Vascular Surgery: Overview

March, 2009
Sharon Dawson RN, BScN, MES
 Outline
 Pathophysiology
 Pre-operative Care
 Surgeries
 Post-operative Care
 Discharge Teaching
 Anatomy
 Arterial versus Venous
 Intima (epithelial lining)
 Media (smooth muscle, collagen, elastic fibers)
 Adventia (connective tissue, collagen and elastic fibers)

Valves*
 Pathophysiology
 Vascular Disease
 Acute or Chronic
 Venous or Arterial Insufficiency

*Peripheral Vascular Disease usually refers to

arterial insufficiency. Chronic arterial
insufficiency is most commonly caused by
atherosclerosis.
 Pathophysiology
 Peripheral Vascular Disease (PVD)
 Arterial Occlusive Disease or Venous Occlusive
Disease
 Both are typically chronic process that are not usually
immediately fatal; may create disability, amputation
 Atherosclerosis (build up of fatty deposits inside
arterial walls) is the most common cause of chronic
PVD
 Thrombosis/ Embolism (blood clot formation/
transportation throughout the vascular system) are
the most common causes of acute PVD
 Pathophysiology
 Risk factors for Peripheral Vascular Disease:
 Over 50 years of age
 Male
 Genetic predisposition
 Hypertension
 Diabetes
 Elevated blood cholesterol
 History of smoking*
 Obesity*
 Stress*
 Atherosclerosis:
 Deposits of atheromatous lesions inside the artery wall.
Atheroma = the lipid/calcium/fibrous plaques that cause
obstruction of the vessel.
 Atherosclerosis
 Common sites:
 Superior distal femoral artery
 Coronary arteries
 Common carotid artery bifurcation
 Proximal internal carotid artery
 Aortic bifurcation
 Iliac and common femoral arteries
Atherosclerosis: Thrombus Formation
Atherosclerosis: Thrombus
Formation
 Arterial Disease: Arterial
Insufficiency
 Acute: Embolism
 Chronic: Atherosclerosis

 *Patients with acute arterial occlusion

usually present with the onset of the:
 6 “P’s”: pain (severe), pulselessness,
parasthesia, paralysis, pallor, poikilothermia
(coolness).
 Signs and Symptoms of Arterial
Disease
Body is not able to meet the muscle demands
for oxygen.
 Intermittent
claudication
 Ischemic rest pain (pain at rest)
 Non-healing ulcers (arterial)
 Gangrene
 Thrombus/embolism
 Venous Disease
 Acute Venous Insufficiency:
 Usually caused by a clot in the venous system
 Virchow’s Triad
 Thedanger with a deep vein thrombosis is the threat
of embolism (leading to pulmonary emboli,
myocardial infarction, thrombotic stroke)
 Venous Disease: Chronic Venous
Insufficiency
 Chronic Venous Insufficiency: (Superficial of
deep vein thrombosis, varicose veins, chronic venous
obstruction)
 Not usually treated surgically*
 Treatment for chronic= increase venous return
and decrease edema (compression therapy)
 Treatment for acute =heparin and bedrest
 Venous occlusive disease is usually localized to
one anatomic area and occurs most frequently
in the legs
 *(pulmonary embolism, myocardial infarction, stroke)
 Signs and Symptoms of Venous
Disease
 Dilated jugular veins
 Swelling of extremities
 Varicose veins
 Swelling/aching discomfort in legs when
standing
 Night cramps
 Ulceration (irregular shape)
 Venous stasis ulcers
 Pre-Operative Care
 Thorough history and physical exam (pupillary
reaction, pulse evaluation, skin color, skin
temperature and capillary refill)
 Medication review
 Diabetic control
 Hypertension management
 Lipid lowering strategies
 Estrogen replacement*
 Smoking cessation
 Modifiable lifestyle choices (stress, alcohol,
smoking, diet, activity level)
 Common Tests-Doppler
 Doppler ultrasound-use of sound waves to
measure the direction and intensity of blood
flow
 Common Tests: Plethysmography
 Plethysmography- measures volume
changes in the limbs
 Common Tests: Arteriography
 Arteriography-visualization of the arteries
using a radiopaque contrast medium
 Common Tests: Computed
Tomography (CT Scan)
 CT Scan-commonly used for staging
abdominal aneurysms, diagnosis of
abscesses, hemorrhage and post-op graft
infection or occlusion
 Surgeries
 Embolectomy, Endarterectomy, Bypass,
Aneurysm Repair
 Inflow versus Outflow
 Management of co-morbidities
 Graft materials
 Dacron
 Gortex
 Harvested vein (saphenous)
 Surgery: Arterial Embolectomy
 Surgical procedure:
 The initial incision is completed and the artery is
exposed (dissection)
 An incision is made into the artery and a
catheter is inserted beyond the clot
 The balloon of the catheter is withdrawn with
the detached clot
 The artery is then flushed with heparinized
saline
 The artery and the wound are closed
Surgery: Arterial Embolectomy
Surgery: Carotid Endarterectomy
 The carotid arteries carry blood to the brain.
 These arteries become narrowed when
atheroma plaques develop resulting in
reduced blood flow to the brain.
 The plaque or blood clots can break off and
briefly interrupt blood flow; resulting in
(Transient Ischemic Attack) TIA’s, or may
lead to thrombus formation and embolic
stroke.
Surgery: Carotid Endarterectomy
Surgery: Carotid Endarterectomy
 Carotid Endarterectomy:
Surgery: Carotid Endarterectomy
 Post-op care:
 OR time approx. 3 hrs
 Hospital stay 2 days
 Airway (trach tray at bedside)
 Neuro-vital Signs assessment*
 Incision – location, staples, drainage, dressing
 IV
 Pain management
 Prevent constipation
 Home with staples, 2-3 months to recuperate
 Axillofemoral Bypass
 Indicated for severe aorto-ileac vascular
disease not amenable to other surgical
approaches
 Axillofemoral Bypass
 Placement of synthetic graft from the axillary
artery to the femoral artery on the same side
 Longitudinal incision made over femoral artery
 Femoral artery dissected free
 Tunnel formed for graft between the femoral
artery and axillary artery through the
subcutaneous tissue
 Synthetic graft positioned through “tunnel”, and
using end to end technique-sutured into place
 Aneurysm
 The exact cause is unknown, but risk factors
include atherosclerosis and hypertension.
 May be caused by infection, congenital
weakening of the artery wall, genetic
predisposition or trauma (rare).
 Common complication is rupture - where the
aneurysm breaks open, resulting in profuse
bleeding (occurs more frequently with larger
aneurysms).
Types of Aneurysms
Surgery: Abdominal Aortic Aneurysm
(AAA)
 Abdominal Aortic Aneurysm: A dilation,
stretching or ballooning of the aorta.
Surgery: Abdominal Aortic Aneurysm
(AAA)
 Abdominal Aortic Aneurysm (AAA)
If an AAA expands rapidly, tears open (rupture) or
blood leaks along the wall of the vessel (aortic
dissection), these symptoms may occur:
 Pulsating sensation in the abdomen
 Pain in the abdomen
 Abdominal rigidity
 Pain in the lower back
 Paleness
 Tachycardia
 Anxiety
 Nausea and Vomiting
 Clammy skin
 Shock
 Abdominal Aortic Aneurysm (AAA)
 Repair is usually done if greater than 5 cm in diameter
 If the aneurysm is small and there are no symptoms, the
patient will have annual U/S to watch for changes.
 Because the surgery is risky, the surgeon may wait for the
aneurysm to get to a certain size before operating (the risk
of complications exceeds the risk of surgery)
 Once the aneurysm reaches 6 cm, the chance of rupture
increases to 42%. The larger the aneurysm, the greater the
risk of a rupture occurring.
 Mortality rate for ruptures is 50-70%, if we can get them to
surgery quickly. Without surgical intervention, the mortality
rate is 100%
Surgery: Abdominal Aortic Aneurysm
(AAA)
 Open Repair:
 A large midline incision is made in the
abdomen.
 Both the renal and ileac arteries are clamped
and the aneurysm is opened and any blood
clots are removed.
 The graft is sewn to the aorta above and below
the aneurysm.
 The aorta wall is snuggly fit over the graft and
sewn together. The incision is closed with
staples or retention sutures.
Surgery: Abdominal Aortic Aneurysm
(AAA)
Surgery: Abdominal Aortic Aneurysm
(AAA)
 Post-op Care:
 ICU/IMCU for 24 - 48 hrs post op
 NG
 Foley
 IV
 Peripheral pulses, CSM*
 Incision – staples
 Pain control
 Management of co-morbidities
 Endovascular Repair
A minimally invasive surgery done by inserting
a graft made of wire mesh and fabric that is
placed inside the abdominal aorta to take the
pressure off the weak arterial wall.

Two small incisions are made in the groin. A

catheter is threaded through the femoral
artery and the graft is placed into the
catheter. Once the graft is in position it is
expanded and the metal springs or hooks
hold it in place and above and below the
aneurysm. The catheters are then removed.
Endovascular Repair
Endovascular Repair
 Surgery: Endovascular Repair
 Post-op care:
 Procedure takes approx. a total of 5 hrs
 Small percentage become open procedure
 Foley
 Incisions in the groins
 Typically shorter recovery time than open
repair
 Follow up every 3-6 months for 2 years, then
yearly.
 Surgery: Aorto-Bifem Bypass
 Surgery performed to bypass blocked iliac
arteries and supply blood to legs.
 Surgical procedure:
Incision is made in the abdomen and both legs.
A synthetic graft is sewn into the artery above
and below the blocked section to reroute the
blood.
 Once the blood flows freely through the graft,
the incision is closed with staples or sutures.
Surgery: Aorto-Bifem Bypass
 Surgery: Aorto-Bifem Bypass
 Post-op Care:
 ICU/IMCU for 24 - 48 hrs post op
 NG
 Foley
 IV
 Peripheral pulses*, CSM
 Incision – staples
 Pain control
 Management of co-morbidities
Surgery: Femorofemoral Bypass
 Surgical procedure:
 A longitudinal incision is made over each
femoral artery
 The femoral artery is located and dissected free
 A graft tunnel between the two femoral arteries
is created across the symphysis pubis under the
subcutaneous tissue
 The synthetic graft is passed through the tunnel
and using an end to end technique and is
sutured into place.
Surgery: Femorofemoral Bypass
 Surgery: Ileo Fem Bypass
 Surgical procedure:
 A longitudinal incision is made over the iliac
artery
 The iliac artery is located and dissected free
 A longitudinal incision is made over the femoral
artery, which is then located and dissected.
 The iliac and femoral artery are joined through
the use of a graft
 The incisions are closed (staples)
Surgery: Ileo Fem Bypass
 Surgery: Femoral Popliteal and
Femoral Tibial Bypass
 Surgical procedure:
 Vertical Incision is made along the inner aspect of the
thigh
 The femoral artery is located and dissected in both
directions
 A vertical incision is made along the medial aspect of
the lower thigh
 The popliteal/tibial artery is dissected and exposed
 The femoral and popliteal/tibial artery are joined through
the use of either the saphenous vein or with a synthetic
graft
 The incisions are closed (staples)
 Surgery: Femoral Popliteal and
Femoral Tibial Bypass
 Post-op care:
 S/S hemorrhage, occlusion, thrombus formation
 Peripheral pulses, CSM
 Pain control
 Managing co-morbidities
 Surgery: Amputation
 Surgical procedure:
 The level of the amputation is determined and
the incision line and flap(s) marked
 The incision is made and muscle and tissue are
divided
 The bones are cut and hemostasis is achieved
 The fascia and skin are closed
 The immediate postoperative stump dressing is
applied
 Surgery: Amputation
 Post-op care:
 Hemorrhage
 Pain control-*Nerve Sheaths*
 IV
 Foley
 Positioning
 Strengthening/Physical therapy
 Management of co-morbidities
 Discharge Teaching
 Indications of Trouble (when to seek help)
 Activity
 Clothing
 Medications
 Weight Control
 Smoking
 Foot care
 References

 MacVitte, B.A. (1998) Perioperative nursing

series:Vascular surgery. Mosby. St Louis: MI
 Merck Manual of Medical Information (1997) Simon
& Schuster Publishing, NY: New York
 Perry, A. & Potter, P. (2006) Clinical nursing skills
and techniques (6th Ed). Elsiver Mosby, St Louis:
MI
 www.vascularsociety.org.uk
 www.vascularweb.org
 Zuidema, Sylvia Vascular Disease and Surgery