POSTOPERATIVE
DIAGNOSIS: Ischemic ulcer of the
right foot.
OPERATION
PERFORMED:
1. Left-to-right cross-over fem-fem bypass with an 8-mm graft.
2. Common femoral and profunda femoral endarterectomy of the right
common femoral and profunda femoral artery with patch angioplasty.
3. A right femoral popliteal
bypass with a 6-mm ring PTFE graft.
4. A popliteal posterior tibial
bypass with reverse saphenous vein.
ANESTHESIA:
General
with endotracheal Intubation.
COMPLICATIONS: None.
BLOOD
LOSS: About 350 mL.
FINDINGS: Good
flow distally. Diseased common femoral
and profunda femoral ostium.
PROCEDURE IN DETAIL: The
patient is a gentleman with ischemic ulcer of the right great toe, who has aortoiliac
occlusive disease with totally occluded right external iliac and a patent left
iliac capture angioplasty. The patient
requires revascularization for limb salvage. Consent was
obtained. The patient was taken to the
Operating Room and placed in supine position.
General anesthetic was administered.
He was endotracheally intubated.
At this time, bilateral groins and right leg were prepped and draped in
usual sterile manner. An incision was
made in the right groin and in the left groin with a #10 blade. Electrocautery utilized to control
hemostasis. Sharp dissection was carried
out to isolate the common femoral, superficial femoral, and profunda femoral
arteries on both sides and vessel loops were placed around each of the vessels. At this time, incision was made at the distal
popliteal below-knee and popliteal artery was dissected out. The incision was then extended distally, and
the posterior tibial artery was dissected out and controlled with vessel
loops. There was a piece of greater
saphenous vein in the leg that was harvested.
The patient was given 5000 units of heparin intravenously and then a
tunnel from the popliteal up into the right groin was performed with an Impra
tunnel, and 6-mm graft was passed through the tunnel. A suprapubic tunnel was performed also from
the left to right, and an 8-mm graft was passed through it. At this point, the posterior tibial artery
was occluded with vascular clamps and arteriotomy was performed. The vein was reversed and an end-to-side
anastomosis was carried out with a
7-0 Prolene stitch. Once this was done,
popliteal artery was occluded proximally and distally and an end-to-side
anastomosis was created between PTFE graft and the artery. Once this was completed, the end of the
saphenous vein graft was placed to the side of the PTFE graft and an
end-to-side anastomosis was created using a 7-0 Prolene stitch. At this point, the left groin was the focus
of attention where an end-to-side anastomosis was created between graft and
common femoral artery. Back bleeding was
performed. Bleeding was controlled with Gelfoam
and thrombin. The next site was the
right groin, where the vessel was controlled proximally and distally and an
arteriotomy was performed. The common
femoral endarterectomy was performed as well as the profunda femoral
endarterectomy was performed. This area
was patched open with a piece of graft.
The fem-fem graft was
anastomosed with an end-to-side fashion using a 6-0 Prolene suture. The 6-mm graft was then attached to the hood
of the graft in an end-to-side anastomosis.
Bleeding was controlled further with thrombin and Gelfoam. The wounds were irrigated with antibiotic
saline solution. The subcutaneous tissue
was reapproximated with a running 3-0 Vicryl suture in 2 layers in the groins
and one layer in the leg. The skin was
closed with staples. Sterile dressings
were applied, and this terminated the procedure. There was no complication.
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