CS Vascular

1. Choose appropriate access site
2. Insert sheaths and catheters
3. Perform AP and lateral abdominal aortogram
4. Adminsiter heparin
5. Obtain wire access of mesenteric vessel
6. Place long guiding catheter or long sheath into target vessel
7. Chose appropriate type and sized stent
8. Treat additional mesenteric vessel as above if indicated
9. Perform completion angiogram
10. Surrender wire access and remove sheaths
11. Consider use of closure devices
12. Check distal pulses and monitor postop

1. Aortomesenteric endarterectomy
2. Antegrade aortomesenteric bypass
a. Conduit : autogenous / prosthetic
b. Target : single / multiple vessels
3. Retrograde bypass
a. Inflow - infrarenal aorta / iliac artery
b. Conduit - autogenous / prosthetic
c. Target : single / multiple vessels

1. Midline abdominal incision
2. Expose inflow vessel - left medial visceral rotation for aortomesenteric endarterectomy , through the lesser sac for antegrade bypass , infrarenal aorta / iliac artery for retrograde bypass
3. Expose target (outflow) vessel - through lesser sac for celiac, root of mesentery for SMA
4. Confirm decision of number of vessels to revascularize
5. Choose appropriate bypass conduit including type and size
6. Systemically heparinize patient
7. Clamp inflow vessel, perform arteriotomy, and complete proximal anastomosis with running monofilament suture
8. Clamp target vessel, perform arteriotomy and complete distal anastomosis with running monofilament suture
9. Reestablish blood flow through graft
10. Assess mesenteric pulses and viability of bowel
11. Obtain hemostasis, consider reversal of heparin
12. Close abdomen and transfer to ICU for postop care

1. Liberal midline incision and full abdominal exploration
2. Exposure of SMA by cephalad retraction of transverse mesocolon, rightward retraction of small bowel, division of ligament of Treitz
3. Obtain proximal and distal control of SMA and administer systemic heparin
4. Perform an embolectomy via transverse arteriotomy and passage of a Fogarty catheter (4-5 F proximally, 3-4F distally, also milk distant clot in mesenteric arcade)
5. If inflow is reestablished, close the SMA utilizing a patch angioplasty if vessel narrowing is anticipated
6. If inflow fails to be reestablished, eitology is likely SMA thrombosis and a retrograde SMA bypass should be performed
7. Create distal anastomosis on SMA first, ideally with saphenous vein graft
8. Proximal anastomosis can be performed either on infrarenal arota or iliac vessels
9. Assess bowel viability after 30 mins using visual inspection, Doppler probe and / or fluorescein

1. Identify GSV and harvest with full length leg incision
2. Obtain control of proximal and distal anastomotic vessels
3. Create tunnels for bypass (SQ / subfascial)
4. Dilate vein with heparinized saline, check for any holes requiring repair
5. Heparinize patient systemically
6. Perform proximal anastomosis, tunel vein and confirm pulsatile flow
7. Perform distal anastomosis
8. Confirm unobstructed Doppler signal in distal artery and at anastomosis
9. Reverse heparin with protamine
10. Close incisions and confirm pulse or signals in foot prior to leaving OR

1. Outline with a marking pen the anterior and posterior skin flaps. (The flaps are usually equal in size, with a fish mouth pattern.)
2. Incise the skin and subcutaneous tissues down to the fascia.
3. Ligate and divide the greater saphenous vein on the medial aspect of the thigh.
4. Divide the fascia and the muscles at the same level as the skin flaps.
5. Locate the superficial femoral/proximal popliteal artery and vein on the deep posteromedial aspect of the thigh. Suture ligate the
artery and vein individually.
6. Locate the sciatic nerve posterior to the femoral/popliteal vessels.
7. Pull, ligate, and divide the sciatic nerve.
8. Make a circular incision in the periosteum of the femur and free the periosteum proximally.
9. Divide the femur with a saw at least 5 cm proximal to the level of the soft-tissue transaction
.10. File any sharp bony edges.
11. Close the periosteum over the transected femur.
12. Approximate the deep investing fascia of the nterior and posterior muscles flaps with interrupted absorbable sutures.
13. Close the skin with interrupted nonabsorbable sutures/staples.

1. Outline, with a marking pen, the skin incisions. (The anterior skin incision is made 10–12 cm below the tibial tuberosity and extends medially and laterally toward the edges of the gastrocnemius muscle. The posterior skin incision creates a posterior flap that extends 10–12 cm distal to the anterior incision.)
2. Incise the skin and subcutaneous tissues down to the fascia.
3. Ligate and divide the greater and short saphenous veins on the medial and posterior aspects of the leg, respectively.
4. Divide the fascia and the muscles at the same level of the anterior skin incision.
5. Divide the muscles in the anterior and lateral compartments.
6. Ligate the anterior tibial vessels.
7. Divide the interosseous membrane.
8. Incise the tibial periosteum at the same level of the skin and muscle division.
9. Strip the tibial periosteum proximally for 2 cm.
10. Divide the tibia with an anterior bevel.
11. Expose and transect the fibula with a bone cutter or Gigli saw 2 cm proximal to the tibial division.
12. Transect the soleus obliquely and the gastrocnemius muscle at the same level as the posterior flap.
13. Ligate and oversew any bleeding soleal veins and posterior tibial and peroneal vessels.
14. File any sharp bony edges.
15. Approximate the fascia of the anterior and posterior muscles flaps with interrupted absorbable sutures.
16. Close the skin with interrupted nonabsorbable sutures/staples.

1. Noninvasive vascular testing suggests transmetatarsal amputation is likely to heal.
2. Mark the skin and the shape of the desired plantar flap.
3. Perform a transverse skin incision over the level of the midmetatarsal bones.
4. Deepen the incision to the bone.
5. Elevate the periosteum 1.5 cm proximal to the level of the skin incision.
6. Divide the bone.
7. Bend the divided bones and create the plantar flap.
8. Secure hemostasis.
9. Irrigate the wound.
10. Close the skin without tension

1. Noninvasive vascular testing suggesting healing of toe amputation is likely.
2. Perform the skin incision (shape varies between toes; refer to variations).
3. Divide all attached tendons.
4. Elevate the periosteum to the level of the amputation.
5. Divide the bone.
6. Close the skin without tension.

1. Neck slighthly hyperextended and turned away, with a roll under shoulder to open the neck.
2. Longitudinal incision along anterior border of SCM
3. IOUS to guide surgeon for limited incision over bifurcation, divide platysma
4. Retract SCM laterally, IJV identified in carotid sheath
5. Facial vein important landmark for identification of bifurcation and is dividef, avoid injuring vagus nerve that is typically posterior to artery
6. CCA carefully dissected controlled with vessel loop
7. ECA and superior thyroid arteries are identified and controlled
8. ICA carefully dissected well above the most cranial plaque and controlled with a vessel loop
9. Hypoglossal nerve is carefully avoided, especially prudenti f lesion is high and requries division of posterior belly of digastric muscle
10. Patient systemically heparinized, clamps placed on ICA, CCA, ECA and superior thyroid artery
11. Arteriotomy made on CCA onto ICA anteriorly
12. Shunt placed into ICA and CCA and secured with Rommel tourniquest. Doppler used to interrogate the shunt to ensure blood si flowing
13. Endarterectomy performed removing plaque
14. Loose debris removed, distal endpoint carefully accomplished . Intimal flaps secured with tacking sutures
15. Repair closed with patch angioplasty using most likely Bovine pericardium
16. Prior to completion of patch repair, shunt is removed
17. Backbleeding on all vessels to remove air / debris that can serve as embolic sources
18. Arterial flow returned to ECA , followed by ICA
19. Duplex US performed intraop to ensure quality of repair. Neuro exam at end of case