Difference between revisions of "Infrainguinal arterial bypass"

From WikiAnesthesia
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| monitors = Standard ASA, ABP
| monitors = Standard ASA, ABP
| considerations_preoperative = Other comorbid conditions including CAD, HTN, DM often present
| considerations_preoperative = Other comorbid conditions including CAD, HTN, DM often present
| considerations_intraoperative = Reperfusion after cross clamp may cause acidosis, ATN, hyperkalemia
| considerations_intraoperative = Ischemia-reperfusion syndrome after cross clamp removal (lactic acidosis, ATN, hyperkalemia)
| considerations_postoperative =  
| considerations_postoperative =  
}}
}}
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|-
|-
|Neurologic
|Neurologic
|
|Peripheral neuropathy
|-
|-
|Cardiovascular
|Cardiovascular
|
|Significant PAD, usually also CAD (prior MIs), HTN
|-
|-
|Pulmonary
|Pulmonary
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|-
|-
|Renal
|Renal
|
|Possible comorbid CKD
|-
|-
|Endocrine
|Endocrine
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|Usually DM
|-
|-
|Other
|Other
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=== 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. --> ===
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=== 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


=== 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). --> ==

Revision as of 17:39, 4 April 2022

Infrainguinal arterial bypass
Anesthesia type

General

Airway

ETT

Lines and access

2 large bore PIVs, arterial line

Monitors

Standard ASA, ABP

Primary anesthetic considerations
Preoperative

Other comorbid conditions including CAD, HTN, DM often present

Intraoperative

Ischemia-reperfusion syndrome after cross clamp removal (lactic acidosis, ATN, hyperkalemia)

Postoperative
Article quality
Editor rating
In development
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

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

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