Difference between revisions of "Infrainguinal arterial bypass"
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| anesthesia_type = General | | anesthesia_type = General | ||
| airway = ETT | | airway = ETT | ||
| lines_access = | | lines_access = Large bore IV x2 | ||
| monitors = Standard | Arterial line | ||
| considerations_preoperative = | | monitors = Standard | ||
| considerations_intraoperative = | ABP | ||
| considerations_preoperative = Evaluate for CAD, HTN, DM | |||
| considerations_intraoperative = Ischemia-reperfusion syndrome after cross clamp removal | |||
*Lactic acidosis | |||
*ATN | |||
*Hyperkalemia | |||
| considerations_postoperative = | | considerations_postoperative = | ||
}} | }} | ||
Infrainguinal arterial bypass procedures include: | '''Infrainguinal arterial bypass''' procedures include: | ||
* Aortofemoral bypass or aortobifemoral bypass | * Aortofemoral bypass or aortobifemoral bypass | ||
* Axillofemoral bypass or axillobifemoral bypass | * Axillofemoral bypass or axillobifemoral bypass | ||
* Femorofemoral bypass (fem-fem) | * Femorofemoral bypass (fem-fem) | ||
*Femoral popliteal bypass (fem-pop) | |||
* Femoral tibial bypass (fem-tib) | * Femoral tibial bypass (fem-tib) | ||
| Line 20: | Line 25: | ||
=== Indications === | === Indications === | ||
Severely PAD causing claudication, ulceration, or infection | |||
=== Surgical procedure === | === Surgical procedure === | ||
* Incision of bypass sites (source and target arteries) | |||
* ± Harvest of vein graft | |||
* Anastomotic tunnel creation | |||
* Clamp of proximal artery | |||
* Distal anastomosis, then proximal anastomosis | |||
* Reperfusion of arteries | |||
* Arteriogram to confirm flow | |||
== Preoperative management == | == Preoperative management == | ||
| Line 35: | Line 49: | ||
|- | |- | ||
|Neurologic | |Neurologic | ||
| | |Peripheral neuropathy | ||
|- | |- | ||
|Cardiovascular | |Cardiovascular | ||
| | |Significant PAD, usually also CAD (prior MIs), HTN | ||
|- | |- | ||
|Pulmonary | |Pulmonary | ||
| Line 50: | Line 64: | ||
|- | |- | ||
|Renal | |Renal | ||
| | |Possible comorbid CKD | ||
|- | |- | ||
|Endocrine | |Endocrine | ||
| | |Usually DM | ||
|- | |- | ||
|Other | |Other | ||
| Line 60: | Line 74: | ||
=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> === | === Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> === | ||
* BMP to evaluate potassium, creatinine | |||
* Coagulation factors (INR, PTT) | |||
=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> === | === Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> === | ||
* Arterial line setup | |||
* Lead for intraop arteriogram | |||
* Heparin and protamine prepared for clamp/unclamping | |||
=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> === | === Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> === | ||
* Anxiolysis as indicated | |||
=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> === | === Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> === | ||
* Spinal or epidural can be considered for intraoperative and postoperative pain control | |||
** There is some evidence that regional anesthesia promotes graft survival [citation needed]. | |||
== Intraoperative management == | == Intraoperative management == | ||
=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> === | === Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> === | ||
* 2 large bore IVs for possible fluid/product resuscitation | |||
* Arterial line for ABP | |||
=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> === | === Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> === | ||
General anesthesia with ETT. Induce with paralysis | |||
=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> === | === Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> === | ||
* Supine | |||
=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> === | === Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> === | ||
* Clamping of large arteries may produce afterload increase, though usually minimal effect | |||
* Unclamping of large arteries may induce ischemia-reperfusion syndrome (lactic acidosis, hyperkalemia, ATN) | |||
* Heparin is needed during anastomosis creation | |||
* Protamine may be needed for reversal at end of case | |||
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> === | === Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> === | ||
| Line 82: | Line 119: | ||
=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> === | === Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> === | ||
IMC vs. ICU | |||
=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> === | === Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> === | ||
If regional anesthetic used, epidural may be redosed. | |||
Consider lower extremity nerve blocks for acute pain in the PACU (femoral, sciatic, popliteal blocks) | |||
- Take care to check ASRA guidelines prior to any regional anesthesia in the patients. | |||
=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> === | === Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> === | ||
* Arterial thrombosis/occlusion | |||
* Acute cardiac event | |||
* Wound hematoma | |||
* Compartment syndrome | |||
== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> == | == Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> == | ||
| Line 127: | Line 175: | ||
[[Category:Surgical procedures]] | [[Category:Surgical procedures]] | ||
[[Category:Vascular surgery]] | |||
Latest revision as of 18:21, 1 February 2023
Infrainguinal arterial bypass
| Anesthesia type |
General |
|---|---|
| Airway |
ETT |
| Lines and access |
Large bore IV x2 Arterial line |
| Monitors |
Standard ABP |
| Primary anesthetic considerations | |
| Preoperative |
Evaluate for CAD, HTN, DM |
| Intraoperative |
Ischemia-reperfusion syndrome after cross clamp removal
|
| Postoperative | |
| Article quality | |
| Editor rating | |
| User likes | 0 |
Infrainguinal arterial bypass procedures include:
- Aortofemoral bypass or aortobifemoral bypass
- Axillofemoral bypass or axillobifemoral bypass
- Femorofemoral bypass (fem-fem)
- Femoral popliteal bypass (fem-pop)
- Femoral tibial bypass (fem-tib)
Overview
Indications
Severely PAD causing claudication, ulceration, or infection
Surgical procedure
- Incision of bypass sites (source and target arteries)
- ± Harvest of vein graft
- Anastomotic tunnel creation
- Clamp of proximal artery
- Distal anastomosis, then proximal anastomosis
- Reperfusion of arteries
- Arteriogram to confirm flow
Preoperative management
Patient evaluation
| System | Considerations |
|---|---|
| Airway | |
| Neurologic | Peripheral neuropathy |
| Cardiovascular | Significant PAD, usually also CAD (prior MIs), HTN |
| Pulmonary | |
| Gastrointestinal | |
| Hematologic | |
| Renal | Possible comorbid CKD |
| Endocrine | Usually DM |
| Other |
Labs and studies
- BMP to evaluate potassium, creatinine
- Coagulation factors (INR, PTT)
Operating room setup
- Arterial line setup
- Lead for intraop arteriogram
- Heparin and protamine prepared for clamp/unclamping
Patient preparation and premedication
- Anxiolysis as indicated
Regional and neuraxial techniques
- Spinal or epidural can be considered for intraoperative and postoperative pain control
- There is some evidence that regional anesthesia promotes graft survival [citation needed].
Intraoperative management
Monitoring and access
- 2 large bore IVs for possible fluid/product resuscitation
- Arterial line for ABP
Induction and airway management
General anesthesia with ETT. Induce with paralysis
Positioning
- Supine
Maintenance and surgical considerations
- Clamping of large arteries may produce afterload increase, though usually minimal effect
- Unclamping of large arteries may induce ischemia-reperfusion syndrome (lactic acidosis, hyperkalemia, ATN)
- Heparin is needed during anastomosis creation
- Protamine may be needed for reversal at end of case
Emergence
Postoperative management
Disposition
IMC vs. ICU
Pain management
If regional anesthetic used, epidural may be redosed.
Consider lower extremity nerve blocks for acute pain in the PACU (femoral, sciatic, popliteal blocks)
- Take care to check ASRA guidelines prior to any regional anesthesia in the patients.
Potential complications
- Arterial thrombosis/occlusion
- Acute cardiac event
- Wound hematoma
- Compartment syndrome
Procedure variants
| Variant 1 | Variant 2 | |
|---|---|---|
| Unique considerations | ||
| Position | ||
| Surgical time | ||
| EBL | ||
| Postoperative disposition | ||
| Pain management | ||
| Potential complications |
References
Top contributors: Tony Wang, Jashvin Patel and Chris Rishel