Table Of ContentVascular Surgical Techniques
Editor
Roger M. Greenhalgh MA, MD, MCWI, FRCS
Professor of Surgery, Charing Cross Hospital Medical School, London, UK
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© Butterworths 1984
British Library Cataloguing in Publication Data
Greenhalgh, Roger M. (Roger Malcolm)
Vascular surgical techniques.
1. Blood vessels — Surgery
617'.43 RD598.5
ISBN 0-407-00351-7
Library of Congress Cataloging in Publication Data
Main entry under title:
Vascular surgical techniques.
Bibliography: p.
1. Blood-vessels — Surgery. 2. Surgery, Operative.
I. Greenhalgh, Roger Malcolm. [DNLM: 1. Vascular
surgery—Methods. WG 170 V3318]
RC598.5.V41984 617'.413 84-5872
ISBN 0-407-00351-7
Photoset by Butterworths Litho Preparation Department
Printed and bound in England by Robert Hartnoll Ltd, Bodmin, Cornwall
Contributors
George Andros MD JohnD. Corson MD, FRCS (Ed)
Vascular Laboratory, Saint Joseph Medical Center, Burbank, Assistant Professor of Surgery, Albany Medical College and
California, USA Veterans Administration Medical Center, Albany, New York,
USA
Y. Bensaid
L. T. Cotton MCh, FRCS
Service de Chirurgie Vasculaire, Group Hospitaller Pitie-
Salpetriere, Paris, France Dean, King's College School of Medicine and Dentistry, London,
UK
JohnJ. Bergan MD
Nathan P. Couch MD
Magerstadt Professor of Surgery and Chief, Division of Vascular
Surgery, Northwestern University Medical School, Chicago, Associate Professor of Surgery, Harvard Medical School; Senior
Illinois, USA Surgeon, Brigham and Women's Hospital, Boston,
Massachusetts, USA
Giorgio Biasi MD
R. Courbier
Assistant Professor, Institute of Clinical Surgery, University of
Milan, Milan, Italy Professeur Agrege a la Faculte de Medicine et Chef du Service de
Chirurgie Cardio Vasculaire, Hopital Saint Joseph, Marseille,
France
Martin Birnstingl MS, FRCS
Consultant Surgeon, St Bartholomew's Hospital, London, UK Herbert Dardik MD,FACS
Chief, Vascular Surgical Service, Englewood Hospital,
N. L. Browse MD, FRCS Englewood, New Jersey; Clinical Associate Professor of Surgery,
University of Medicine and Dentistry of New Jersey, Newark,
Professor of Surgery, Department of Surgery, St Thomas'
New Jersey, USA
Hospital, London, UK
Leopoldo B. Dulawa MD
K. G. Burnand MS, FRCS
Vascular Laboratory, Saint Joseph Medical Center, Burbank,
Assistant Director, Department of Surgery, St Thomas' Hospital,
California, USA
London, UK
D. Charles worth DSc, MD, FRCS William K. Ehrenfeld MD
Reader in Surgery, University Hospital of South Manchester, Prof essor of Surgery, University of California, San Francisco,
Manchester, UK California, USA
Harold Ellis DM, MCh, FRCS
F. B. Cockett MS, FRCS
Consulting Surgeon, St Thomas' Hospital, London, UK Professor of Surgery, Westminster Hospital Medical School,
London, UK
T. Cooke MD, FRCS
James C. Finn BA
Senior Lecturer, Department of Surgery, Charing Cross Hospital
Medical School, London, UK Sequoia Hospital, Redwood City, California, USA
Thomas J. Fogarty MD, FACS John A. Mannick MD
Sequoia Hospital, Redwood City, California, USA Moseley Professor of Surgery, Harvard Medical School; Surgeon-
in-Chief, Brigham and Women's Hospital, Boston,
Massachusetts, USA
Roger M. Greenhalgh MA, MD, MChir, FRCS
Professor of Surgery, Charing Cross Hospital Medical School, Averil O. Mansfield ChM, FRCS
London, UK
Consultant Surgeon, St Mary's Hospital, London; Honorary
Senior Lecturer in Vascular Surgery, Royal Postgraduate Medical
P. L. Harris MD, FRCS
School, London, UK
Consultant in Vascular Surgery, Broadgreen Hospital, Liverpool
and Royal Liverpool Teaching Hospital; Lecturer in Clinical Sergio Miani MD
Surgery, University of Liverpool, UK
Assistant Professor, Institute of Clinical Surgery, University of
Milan, Milan, Italy
Robert W. Harris
Vascular Laboratory, Saint Joseph Medical Center, Burbank, J. Natali
California, USA
Service de Chirurgie Vasculaire, Group Hospitaller Pitie-
Salpetriere, Paris, France
Larry H. Hollier MD, FACS, FACC
Head, Section of Vascular Surgery, Mayo Clinic, Rochester, Robert W. Oblath MD
Minnesota, USA
Vascular Laboratory, Saint Joseph Medical Center, Burbank,
California, USA
J. M. Jausseran
Assistant du Service de Chirurgie Cardio Vasculaire, Hopital Thomas F. O'Donnell Jr MD
Saint Joseph, Marseille, France
Chief- Vascular Surgery, New England Medical Center;
Professor of Surgery, Tufts University School of Medicine,
Allastair M. Karmody MD, ChM, FRCS, FRCS(Ed), Boston, Massachusetts, USA
FACS
Professor of Surgery, Albany Medical College, Albany, New Bruce J. Pardy ChM, FRCS, FRACS
York, USA
Consultant Surgeon, Newham General Hospital, London, UK
J. R. Kenyon BSc, ChM, FRCS
C. Petitjean
Consultant Surgeon, St Mary's Hospital, London, UK
Service de Chirurgie Vasculaire, Group Hospitaller Pitie-
Salpetriere, Paris, France
E. Kieffer
John G. Pollock MBChB, FRCS(Glas), FRCS(Ed)
Service de Chirurgie Vasculaire, Group Hospitaller Pitie-
Salpetriere, Paris, Prance Consultant in Administrative Charge, Peripheral Vascular Unit,
Royal Infirmary, Glasgow, UK
Robert P. Leather MD, FACS
Peter G. Qvarfordt MD
Professor of Surgery, Albany Medical College, Albany, New
York, USA Vascular Research Fellow, University of California, San
Francisco, California, USA
J. S. P. Lumley MBBS, FRCS
K. W. Reynolds MS, FRCS
Professor of Vascular Surgery and Honorary Consultant Surgeon,
Consultant Surgeon, Gastrointestinal Unit, Charing Cross
St Bartholomew's Hospital, London, UK
Hospital Medical School, London, UK
Charles N. McCollum MD, FACS
UgoRoberti MD
Senior Lecturer in Surgery, Charing Cross Hospital Medical
Professor and Chief, Institute of Clinical Surgery, University of
School, London, UK
Milan, Milan, Italy
James Mclvor MBChB, FRCR, FFR, FDSRCS Sidney S. Rose MBChB, FRCS
Consultant Radiologist, Charing Cross Hospital; Senior Lecturer Consulting Surgeon, University Hospital of South Manchester,
(Radiology), Institute of Dental Surgery, London, UK Withington Hospital, Manchester, UK
John P. Royle MBBS, FRCS(Ed), FRCS, FRACS, FACS N. A. Theodorou FRCS
Director of Vascular Surgery Unit, Austin Hospital, Heidelberg, Senior Surgical Registrar, Gastrointestinal Unit, Charing Cross
Australia; Senior Associate, University of Melbourne, Australia; Hospital Medical School, London, UK
Consultant Vascular Surgeon, Fairfield Hospital, Melbourne,
Australia
Frank J. Veith MD
Montefiore Medical Center-Albert Einstein College of Medicine,
Sergio X. Salles-Cunha PhD New York, New York, USA
Vascular Laboratory, Saint Joseph Medical Center, Burbank,
O. Wagner MD
California, USA
Professor of Surgery, University of Vienna, Vienna, Austria
John H. Scurr BSc, FRCS
Anthony D. Whittemore MD
Senior Surgical Registrar, Westminster Hospital, London, UK
Assistant Professor of Surgery, Harvard Medical School;
Surgeon, Brigham and Women's Hospital, Boston,
Massachusetts, USA
Dhiraj M. Shah MD, FACS
Associate Professor of Surgery, Albany Medical College and James S. T. Yao MD,PhD
Veterans Administration Medical Center, Albany, New York,
Professor of Surgery and Director, Blood Flow Laboratory,
USA
Northwestern University Medical School, Chicago, Illinois, USA
Ronald J. Stoney MD Howard L. Young ChM, FRCS
Professor of Surgery, University of California, San Francisco, Lecturer in Surgery, Welsh National School of Medicine, Cardiff,
California, USA UK
Preface
Vascular surgical techniques are continually increasing in Percutaneous transluminal angioplasty is gaining in
number and complexity and it is doubtful whether a single popularity, though at present it is far from clear whether
volume could do justice to all of those which are currently the long-term results of this form of intervention will be
performed. This volume does not attempt to be compre- sufficiently encouraging to justify its widespread usage.
hensive; rather it describes a number of complex, new and These then are but some of the fascinations and
controversial operations as they are currently performed by challenges of vascular surgery - a discipline which is
the most eminent vascular surgeons from around the constantly evolving and advancing for the better. It is not of
world. course suggested that vascular surgery can or should be
The operations chosen are those in which special learned solely from a book; nothing can equal a long
manoeuvres or aspects of technique are important in personal apprenticeship in which the trainee will observe,
determining a successful outcome. The section on arterial or better still, assist the experts, until eventually he is
surgery includes procedures for revascularization of the capable of using his own skill and judgement to perform
brain, operations on the larger arteries and also covers the operation himself. Nevertheless this is not to decry the
microvascular surgery. There is an extensive section on the value of a book in which the emphasis is visual. If it is
problems associated with aortic surgery and its important accepted that one can learn operative surgery by watching
branches to the kidneys and viscera. It is clear that an operation perfectly performed then it must also be
endarterectomy is being performed less often though the accepted that this same skill, however imperfectly transmit-
technique still has an important place in vascular surgery - ted through the medium of a book, may be of considerable
especially for corrective surgery to the carotid bifurcation. help in consolidating or refreshing experiences previously
Apart from surgery to the profunda femoris artery, lower gained in theatre. It is hoped then that this compendium of
limb revascularization almost invariably involves a bypass operations will be of interest and value not only to
technique of one sort or another. One of surgery's main practising general and vascular surgeons but also to general
controversies at the present time concerns the most surgical trainees with an interest in this field.
effective way to reconstruct the femorodistal segment and In conclusion I would like to thank the contributors for
this section features several chapters which describe their collaboration and efforts to submit chapters under
methods of performing the technique. extreme pressure. The quality of the illustrations bears
The management of portal hypertension too is controver- testimony to the remarkable work of a succession of
sial, the general trend being towards avoiding portacaval or medical artists whose names are given at the end of each
splenorenal anastomosis where possible. The technique of chapter. However, a special acknowledgement must go to
injecting sclerosant for treating oseophageal varices has Alison George (from the Department of Surgery, Charing
gained ground and both this and the classic portacaval Cross Hospital) whose constant support and skill through-
anastomosis are described here. out the preparation of the volume have enabled us to meet
In the venous section, operations for the management of the stiff deadlines set by the publishers, without sacrificing
varicose veins using conventional and newer methods are anything in the excellent standard of the illustrations.
fully covered. Surgical intervention of the deep venous Finally thanks are due to our departmental secretary Jill
system is somewhat controversial but attempts are being Wallace whose assistance in co-ordinating the activities of
made to minimize the discomfort of the post-thrombotic the contributors and more importantly myself has been
limb and to reduce the risk of pulmonary embolism. invaluable.
Techniques for reconstructing the deep venous system are
therefore described in detail and also methods of perform- Roger M. Greenhalgh
ing emergency venous embolectomy. In addition there is a
description of the way in which the vena caval filter is
introduced.
Operation planning
Roger M. Greenhalgh MA, MD, MChir, FRCS
Professor of Surgery, Charing Cross Hospital Medical School, London, UK
Introduction
All operative procedures require careful planning and this the beginning of the later chapters but are only given in
is especially important for arterial reconstructive surgery. outline, as this really is a separate subject.
The desired result cannot be achieved if patient selection is Preoperative assessment, non-invasive testing and
poor. Learning how to choose the right procedure for the angiography are essential stages in accurate patient
right patient takes at least as much experience as learning selection for a procedure and these are outlined here. This
how to do the vascular surgical techniques and both should is followed by a note on anaesthetic aspects and monitoring
form an integral part of training for vascular surgeons. The during the operative procedure, followed by some haema-
indications for the individual procedures are mentioned at tological considerations.
1
2 Operation planning
Preoperative assessment Non-invasive testing
A very careful history of the patient must initially be taken. Until recently it was felt that a thorough clinical examina-
It is vital to relate the patient's complaint to age, occupation tion and an angiogram were all that were required for
and way of life before deciding what is the best treatment. correct patient selection. Increasingly, the place of non-
Almost all patients with severe arterial disease have been invasive tests has become established. These now have a
heavy smokers for many years. Patients at risk of stroke or firm place in the investigation of carotid artery disease and
suffering from ischaemic rest pain or imminent gangrene disease of the arteries supplying the lower limbs. Ideally,
should be offered any possible operative procedure the carotid vessel should be investigated whenever the
immediately. If the situation is not so urgent, the surgeon arterial tree is to be operated upon at another site. It is
must decide whether to ask the patient to stop smoking mandatory to evaluate the carotids in patients who have a
before the operation is carried out. carotid bruit. Oculoplethysmography and carotid phonan-
The cardiac status needs to be thoroughly assessed. giography have been used to assess the carotid vessels by
Approximately one-third of patients presenting with the an indirect method. The Kartschner and McRae oculo-
symptoms of peripheral arterial disease have already had a plethysmography system (OPG) compares the transit time
myocardial infarction in the past as demonstrated by to the eyeballs and the transit times to the ears. The Gee
resting electrocardiographic abnormality and a greater OPG works on a completely different principle and
proportion have exercise ECG changes. Those centres with measures pressure in the orbit.
the facility should always perform ventricular injection The indirect methods are now being superceded by
fractions on their patients to assess the cardiac status before imaging methods. The Mobile Arterial and Venous Imaging
embarking upon arterial reconstruction in the extremities. System (MAVIS) is a pulsed gated Doppler imaging system
Centres without this facility can still rely to a great extent on which enables an image to be built up using Doppler
careful history taking and examination of cardiac function ultrasound based on the moving blood in the vessels. The
to establish which patients are at high risk of cardiac failure. duplex scanner combines B-mode ultrasound with Doppler
Often, such as for impending gangrene or stroke, there is velocity profile. This scanner has been shown to have a 98%
no alternative but to perform a reconstruction. correlation with conventional angiography. Digital subtrac-
Approximately 10% of patients with peripheral arterial tion angiography also provides valuable additional anato-
disease are diabetic and just as it is important to work mical information about the carotid vessels but this is
closely with a cardiologist for cardiac problems, it is equally strictly invasive because the contrast material is injected
important to work hand in hand with an endocrine into a vein. This technique also has approximately 98%
physician when dealing with diabetic patients. Each correlation with conventional angiography, and when
endocrine specialist has his own way of managing the combined with duplex scanning, a 99% correlation. The
problem. There is increasing use of a constant infusion of main concern about conventional angiography is that it
insulin over the perioperative period. It is claimed that this carries a small but definite morbidity risk. This suggests
facilitates easier moment-to-moment control of diabetes that its use is only justified in patients with symptomatic
mellitus. Of course, the most important rule is that the carotid arterial disease, whereas the non-invasive tests
blood glucose level should never be allowed to fall; a slight mentioned here have no morbidity and provide an
rise is preferable but the expert will aim at perfect control of extremely convenient method of assessment of the carotid
the blood glucose level over the whole perioperative vessels before arterial reconstruction at another site is
period. undertaken.
If patients are taking warfarin or similar oral anticoagu- Non-invasive tests are equally valuable in assessing the
lant drug this should be stopped and the prothrombin time arteries supplying the lower limbs. The simplest test
should become normal before surgery. If it is thought that a involves the use of a Doppler probe with a blood pressure
prosthetic graft is going to be used in a low flow situation, cuff. This enables the ultrasonic systolic pressure to be
an antithrombotic regimen may be instituted 48 h before recorded at a particular segment. If the cuff is placed
surgery. Aspirin 300 mg daily with dipyridamole 75 mg around the ankle, calf and upper thigh, segmental
three times daily is found to be an acceptable dosage in pressures can be measured on both legs and this can give
most centres. vital information to be considered alongside an arterio-
A complete physical examination should be undertaken gram. Where all pulses are present, and the Doppler
for all patients. The chest must, of course, be examined systolic pressure in the ankle is normal compared to that in
most carefully in those patients who are to undergo general the arm, it is important to perform an exercise test to ensure
anaesthesia. All of the pulses are felt and a careful that pressure is maintained after exercise (Laing and
examination is made for aneurysmal disease over the aorta, Greenhalgh, 1980). The waveforms of the velocity profiles
femoral and popliteal regions. It is important to listen for on different points along the leg can also give vital
bruit over diseased arteries, particularly in the neck. information on the site and severity of disease.
Two of the most important special investigations that are An example of where these tests are of a special value is
performed are for detection of diabetes mellitus and renal before performance of a femorofemoral cross-over graft.
disease. Examination of urine and measurement of blood For this procedure it is not enough just to look at the
sugar and plasma creatinine levels is essential and any arteriogram; it is absolutely essential to know that the
abnormalities discovered required further investigation. donor iliac segment is normal and that it is a suitable source
of blood supply for the opposite limb. A combination of
waveform analysis, segmental pressure measurement and
exercise testing can be most helpful here.
Operation planning 3
Angiography increasingly. Ideally the catheter is inserted a day or so
before the operation so that the optimal capillary wedge
pressure for maximal cardiac output can be determined and
The perfemoral Seldinger technique is the most commonly the knowledge is used during surgery.
used method of arteriography today. With this approach it During the operation it is vital to estimate blood gases at
is possible to pass catheters to almost all parts of the arterial least every 30 min so an anaesthetic is chosen that does not
tree, provided that there are no arterial occlusions or very depress the myocardium. For muscle relaxation, muscle
tight stenoses. If the iliac system above or the aorta is relaxant drugs are used. A urinary catheter is passed so that
occluded it may be necessary to approach the arterial tree the the hourly urine output can be monitored. When the
from another route. The transaxillary approach gives the surgeon clamps a major blood vessel he should work with
same degree of flexibility as the femoral approach but this the anaesthetist, observing the monitoring system and, if
requires proper training to avoid damage to the nearby necessary, performing the clamping and unclamping very
brachial plexus. The advantage of this approach is the slowly. The use of heparin is very controversial. Most
ability to perform selective arterial catheterization, e.g. of surgeons performing arterial bypass use approximately
the carotid subclavian, vertebral, renal or visceral vessels. 5000 i.u. of heparin intravenously before cross-clamping. A
These techniques do not require general anaesthesia but wait of approximately 3 min before applying the clamps is
the patient is frequently slightly sedated. generally recommended to allow the heparin to circulate.
Translumbar aortography requires general anaesthesia For emergency abdominal aneurysms and for all thoracoab-
but can be performed as an outpatient procedure. It is dominal aneurysm replacements the use of heparin is not
difficult though to take films in more than one plane and advisable.
this is essential for satisfactory assessment of the arteries,
particularly, at, for example, the origin of the profunda
femoris artery which arises from behind the main vessel.
Haematological considerations
Anaesthetic options and monitoring
It is necessary to work closely with the haematology
department. Adequate whole blood needs to be cross-
Most of the contributors to this book draw attention to the matched before the operation, and if excessive blood loss is
great value of the expertise of the anaesthetist who has anticipated, albumin and fresh frozen plasma should be at
experience with vascular surgical patients. Either a general hand. For major procedures such as thoracoabdominal
anaesthetic or a light anaesthetic with continuous epidural aneurysms 10-16 u of platelets should be available so that
can be used. It is essential to assess pulmonary function these can be infused the moment the blood flow is restored
properly before embarking upon a procedure and to decide to the graft. For major transfusions it is wise to alternate 1 u
on the most appropriate form of anaesthesia. In some of frozen plasma to every 2u of whole blood.
circumstances it is possible to provide a local block or even The planning of venous procedures is just as important
local infiltration to perform simple procedures as, for as the planning of arterial ones. Varicose veins are assessed
example, in the groins. The monitoring system which is and marked following clinical examination and the use of
used for continuous assessment of the patient during the the Doppler probe can be valuable to determine whether
operative procedure is designed for the benefit of the there is any incompetence at a particular site. When
anaesthetist and the surgeon. A radial intra-arterial catheter considering surgery of the deep venous system, it is
should be passed so that continuous monitoring of the important to perform ascending and descending veno-
systolic and diastolic pressures is possible throughout the grams.
procedure. A central venous pressure line and ECG
monitor are essential for every arterial operation. A number
of venous lines is required - up to four if rapid transfusion Reference
is envisaged as, for example, when operating upon
thoracoabdominal aneurysms. The insertion of a Swan- Laing, S. P. and Greenhalgh, R. M. (1980). Standard exercise test to
Ganz catheter is more controversial, but this is being used assess peripheral arterial disease. British Medical Journal 280,13
Techniques of anastomosis
Roger M. Greenhalgh MA, MD, MChir, FRCS
Professor of Surgery, Charing Cross Hospital, Medical School, London, UK
Introduction
The various techniques of anastomosis, or joining of blood dispense with or minimize preclotting, there has been a
vessels, fall into two main types: end-to-end anastomosis recent introduction of collagen coating of Dacron. An
and end-to-side anastomosis. Various graft materials are externally supported Dacron graft has gained much favour
preferred for bypass in different parts of the body and these and may prove ideal in sites where it is important that the
are described in detail in subsequent chapters. For graft should not be squashed, such as for axillofemoral
replacement of large vessels such as the aorta, Dacron has bypass.
become the material of choice. Essentially Dacron prosth- Dacron is perhaps the material of choice for the
eses are of two main types, woven and knitted. The woven replacement or bypass of arteries ranging in size from the
variety has the advantages that it does not require any aorta to the common femoral artery. Expanded polytetra-
preclotting of the Dacron and it does not leak blood. Its fluoroethylene (PTFE) is mainly used in long straight tubes
disadvantage is that it is rather stiff and when cut it frays. It for the replacement of smaller arteries than is ideal for
is advisable to cut woven Dacron with an electric diathernv Dacron. However, a bifurcated graft of PTFE is now
needle so that the ends are sealed, but this can be quite a available to replace or bypass the aortic bifurcation; it does
tricky procedure compared with the precise cutting of a not require preclotting and is easy to work. Patients who
knitted Dacron graft which can be performed with scissors. are expected to have a PTFE graft should begin aspirin and
The great advantage of knitted Dacron is that it can be dipyridomole 48 h before surgery to minimize postopera-
shaped exactly as required but must be preclotted. tive graft thrombosis. It is an excellent graft material for
Preclotting can be achieved by taking approximately 100 ml femorofemoral crossover, axillobifemoral bypass and
of blood from a nearby vein such as the vena cava and bypass of the femoral artery in the thigh.
syringing it down through the graft so that the blood pours Human umbilical vein does not require preclotting and is
through the holes. The blood is then caught in a dish and perhaps the best alternative to autologous vein for bypass
syringed through the graft again and again with some from the groin to below the knee. It is also advisable to give
pressure until the interstices become blocked by the clotting aspirin and dipyridomole 48 h before the insertion of this
blood. The blood is then squeezed out of the Dacron which graft as this is thought to reduce the risk of graft
should be leak proof and it is ready for anastomosis. To thrombosis.
5
