.5. Be
mindful and careful when repleting electrolytes in patients with ESRD (often you
don’t need to).
 For inpatients that are going to the OR, make sure they are consented, marked the
day before and have a progress note in the chart the day of surgery
 Vascular Studies
o VUS is the prefix for all vascular studies
o When ordering LE Arterial Duplexes, always order ABI’s. Arterial
Duplex’s + ABIs are like peanut butter + jelly. Gotta have both for
attendings to be happy!
o If patients are ESRD or have DM, consider ordering Toe Brachial Indices
(ABI’s will likely be artificially high)- Place ABI order and specify in
comments Toe brachial indices.
o The vascular lab ladies are your friends! They are very knowledgeable
and can help you order and interpret tests. If you have questions about
what test to order, feel free to call and ask (2-6261).
 Order PT/OT early (place order post-op) so pts are seen by PT/OT on POD#1 to
help with dispo and possibly plan for rehab.
 Talk to Case Manager as soon as it is known that a patient will need home IV abx,
Home PT/OT, Home wound vac, etc.
 Social Worker assists with rehab/sub-acute rehab, SNF placements. SW is
required for patient placement. Notify them as soon as have PT/OT recs if will
need referral to rehab/sub-acute. Notify them if patients need IV abx, HD in
rehab, or any special needs.
 For future OR scheduling, e-mail or call 2-0212 -Cathy Hoover
(Catherine.Hoover@uchospitals.edu). She will help set up anesthesia and OR
dates. Update her with any changes to OR schedule.
Preop Orders
 The senior resident has been doing all preop orders for all cases
 Use Vascular IP pre-operative orders (VAS: PRE-Operative VASCULAR
Procedure)
o Most cases will be inpatient admissions except angios or dialysis access,
sometimes those will stay for obs unless they are staying to be bridged
back onto Coumadin
o Carotids/TEVARS/Aortobifems go to the ICU
o Carotids/EVARS/TEVARS usually go home POD1, but should all have
inpatient admit orders
o Often Milner/Babrowski EVARS will go to the floor
o All ESRD patients on HD are considered high risk for MRSA – adjust abx
o Adjust abx in all PCN allergic patients, but if not on HD, most attendings
don’t want the Gent given
o RFAs in OR: Order tumescence in preop order set. APNs will take care of
the outpatient ablation orders.
o All get HSQ unless they just stopped heparin gtt or have a spinal drain in
place

Postop Orders
 Postop Ordersets
o VAS: IP Lower Extremity Bypass and Amputation (for AKAs, BKAs)
o VAS: IP Open Abdominal Aortic Aneurysm Repair Post Op ICU Admit
(for Open AAAs, Aortobifems, Axfems, Carotids)
o VAS: IP Post Angio Orders CD5 (for discharging after Angios)
o VAS: IP Vascular Surgery Endovascular, Endovascular Aneurysm Repair
(EVAR), and Angiogram Procedure Post-op (for EVARs, TEVARs,
Angios that are staying)
 Make sure that patients have prophylactic heparin or lovenox ordered as well as a
bowel regimen (peri-colace +/- miralax)
 Post op IVF should be Normal Saline at 42 (because most patient have renal
insufficiency). ALWAYS check cardiac status/EF and renal function to avoid
fluid overload. These pts don’t have the 3rd spacing issues that gen surg pts do, so
resuscitation is not as much of a concern.
 For MALS patients, pain control is most important. Patients usually have PCA or
epidural post op with APS on consult. Ensure pts on bowel regimen. Slowly
advance diet as directed by Dr. Skelly. PCA generally d/c POD #2-3. Patients
generally inpatient for 3-5 days.
 Order PT/OT early (place order post-op) so pts are seen by PT/OT on POD#1 to
help with dispo and possibly plan for rehab.

Procedure specific Post-op Orders and things to Monitor

EVAR
 Floor if uncomplicated, ICU if complicated
  Monitor for groin hematomas
 If use brachial approach, watch arm closely for hematoma and parasthesias
 BP goals: Usually >140 for TEVAR, Usually <140 for EVAR, confirm with
fellow
 If UOP ok, can usually d/c Foley at MN (ask attending)
 If ok, patients can sometimes be discharged on POD#1
TEVAR
 Spinal Drain Protocol: Still evolving. Check with the fellow on the latest version.
The fellow should do the coordination.
 Usually placed by anesthesia the day prior to TEVAR
 Will need H&P by vascular prior to placement
 Drain should stay capped overnight
 Should be on scheduled q8 Ancef while spinal drain in place (not in orderset)
 See the “Periop Management of CSF drainage in Thoracoabdominal Aortic
surgery” document in the Sandbox
Carotid Endarterectomy
 Usually in ICU post-op
 Closely follow cranial nerve exam
 Monitor for hematoma
 Ok to advance diet after POC
 If ok, can be discharged POD #1
 Typically sent home on ASA 81 and +- Plavix 75 (ask attending)
LE Angiograms/Angioplasty
 Lie flat for 6 hours post-op, unless closure device used – just 2 hours
 Ok for diet after time spent flat completed
LE Bypass Surgery
 Monitor pulse exam closely
 Pain control is important
 Order PT/OT on POD#0
 Must have ABI’s prior to discharge for VQI (vascular quality initiative)
 Advance diet as tolerated post-op
 Change dressing on POD#1
AKA/BKA
 Blecha uses posterior mold casts for BKA. Apply bacitracin to incision daily.

Plavix: very attending-dependent

 for complex EVAR/TEVAR patients (i.e. renal/celiac/SMA stents done as well),
Plavix 75mg daily is started 24hrs after spinal drain removal (or POD#1 if no
spinal drain) - generally just for 30 days
 for patients who came in on Plavix: if for symptomatic carotid dz only & carotid
is fixed, can usually stop it and do ASA only, but double check; if on it for
cardiac reasons, generally restart the next day (but again, check first)
 for Milner & Babrowski extremity angio patients: only added when drug-coated
balloons (DCBs) are used or iliac/infrainguinal stents are placed; NO plavix-load,
just start 75mg daily x30 days
  for Blecha extremity angio patients: when drug-coated balloons (DCBs) are used
or iliac/infrainguinal stents are placed, check with him about the load (will either
be 150mg or 300mg in PACU), then 75mg daily x30 days starting POD#1
 for Dorsey extremity angio patients: when ANY lower extremity or iliac
intervention occurs (DCB or plain balloon), load with 300mg in PACU and then
75mg daily x30 days starting POD#1

Discharge
 There are Vascular discharge dot phrases with discharge instructions
o .vasdcangio – For LE angio’s/stent placement/plasty’s
o .vasdcmals- For Dr. Skelly’s MALS patients
o .vasdccarotid – For CEA’s and carotid stent placements
o .vasdchd/.vasdcdialysis – For Dialysis access placement
o .vasdcevar – For EVAR and TEVARs
o .vasedcea – For Carotids
o .vasdcvein  - For RFA vein ablations and stab phlebectomies

 For these discharge instructions, they are guidelines. Read through and adjust
accordingly for each patient. Include patient’s post-op appointments in discharge
instructions.
 Ask attendings specifically what they when they would like follow-up. Follow-up
appointments not standardized for procedure-Dependent upon MD.
o Our patients should have follow-up appointments scheduled prior to
leaving the hospital.
o You can call the Vascular schedulers at 2-6128, option 2, or Inbasket
Heart and Vascular Scheduling (P HEART AND VASCULAR SCHEDULING
[222006]) to schedule follow-up appointments, include name, MRN,
follow-up appt date, f/u imaging or v-lab needs (order needs to be in prior
to calling/messaging)
o It is not acceptable to tell patients to call and schedule an appointment in x
weeks. Often they need coordinated vascular studies. Schedule follow-ups
before the patients leave.
o If you need to make appointments during off-hours/weekends, either add
as a to-do for the next business day, or send an in-basket to “Heart &
Vascular Scheduling” with the details (also need to have all outpatient
orders in & signed) and request a call to the patient.
 When patient is being transferred to rehab or sub-acute rehab, make sure transfer
form completed (under discharge tab). This is often the main communication
between the hospital and NH- please work to ensure accuracy.
 If pt being d/c on Coumadin, you MUST contact PCP or whomever follows
dosage/INR as outpatient to confirm they will follow/adjust patients
Coumadin to goal INR. Do this even if patient was previously on Coumadin.
Assume nothing. Chart this conversation in EPIC. Vascular surgery does
not follow/adjust patients Coumadin as an outpatient
 All patients with PAD must be d/c home on a statin and aspirin 81mg
Follow Up
Typical Follow up by procedure
Distal bypass 4 weeks Bilat ABIs and Arterial dupex on affected side
Carotid 4 weeks Carotid duplex
Endarterectomy
EVAR/TEVAR 4 weeks CTA (Chest)/Abd/Pelvis, ?ABIs, ? Aortoiliac duplex
MALS 2 weeks None
IVC filter 4 weeks Bilat LE venous duplexes (eval for DVTs)
Dialysis Access 2-4 weeks +/- Hemodialysis duplex
with Diane
Fodor
AKA/BKA Ask attending

Basic OR setup/skills:
1. Review and know most recent non-invasive imaging results.
2. Load either OR or CT angios on PACS
3. Review and know GFR, BUN/Cr and weight (for contrast & heparin dosing)
4. Doppler and mark out DP, PT and femoral signals
5. Foley if makes urine and for all CEAs, bypasses, EVARS, Aortas, or long cases
6. For LE bypasses: prep entire leg circumferentially (use fence with blue towel to
elevate leg) up to belly button. Prep both legs if harvesting vein from other side.
7. Use sleds or tuck both arms for angiograms in the hybrid suite
8. Cover feet with clear plastic bags with white ties
9. Try to avoid an incision across the groin crease if possible (prevents wound
infections)
10. Continuously check for femoral pulse to direct your dissection
11. Bovie at groin incision until close to artery, then metz.
12. Need enough length on common femoral to clamp and anastomose to (~2-3cm)
13. Distal anastomosis: use bump of ~7 blue towels to allow knee to bend to get into
popliteal fossa.
14. Avoid peroneal nerve during dissection.
15. Tunnel graft medial to gastroc +/- above or below fascia
16. 5-0 1:1 goretex for PTFE grafts and prolene for vein, running
17. Unclamp and Flush before last couple of stitches
18. Irrigate with bacitracin
19. Close in 3 layers: running 3-0 vicryl for deep and deep dermal, 4-0 biosyn for skin

Go to Clinic if you have time

Clinic:
- Monday: Skelly 9-12, Dorsey 12-5
- Tuesday: Milner 7:30-12, Babrowski 1-5
-Wednesday: Babrowski 8-12
- Thursday: Milner/Dorsey 12-4 (1st, 3rd, and 5th Thursdays)
Blecha (2nd & 4th Thursdays)
  Jackie Braun/Amanda Hasseltine and Nastassia Gurganus are the outpatient NP’s.
Talk to them if you have any questions regarding clinic
 It is the expectation that residents participate in clinic, when not in the OR.

THE TEN COMMANDMENTS: Resident Expectations for Vascular Surgery

Senior:
1. Own the service and demand excellence from everyone around you. You are expected
to run the service and communicate with update/discuss with attendings daily the plan of
care.
2. Review all of the patient’s status and care plans with the fellow at least twice per day.
This should occur late morning, between cases and especially prior to leaving the hospital
if the fellow is still operating.
3. See all new consults promptly. Report the findings to the fellow and attending,
preferably in person.
4. Promptly report any major change in a patient’s clinical status to the fellow and
attending, or any difficulty with instituting the day’s plan of care.
5. Be prepared for all assigned cases: review the angiograms, CTA, etc. The fellow is
available at all times to assist you on request.
6. See consult patients each weekday morning.
7. Discuss weekend call with fellow at the beginning of the month. You are also
expected to take call one night per week, usually Wednesday or Thursday night.
8. Unless assigned to a case, or seeing a consult, attend clinic. Inform the
fellow/attending if you need to be absent from clinic.
9. You are expected to present 1-2 patients/week at Thursday conference. Discuss with
fellow on Monday/Tuesday patients you would like to present, as well as any patients the
attendings have asked to be presented. Be able to present patients you operated on in
M&M should the need arise.
10. During large or unusual cases, check in with the team to make sure we are doing
alright, and to witness the magic! Double scrubbing on cases is highly encouraged,
especially if nothing else is going on. The more you are present, the more involvement
you will have with cases.
Junior:
1. At the end on morning team rounds, review the plan for each patient with the fellow.
2. Discharge patients in an expeditious fashion. The current case manager and is essential
in expediting discharges. They will help you set up home IV meds or abx, home health
nursing or PT/OT, home O2, etc. The social worker will do rehab placements, etc.
3. Perform daily dressing changes as necessary. Dressings for BKAs or AKAs (besides
open guillotine amps) will usually stay on for 48hours. Keep BKA in a knee immobilizer,
with elevation on a wedge. Keep AKAs flat – no elevation as this can risk hip
contracture.
4. Inbasket Heart and Vascular scheduling to schedule any needed follow-up
appointments. Let them know about same day testing, imaging needed with the
appointments.
5. Review the patient’s med list each day, ensure the use of ASA and/or Plavix, Statin,
unless a contraindication exists. All patients need DVT prophylaxis.
6. Update the patient list in Sandbox and the Vascular Census list. (This is an EPIC list
under “shared lists.” The fellow or the team preceding you will add you as a user.)
7. Be prepared for all assigned cases.
8. Be prepared to review all floor patients with the Fellow in AM daily.
9. Update the fellow on any major change in a patient’s clinical status, or if things are not
going according to plan. This should be done in person if the fellow is scrubbed in a
case.
10. Unless assigned to a case, or seeing a consult, attend clinic. Inform the
fellow/attending if you need to be absent from clinic.
11. You are expected to present 1-2 patients/week at Thursday conference. Discuss with
fellow on Monday/Tuesday patients you would like to present, as well as any patients the
attendings have asked to be presented. Be able to present patients you operated on in
M&M should the need arise.
12. During large or unusual cases, check in with the team to make sure we are doing
alright, and to witness the magic! Double scrubbing on cases is highly encouraged,
especially if nothing else is going on. The more you are present, the more involvement
you will have with cases.
13. You are responsible for ensuring that you do not violate duty hour restrictions. If
you are at risk of duty hour violation, please notify senior resident, fellow, or APN. Look
ahead and be mindful of your general surgery call hours.
CONCLUSION:
This may be your only opportunity to experience vascular surgery. The clinical
judgment, technical skill, and patient acuity associated with your time on service will
help you regardless of what surgical field you choose. Make the most of it. The fellows
and attendings are absolutely committed to your experience being a positive and
meaningful one.