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General Principles of Vascular Surgical Technique

Chapter · January 2006

DOI: 10.1007/978-3-540-68933-1_15

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 General Principles
of Vascular Surgical Technique 15

CONTENTS 15.1 Summary

15.1 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
Always use atraumatic technique and spe-
15.2 Background . . . . . . . . . . . . . . . . . . . . . . . . 179 cial vascular instruments.
15.3 Exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 For proximal and distal control, all inflow
and outflow vessels must be controlled and
15.4 Control of Bleeding clamped prior to repair or arteriotomy or
and Clamping . . . . . . . . . . . . . . . . . . . . . . 180 venotomy.
15.4.1 Proximal Endovascular Blind application of vascular clamps in a
Aortic Control . . . . . . . . . . . . . . . . . . . . . . 182 bleeding traumatic wound as dangerous.
15.5 Vascular Suture . . . . . . . . . . . . . . . . . . . . 182 A nonsecure distal intimal edge is always a
15.5.1 Choice of Suture Material . . . . . . . . . . 184 risk for dissection and creation of an inti-
15.6 Arteriotomy . . . . . . . . . . . . . . . . . . . . . . . . 184 mal flap causing occlusion.
Veins are vulnerable and extreme care is
15.7 Closure with Patch necessary during dissection and repair.
(Patch Angioplasty) . . . . . . . . . . . . . . . . 184 A vascular suture should always be tied
15.8 Interposition Graft . . . . . . . . . . . . . . . . 186 with the artery clamped.
15.8.1 Autologous Vein . . . . . . . . . . . . . . . . . . . 187
15.8.2 Synthetic Vascular Prosthesis . . . . . . . 187
15.9 Veins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188
15.2 Background
15.10 Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190
15.10.1 Drains . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190 For surgeons who do not routinely perform vascu-
15.10.2 Infection Prophylaxis . . . . . . . . . . . . . . . 190 lar operations it might be helpful to recapitulate
the basic vascular surgical technique to facilitate
their management of common vascular emergen-
cies. First, it is always necessary to obtain control
of and clamp all branches to the of interest vascu-
lar segment to make a vascular operation possible
at all. The rationale for being extra cautious with
blood vessels is that they are extremely sensitive to
trauma, which can induce undesired thrombo-
genic activity on the intimal surface. Furthermore,
their structure of separated wall layers demands
special consideration to avoid dissection and oc-
clusion. A successful vascular operation requires
the surgeon to pay constant attention to technical
details to avoid jeopardizing the entire operation.
180 Chapter 15 General Principles of Vascular Surgical Technique

15.3 Exposure

Good exposure is always mandatory for optimiz-

ing the prerequisites for reconstruction or repair.
Exposure of most specific vascular segments is
described in the corresponding chapter (e.g., ex-
posure of the superficial femoral artery in the
groin for embolectomy is covered in the chapter
on acute leg ischemia).
With a few exceptions (for instance, the trans-
verse incision in the cubital fossa for exposing the
brachial artery), a longitudinal skin incision over
the vessel is used. The incision is made approxi-
mately 2 cm longer in each direction than the re-
quired exposed vessel length. An incision that is
too small increases the risk for wound complica-
tions in the skin and other tissues with already
impaired perfusion due to unnecessary trauma
from retractors. Familiarity with the anatomy is
essential because it is not always possible to be
guided by palpation of a pulse or hard arterioscle-
rotic plaques. Use small, blunt, self-retaining re-
tractors to achieve tension in the tissue to facilitate
dissection. When approaching the vessel special
atraumatic vascular instruments should always be Fig. 15.1. a Pass a right-angle clamp gently through
used. Never use a toothed forceps in the vicinity of the soft tissue on the dorsal aspect of the artery and
a blood vessel. The correct plane of final exposure direct it away from larger veins to avoid iatrogenic inju-
is the outer soft layer of the adventitia. A common ries. Caution! Avoid accidental penetration of the dor-
error is exaggerated caution in trying to obtain ex- sal wall of the artery. b Gently lift the artery with the
vessel-loop to achieve tension in the tissue, thus facili-
posure in a layer that is too superficial. The adven-
tating the dissection
titia is characterized by a visible net of vasa vaso-
rum. It is important to be aware of the differences
between a healthy and a diseased artery. The for-
mer is soft, easily compressible, and has a grey/red NOTE
color. This is what can be expected in trauma pa- Good exposure of the segment to be
tients who are mostly young and otherwise healthy. repaired, including space enough to allow
When there is no pulse in the artery it may even be safe clamping, is essential for a successful
difficult to distinguish it from a vein. An arterio- vascular operation. Always use special
sclerotic artery in a patient with peripheral vascu- atraumatic vascular instruments when
lar disease is yellow/white and has a thick and approaching the vessel.
often hard or calcified wall.
Expose the anterior and lateral aspects of the
artery and use a right-angle clamp with its tip 15.4 Control of Bleeding
turned away from the adjacent larger vein – thus and Clamping
avoiding accidental perforations – to surround
the posterior aspect with a vessel-loop of fabric or In all vascular procedures, including vascular
rubber. By lifting the vessel-loop, tension can be trauma, proximal and distal control is mandatory
achieved in the tissue, thus facilitating the dissec- before attempting repair or doing an arteriotomy.
tion in an atraumatic way (Fig. 15.1). All branches It is desirable to have a completely empty vascular
should be saved because they are potential impor- segment in order to perform a vascular opera-
tant collaterals. tion without unnecessary technical difficulties. To

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