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 = Ischemia-reperfusion syndrome after cross clamp removal | 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 | ||
| Line 84: | Line 89: | ||
=== 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 | |||
* 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 == | ||
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=== 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 | 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. --> === | ||
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[[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