Vascular reconstructions: anatomy, exposures, and techniques

396 Pages·2000·2.99 MB·English

by  Jamal J. Hoballah

VASCULAR
RECONSTRUCTIONS

VASCULAR
RECONSTRUCTIONS
Anatomy, Exposures, and Techniques
Jamal J. Hoballah, MD
Department of Surgery
University of Iowa Hospitals and Clinics
With 961 Illustrations
Jamal J. Hoballah,MD
Department of Surgery
University of Iowa Hospitals and Clinics
200 Hawkins Drive
Iowa City,IA 52242
USA
[email protected]
Library of Congress Cataloging-in-Publication Data
Hoballah,Jamal J.
Vascular reconstructions :anatomy,exposures and techniques / Jamal J. Hoballah.
p. cm.
Includes bibliographical references and index.
ISBN 0-387-98500-X (softcover :alk. paper)
1. Blood-vessels—Surgery Handbooks,manuals,etc. I. Title.
[DNLM: 1. Anastomosis,Surgical—methods. 2. Vascular Surgical
Procedures—methods. WG 170 H68lv 2000]
RD598.5.H83 2000
617.4’13—dc2l
DNLM/DLC
99-29750
Printed on acid-free paper.
©2000 Springer-Verlag New York,Inc.
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ISBN 0-387-98500-X Springer-Verlag New York Berlin Heidelberg SPIN 10671934
This book is dedicated to my mother and father
with love and appreciation.
Preface
“Practice makes perfect,” and time spent in the operating room should be used
most efficiently. In an attempt to comply with these two principles, I designed a
vascular anastomoses workshop for our surgical residents at the University of
Iowa. The workshop introduced the basic steps of constructing various vascular
anastomoses in a relaxed environment outside the operating room. During the
workshop, the residents expressed the need for a manual that outlines and de-
scribes the various vascular reconstructions in a step-by-step manner from begin-
ning to end. Most textbooks usually include a picture of a vascular anastomosis
during or after the completion of the reconstruction without detailing the begin-
ning and conduct of the procedure. The usefulness of including sections that ad-
dress commonly asked or unasked questions was also apparent. These questions
pertain to vascular instruments, grafts, and sutures, as well as vascular anatomy
and exposures. It is with these thoughts in mind that this book was conceived.
This book is not intended to be a substitute for traditional atlases of specific vas-
cular procedures; rather, it was written to focus on the technical aspects of vascu-
lar reconstructions and to better prepare the surgical residents before they start
their vascular rotation.
This book is divided into four parts. The first part starts with a review of com-
monly used vascular instruments and an overview of grafts and sutures used in
vascular reconstructions. Adetailed chapter on vascular anatomy and exposures
is provided to serve as a quick reference before starting a vascular procedure. The
remaining chapters in the first part of this book review the basic steps usually
performed before and after constructing a vascular anastomosis in addition to
thrombectomy and endarterectomy. The second part of this book focuses on the
various methods used to conduct a vascular reconstruction, which include pri-
mary closure, closure with a patch angioplasty, end-to-end, end-to-side, and side-
to-side anastomoses. The various possible modifications used are outlined. The
third part of this book reviews the various adjunctive methods used when con-
structing the proximal or distal anastomoses of an infrainguinal bypass. The
fourth part of the book reviews the various modifications that are carried out
when constructing the proximal and distal anastomoses of an aortic occlusive or
aneurysmal pathology. Finally, the vascular anastomoses workshop that inspired
the conception of this book is included as an appendix.
I certainly hope that this book will help make the vascular rotation a pleasant
experience for both the surgical residents and the vascular faculty. I believe this
book can also be very useful to recent graduates embarking on conducting vascu-
lar reconstructions independently as well as healthcare providers who wish to be
familiar with the various steps involved in conducting of a vascular procedure.
vii
viii Preface
We hope you enjoy this book as much as we enjoyed putting it together. We
are eager for your comments, feedback, and suggestions for future editions.
You may write directly to the medical editorial department at Springer-Verlag
New York, Inc., 175 Fifth Avenue, New York, New York 10010. Send your com-
ments to the attention of the Editor, General Surgery Book Program.
Jamal J. Hoballah
Iowa City, Iowa
Contents
Preface vii
Part 1 Basic Principles in Vascular Reconstructions 1
Chapter 1 Vascular Instruments 3
Vascular Clamps 5
Valvulotomes 6
Carotid Shunts 7
Reference 7
Chapter 2 Vascular Grafts, Patches, and Sutures 17
Vascular Grafts 17
Vascular Patches 22
Vascular Sutures 23
References 26
Chapter 3 Vascular Anatomy and Exposures 27
Arteries of the Neck and Upper Extremity 27
Abdominal Aorta and Its Branches 48
Arteries of the Lower Extremity 74
Veins of the Upper and Lower Extremities 100
References 104
Chapter 4 Basic Steps in Vascular Reconstructions 107
Blood Vessel Exposure 107
Blood Vessel Dissection 107
Tunneling 109
Anticoagulation 117
Blood Vessel Control 117
Creation of Blood Vessel Incision 124
Preparation of a Patch 125
Preparation of a Bypass 127
Construction of the Suture Line 129
Securing Hemostasis 134
Evaluating the Vascular Reconstruction 134
Chapter 5 Hemostasis 137
Suture Ligation 138
Closure of a Large Transected Artery 141
Repair of Loose Suture Line 144
Repair of Longitudinal Tears 147
ix
x Contents
Chapter 6 Thrombectomy-Embolectomy 149
Thrombo-Embolectomy 149
References 152
Chapter 7 Endarterectomy 157
Open Endarterectomy 159
Eversion Endarterectomy 164
Part 2 Basic Vascular Reconstructions 165
Chapter 8 Closure of an Arteriotomy 167
References 168
Primary Closure of a Transverse Arteriotomy 169
Patch Closure of a Longitudinal Arteriotomy 173
Chapter 9 End-to-Side Anastomosis 182
Geometry of an End-to-Side Anastomosis 182
References 184
End-to-Side Anastomosis: Anchor Technique 185
End-to-Side Anastomosis: Parachute Technique 202
Chapter 10 End-to-End Anastomosis 218
References 220
End-to-End Anastomosis in Large Vessels of Comparable Diameters (8mm or Greater in Diameter) 221
End-to-End Anastomosis in Small Vessels of Comparable Diameters (6mm or Smaller in Diameter) 234
End-to-End Anastomosis Between Vessels of Unequal Caliber 245
Chapter 11 Side-to-Side Anastomosis 254
Anchor Technique 255
Parachute Technique 259
Part 3 Infrainguinal Bypass Surgery 265
Chapter 12 Adjunctive Techniques: Proximal Anastomosis of an Infrainguinal Bypass 267
References 269
Saphenofemoral Junction with Femoral Vein Cuff 270
T-junction 271
Patch Angioplasty of the Inflow Vessel 272
Patch Angioplasty of the Hood of the Bypass 273
Incorporation of Profundaplasty 274
Sartorious Muscle Flap 275
Chapter 13 Adjunctive Techniques: Distal Anastomosis of an Infrainguinal Prosthetic Bypass 276
References 277
Vein Patches and Cuffs 279
Arteriovenous Fistulae 294
References 293