Peripheral vascular surgery

1What vascular surgery covers

Peripheral vascular surgery is the specialty of the arteries, veins and lymphlymphLIMFThe clear fluid that flows through the lymphatic vessels and carries white blood cells.Full entry Close vessels outside the area of the heart. It treats disease, injury and malformationsmalformationmal-for-MAY-shunA body part or organ that formed in an abnormal way before birth.mal- badformation shapingFull entry Close a patient is born with. Vascular surgeons also build the access that dialysisdialysisdy-AL-ih-sisA treatment that removes wastes and extra fluid from the blood when the kidneys can no longer do it.dia- through, apart-lysis separation, looseningFull entry Close needles use, and they repair arteries torn by gunshots, stab wounds and crashes.

The Core Curriculum sorts the specialty's cases three ways: operations on a blood vessel, on an artery and on a vein. Each can be done open or by a minimally invasive, endovascular approach, either through the skin (percutaneous) or with a scope. Three words come up again and again:

• Open: the surgeon cuts down to the vessel, controls it, clamps it, opens it and repairs it under direct view.
• Endovascular: the work happens inside the vessel. A needle or a small cutdown gives access, and wires, sheathssheathSHEETHA covering that wraps around a structure; in procedures, a short hollow tube left in a blood vessel to pass catheters through.Full entry Close, catheters, balloons and stentsstentstentA small tube, often of metal mesh, placed inside a vessel or duct to hold it open.Full entry Close travel through the vessel under live x-ray. Percutaneous means through the skin: no incision is made, and the devices go in through a puncture.
• Hybrid: an endovascular repair done in a hybrid operating room, a room built for both endovascular and open surgery, with fixed imaging and everything needed to open if the repair goes wrong.

Many operations that were once done open are now done from inside the vessel, with far less trauma and a faster recovery. Endovascular repair of an abdominal aortic aneurysmabdominal aortic aneurysmab-DOM-ih-nul ay-OR-tik AN-yuh-riz-umA weak, bulging section of the aorta where it passes through the belly.Full entry Close, for example, is now done more often than the open repair. Vascular cases also share a great deal: the same clamps, the same steps for opening and closing an artery, and the same drugs on the field. The Core Curriculum calls cases like these co-related procedures, so learn the pattern once and each new case is mostly a new middle. Most cases below link to their setup card, which holds the full instrument list and every step.

Vascular surgery asks a lot of the scrub. Some steps stop the blood flow to an organ or a limb, and during those minutes you watch the field closely and have the next item ready, from a well-organized instrument table. Surgeons often name exactly which vascular instruments they want on the setup, so the right clamp is there at the critical moment.

Other chapters hold the pieces around this one:

• The arteries and veins by name, the systemicsystemicsis-TEM-ikAffecting the whole body rather than one part.Full entry Close and pulmonary circulations, the pulse points and blood pressure: chapter 5.
• HeparinheparinHEP-uh-rinAn anticoagulant drug, given by injection or IV, that keeps blood clots from forming or growing.Full entry Close, protamineprotaminePROH-tuh-meenAn IV drug that binds heparin and reverses its blood-thinning effect.Full entry Close, contrastcontrastKON-trastA dye or other substance given before an imaging test so body parts show up more clearly.Full entry Close and the other drugs as drugs: chapter 12.
• Interventional radiology, guidewires and sheaths as IR uses them, radiationradiationray-dee-AY-shunEnergy that travels as waves or particles, such as X-rays, used to make images or treat cancer; also pain that spreads from its starting point.radi/o rays, radiation-ation processFull entry Close safety and the hybrid OR as a room: chapter 22.
• Heart surgery, the thoracicthoracicthuh-RAS-ikRelating to the chest, or to the middle part of the spine.thorac/o chest-ic relating toFull entry Close aorta and coronary artery diseasecoronary artery diseaseKOR-uh-nair-ee AR-tuh-ree dih-ZEEZNarrowing of the arteries that supply blood to the heart muscle, most often from fatty plaque buildup.Full entry Close, the cardiothoracic supplies (such as the balloon pump), and endoscopicendoscopicen-doh-SKOP-ikDone with an endoscope, a thin tube with a light and camera passed into the body.endo- within-scopic viewingFull entry Close vein harvesting: chapter 41.
• Amputationamputationam-pyoo-TAY-shunThe removal of all or part of a limb or other body part, by surgery or by injury.Full entry Close technique: chapter 39.
• Hemostatic agentshemostatichee-moh-STAT-ikStopping bleeding; also, a product or agent used to stop bleeding.hem/o blood-stasis stopping, standing still-ic relating toFull entry Close and how they are prepared: chapter 29.

2Anatomy that matters

The vessel wall

Chapter 5 teaches the three layers of a vessel wall: the intima inside, the muscular media and the tough adventitia outside. Two of them matter most here. Fatty, calcified plaqueplaquePLAKA deposit that builds up on a surface in the body, such as a sticky film of bacteria on teeth or a fatty buildup in an artery wall.Full entry Close builds up on the intima, the smooth lining that normally keeps plateletsplateletPLAYT-litA tiny cell fragment in the blood that sticks together at a wound to help form a clot.Full entry Close from clumping. An endarterectomy lifts the plaque out along a cleavage plane inside the wall, usually in the media, and leaves the smooth outer wall behind.

The space inside a vessel is its lumenlumenLOO-menThe open space inside a tube, such as a blood vessel, the intestine or a catheter.Full entry Close. A vein is thinner and more fragile than an artery, and venous bleeding can be hard to control. Veins have one-way valves, so a vein used as an arterial graftgraftGRAFTTissue or a man-made material moved into place in surgery to replace or repair a damaged part.Full entry Close must be reversed, or its valves cut, before arterial blood can flow through it.

A fork in an artery or a graft is a bifurcation, and plaque is thickest there. A narrowing, a curve or a fork makes the blood swirl, and that turbulence makes a bruitbruitbroo-EEA whooshing or blowing sound heard with a stethoscope over a blood vessel.Full entry Close, a low-pitched blowing sound heard through a stethoscope, and an abnormal DopplerDoppler ultrasoundDOP-ler UL-truh-soundAn ultrasound that uses sound waves to hear or show blood flowing through vessels or the fetal heartbeat.Full entry Close signal. The pressure, flow and resistance of the blood in the system are its hemodynamicshemodynamicshee-moh-dy-NAM-iksThe study and measurement of blood flow and the pressures that move blood through the heart and vessels.hem/o blooddynam power, force-ics study ofFull entry Close.

The vessels you will work on

Chapter 5 names every major artery and vein and where each runs. This is where each one meets the operations in this chapter.

When an artery narrows slowly, the body grows a network of side branches, collateral vessels, that carry some blood around the blockage. The portal circulation of the liver (chapters 5 and 7) and the lymphlymphLIMFThe clear fluid that flows through the lymphatic vessels and carries white blood cells.Full entry Close system (chapter 5) are taught with their organs.

3Diseases of the arteries and veins

Hardening and narrowing of the arteries

• Arteriosclerosisarteriosclerosisar-teer-ee-oh-skluh-ROH-sisThickening and stiffening of the walls of the arteries, so they lose their ability to stretch.arteri/o arteryscler/o hard-osis conditionFull entry Close: thickening, hardening and loss of elasticity of the artery wall. It comes partly with age.
• Atherosclerosisatherosclerosisath-er-oh-skluh-ROH-sisA buildup of fatty deposits (plaque) inside the walls of the arteries.ather/o fatty pastescler/o hard-osis conditionFull entry Close: the most common form of arteriosclerosis and the disease that most often brings a patient to vascular surgery. Fatty plaqueplaquePLAKA deposit that builds up on a surface in the body, such as a sticky film of bacteria on teeth or a fatty buildup in an artery wall.Full entry Close and calcium build up on the intima and narrow the lumenlumenLOO-menThe open space inside a tube, such as a blood vessel, the intestine or a catheter.Full entry Close, a narrowing called stenosisstenosisstuh-NOH-sisNarrowing of a passage or opening in the body, such as a blood vessel, heart valve or the spinal canal.sten/o narrow-osis conditionFull entry Close, so less blood gets through.

Plaque begins with damage to the intima. PlateletsplateletPLAYT-litA tiny cell fragment in the blood that sticks together at a wound to help form a clot.Full entry Close gather there, inflammation follows, and fat and scar tissue build a deposit called an atheroma, which hardens with calcium into plaque. Plaque may be soft and rubbery, hard and calcified, or both. Smoking, high cholesterol, high blood pressure and diabetes are the firmly established risk factors; age, male sex, an inactive life and family history add to the risk.

Atherosclerosis harms in two ways. It slowly starves tissue of blood, and pieces of plaque can break off and travel downstream, which in the carotidcarotidkuh-ROT-idHaving to do with the carotid arteries, the two large arteries on each side of the neck that carry blood to the head and brain.Full entry Close artery means a stroke. Ischemiaischemiais-KEE-mee-uhToo little blood flow to a part of the body, so the tissue does not get enough oxygen.isch- hold back-emia blood conditionFull entry Close is too little blood flow to a tissue, usually from a blocked vessel. An infarctioninfarctionin-FARK-shunDeath of an area of tissue (an infarct) because its blood supply has been cut off.Full entry Close is tissue that dies when its blood supply stops. Peripheral artery diseaseperipheral artery diseasepuh-RIF-er-ul AR-tuh-ree dih-ZEEZNarrowing of the arteries that carry blood to the legs, and sometimes the arms, usually from fatty plaque.Full entry Close (PADPADpee-ay-DEE (said as letters)An abbreviation that most often means peripheral artery disease, a narrowing of the arteries outside the heart and brain.Full entry Close) is the narrowing or blockage of the arteries that carry blood out from the heart, most often in the legs, and atherosclerosis is its most common cause.

From claudication to gangrene

Blocked leg arteries cause trouble in stages.

• Intermittent claudication, the first and most common symptom: cramping pain in a working muscle below the blockage, such as the calf, that comes on with walking, at about the same distance each time, and eases with rest. Blood flow is enough at rest but not for exercise. Surgery is not usually done for claudication unless it is disabling.
• Rest pain: as the disease worsens, a constant burning pain in the lower leg, foot or toes comes on even at rest, often worse at night. Ischemia at this stage is called critical.
• UlcersulcerUL-serAn open sore where the skin or the lining of an organ has broken down.Full entry Close and gangrenegangreneGANG-greenThe death of body tissue because its blood supply has been lost or because of severe infection.Full entry Close: without treatment, sores that will not heal and gangrene, the death and decay of tissue whose blood supply has failed, follow. Dry gangrene can develop in a severe blockage left untreated.

Patients with diabetes are at special risk, because nerve damage in the feet (peripheral neuropathyperipheral neuropathypuh-RIF-er-ul noo-ROP-uh-theeDamage to the nerves outside the brain and spinal cord, most often in the feet and hands.neur/o nerve-pathy diseaseFull entry Close) can keep them from feeling the tenderness and early signs of an infection, and a foot infection can grow severe enough to threaten the leg.

Thrombus and embolus

A thrombusthrombosisthrom-BOH-sisThe forming of a blood clot (a thrombus) inside a blood vessel or the heart.thromb/o clot-osis conditionFull entry Close is a clot that stays where it formed, attached to the vessel wall. An embolusembolismEM-buh-liz-umThe blocking of a blood vessel by a mass carried there in the blood (an embolus), such as a clot, fat or an air bubble.embol/o plug-ism conditionFull entry Close moves through the circulation until it reaches a vessel too small to pass, where it lodges and blocks the flow. An embolus may be a blood clot, a piece of plaque, air, fat, a foreign body or tumor cells. Chapter 11 teaches thrombosis and embolism as disease processes.

Emboli in the arteries most often come from the heart: a clot forms in a heart that beats irregularly in atrial fibrillationatrial fibrillationAY-tree-ul fib-rih-LAY-shunAn irregular heart rhythm in which the upper chambers of the heart quiver instead of beating in an organized way.atri/o atrium (upper heart chamber)fibrill/o small fibers, quivering-ation processFull entry Close, or on the wall of a heart damaged by a heart attackmyocardial infarctionmy-oh-KAR-dee-ul in-FARK-shunDeath of part of the heart muscle because its blood supply is blocked; a heart attack.my/o musclecardi/o heart-al having to do withinfarct area of dead tissueFull entry Close. When one lodges in a limb artery, the limb shows the signs of acute arterial blockage, often taught as the six Pssix P'ssiks peezA memory aid listing six things checked in a limb: pain, pallor, pulselessness, paresthesia, paralysis and poikilothermia (coldness).Full entry Close: pain, sudden and severe; pulselessnesspulselessnessPULS-les-nusThe absence of a pulse that can be felt.Full entry Close; paresthesiaparesthesiapair-es-THEE-zhuhAn abnormal feeling in the skin, such as tingling, prickling or "pins and needles," with nothing touching it.para- abnormalesthesi/o feeling, sensation-ia conditionFull entry Close (numbness and tingling); paralysisparalysispuh-RAL-uh-sisLoss of the ability to move a part of the body, and sometimes loss of feeling in it.para- beside, abnormal-lysis looseningFull entry Close; pallorpallorPAL-erSkin or mucous membranes that look paler than is normal for that person.Full entry Close; and poikilothermiapoikilothermiapoy-kil-oh-THER-mee-uhThe inability to keep a steady temperature, so the body or a body part takes on the temperature around it.poikilo- variedtherm/o heat-ia conditionFull entry Close, a limb gone cold.

HeparinheparinHEP-uh-rinAn anticoagulant drug, given by injection or IV, that keeps blood clots from forming or growing.Full entry Close is started at once so the clot cannot grow. A threatened limb then needs the clot removed, by surgery (embolectomy) or by a drug that dissolves it (a thrombolyticthrombolyticthrom-boh-LIT-ikA drug that dissolves blood clots that have already formed.thromb/o clot-lytic breaking downFull entry Close). Once the muscle has become rigid, the limb cannot be saved, and amputationamputationam-pyoo-TAY-shunThe removal of all or part of a limb or other body part, by surgery or by injury.Full entry Close is done to save the patient.

Aneurysms

An aneurysmaneurysmAN-yuh-riz-umA weak spot in the wall of an artery that bulges outward like a balloon.aneurysm a widening (Greek)Full entry Close is a weakened section of artery that has ballooned to more than half again its normal diameter. As it grows, it can burst. There are three kinds:

• True aneurysm: all three layers of the wall are stretched out together.
• False aneurysm (pseudoaneurysm): a hole goes through every layer of the wall, and the blood that escapes is held in by the tissue around the vessel. It follows trauma, infection or a suturesutureSOO-cherA stitch, or the thread used to stitch, that holds the edges of a wound or incision together.Full entry Close line that comes apart, and it can form at a puncture site after a catheter procedure.
• Dissecting aneurysm: a tear in the intima lets blood force its way between the layers and split the wall.

By shape, a fusiform aneurysm bulges evenly all the way around and is the most common; a saccular aneurysm bulges out from one side. Atherosclerotic damage to the wall is the most common cause, with genes, age and inflammation playing a part; the Core Curriculum's full list of causes is in the EVAR section.

The abdominal aortic aneurysmabdominal aortic aneurysmab-DOM-ih-nul ay-OR-tik AN-yuh-riz-umA weak, bulging section of the aorta where it passes through the belly.Full entry Close (AAA) is the most common. It forms mostly below the renal arteries and above the aortic bifurcation, and often reaches the iliaciliacIL-ee-akHaving to do with the ilium, the large, wing-shaped upper part of the hip bone.Full entry Close arteries. True aneurysms also form in the thoracicthoracicthuh-RAS-ikRelating to the chest, or to the middle part of the spine.thorac/o chest-ic relating toFull entry Close aorta and the iliac, femoralfemoralFEM-er-ulRelating to the thigh or the femur, the thigh bone.Full entry Close and popliteal arteries. AAAs affectaffectAF-ekt (stress on the first syllable)In mental health, the outward expression of a person's emotions, as seen in the face, voice and body language.Full entry Close more men than women, mostly older adults, and they run in families.

Most AAAs cause few or no symptoms and are found on a routine exam or scan. Severe back pain with low blood pressure and shockshockshokA life-threatening state in which blood flow is too low to bring enough oxygen to the body's tissues.Full entry Close usually means a rupture, a true emergency. Repair is planned once an aneurysm without symptoms reaches about 5.5 cm across in a man or 5.0 cm in a woman, or grows fast. Trials found that the risk of rupture does not outweigh the risk of repair until an aneurysm reaches about 5.5 cm. One that causes symptoms or has ruptured is repaired urgently. The patients often have coronary artery diseasecoronary artery diseaseKOR-uh-nair-ee AR-tuh-ree dih-ZEEZNarrowing of the arteries that supply blood to the heart muscle, most often from fatty plaque buildup.Full entry Close, high cholesterol, high blood pressure or a smoking history as well, and a heart attack is the leading cause of death after AAA repair. Aneurysms in the chest and heart are chapter 41's, and those in the brain chapter 42's. Coronary artery disease, which the Core Curriculum lists with the peripheral vascular diseases, is chapter 41's as well.

Carotid disease and stroke

Plaque in the carotid artery builds up mostly at the bifurcation, where the common carotid divides. It narrows the flow to the brain, and small pieces can break off and lodge in the brain's vessels. The warning signs are:

• A transient ischemic attacktransient ischemic attackTRAN-zee-unt is-KEE-mik uh-TAKA short-lived blockage of blood flow to part of the brain that clears on its own and leaves no lasting brain damage.transient passingisch hold back-emic relating to the bloodFull entry Close (TIA): a short episode of lost brain function, such as weakness or trouble speaking, that clears within 24 hours.
• Amaurosis fugax: brief loss of part or all of the vision in one eye, often described as a curtain coming down, because the first branch of the internal carotid feeds the eye.

Either can lead on to a full stroke (a cerebrovascular accidentcerebrovascular accidentser-uh-broh-VAS-kyuh-ler AK-sih-dentA stroke: injury to part of the brain because a blood vessel in the brain is blocked or has burst.cerebr/o brainvascul blood vessel-ar relating toFull entry Close). A TIA, or a severe narrowing even without symptoms, is a reason for a carotid endarterectomy. A carotid artery that is completely blocked is generally not opened.

Raynaud phenomenon

Raynaud phenomenonRaynaud phenomenonray-NOH fuh-NOM-uh-nonA condition in which small arteries of the fingers and toes narrow too much in response to cold or stress.Full entry Close is an exaggerated response of the extremities to cold or emotional stress: the fingers typically turn white, then blue, then red as the blood returns. The common primary form, which the Core Curriculum calls Raynaud's disease, is a harmless, reversible spasmspasmSPAZ-umA sudden, involuntary tightening of a muscle or of the muscle in a hollow organ or tube.Full entry Close; the secondary form, which comes with another disease, can lead to ulcers of the fingers or toes, scarring or gangrene.

Intimal hyperplasia

Intimal hyperplasiahyperplasiahy-per-PLAY-zhuhAn increase in the number of cells in a tissue or organ, making it larger.hyper- more than normal-plasia formation, growthFull entry Close is an overgrowth of the intima that thickens it, in an artery or a vein, after a long-term central linecentral venous catheterSEN-trul VEE-nus KATH-uh-terAn IV catheter whose tip sits in a large vein near the heart, used for long-term drugs, fluids, nutrition or blood draws.Full entry Close, a graftgraftGRAFTTissue or a man-made material moved into place in surgery to replace or repair a damaged part.Full entry Close or another treatment irritates the vessel. In an artery it narrows the lumen much as atherosclerosis does; in a vein it slows the return of blood and causes swelling and tissue breakdown.

Diseases of the veins

• Varicose veinsvaricose veinVAIR-ih-kohs VAYNA swollen, twisted vein just under the skin, most often in the legs, in which the valves do not work well.varic/o swollen, twisted vein-ose full ofFull entry Close: a varicose vein is an enlarged, swollen vein, seen and felt under the skin, whose wall has weakened and whose valves no longer close. In primary varicose veins, the more common kind, the superficial saphenous veins are affected and the deep veins are healthy; secondary varicose veins follow failure of the deep venous system. The great saphenous vein is affected most often. The risk is higher in women, with age and in pregnancy.
• Venous stasisvenous stasisVEE-nus STAY-sisSlow or pooled blood flow in the veins, most often in the legs.Full entry Close is the pooling of blood in the veins from inactivity or disease. The pressure in the veins rises, fluid leaks out of the capillariescapillaryKAP-ih-lair-eeOne of the tiniest blood vessels, joining the smallest arteries to the smallest veins.Full entry Close into the tissues, and the leg swells (edema); venous stasis ulcers can follow.
• Chronic venous insufficiencyvenous insufficiencyVEE-nus in-suh-FISH-en-seeA long-term condition in which the leg veins cannot carry blood back to the heart well.ven vein-ous relating toin- notFull entry Close: over time the vein walls or valves stop returning blood well; it is seldom treated with surgery, and graduated compression stockingscompression stockingkum-PRESH-un STOK-ingA tight elastic stocking that squeezes the leg, most firmly at the ankle, to help blood flow back toward the heart.Full entry Close are the usual treatment.
• Thrombophlebitis: painful clots and inflammation in the superficial veins of the legs, often from venous stasis after inactivity.
• Deep vein thrombosisdeep vein thrombosisDEEP VAYN throm-BOH-sisA blood clot in a deep vein, most often in the leg or pelvis.thromb/o clot-osis conditionFull entry Close (DVT): a clot, or several, in the deep veins of a leg. Three things set it off, known as the Virchow triadVirchow triadFEER-koe TRY-adThree conditions that together promote blood clots in vessels: slowed blood flow, damage to the vessel wall, and blood that clots too easily.Full entry Close: injury to the vessel lining, pooling of blood, and blood that clots too easily. Its danger is that a piece breaks off and travels to the lungs as a pulmonary embolismpulmonary embolismPUL-muh-nair-ee EM-buh-liz-umA blockage of an artery in the lungs, usually by a blood clot that has traveled there from elsewhere in the body.pulmon/o lung-ary relating toembol/o plug-ism conditionFull entry Close, which can kill; most pulmonary emboli start as a DVT in the legs. A DVT is treated with heparin; when heparin cannot be used or does not work, a vena cavavena cavaVEE-nuh KAY-vuhOne of the two large veins that return oxygen-poor blood from the body to the right atrium of the heart.Full entry Close filter may be placed. Chapter 11 teaches how compression devices and drugs prevent it.

4Diagnostic tests

Diagnosis starts with the patient's history, the physical exam and routine blood tests; more specific studies follow from what they show.

• Pulses and skin: the color, warmth and pulses of the limbs, and any ulcersulcerUL-serAn open sore where the skin or the lining of an organ has broken down.Full entry Close, wasted muscle or dead tissue, are checked and recorded so there is a baseline to compare with during and after surgery. Chapter 5 teaches where to feel each pulse.
• Ankle-brachial index (ABI): the simplest test for blocked leg arteries. Blood pressures are taken at both arms and both ankles, and the higher ankle pressure on each side is divided by the higher arm pressure; the lower the index, the worse the disease.
• Segmental pressures and plethysmography: blood pressure cuffs placed at several levels on the leg show where the flow drops off, either as pressures read with a DopplerDoppler ultrasoundDOP-ler UL-truh-soundAn ultrasound that uses sound waves to hear or show blood flowing through vessels or the fetal heartbeat.Full entry Close or as the changing volume of the limb with each beat (plethysmography).
• Doppler: a probe aimed at a vessel turns the moving blood into sound, a swishing signal, not a pulse. A normal arterial signal has two or three phases; a single low-pitched phase suggests a narrowing or a blockage. Gel carries the signal through the skin.
• Duplex ultrasound (Doppler duplex ultrasonography): Doppler combined with a live ultrasound picture of the vessel. It shows narrowing, clots and swirling flow, and it is the test of choice for venous insufficiencyvenous insufficiencyVEE-nus in-suh-FISH-en-seeA long-term condition in which the leg veins cannot carry blood back to the heart well.ven vein-ous relating toin- notFull entry Close.
• Angiographyangiographyan-jee-OG-ruh-feeAn imaging test that shows blood vessels by injecting a contrast dye and taking x-ray, CT or MRI pictures.angi/o vessel-graphy process of recordingFull entry Close (arteriography for the arteries): contrastcontrastKON-trastA dye or other substance given before an imaging test so body parts show up more clearly.Full entry Close is injected into the vessels and x-ray images follow it through them, showing exactly where an artery is narrowed or blocked, which the surgeon needs to plan a bypass. A venogram does the same for the veins, to find a DVTdeep vein thrombosisDEEP VAYN throm-BOH-sisA blood clot in a deep vein, most often in the leg or pelvis.thromb/o clot-osis conditionFull entry Close or test the valves.
• CT angiographyCTAsee-tee-ay (said as letters)Computed tomography angiography: a CT scan with IV contrast dye that shows blood vessels in detail.Full entry Close and MR angiography: CT angiography has largely taken the place of catheter angiography for diagnosis, and MRImagnetic resonance imagingmag-NET-ik REZ-uh-nunts IM-uh-jingAn imaging test that uses a strong magnet and radio waves to make detailed pictures of the inside of the body.Full entry Close gives detailed 3-D pictures of the carotids, the aorta and the leg arteries.
• Intravascular ultrasound (IVUS): a tiny ultrasound probe on a catheter inside the vessel maps the lumenlumenLOO-menThe open space inside a tube, such as a blood vessel, the intestine or a catheter.Full entry Close, the wall and its plaqueplaquePLAKA deposit that builds up on a surface in the body, such as a sticky film of bacteria on teeth or a fatty buildup in an artery wall.Full entry Close in a full 360-degree image.

Doppler UnitOn 25 setups Intravascular Ultrasound SystemOn 3 setups

Before a study with contrast during surgery, the team reviews the patient's allergies and clottingclottingKLOT-ingThe process by which blood thickens into a gel to plug a damaged vessel and stop bleeding; also called coagulation.Full entry Close status, with the kidney checks chapter 22 teaches.

5The patient and the room

Before the patient arrives

Vascular disease is usually a disease of the whole body, so the patient's heart, kidney and lung disease is reviewed before surgery. Many fear a stroke or the loss of a leg, so answering their questions is part of the team's care.

The circulator confirms that blood ordered from the blood bank is ready, and whether a cell saver will be used to return the patient's own shed blood. Chapter 12 teaches the cell saver. Because angiographyangiographyan-jee-OG-ruh-feeAn imaging test that shows blood vessels by injecting a contrast dye and taking x-ray, CT or MRI pictures.angi/o vessel-graphy process of recordingFull entry Close or fluoroscopyfluoroscopyfloo-ROS-kuh-peeAn x-ray method that shows moving pictures of the inside of the body in real time.fluor/o glowing (from the fluorescent screen)-scopy looking, viewingFull entry Close may be needed in almost any vascular case, the patient lies on a bed that x-rays can pass through, with contrastcontrastKON-trastA dye or other substance given before an imaging test so body parts show up more clearly.Full entry Close, catheters, sterile x-ray covers and lead aprons in the room. Chapter 22 teaches radiationradiationray-dee-AY-shunEnergy that travels as waves or particles, such as X-rays, used to make images or treat cancer; also pain that spreads from its starting point.radi/o rays, radiation-ation processFull entry Close safety.

Vascular cases are often long, so the team works to keep the patient warm: as little skin uncovered as possible, a forced-air warmer, warmed IV fluids, and irrigationirrigationeer-ih-GAY-shunWashing out a wound, body cavity, tube or eye with a steady flow of liquid.Full entry Close at body temperature, 37°C and no warmer, as chapter 29 teaches. A prophylacticprophylaxisproh-fuh-LAK-sisTreatment given to prevent a disease or problem, rather than to treat one that is already present.pro- beforephylax guardFull entry Close antibiotic is given within 1 hour before the incision, because an infected graftgraftGRAFTTissue or a man-made material moved into place in surgery to replace or repair a damaged part.Full entry Close can cost a patient a leg, or a life.

Anesthesia and monitoring

Chapter 13 teaches the anestheticsanesthetican-us-THET-ikA drug that causes loss of feeling, with or without loss of consciousness.an- withoutesthesi/o feeling, sensation-ic relating toFull entry Close and the monitors. Open vascular surgery may be done under general, regional or local anesthesialocal anesthesiaLOH-kul an-es-THEE-zhuhNumbing medicine applied to or injected into one small area, so a procedure there is not felt while the person stays awake.Full entry Close, and most percutaneous endovascular cases need only short-acting IV sedationsedationsih-DAY-shunA calm, relaxed or sleepy state brought on by drugs, or the use of drugs to cause it.sed calm, settle-ation processFull entry Close with local anestheticlocal anestheticLOH-kul an-es-THET-ikA drug that blocks feeling in one part of the body without making the person unconscious.Full entry Close at the access site. What vascular cases add: an arterial linearterial linear-TEER-ee-ul lineA thin catheter placed in an artery, often in the wrist, to measure blood pressure all the time and draw blood.Full entry Close in the radial artery for a long case; a central venous or pulmonary arterypulmonary arteryPUL-muh-nair-ee AR-ter-eeThe large blood vessel that carries blood low in oxygen from the right side of the heart to the lungs.Full entry Close catheter as needed, the pulmonary artery catheter common in aortic surgery; an EEGelectroencephalogramih-lek-troh-en-SEF-uh-loh-gramA test that records the electrical activity of the brain through small sensors placed on the scalp.electr/o electricityencephal/o brain-gram recordFull entry Close to watch the brain in a carotidcarotidkuh-ROT-idHaving to do with the carotid arteries, the two large arteries on each side of the neck that carry blood to the head and brain.Full entry Close case; and a urinary catheter when the case involves the renal arteries or clamps the aorta above them, heavy blood loss is expected, the case is long, or a spinal or epiduralepidural anesthesiaep-ih-DOOR-ul an-us-THEE-zhuhPain relief or numbness from an anesthetic drug given through a thin catheter into the space just outside the covering of the spinal cord.epi- upon, overdur/o dura (the tough covering of the spinal cord)-al relating toFull entry Close is used.

Position, prep and drape

Most vascular cases are supine, padded and with the arms placed as chapter 31 teaches. The patient lies on a pressure-redistributing surface, and a footboard can keep the weight of the drapes off the feet. For a leg case, the thigh may be turned outward and spread a little with the knee bent over a small pillow. The patient's pulses are found, graded and marked on the skin before the prep, so the surgeon can find them fast when a pulse check is called for.

The prep areas are wide:

• Carotid: from the ear and chin on the operative side to below the collarbone.
• Abdominal aorta: from the nipple line to mid-thigh, so the groins are ready if the femoral arteriesfemoral arteryFEM-er-ul AR-ter-eeThe large artery that carries blood to the leg, running through the groin and down the thigh.Full entry Close must be reached.
• Legs: from the umbilicus to the feet, each leg prepped all the way around (circumferentially) and then draped free.

An alcohol-based prep must dry completely before the drapes go on, because its fumes can catch fire. The drapes are impervious, and they leave the surgeon every area the case might need: both groins in an aortic case, the other leg when its saphenous vein may be taken. When both legs are draped, the genitals are covered with a towel and a barrier drape.

6Vascular instruments

Vascular surgery uses general surgery instruments with a vascular set added, plus extra instruments for the region. Every vascular case needs right-angle (Mixter) clamps, tonsiltonsilTON-sulOne of the masses of lymph tissue at the back of the throat that help fight germs entering the mouth and nose.Full entry Close (Schnidt) clamps, and Kelly, Crile and mosquito clamps.

Clamps

Vascular clamps close a vessel without damaging it. Their jaws carry fine, atraumatic serrationsserrationsair-AY-shunA row of small tooth-like ridges, such as the grooves on the jaws of a surgical clamp.Full entry Close that grip without crushing the wall, even when the clamp is fully closed. They come in hundreds of shapes, made to fit around a vessel as it lies, and the peripheral ones are smaller than the clamps of heart surgery. The two common serration patterns are the DeBakey and the Cooley types.

• Occlusionocclusionuh-KLOO-zhunA blockage or closing off of a passage, such as a blood vessel, tube or IV line.Full entry Close clamps close the vessel completely. A DeBakey or similar angled clamp crosses the aorta or the iliaciliacIL-ee-akHaving to do with the ilium, the large, wing-shaped upper part of the hip bone.Full entry Close arteries.
• Partial occlusion (tangential) clamps, such as the Satinsky, close off only part of a large vessel, so blood keeps flowing past while the surgeon works on the side wall.
• Clamps with inserts, such as the Fogarty, carry disposable plastic inserts that slide onto each jaw and protect the vessel; the Core Curriculum lists them as vascular clamp inserts. Clamps with rubber, plastic or fluid-filled jaws protect a vein graftgraftGRAFTTissue or a man-made material moved into place in surgery to replace or repair a damaged part.Full entry Close.
• Bulldogs are small, spring-loaded clamps with atraumatic serrations that close off a small vessel or a side branch while the surgeon works.

DeBakey Multipurpose ClampOn 4 setups Satinsky Vena Cava ClampOn 8 setups Fogarty ClampOn 24 setups Bulldog ClampOn 9 setups

Scissors, forceps, retractors and suction

• Scissors: Potts scissors, with blades angled to the side, open and lengthen the cut in an artery; De Martel scissors are straight, and fine Metzenbaums dissectdissectdy-SEKT, or dih-SEKTTo cut apart or separate tissues carefully during surgery.Full entry Close. Vascular scissors are very delicate. Never use them on suturesutureSOO-cherA stitch, or the thread used to stitch, that holds the edges of a wound or incision together.Full entry Close or graft material, which dulls them and knocks the blades out of line.
• ForcepsforcepsFOR-sepsA hand instrument with two blades or arms used to grasp, hold or pull tissue or objects.Full entry Close: vascular forceps, such as the DeBakey, have very fine serrations at the tips that hold a vessel without injuring it. Pass them whenever a vessel or other delicate tissue will be handled; plain forceps do not grip it well enough, and toothed forceps are never used on a vessel, because they can puncture its wall.
• Retractorsretractorrih-TRAK-terA surgical instrument that holds back tissue or organs so the surgeon can see and reach the operative site.Full entry Close: shallow, blunt retractors for the superficial cases: a blunt Weitlaner, the Senn, vein retractors, small Richardsons. Take great care with any sharp retractor near a vessel. Deep cases use the Deaver, Richardson and Army-Navy.
• Suction: a dry field is critical, and suction is used more than sponges. Small Frazier tips are used near vessels, with the suction pressure turned down for the vessel itself. They clog easily, so keep two ready, one on the field and one in reserve, and clear a clogged tip with its stylet or by suctioningsuctioningSUK-shun-ingRemoving mucus, saliva or other secretions from the mouth, nose or airway with a tube connected to a suction source.Full entry Close a little water through it. The aorta needs larger tips, sometimes two suctions.

Potts Arteriotomy ScissorOn 1 setup Potts-Smith ScissorsOn 61 setups3D DeBakey ForcepsOn 159 setups

Tunnelers

A tunneler is a long blunt-tipped metal shaft that is pushed under the skin or between tissue layers from one incision to another, making a path for a graft. The graft is then pulled through, by the tunneler itself or by a long clamp passed through the tunnel.

Kelly-Wick Vascular TunnelerOn 2 setups

7Vascular supplies

Vessel loops, tapes and the Rummel tourniquet

Before a vessel is opened, the surgeon frees it and passes a vessel loop around it with a right-angle clamp, to lift it, pull it aside or stop its flow. The ends are clamped together with a hemostathemostatHEE-moe-statA clamp with finger rings and a locking ratchet used in surgery to grasp and close off bleeding vessels.hem/o blood-stat stopping, standing stillFull entry Close. Most loops are thin colored Silastic; chapter 25 gives the color code, usually red for arteries and blue for veins. Umbilical tapes, flat cotton tapes used wet, do the same job. Load the loops on tonsiltonsilTON-sulOne of the masses of lymph tissue at the back of the throat that help fight germs entering the mouth and nose.Full entry Close clamps on the back table so they are ready to pass. Vessel loops and tapes used in the wound are counted with the miscellaneous items.

Vessel LoopsOn 38 setups Umbilical TapeOn 45 setups

A Rummel tourniquet is an umbilical tape passed around a vessel, with its ends threaded through a short length of tubing. The tubing is pushed down snug against the vessel and secured, so it closes the vessel for a time, as a temporary tourniquet. To get one ready, feed one end of the tape into the tubing. The surgeon carries the tape around the vessel on a right-angle clamp, and a hemostat holds its ends.

Rummel TourniquetOn 27 setups

Sutures, boots and pledgets

Vascular suturessutureSOO-cherA stitch, or the thread used to stitch, that holds the edges of a wound or incision together.Full entry Close are synthetic nonabsorbable monofilaments, most often polypropylene, because a monofilament is nonreactive, which keeps clot from forming on it inside the vessel. Sizes run from about 3-0 for the aorta to 6-0 or 7-0 for small arteries and a dialysisdialysisdy-AL-ih-sisA treatment that removes wastes and extra fluid from the blood when the kidneys can no longer do it.dia- through, apart-lysis separation, looseningFull entry Close fistulafistulaFIS-choo-luhAn abnormal passage between two organs or vessels, or between an organ and the skin.Full entry Close, with finer still in microsurgery. The needles are swaged on, usually with a 3/8 or 1/2 curve, and the suture may be single-armed or double-armed, a needle at each end.

• Loading: vascular needles are delicate, so use fine-tipped needle holders and draw the suture gently out of the package.
• Double-armed sutures: mount one needle on the needle holder and put the other on a small hemostat whose jaws wear jaw covers: short pieces of Silastic tubing, also called suture boots or booties, that cushion the grip so the suture is not damaged.
• Never pull a needle holder away from the field until you are sure it is free of the anastomosisanastomosisuh-nas-tuh-MOH-sisA connection between two tube-shaped structures, such as two ends of bowel or two blood vessels, made by surgery or found naturally.Full entry Close. The two ends of a double-armed suture work together, and pulling one can drag the other out of the tissue.

Pledgets are small squares of Teflon (PTFE) felt, or leftover pieces of graftgraftGRAFTTissue or a man-made material moved into place in surgery to replace or repair a damaged part.Full entry Close, threaded onto a suture as a buttress, to keep the stitch from cutting through a fragile vessel wall or to seal a leaking anastomosis. The pledget stays on the suture line.

PTFE Felt PledgetOn 25 setups

Grafts and patches

A vascular graft replaces a section of vessel, carries blood around a blockage (a bypass), patches a vessel, or makes dialysis access. Grafts come straight, tapered, bifurcated (Y-shaped) for the aorta and both iliaciliacIL-ee-akHaving to do with the ilium, the large, wing-shaped upper part of the hip bone.Full entry Close or femoral arteriesfemoral arteryFEM-er-ul AR-ter-eeThe large artery that carries blood to the leg, running through the groin and down the thigh.Full entry Close, or as patches cut to size. Their length is measured in centimeters and their outside diameter in millimeters.

• Polyester (Dacron): woven polyester is strong and leaks little through its fabric but is stiffer, so it is kept for large arteries such as the aorta; knitted polyester is easier to handle. Many polyester grafts now come coated with albuminalbuminal-BYOO-minThe main protein in blood plasma, made by the liver, which holds fluid inside the blood vessels and carries drugs and hormones.Full entry Close, collagencollagenKOL-uh-jenThe main structural protein of the body, which gives strength to skin, bones, tendons, ligaments and scar tissue.coll/a glue-gen producingFull entry Close or gelatin, so they need no preclotting.
• PTFE (expanded polytetrafluoroethylene): sometimes with rings on the outside to keep it from being squeezed or kinked. It can cross the knee without kinking. It does not stretch, so its needle holes can bleed.
• Biologic grafts: the patient's own vein (an autograft, usually the great saphenous vein), a banked human umbilical cord, a bovine (cow) carotidcarotidkuh-ROT-idHaving to do with the carotid arteries, the two large arteries on each side of the neck that carry blood to the head and brain.Full entry Close artery, or a cryopreserved donor saphenous vein.

The patient's own vein is the best choice below the groin, because its living lining resists clottingclottingKLOT-ingThe process by which blood thickens into a gel to plug a damaged vessel and stop bleeding; also called coagulation.Full entry Close; synthetic grafts are used above the knee, to spare the veins, or for a patient who cannot have a vein taken. Some synthetic grafts carry an antibacterial substance to lower the risk of infection.

A graft is an implant, and chapter 29's rules apply. Grafts are very expensive: keep each one in its package until the surgeon is ready and has asked for the size aloud, then confirm it with the circulator before you open it. Its size, lot and identification number go on the patient's record. A synthetic graft needs only trimming; a bovine graft is soaked in saline, and a cryopreserved vein rinsed of its preservative, exactly as the maker's instructions say. Keep a graft from touching the patient's skin, where it could pick up bacteria. A harvested vein is kept moist until it is used.

Vascular GraftOn 22 setups Cardiovascular PatchOn 6 setups

Other vascular supplies

• Embolectomy catheters: thin catheters with a small balloon behind the tip, passed beyond a clot, inflated and drawn back to pull the clot out.
• Irrigationirrigationeer-ih-GAY-shunWashing out a wound, body cavity, tube or eye with a steady flow of liquid.Full entry Close tips and syringes: a blunt heparin flushing needle or a soft catheter on a 20 or 30 mL syringe of heparinized saline.
• ShuntsshuntSHUNTA passage that moves blood or other fluid from one place to another, either made by a surgeon or present in the body.Full entry Close: flexible tubes that carry blood past an opened artery, as in a carotid endarterectomy.
• Valvulotome: a cutting instrument passed through a vein to cut its valves, so arterial blood can flow through the vein.
• Vein stripper: a long, very flexible cable with olive (acorn) tips that pulls a vein out through its own lumenlumenLOO-menThe open space inside a tube, such as a blood vessel, the intestine or a catheter.Full entry Close.
• Aortic punch: punches a round hole in an artery for a graft to be sewn to.
• Sterile DopplerDoppler ultrasoundDOP-ler UL-truh-soundAn ultrasound that uses sound waves to hear or show blood flowing through vessels or the fetal heartbeat.Full entry Close probe: sterilizedsterilizationstair-uh-luh-ZAY-shunA process that destroys all microorganisms, including spores, on an item; also a permanent birth control procedure.Full entry Close by its maker's instructions or put in a sterile cover, to check flow on the field. The probes are heat sensitive, and the tip is easily damaged if it is dropped or crushed.
• Endovascular supplies: guidewires, sheathssheathSHEETHA covering that wraps around a structure; in procedures, a short hollow tube left in a blood vessel to pass catheters through.Full entry Close, catheters, balloons and stentsstentstentA small tube, often of metal mesh, placed inside a vessel or duct to hold it open.Full entry Close, taught below and in chapter 22.

Fogarty Balloon CatheterOn 4 setups Heparin Flushing NeedleOn 10 setups Karp Aortic PunchOn 7 setups

8Drugs on the vascular field

Several high-alert drugshigh-alert medicationHY-uh-lert med-ih-KAY-shunA drug that can cause serious harm to a client if it is used in error; also called a high-risk medication.Full entry Close share the vascular field, and most of them are clear liquids, so every cup and syringe is labeled the moment it arrives, as chapter 12 teaches. Keep track of how much of each drug and of the contrastcontrastKON-trastA dye or other substance given before an imaging test so body parts show up more clearly.Full entry Close is used, because the circulator records every drug and solution and the amount given.

• HeparinheparinHEP-uh-rinAn anticoagulant drug, given by injection or IV, that keeps blood clots from forming or growing.Full entry Close, systemicsystemicsis-TEM-ikAffecting the whole body rather than one part.Full entry Close: given into a vein by the anesthesia provideranesthesia provideran-us-THEE-zhuh pruh-VY-derThe licensed professional who gives anesthesia and watches over the client's breathing and vital functions during a procedure.Full entry Close shortly before an artery is clamped, so no clot forms while the flow is stopped; it acts within minutes. The activated clottingclottingKLOT-ingThe process by which blood thickens into a gel to plug a damaged vessel and stop bleeding; also called coagulation.Full entry Close time (ACT), a quick test of how long the blood takes to clot, shows whether more is needed.
• Heparinized saline: heparin mixed into saline to the surgeon's order, for flushing the open vessel, a graftgraftGRAFTTissue or a man-made material moved into place in surgery to replace or repair a damaged part.Full entry Close, a shuntshuntSHUNTA passage that moves blood or other fluid from one place to another, either made by a surgeon or present in the body.Full entry Close and every endovascular device. It keeps clot from forming at the repair and lowers the risk of an embolusembolismEM-buh-liz-umThe blocking of a blood vessel by a mass carried there in the blood (an embolus), such as a clot, fat or an air bubble.embol/o plug-ism conditionFull entry Close. Draw it up in a 20 or 30 mL syringe with a tapered irrigationirrigationeer-ih-GAY-shunWashing out a wound, body cavity, tube or eye with a steady flow of liquid.Full entry Close tip.
• Protamine sulfateprotaminePROH-tuh-meenAn IV drug that binds heparin and reverses its blood-thinning effect.Full entry Close: reverses heparin at the end of the case, given slowly into the vein by the anesthesia provider, because a fast dose can drop the blood pressure and the heart rate. It is made from fish, so ask about fish allergy and about insulininsulinIN-suh-linA hormone made by the pancreas that lets the body's cells take in glucose, also made as a medicine.Full entry Close that contains protamine.
• Papaverine: relaxes the smooth musclesmooth musclesmooth MUS-ulMuscle that works without conscious control and lines hollow organs such as the stomach, intestines, bladder, airways and blood vessels.Full entry Close of the vessel wall, which widens the vessel and eases spasmspasmSPAZ-umA sudden, involuntary tightening of a muscle or of the muscle in a hollow organ or tube.Full entry Close. It is often added to heparinized saline to distend a vein graft gently.
• Drugs for vasospasm: when a vessel clamps down in spasm, the surgeon may lay on it a gauze sponge soaked in papaverine, lidocainelidocaineLY-doh-kaynA local anesthetic that numbs an area, also given by IV to treat some fast, abnormal heart rhythms.Full entry Close or verapamilverapamilver-AP-uh-milA calcium channel blocker that slows the heart rate and relaxes blood vessels.Full entry Close.
• Dextran 40: an antithrombotic, given into a vein after a bypass or endarterectomy, or diluted as an irrigation on the field.
• Topical hemostatic agentshemostatichee-moh-STAT-ikStopping bleeding; also, a product or agent used to stop bleeding.hem/o blood-stasis stopping, standing still-ic relating toFull entry Close: collagencollagenKOL-uh-jenThe main structural protein of the body, which gives strength to skin, bones, tendons, ligaments and scar tissue.coll/a glue-gen producingFull entry Close or fibrin products, a gelatin sponge or topical thrombinthrombinTHROM-binAn enzyme in the blood that turns fibrinogen into fibrin, the threads that hold a blood clot together.thromb/o clot-in substanceFull entry Close, laid on an oozing anastomosisanastomosisuh-nas-tuh-MOH-sisA connection between two tube-shaped structures, such as two ends of bowel or two blood vessels, made by surgery or found naturally.Full entry Close. Chapter 29 teaches preparing them.
• Contrast: for the angiogramsangiographyan-jee-OG-ruh-feeAn imaging test that shows blood vessels by injecting a contrast dye and taking x-ray, CT or MRI pictures.angi/o vessel-graphy process of recordingFull entry Close. Track the total amount and strength used.

Chapter 12 teaches each drug, its doses and its cautions, including the strengths of heparin that look alike and how much protamine neutralizes it.

9Opening and joining vessels

Most open vascular operations follow the same order. Learn it once, and you can follow the open cases in this chapter.

1. Exposure: the surgeon dissectsdissectdy-SEKT, or dih-SEKTTo cut apart or separate tissues carefully during surgery.Full entry Close down to the vessel and frees it from the tissue around it.
2. Control: vessel loops or umbilical tapes go around the vessel above and below the area to be opened, and around its branches.
3. HeparinheparinHEP-uh-rinAn anticoagulant drug, given by injection or IV, that keeps blood clots from forming or growing.Full entry Close: the anesthesia provideranesthesia provideran-us-THEE-zhuh pruh-VY-derThe licensed professional who gives anesthesia and watches over the client's breathing and vital functions during a procedure.Full entry Close gives systemicsystemicsis-TEM-ikAffecting the whole body rather than one part.Full entry Close heparin just before the clamps go on; it acts within minutes.
4. Clamping: the surgeon chooses a clamp that fits the vessel where it lies. The circulator records the time each clamp goes on and comes off, because that is how long the tissue beyond it is without blood.
5. Arteriotomy: an incision into the artery, usually with a #11 blade, lengthened with Potts scissors.
6. The repair: the plaqueplaquePLAKA deposit that builds up on a surface in the body, such as a sticky film of bacteria on teeth or a fatty buildup in an artery wall.Full entry Close or clot is removed, or a graftgraftGRAFTTissue or a man-made material moved into place in surgery to replace or repair a damaged part.Full entry Close is sewn on.
7. Flushing: before the last stitches are tied, each clamp is opened briefly, one at a time, so blood flushes air, clot and loose debris out through the gap. Heparinized saline may be injected too.
8. Restoring flow: the clamps come off in the order the surgeon chooses, so anything still loose travels where it does the least harm.
9. Checking: the surgeon looks for leaks and closes them with extra stitches, pledgets or a hemostatic agenthemostatichee-moh-STAT-ikStopping bleeding; also, a product or agent used to stop bleeding.hem/o blood-stasis stopping, standing still-ic relating toFull entry Close, and checks the flow beyond the repair with a sterile DopplerDoppler ultrasoundDOP-ler UL-truh-soundAn ultrasound that uses sound waves to hear or show blood flowing through vessels or the fetal heartbeat.Full entry Close, the pulses or an angiogramangiographyan-jee-OG-ruh-feeAn imaging test that shows blood vessels by injecting a contrast dye and taking x-ray, CT or MRI pictures.angi/o vessel-graphy process of recordingFull entry Close.

Endarterectomy

An endarterectomy removes plaque from inside an artery. The surgeon finds the plane between the plaque and the wall and lifts the plaque away with a Penfield or Freer elevator, using gentle tractiontractionTRAK-shunA steady pulling force applied to a body part with weights, ropes and pulleys.Full entry Close; the plaque may be cut across over a right-angle clamp at its ends. Loose plaque can break up and travel as an embolusembolismEM-buh-liz-umThe blocking of a blood vessel by a mass carried there in the blood (an embolus), such as a clot, fat or an air bubble.embol/o plug-ism conditionFull entry Close, especially when the clamps come off. Hand the plaque off as a specimen, in a small basin.

Anastomosis

An anastomosisanastomosisuh-nas-tuh-MOH-sisA connection between two tube-shaped structures, such as two ends of bowel or two blood vessels, made by surgery or found naturally.Full entry Close is the join between two vessels, or between a vessel and a graft. It can be made three ways:

• End to end: two cut ends joined, as when a damaged piece of vessel is replaced.
• End to side: the cut end of one vessel or graft sewn over a slit in the side of another. It is the join a bypass graft usually makes at each end, and the usual join in a dialysisdialysisdy-AL-ih-sisA treatment that removes wastes and extra fluid from the blood when the kidneys can no longer do it.dia- through, apart-lysis separation, looseningFull entry Close fistulafistulaFIS-choo-luhAn abnormal passage between two organs or vessels, or between an organ and the skin.Full entry Close. The end of the graft is cut at a slant (beveled) so it meets the artery at a gentle angle.
• Side to side: two vessels lying next to each other, each slit and the edges sewn together.

The surgeon usually sews with a double-armed suture, often anchoring a stitch at each end first and then running a continuous stitch around. An arteriotomy can also be closed with a patch, a piece of vein or synthetic material sewn into the opening, so that closing a small artery does not narrow it.

Tunneling a graft

A bypass graft often runs between two incisions some distance apart. The surgeon makes a tunnel between them with the fingers or a tunneler, and the graft is pulled through without kinks or twists.

10Endovascular supplies and how they are used

Chapter 22 teaches the endovascular supplies as interventional radiology uses them: the way into the vessel, the guidewire's job and lengths, the access sheathsheathSHEETHA covering that wraps around a structure; in procedures, a short hollow tube left in a blood vessel to pass catheters through.Full entry Close, the five kinds of catheter, the balloon and its inflation device, and closing the site when the sheath comes out. This section adds what a vascular case asks of the scrub.

Guidewires

• Diameter: usually 0.014, 0.018 or 0.035 inch. The channel of each catheter, balloon and stentstentstentA small tube, often of metal mesh, placed inside a vessel or duct to hold it open.Full entry Close delivery system is sized for one wire diameter, so check that they match.
• Material: stainless steel, or nitinol, a more flexible metal alloy.
• Tip: stiff and rigid, J-curved, or floppy and flexible to protect a delicate vessel wall; a stiff wire carries a large device such as a stent graftgraftGRAFTTissue or a man-made material moved into place in surgery to replace or repair a damaged part.Full entry Close.
• A smaller first stick: a micropuncture set starts with a 21-gauge needle and a thin 0.018-inch wire, then changes up to the 0.035-inch wire.

Keep every wire wet and free of clot and debris. Wipe it with a moist gauze sponge before and after each pass into the patient, and coil it back quickly and safely after each use; long wires slide off a field easily, and holders are made to keep them on it.

GuidewireOn 22 setups Micropuncture Access SetOn 3 setups

Sheaths and the French scale

Sheaths and catheters are sized on the French (Fr) scale: each French unit is about a third of a millimeter of diameter, so a 24 Fr sheath is about 8 mm across. Sheaths run from 4 to 24 Fr, chosen for the vessel and the devices that must pass. When a larger sheath is needed, a wire holds the access while the small sheath comes out and the larger one goes in over the same wire; dilatorsdilatorDY-lay-terAn instrument used to stretch or widen an opening, canal or passage in the body.Full entry Close are part of the setup. The sheath stays in until the end of the procedure.

Introducer SheathOn 11 setups Endovascular DilatorOn 4 setups

Balloons and the inflation device

An angioplasty balloon stretches a narrowed artery or vein open; a stent expansion balloon presses a stent firmly against the vessel wall. Balloons are inflated and held for several seconds to several minutes.

The inflation device fills the balloon to an exact pressure, measured in atmospheres (atm). You load it with 10 to 20 mL of the contrastcontrastKON-trastA dye or other substance given before an imaging test so body parts show up more clearly.Full entry Close solution, so the balloon shows on fluoroscopyfluoroscopyfloo-ROS-kuh-peeAn x-ray method that shows moving pictures of the inside of the body in real time.fluor/o glowing (from the fluorescent screen)-scopy looking, viewingFull entry Close, connect it to the balloon catheter, and clear every bit of air from the device, its tubing and the balloon: trapped air blurs the image and could become an air embolusembolismEM-buh-liz-umThe blocking of a blood vessel by a mass carried there in the blood (an embolus), such as a clot, fat or an air bubble.embol/o plug-ism conditionFull entry Close if the balloon burst.

Angioplasty BalloonOn 3 setups Balloon Inflation DeviceOn 1 setup

Stents and stent grafts

A stent is a tube of metal mesh that fits against the inside of a vessel and holds it open. In an artery it walls the plaqueplaquePLAKA deposit that builds up on a surface in the body, such as a sticky film of bacteria on teeth or a fatty buildup in an artery wall.Full entry Close off from the lumenlumenLOO-menThe open space inside a tube, such as a blood vessel, the intestine or a catheter.Full entry Close and lets blood flow freely without plateletsplateletPLAYT-litA tiny cell fragment in the blood that sticks together at a wound to help form a clot.Full entry Close clumping. Stents are made of stainless steel, titanium or nitinol, and they stay in for life.

• Balloon-expandable stent: the mesh is crimped onto a balloon, and inflating the balloon pushes it out against the wall.
• Self-expanding stent: it opens out against the wall by itself as it is deployed, with no balloon needed to expand it.
• Stent graft (covered stent): a metal frame covered with ePTFE or woven polyester. It lines a weakened artery from the inside, gives the blood a smooth path, and walls the aneurysmaneurysmAN-yuh-riz-umA weak spot in the wall of an artery that bulges outward like a balloon.aneurysm a widening (Greek)Full entry Close sac off from the circulation. It opens partly on its own, then a balloon presses it snug against the wall so it does not leak. Stent grafts come tubular or bifurcated, and self-expanding or balloon-expanded.

Every stent and stent graft is an implant. Confirm its exact type, length and diameter with the surgeon and the circulator before you open it, and make sure its lot and serial numbers reach the record, as chapter 29 teaches.

Peripheral Arterial StentOn 1 setup Endovascular Stent GraftOn 2 setups

Other endovascular tools

• Snare: a device passed into the vessel to catch and pull on a wire or a device inside it, such as the hook of a vena cavavena cavaVEE-nuh KAY-vuhOne of the two large veins that return oxygen-poor blood from the body to the right atrium of the heart.Full entry Close filter.
• Embolization: blocking a vessel from inside on purpose, with platinum or titanium coils, fast-setting glue or tiny plastic particles. It is used to shrink an abnormal tangle of vessels before surgery, and to close a side branch that keeps filling an aneurysm after an endovascular repair.
• Intravascular ultrasound: the IVUS probe rides into the vessel on a catheter to measure it from inside.
• Closure devices: at the end, an arterial puncture can be closed with a device instead of a stitch, such as one that pulls a purse-string suturesutureSOO-cherA stitch, or the thread used to stitch, that holds the edges of a wound or incision together.Full entry Close tight around the hole, or a collagencollagenKOL-uh-jenThe main structural protein of the body, which gives strength to skin, bones, tendons, ligaments and scar tissue.coll/a glue-gen producingFull entry Close plug; the Core Curriculum lists vascular closure devices and plugs.
• Atherectomy: newer devices shave or laser plaque out of the artery from inside.

11Angiography, angioplasty and angioscopy

Angiography in the OR

What and why: an angiogramangiographyan-jee-OG-ruh-feeAn imaging test that shows blood vessels by injecting a contrast dye and taking x-ray, CT or MRI pictures.angi/o vessel-graphy process of recordingFull entry Close injects contrastcontrastKON-trastA dye or other substance given before an imaging test so body parts show up more clearly.Full entry Close into a selected artery and its branches to show exactly where a vessel is narrowed, blocked or malformed. Done before surgery it maps the disease; done during surgery it guides an angioplasty or a stentstentstentA small tube, often of metal mesh, placed inside a vessel or duct to hold it open.Full entry Close, places a stent graftgraftGRAFTTissue or a man-made material moved into place in surgery to replace or repair a damaged part.Full entry Close, and checks a new bypass, looking above and below the repair for blockages or emboliembolismEM-buh-liz-umThe blocking of a blood vessel by a mass carried there in the blood (an embolus), such as a clot, fat or an air bubble.embol/o plug-ism conditionFull entry Close.

Setup: two or more 30 or 60 mL syringes, an arterial needle or angiocatheter, one or more IV extension tubes, a three-way stopcock, contrast as the surgeon orders, IV saline and heparinheparinHEP-uh-rinAn anticoagulant drug, given by injection or IV, that keeps blood clots from forming or growing.Full entry Close as ordered. Position, prep and drape depend on the vessel.

Steps:

1. The circulator passes you the contrast. Draw it into two syringes and fill a third with IV saline to flush the contrast out of the artery afterward. Label all three.
2. Connect the needle to the extension tubing and the tubing to the stopcock and the contrast syringe. Remove every air bubble, so no air goes into the artery; a hemostathemostatHEE-moe-statA clamp with finger rings and a locking ratchet used in surgery to grasp and close off bleeding vessels.hem/o blood-stat stopping, standing stillFull entry Close across the tubing keeps air from backing in, and the stopcock stays closed until the injection.
3. Move metal instruments out of the area to be imaged. The C-arm is draped just before it is needed and parked a little away from the field. Everyone in the room wears a lead apron, put on before scrubbing, as chapter 22 teaches.
4. The surgeon injects through a needle placed between the stitches of a closed arteriotomy, through a catheter tied into the vessel, or through the stopcock of a sheathsheathSHEETHA covering that wraps around a structure; in procedures, a short hollow tube left in a blood vessel to pass catheters through.Full entry Close already in place, and images are recorded during the injection.
5. The contrast is flushed out with saline, and injections are repeated as needed.

Wound class and after: a percutaneous angiogram enters no tract, so by the CDC's definitions it is Class I; done during an operation, it takes that operation's class. Afterward the puncture site is watched for bleeding and a hematomahematomahee-muh-TOH-muhA collection of blood, often clotted, that has leaked out of the blood vessels into the tissue.hem/o blood (here as hemat-)-oma swelling or massFull entry Close, and the patient for a reaction to the contrast, which can come late, as chapter 22 teaches.

Angioplasty and stenting

What and why: angioplasty opens a narrowed or blocked artery from inside, with a balloon. The balloon cracks the plaqueplaquePLAKA deposit that builds up on a surface in the body, such as a sticky film of bacteria on teeth or a fatty buildup in an artery wall.Full entry Close, and the artery heals with a new lining. A stent may follow to hold the artery open, especially when the balloon result is not good enough. Percutaneous transluminal angioplasty (PTA) is used routinely for narrowings and short blockages of the iliaciliacIL-ee-akHaving to do with the ilium, the large, wing-shaped upper part of the hip bone.Full entry Close arteries. Angioplasty works well at first, but the artery can narrow again (restenosis).

Diagnosis: detailed angiographic mapping locates the narrowing and measures it before the balloon is chosen; have the images in the room.

Anesthesiaanesthesiaan-us-THEE-zhuhLoss of feeling or sensation, often brought on by drugs so that surgery or a procedure can be done without pain.an- withoutesthesi/o feeling, sensation-ia conditionFull entry Close and position: local anestheticlocal anestheticLOH-kul an-es-THET-ikA drug that blocks feeling in one part of the body without making the person unconscious.Full entry Close with monitored sedationsedationsih-DAY-shunA calm, relaxed or sleepy state brought on by drugs, or the use of drugs to cause it.sed calm, settle-ation processFull entry Close, often as same-day surgery; supine, prepped from the groin to the knee.

Setup: an angioplasty tray with an arterial introducer needle and a sheath introducer; a guiding catheter, guidewires, the balloon catheter and stents; heparin and contrast; the C-arm and its drape.

Key steps:

1. Under fluoroscopyfluoroscopyfloo-ROS-kuh-peeAn x-ray method that shows moving pictures of the inside of the body in real time.fluor/o glowing (from the fluorescent screen)-scopy looking, viewingFull entry Close, a needle enters the femoral arteryfemoral arteryFEM-er-ul AR-ter-eeThe large artery that carries blood to the leg, running through the groin and down the thigh.Full entry Close, often with the flow (antegrade), the best approach for most narrowings in the legs; a guidewire goes in and a small sheath, 4 to 8 Fr, goes over it.
2. Contrast shows the narrowing, and its place is marked on the images. Be ready with heparin for the surgeon to give through the catheter.
3. The wire is passed through the narrowing, the most delicate part of the case.
4. The balloon goes over the wire to the narrowing and is inflated with the inflation device to a set pressure for a set time, watched on fluoroscopy.
5. A stent may be placed over the wire and expanded against the wall, and the final images are recorded.

Wound class and after surgery: Class I, clean. The complications include a hematoma at the puncture site, which may need surgical repair, a reaction to the contrast, a surgical site infection and a heart attackmyocardial infarctionmy-oh-KAR-dee-ul in-FARK-shunDeath of part of the heart muscle because its blood supply is blocked; a heart attack.my/o musclecardi/o heart-al having to do withinfarct area of dead tissueFull entry Close.

Carotidcarotidkuh-ROT-idHaving to do with the carotid arteries, the two large arteries on each side of the neck that carry blood to the head and brain.Full entry Close artery stenting is the endovascular alternative to carotid endarterectomy; one large database study found the two about equally safe overall, with slightly more strokes after stenting and slightly more heart attacks after endarterectomy.

Angioscopy

What and why: angioscopy looks inside a vessel with a thin, flexible fiberoptic scope, about 0.5 to 3.0 mm across, on a video camera and monitor. It lets the surgeon see the inside of the vessel, as when the valves of a vein are cut under direct view for an in situ bypass, or after a clot is pulled out. Its main challenge is clearing the blood, because even a little blood blurs the view, so the segment is flushed with pressurized irrigationirrigationeer-ih-GAY-shunWashing out a wound, body cavity, tube or eye with a steady flow of liquid.Full entry Close.

Setup: the angioscope (confirm its size with the surgeon, and pick one smaller than the vessel, so it does not rub the wall into spasmspasmSPAZ-umA sudden, involuntary tightening of a muscle or of the muscle in a hollow organ or tube.Full entry Close), a light cord, the video system, a vein irrigating catheter, and a 1,000 mL bag of Ringer's solutionRinger's solutionRING-erz suh-LOO-shunAn IV fluid of water with sodium, potassium and calcium salts at about the same concentration as blood.Full entry Close in a pressure cuff inflated to 200 to 300 mm Hg, or an irrigation pump; a DopplerDoppler ultrasoundDOP-ler UL-truh-soundAn ultrasound that uses sound waves to hear or show blood flowing through vessels or the fetal heartbeat.Full entry Close with a sterile probe.

Anesthesia and position: general anesthesiageneral anesthesiaJEN-er-ul an-es-THEE-zhuhDrug-induced loss of consciousness and feeling over the whole body, so a person feels nothing and is not aware during surgery.an- withoutesthesi/o feeling, sensation-ia conditionFull entry Close, supine. The prep depends on where the scope goes in, but it is still wide.

Key steps: the vessel is exposed through a cutdown and a segment is isolated between two vascular clamps. A small arteriotomy or venotomy is made with a #11 or #15 blade, the blood is flushed out, and the irrigating catheter is placed. The scope goes in down the center of the vessel, the far clamp comes off, and you may help advance the irrigating catheter beside the scope. At the end both come out, the vessel is closed, the last clamp is removed and flow is checked with the Doppler.

Wound class and complications: Class I. Complications include infection, vasospasm, injury to the intima from the scope or the force of the irrigation, and a loosened piece of plaque that travels as an embolus.

12Carotid endarterectomy

What and why: a carotidcarotidkuh-ROT-idHaving to do with the carotid arteries, the two large arteries on each side of the neck that carry blood to the head and brain.Full entry Close endarterectomy (CEAcarcinoembryonic antigenkar-sin-oh-em-bree-ON-ik AN-tih-jenA protein measured in the blood as a tumor marker, mainly to follow colorectal cancer.Full entry Close) removes atheroscleroticatherosclerosisath-er-oh-skluh-ROH-sisA buildup of fatty deposits (plaque) inside the walls of the arteries.ather/o fatty pastescler/o hard-osis conditionFull entry Close plaqueplaquePLAKA deposit that builds up on a surface in the body, such as a sticky film of bacteria on teeth or a fatty buildup in an artery wall.Full entry Close from the carotid artery, through an incision in the artery, at the bifurcation where the common carotid divides. It restores the flow of blood to the brain and lowers the risk that plaque or clot will break off and cause a stroke. Most patients go home the day after surgery.

Diagnosis: duplex ultrasound and arteriography show where the plaque is and how much it narrows the artery, and a CT scancomputed tomographykum-PYOO-tid toh-MOG-ruh-feeAn imaging test that uses x-rays and a computer to make cross-section pictures of the inside of the body.tom/o cut, slice-graphy process of recordingFull entry Close or MRImagnetic resonance imagingmag-NET-ik REZ-uh-nunts IM-uh-jingAn imaging test that uses a strong magnet and radio waves to make detailed pictures of the inside of the body.Full entry Close checks the brain for an earlier stroke. Have the patient's images in the room.

Anesthesiaanesthesiaan-us-THEE-zhuhLoss of feeling or sensation, often brought on by drugs so that surgery or a procedure can be done without pain.an- withoutesthesi/o feeling, sensation-ia conditionFull entry Close and watching the brain: general or regional anesthesia, such as a cervicalcervicalSER-vih-kulRelating to the neck, or to the cervix, the lower end of the uterus.cervic/o neck, cervix-al relating toFull entry Close plexusplexusPLEK-susA network of nerves or blood vessels that branch and join together.Full entry Close block. While the carotid is clamped, the brain must get its blood through the other arteries joined at its base (the circle of Willis, chapter 5), and in some patients that is not enough, so the team watches for signs of trouble:

• An awake patient under a regional block is asked to squeeze a hand or to speak.
• Under general anesthesiageneral anesthesiaJEN-er-ul an-es-THEE-zhuhDrug-induced loss of consciousness and feeling over the whole body, so a person feels nothing and is not aware during surgery.an- withoutesthesi/o feeling, sensation-ia conditionFull entry Close, an EEGelectroencephalogramih-lek-troh-en-SEF-uh-loh-gramA test that records the electrical activity of the brain through small sensors placed on the scalp.electr/o electricityencephal/o brain-gram recordFull entry Close shows the brain's electrical activity slowing.
• The back pressure in the carotid above the clamp (the stump pressure) can also guide the decision.

If the brain shows signs of too little blood flow, the surgeon places a temporary shuntshuntSHUNTA passage that moves blood or other fluid from one place to another, either made by a surgeon or present in the body.Full entry Close, a tube that carries blood around the open artery. Placing it takes extra dissectiondissectiondy-SEK-shunA tear in the inner layer of an artery wall that lets blood split the layers apart; also, the cutting apart of tissue in surgery.Full entry Close and can knock debris loose, so not every surgeon uses one, but a shunt must be ready at the start of every case. The time the clamps are on is kept as short as possible.

Position, prep and drape: supine, the head on a head support or donut, turned away from the operative side, with a small roll between the shoulder blades so the neck is slightly extended; the arms are at the sides. The prep runs from the ear and chin to below the collarbone on the operative side, and the draping is like a thyroidectomythyroidectomythy-roy-DEK-tuh-meeSurgery to remove all or part of the thyroid gland in the neck.thyr/o thyroid-ectomy surgical removalFull entry Close's. If a vein patch is likely, a leg is prepped and draped as well.

Setup: a vascular set with the surgeon's choice of right-angle vascular clamps, right-angle clamps, Freer and Penfield elevators, vessel loops, Rummel tourniquets, umbilical tapes, jaw covers, and topical hemostatic agentshemostatichee-moh-STAT-ikStopping bleeding; also, a product or agent used to stop bleeding.hem/o blood-stasis stopping, standing still-ic relating toFull entry Close. On hold: a carotid shunt and the clamps that hold it, such as the Javid clamp, contrastcontrastKON-trastA dye or other substance given before an imaging test so body parts show up more clearly.Full entry Close and the C-arm, and the DopplerDoppler ultrasoundDOP-ler UL-truh-soundAn ultrasound that uses sound waves to hear or show blood flowing through vessels or the fetal heartbeat.Full entry Close. Small bulldog clamps close side branches, such as the superior thyroid artery off the external carotid. For irrigationirrigationeer-ih-GAY-shunWashing out a wound, body cavity, tube or eye with a steady flow of liquid.Full entry Close inside the artery, a 20 mL syringe with a heparinheparinHEP-uh-rinAn anticoagulant drug, given by injection or IV, that keeps blood clots from forming or growing.Full entry Close needle or an angiocatheter cannulacannulaKAN-yoo-luhA thin tube placed into the body or a body opening to deliver or remove fluid or air.Full entry Close. Retractorsretractorrih-TRAK-terA surgical instrument that holds back tissue or organs so the surgeon can see and reach the operative site.Full entry Close include a blunt Weitlaner, blunt rakes and Army-Navy retractors.

Gregory Carotid Bulldog Clamp Javid Carotid Artery ClampOn 1 setup

Medications: systemicsystemicsis-TEM-ikAffecting the whole body rather than one part.Full entry Close heparin; heparinized saline for irrigation; 1% lidocainelidocaineLY-doh-kaynA local anesthetic that numbs an area, also given by IV to treat some fast, abnormal heart rhythms.Full entry Close, which the surgeon may inject around the carotid sinussinusSY-nusA hollow space in the body, most often one of the air-filled spaces in the skull bones around the nose.Full entry Close to prevent the slow heart rate and low blood pressure that handling it can cause (chapter 5 explains the reflexreflexREE-fleksAn automatic body response to something that stimulates it, which happens without thought, such as the knee jerk.Full entry Close); topical hemostatic agents.

Key steps:

1. The incision runs along the front border of the sternocleidomastoid muscle, and a Weitlaner holds it open.
2. The surgeon dissectsdissectdy-SEKT, or dih-SEKTTo cut apart or separate tissues carefully during surgery.Full entry Close with vascular forcepsforcepsFOR-sepsA hand instrument with two blades or arms used to grasp, hold or pull tissue or objects.Full entry Close, the ESUelectrosurgeryee-LEK-troh-SUR-jer-eeUsing high-frequency electric current through a handheld tool to cut tissue or seal bleeding vessels during surgery.Full entry Close, Metzenbaum scissors and sponge dissectors down to the carotid arteries, moving the internal jugular veininternal jugular veinin-TUR-nul JUG-yuh-ler vaynA large vein deep on each side of the neck that carries blood from the brain, face and neck back toward the heart.Full entry Close aside.
3. Vessel loops go around the common, internal and external carotid arteries, their ends clamped with small hemostatshemostatHEE-moe-statA clamp with finger rings and a locking ratchet used in surgery to grasp and close off bleeding vessels.hem/o blood-stat stopping, standing stillFull entry Close; the bifurcation itself is not fully freed.
4. Heparin is given. Have ready a #11 blade, Potts and De Martel scissors, Penfield and Freer elevators, straight hemostats and an atraumatic suction tip.
5. The three arteries are clamped, and the surgeon tells the anesthesia provideranesthesia provideran-us-THEE-zhuh pruh-VY-derThe licensed professional who gives anesthesia and watches over the client's breathing and vital functions during a procedure.Full entry Close and the circulator. The clamp time is recorded and the EEG watched. The order of clamping varies with the surgeon and the reference.
6. The arteriotomy starts in the common carotid and is extended up into the internal carotid with Potts scissors. The plaque shows as a thick, yellow, rubbery layer stuck to the lining.
7. If a shunt is used, it goes in now, one end in the common carotid and one in the internal carotid, held by a shunt clamp or by vessel loops; flush it with heparinized saline before you pass it.
8. The surgeon lifts the plaque away with an elevator, finishes it cleanly in the internal carotid, and flushes the artery with heparinized saline to wash away loose strands. Keep a small basin ready for the plaque.
9. The arteriotomy is closed with 6-0 or 7-0 polypropylene, directly or with a patch of PTFE, polyester or vein.
10. Just before the closure is finished, any shunt comes out, and each clamp is opened briefly so blood flushes out air and debris.
11. The clamps come off the external carotid first, then the common carotid, and the internal carotid last, so any debris or air still loose is carried up the external carotid to the face instead of to the brain. One reference releases the common carotid first; all agree the internal carotid is released last. The time flow returns is noted.
12. The surgeon checks for leaks and the flow with the Doppler, places a drain through a separate stab wound, and closes the wound.

Specimen: the plaque.

Counts: initial and closing, with the vessel loops and tapes included.

Dressing: gauze, or a clear film the patient can shower with.

Wound class: I, clean.

After surgery: the patient is watched closely for any new neurologic deficit, bleeding and breathing problems. Stroke is one of the most feared complications. Injury to a cranial nervecranial nerveKRAY-nee-ul NERVOne of the 12 pairs of nerves that come straight from the brain and brainstem rather than the spinal cord.Full entry Close is the most common, most often the hypoglossal nerve, which makes the tongue point to the operated side, and most of these injuries recover. Bleeding, infection and too much blood flow to the brain once the artery is open (hyperperfusion) can also occur. Patients are taught that numbness around the incision is normal, and to report any new TIAtransient ischemic attackTRAN-zee-unt is-KEE-mik uh-TAKA short-lived blockage of blood flow to part of the brain that clears on its own and leaves no lasting brain damage.transient passingisch hold back-emic relating to the bloodFull entry Close symptoms, confusion or trouble speaking.

13Open abdominal aortic aneurysm repair

What and why: the open repair replaces the aneurysmaneurysmAN-yuh-riz-umA weak spot in the wall of an artery that bulges outward like a balloon.aneurysm a widening (Greek)Full entry Close with a graftgraftGRAFTTissue or a man-made material moved into place in surgery to replace or repair a damaged part.Full entry Close, a straight tube from aorta to aorta or a bifurcated graft from the aorta to both iliaciliacIL-ee-akHaving to do with the ilium, the large, wing-shaped upper part of the hip bone.Full entry Close arteries, which restores the flow to the legs and pelvis. It can be planned (elective) or an emergency. The sac is not removed: it is opened, emptied, and closed again around the graft.

Diagnosis: ultrasound and CT angiographyCTAsee-tee-ay (said as letters)Computed tomography angiography: a CT scan with IV contrast dye that shows blood vessels in detail.Full entry Close measure the aneurysm, and the heart is checked carefully first, because heart disease is common in these patients.

Anesthesiaanesthesiaan-us-THEE-zhuhLoss of feeling or sensation, often brought on by drugs so that surgery or a procedure can be done without pain.an- withoutesthesi/o feeling, sensation-ia conditionFull entry Close and position: general anesthesiageneral anesthesiaJEN-er-ul an-es-THEE-zhuhDrug-induced loss of consciousness and feeling over the whole body, so a person feels nothing and is not aware during surgery.an- withoutesthesi/o feeling, sensation-ia conditionFull entry Close, with a central venous linecentral venous catheterSEN-trul VEE-nus KATH-uh-terAn IV catheter whose tip sits in a large vein near the heart, used for long-term drugs, fluids, nutrition or blood draws.Full entry Close and an arterial linearterial linear-TEER-ee-ul lineA thin catheter placed in an artery, often in the wrist, to measure blood pressure all the time and draw blood.Full entry Close; supine. The pedal pulses are marked, and a urinary catheter goes in before the prep.

Prep and drape: from the nipple line to mid-thigh, draped for a laparotomylaparotomylap-uh-ROT-uh-meeSurgery that opens the abdomen through a large cut to reach the organs inside.lapar/o abdomen-tomy cutting intoFull entry Close that leaves the groins open in case the femoral arteriesfemoral arteryFEM-er-ul AR-ter-eeThe large artery that carries blood to the leg, running through the groin and down the thigh.Full entry Close are needed.

Setup: a major laparotomy set with long instruments, Deaver retractorsretractorrih-TRAK-terA surgical instrument that holds back tissue or organs so the surgeon can see and reach the operative site.Full entry Close, a self-retaining retractor that mounts on the table (a Bookwalter or an Omni-Tract), a major vascular set, vessel loops, umbilical tapes, jaw covers, a long Penrose drain for retractionretractionrih-TRAK-shunA drawing back or pulling in of tissue; in breathing, the skin sinking in between, below or above the ribs with each breath.Full entry Close, the graft, IV saline and heparinheparinHEP-uh-rinAn anticoagulant drug, given by injection or IV, that keeps blood clots from forming or growing.Full entry Close, topical thrombinthrombinTHROM-binAn enzyme in the blood that turns fibrinogen into fibrin, the threads that hold a blood clot together.thromb/o clot-in substanceFull entry Close and other hemostatic agentshemostatichee-moh-STAT-ikStopping bleeding; also, a product or agent used to stop bleeding.hem/o blood-stasis stopping, standing still-ic relating toFull entry Close, and a cell saver. Have extra aortic clamps, suction and mounted suturessutureSOO-cherA stitch, or the thread used to stitch, that holds the edges of a wound or incision together.Full entry Close ready, and a basin to collect the clot and plaqueplaquePLAKA deposit that builds up on a surface in the body, such as a sticky film of bacteria on teeth or a fatty buildup in an artery wall.Full entry Close.

Medications: systemicsystemicsis-TEM-ikAffecting the whole body rather than one part.Full entry Close heparin before the clamps, heparinized saline, topical thrombin and other hemostatic agents, and protamineprotaminePROH-tuh-meenAn IV drug that binds heparin and reverses its blood-thinning effect.Full entry Close at the end if the heparin must be reversed.

DeBakey Aortic Aneurysm ClampOn 6 setups

Key steps:

1. A long midlinemidlineMID-lineAn imaginary line down the center of the body; also, a type of IV catheter placed in a vein of the upper arm.Full entry Close incision from the xiphoid to the pubispubisPYOO-bisThe front part of each hip bone, low in the pelvis; the two meet in the middle at the pubic symphysis.pub/o pubisFull entry Close. A self-retaining retractor goes in, and the small bowel is moved to the right, in moist laps or a bowel bag.
2. The tissue behind the peritoneumperitoneumpair-ih-toh-NEE-umThe thin membrane that lines the belly cavity and covers most of the organs inside it.peri- aroundton stretched-eum a structureFull entry Close (the retroperitoneum) over the aneurysm is opened with long Metzenbaum scissors and the ESUelectrosurgeryee-LEK-troh-SUR-jer-eeUsing high-frequency electric current through a handheld tool to cut tissue or seal bleeding vessels during surgery.Full entry Close; a long ESU tip may be needed.
3. The aorta is freed above the aneurysm (its neck), avoiding the renal arteries and the uretersureterYOOR-uh-terOne of the two tubes that carry urine from the kidneys down to the bladder.Full entry Close, and the iliac arteries below it, mainly by blunt dissectiondissectiondy-SEK-shunA tear in the inner layer of an artery wall that lets blood split the layers apart; also, the cutting apart of tissue in surgery.Full entry Close; the surgeon checks the iliacs for aneurysms, clot and calcium. Have sponge sticks and small sponge dissectors ready. An injured vena cavavena cavaVEE-nuh KAY-vuhOne of the two large veins that return oxygen-poor blood from the body to the right atrium of the heart.Full entry Close is repaired at once with 4-0 or 5-0 vascular suture.
4. Heparin is given. The iliac arteries are clamped with angled vascular clamps, and the aorta is cross-clamped above the aneurysm with the surgeon's choice of aortic clamp.
5. The aneurysm is opened lengthwise with the ESU or a blade, with short cuts across each end. Clot and plaque come out piece by piece into your basin, and the lumbarlumbarLUM-barHaving to do with the lower back, the part of the spine between the ribs and the pelvis.Full entry Close arteries that bleed back into the sac from behind are oversewn with polypropylene. The sac itself is left in place.
6. Pass the graft the surgeon names in a basin with straight Mayo scissors to trim it; a polyester graft coated with collagencollagenKOL-uh-jenThe main structural protein of the body, which gives strength to skin, bones, tendons, ligaments and scar tissue.coll/a glue-gen producingFull entry Close, albuminalbuminal-BYOO-minThe main protein in blood plasma, made by the liver, which holds fluid inside the blood vessels and carries drugs and hormones.Full entry Close or gelatin may be used. The upper (proximalproximalPROK-sih-mulNearer the center of the body, or nearer the place where a part is attached.Full entry Close) end is sewn to the aorta with a double-armed 3-0 polypropylene suture, sometimes reinforcedreinforceree-in-FORSTo repeat and support teaching or care that has already been started, so the client remembers and follows it.Full entry Close with a strip of felt.
7. The vessels below are opened to check that they bleed back, and flushed with heparinized saline. The lower end, or each limb of a bifurcated graft, is sewn on with a smaller suture.
8. When the first side is done, blood is let into that limb while the other limb stays clamped; then the second side is finished.
9. The suture lines are tested with saline or by easing the clamps; leaks get figure-of-eight stitches, pledgets or a hemostatic agent. The pedal pulses are checked with the DopplerDoppler ultrasoundDOP-ler UL-truh-soundAn ultrasound that uses sound waves to hear or show blood flowing through vessels or the fetal heartbeat.Full entry Close.
10. The aneurysm wall is closed over the graft with running polypropylene, and the retroperitoneum is closed over it. The abdomen is closed, and the skin is stapled.

Ruptured aneurysm: the first goal is to stop the bleeding by blocking the aorta above the rupture, by a clamp or by a balloon passed up from the groin. A ruptured aneurysm may also be repaired from inside, and the room is made ready for either repair.

Counts: as for any laparotomy, chapter 28's rules, with the vessel loops and tapes counted.

Wound class: I, clean.

After surgery: the patient goes to the PACU, the ICU or a cardiac unit, where the heart, lungs and kidneys are watched, and the legs are checked every hour. The risks are heavy bleeding, low blood pressure, injury to a ureter, kidney failurerenal failureREE-nul FAYL-yerLoss of the kidneys' ability to filter waste and extra fluid from the blood.ren kidney-al relating toFull entry Close, a spinal cord that loses its blood supply, and death. A graft infection is rare but very serious. Patients with a graft may need antibiotics before future dental or endoscopicendoscopicen-doh-SKOP-ikDone with an endoscope, a thin tube with a light and camera passed into the body.endo- within-scopic viewingFull entry Close procedures.

14Endovascular abdominal aortic aneurysm repair (EVAR)

This is the Core Curriculum's model case for vascular surgery, so it is taught here from start to finish. In an EVAR the surgeon reaches the aneurysmaneurysmAN-yuh-riz-umA weak spot in the wall of an artery that bulges outward like a balloon.aneurysm a widening (Greek)Full entry Close from the femoral arteriesfemoral arteryFEM-er-ul AR-ter-eeThe large artery that carries blood to the leg, running through the groin and down the thigh.Full entry Close and lines it from inside with a stentstentstentA small tube, often of metal mesh, placed inside a vessel or duct to hold it open.Full entry Close graftgraftGRAFTTissue or a man-made material moved into place in surgery to replace or repair a damaged part.Full entry Close. The graft is held to the healthy aorta below the renal arteries and to the iliaciliacIL-ee-akHaving to do with the ilium, the large, wing-shaped upper part of the hip bone.Full entry Close arteries by self-expanding or balloon-expanded stents with hooks, not by suturessutureSOO-cherA stitch, or the thread used to stitch, that holds the edges of a wound or incision together.Full entry Close, so blood flows through the graft and the aneurysm sac is shut out of the circulation. No large abdominal incision is made, so the hospital stay is short, often 1 to 2 days, recovery is quick, and death and complications are fewer than after the open repair. It can also be used for a patient at high risk from open surgery.

Pathophysiology

The Core Curriculum's outline for the case reviews what you met earlier in this chapter:

• The aneurysm: caused by arteriosclerosisarteriosclerosisar-teer-ee-oh-skluh-ROH-sisThickening and stiffening of the walls of the arteries, so they lose their ability to stretch.arteri/o arteryscler/o hard-osis conditionFull entry Close, atherosclerosisatherosclerosisath-er-oh-skluh-ROH-sisA buildup of fatty deposits (plaque) inside the walls of the arteries.ather/o fatty pastescler/o hard-osis conditionFull entry Close, a defect present from birth, infection, inflammation or trauma; it lies between the renal arteries and the aortic bifurcation; it is fusiform or saccular in shape; and it is a true aneurysm or a dissecting one.
• Atherosclerosis: atheroma and plaqueplaquePLAKA deposit that builds up on a surface in the body, such as a sticky film of bacteria on teeth or a fatty buildup in an artery wall.Full entry Close in the wall, and thrombithrombosisthrom-BOH-sisThe forming of a blood clot (a thrombus) inside a blood vessel or the heart.thromb/o clot-osis conditionFull entry Close, the clot that lines the sac.
• Turbulent blood flow in the widened sac.
• Other disease the patient brings: coronary artery diseasecoronary artery diseaseKOR-uh-nair-ee AR-tuh-ree dih-ZEEZNarrowing of the arteries that supply blood to the heart muscle, most often from fatty plaque buildup.Full entry Close, high cholesterol, high blood pressure and smoking.

Diagnosis

A DopplerDoppler ultrasoundDOP-ler UL-truh-soundAn ultrasound that uses sound waves to hear or show blood flowing through vessels or the fetal heartbeat.Full entry Close exam, then imaging: angiographyangiographyan-jee-OG-ruh-feeAn imaging test that shows blood vessels by injecting a contrast dye and taking x-ray, CT or MRI pictures.angi/o vessel-graphy process of recordingFull entry Close, an aortogram (an angiogram of the aorta), arteriography, CT scancomputed tomographykum-PYOO-tid toh-MOG-ruh-feeAn imaging test that uses x-rays and a computer to make cross-section pictures of the inside of the body.tom/o cut, slice-graphy process of recordingFull entry Close and CT angiographyCTAsee-tee-ay (said as letters)Computed tomography angiography: a CT scan with IV contrast dye that shows blood vessels in detail.Full entry Close, fluoroscopyfluoroscopyfloo-ROS-kuh-peeAn x-ray method that shows moving pictures of the inside of the body in real time.fluor/o glowing (from the fluorescent screen)-scopy looking, viewingFull entry Close, MRImagnetic resonance imagingmag-NET-ik REZ-uh-nunts IM-uh-jingAn imaging test that uses a strong magnet and radio waves to make detailed pictures of the inside of the body.Full entry Close and ultrasound. The images decide whether an EVAR is possible. The graft needs healthy, undiseased aorta and iliac artery to seal against at each end, called the landing zones: a neck of at least 1 to 2 cm below the renal arteries, iliac arteries for the lower end, and femoralfemoralFEM-er-ulRelating to the thigh or the femur, the thigh bone.Full entry Close and iliac arteries wide and straight enough for the large delivery system to pass. The size and the place of the aneurysm can rule an EVAR out. So can the need for imaging for the rest of the patient's life.

Preparing the patient

• Anesthesiaanesthesiaan-us-THEE-zhuhLoss of feeling or sensation, often brought on by drugs so that surgery or a procedure can be done without pain.an- withoutesthesi/o feeling, sensation-ia conditionFull entry Close: epiduralepidural anesthesiaep-ih-DOOR-ul an-us-THEE-zhuhPain relief or numbness from an anesthetic drug given through a thin catheter into the space just outside the covering of the spinal cord.epi- upon, overdur/o dura (the tough covering of the spinal cord)-al relating toFull entry Close, general or spinal. If an epidural is used, mechanical ventilationmechanical ventilationmeh-KAN-ih-kul ven-tuh-LAY-shunBreathing support from a machine, a ventilator, that pushes air into the lungs through a tube or a mask.Full entry Close must be ready in case the case converts to an open repair.
• Position: supine, on a radiolucent bed, so the whole aorta and both groins can be imaged.
• Monitoring: the depth of anesthesia (BIS) and exhaled carbon dioxidecarbon dioxideKAR-bun dy-OK-sideA gas made by the body's cells as waste, carried in the blood to the lungs and breathed out.Full entry Close (capnography) under general anesthesiageneral anesthesiaJEN-er-ul an-es-THEE-zhuhDrug-induced loss of consciousness and feeling over the whole body, so a person feels nothing and is not aware during surgery.an- withoutesthesi/o feeling, sensation-ia conditionFull entry Close; a Doppler probe for the pulses; DVTdeep vein thrombosisDEEP VAYN throm-BOH-sisA blood clot in a deep vein, most often in the leg or pelvis.thromb/o clot-osis conditionFull entry Close prophylaxisprophylaxisproh-fuh-LAK-sisTreatment given to prevent a disease or problem, rather than to treat one that is already present.pro- beforephylax guardFull entry Close; and the hemodynamichemodynamicshee-moh-dy-NAM-iksThe study and measurement of blood flow and the pressures that move blood through the heart and vessels.hem/o blooddynam power, force-ics study ofFull entry Close signs: blood pressure, heart rate, oxygen saturationsaturationsach-uh-RAY-shunHow full something is; in nursing, usually the percentage of hemoglobin in the blood that is carrying oxygen.Full entry Close, breathing rate, temperature and urine output. A central venous linecentral venous catheterSEN-trul VEE-nus KATH-uh-terAn IV catheter whose tip sits in a large vein near the heart, used for long-term drugs, fluids, nutrition or blood draws.Full entry Close and an arterial linearterial linear-TEER-ee-ul lineA thin catheter placed in an artery, often in the wrist, to measure blood pressure all the time and draw blood.Full entry Close go in, and the circulator places a urinary catheter.
• Skin prep: the abdomen, and the legs all the way around.
• Draping: a sheet below the legs, the genitals isolated, folded towels to square off the groins, incise drapes, and fenestrated or plain sheets, draped so the case can become an open repair at once.
• Verification: the time out. Blood ordered from the blood bank is confirmed before the procedure begins.

The room, instruments and supplies

EVAR is done in a hybrid OR, which gives the team fixed and rotating angiography and fluoroscopy beside a full surgical setup. Chapter 22 teaches the hybrid room and radiationradiationray-dee-AY-shunEnergy that travels as waves or particles, such as X-rays, used to make images or treat cancer; also pain that spreads from its starting point.radi/o rays, radiation-ation processFull entry Close safety.

Equipment: extra tables (a back table, a Mayo standMayo standMAY-oh standA small tray on an adjustable stand placed over or beside the patient during surgery to hold the instruments used most often.Full entry Close and a ring stand); a cell salvage system; the Doppler; an ESUelectrosurgeryee-LEK-troh-SUR-jer-eeUsing high-frequency electric current through a handheld tool to cut tissue or seal bleeding vessels during surgery.Full entry Close; fluoroscopy, with its control room and imaging monitors; a headlight; lead aprons or shields; positioning aids (armboards and safety straps); and suction.

Instruments: assorted vascular clamps and a minor vascular tray, with a major vascular tray and a self-retaining abdominal retractorretractorrih-TRAK-terA surgical instrument that holds back tissue or organs so the surgeon can see and reach the operative site.Full entry Close on hold.

Basic supplies: a back table or custom pack, a basin set, #10 blades, an ESU pencil with its holder and tips, light handle covers, suction tubing, drapes, gowns, gloves and sponges.

Specialty supplies:

• Arteriogram supplies: an angiocatheter, an arterial (butterfly) needle, IV extension tubing, syringes and three-way stopcocks
• Balloons: angioplasty balloons with their inflation device (the Core Curriculum calls it an insufflationinsufflationin-suh-FLAY-shunBlowing a gas into a body cavity, such as carbon dioxide into the abdomen during laparoscopic surgery.Full entry Close device), and stent expansion balloons
• Catheters: balloon, directional, exchange, pigtail and sizing
• Guidewires: exchange, introducing, steerable and non-steerable, with flexible, J-curved, rigid or stiff tips
• Needles: a Seldinger needle and an 18-gauge spinal needle
• SheathssheathSHEETHA covering that wraps around a structure; in procedures, a short hollow tube left in a blood vessel to pass catheters through.Full entry Close, each with its introducer (dilatordilatorDY-lay-terAn instrument used to stretch or widen an opening, canal or passage in the body.Full entry Close), port and stopcock
• The stent graft, tubular or bifurcated, balloon-expanded or self-expanding
• A snare, hemoclips, a Rummel tourniquet, vessel loops and suture boots
• Pressure bags with high-pressure tubing, and cell salvage suction tubing
• Frazier and Yankauer suction tips, 30 and 60 mL syringes, and vascular closure devices or plugs
• Sutures for hemostasishemostasishee-moh-STAY-sisThe stopping of bleeding, either by the body's own clotting process or by medical or surgical methods.hem/o blood-stasis stopping, standing stillFull entry Close, the femoral arteries, the fasciafasciaFASH-ee-uhA sheet or band of tough connective tissue that covers and separates muscles and organs.fasci/o bandFull entry Close, the subcutaneoussubcutaneoussub-kyoo-TAY-nee-usUnder the skin; in the fatty layer between the skin and the muscle.sub- undercutane/o skin-ous relating toFull entry Close layer and the skin

Hybrid OR Angiography SystemOn 1 setup

Most stent grafts are modular: the main body comes separate from the limbs that make the two legs of the Y. Each part comes loaded in its own delivery system, and the controls at its handle release and open it in steps. Exactly how depends on the maker, so the maker's instructions for that system are followed, but the patient's preparation is the same for all of them.

Medications: contrastcontrastKON-trastA dye or other substance given before an imaging test so body parts show up more clearly.Full entry Close; heparinheparinHEP-uh-rinAn anticoagulant drug, given by injection or IV, that keeps blood clots from forming or growing.Full entry Close; injectable saline; irrigationirrigationeer-ih-GAY-shunWashing out a wound, body cavity, tube or eye with a steady flow of liquid.Full entry Close fluid; papaverine; topical hemostatic agentshemostatichee-moh-STAT-ikStopping bleeding; also, a product or agent used to stop bleeding.hem/o blood-stasis stopping, standing still-ic relating toFull entry Close. Label each one, and keep a running total of the contrast and heparin.

The operation

The Core Curriculum's incisions are oblique groin incisions on both sides, from the inguinalinguinalING-gwih-nulRelating to the groin, the fold where the thigh meets the lower abdomen.Full entry Close ligament to below the femoral bifurcation; the right femoral artery is opened (an arteriotomy) and the left is punctured with an introducer, and a vessel may be entered against the flow (retrograde) or with it (antegrade). Access through the skin, closed with suture closure devices, is growing; because about 5 to 10 percent of closures of larger arteriotomies fail, a surgical cutdown to close the artery must be ready at once.

1. Bilateral oblique groin incisions are made at the inguinal ligament, extending to below the femoral bifurcation, with a knife and toothed tissue forcepsforcepsFOR-sepsA hand instrument with two blades or arms used to grasp, hold or pull tissue or objects.Full entry Close.
2. A Halsted mosquito or a Kelly or Crile clamp spreads the tissue bluntly down to the femoral arteries, and Weitlaner retractors are placed.
3. The common, superficial and deep femoral arteries are freed and controlled with vessel loops, a Rummel tourniquet and mosquito clamps.
4. The anesthesia provideranesthesia provideran-us-THEE-zhuh pruh-VY-derThe licensed professional who gives anesthesia and watches over the client's breathing and vital functions during a procedure.Full entry Close gives heparin.
5. A DeBakey or similar vascular clamp goes across the right femoral artery.
6. An arteriotomy is made in the right femoral artery with a #11 blade and lengthened with Potts-Smith scissors.
7. You flush the sheath with heparinized saline. It goes into the right femoral artery and is advanced up into the right external iliac artery.
8. On the left, the surgeon punctures the femoral artery with an introducer needle and advances a second sheath up into the left external iliac artery.
9. An angiocatheter goes in and an arteriogram is taken, marking the renal arteries and the aortic bifurcation on the screen.
10. A sizing catheter measures the aorta so the right size and length of graft can be chosen. Confirm the graft with the surgeon before you open it.
11. The graft, on its delivery system, goes into the right femoral artery over a stiff guidewire and is positioned just below the renal arteries under fluoroscopy.
12. A measuring catheter checks the position of the graft segment.
13. A stent expansion balloon is passed up to the graft and inflated with the inflation device, to secure the graft's attachmentattachmentuh-TACH-mentThe deep emotional bond between an infant and a parent or caregiver.Full entry Close.
14. The limbs of the graft are positioned in the iliac arteries. The main body has a short limb with an opening on the far side; a second guidewire is passed up into it from the other groin, and the separate limb is slid in and opened so it overlaps snugly inside the main body.
15. The graft is fully deployed, and its hooks grip the aortic and iliac walls.
16. The stent expansion balloon is inflated again to press each attachment snug; for a stent graft this is a large, soft (compliant) molding balloon, pressed at each seal and where the parts overlap.
17. A completion arteriogram confirms the position and that no blood still reaches the sac, and IV saline is injected to flush out the contrast. The graft is ideally placed so it covers the inferior mesenteric artery, which then cannot keep filling the sac, while the flow to the internal iliac arteries is kept.
18. The guidewires, catheters and sheaths come out, and the arteries are irrigated with heparinized saline.
19. Each femoral arteriotomy or puncture is closed, with a double-armed nonabsorbable suture loaded on a Castroviejo needle holder, or with a collagencollagenKOL-uh-jenThe main structural protein of the body, which gives strength to skin, bones, tendons, ligaments and scar tissue.coll/a glue-gen producingFull entry Close plug or another vascular closure device.
20. The fascia is closed with a continuous absorbable suture of the surgeon's choice.
21. The subcutaneous layer may be closed with a continuous absorbable suture.
22. The skin gets a subcuticular absorbable stitch or staples.

Aortic Molding BalloonOn 2 setups

Ruptured aneurysm: when an aneurysm has burst, an aortic occlusionocclusionuh-KLOO-zhunA blockage or closing off of a passage, such as a blood vessel, tube or IV line.Full entry Close balloon may be passed up from the groin on a sheath pushed fully up into the aortic neck, and gently inflated to block the aorta above the aneurysm, holding back the bleeding while the stent graft is readied.

Dressings: nonadherent pads, 4x4 gauze and clear film over the groins.

Counts: initial, at fascia closure and at skin closure.

Wound class: I, clean.

After surgery

The patient goes to PACU, or to the ICU. The outlook is guarded when complications occur; otherwise medicines continue, the patient returns to normal activities, and illness and death are lower than after an open repair. The pulses in the legs are checked often in the first hours, and the patient is watched for belly or back pain and for the feeling and movement of the legs. Many walk within hours and go home on the second day. Imaging follows for life, because a stent graft can later leak or move, and some need another procedure.

The Core Curriculum lists the complications: death; an endoleak, and enlargement of the aneurysm sac; migration (movement) or occlusion of the graft; hemorrhagehemorrhageHEM-uh-rijA large loss of blood from a blood vessel, inside the body or out of it.hem/o blood-rrhage bursting forthFull entry Close; infection of the graft, and surgical site infection; thrombosis of a limb of the graft, and other thrombus formation; pelvic ischemiaischemiais-KEE-mee-uhToo little blood flow to a part of the body, so the tissue does not get enough oxygen.isch- hold back-emia blood conditionFull entry Close; a pseudoaneurysm; and rupture.

An endoleak is blood still flowing into the aneurysm sac after the stent graft is placed. There are five types:

• Type I: blood leaks around the end of the graft, at the top (IA) or the bottom (IB) seal. It carries a high risk of rupture and is fixed at once, often by extending the graft or adding a bare stent at the neck.
• Type II: a side branch, such as the inferior mesenteric or a lumbarlumbarLUM-barHaving to do with the lower back, the part of the spine between the ribs and the pelvis.Full entry Close artery, keeps filling the sac backward. Its risk of rupture is small, and many close on their own within 6 to 12 months; it is treated, with coils or glue, only if the sac keeps growing.

The other three are a hole in the graft fabric or a gap where two parts overlap (Type III), blood seeping through porous fabric, seen as a faint blush on the final angiogram (Type IV), and a sac that keeps growing with no leak that can be seen (Type V, endotension).

If the bleeding cannot be stopped from inside, the graft cannot be placed, or the repair fails, the case converts to an open repair, and the team must be ready for it from the first minute.

15Bypass operations

A bypass carries blood around a blocked artery, through a graftgraftGRAFTTissue or a man-made material moved into place in surgery to replace or repair a damaged part.Full entry Close sewn to healthy artery above the blockage (the inflow) and below it (the outflowoutflowOWT-flohThe flow of a fluid out of an organ, space or vessel.Full entry Close). The steps are the same ones you learned for opening and joining vessels: exposure, control, heparinheparinHEP-uh-rinAn anticoagulant drug, given by injection or IV, that keeps blood clots from forming or growing.Full entry Close, clamps, arteriotomy, anastomosisanastomosisuh-nas-tuh-MOH-sisA connection between two tube-shaped structures, such as two ends of bowel or two blood vessels, made by surgery or found naturally.Full entry Close, flushing and a flow check. What changes from case to case is where the graft runs and what it is made of.

Aortofemoral (aortobifemoral) bypass

What and why: the iliaciliacIL-ee-akHaving to do with the ilium, the large, wing-shaped upper part of the hip bone.Full entry Close arteries are a common site of atherosclerosisatherosclerosisath-er-oh-skluh-ROH-sisA buildup of fatty deposits (plaque) inside the walls of the arteries.ather/o fatty pastescler/o hard-osis conditionFull entry Close. An aortobifemoral bypass treats blockage of the aorta and iliac arteries (aortoiliac occlusiveocclusiveuh-KLOO-sivClosing something off, or sealed so that air and water cannot pass through.Full entry Close disease) with a bifurcated graft from the aorta to both femoral arteriesfemoral arteryFEM-er-ul AR-ter-eeThe large artery that carries blood to the leg, running through the groin and down the thigh.Full entry Close, passing over the iliacs. It stays open better than an endarterectomy or an aortoiliac bypass, and it works even when the arteries are heavily calcified.

Diagnosis: arteriography or CT angiographyCTAsee-tee-ay (said as letters)Computed tomography angiography: a CT scan with IV contrast dye that shows blood vessels in detail.Full entry Close shows where the aorta and iliac arteries are blocked and which arteries below are open.

Position, prep and drape: supine; a urinary catheter before the prep. The prep runs from the chest to the mid-thighs or below, both legs are draped all the way around, and the genitals are covered with a towel and a barrier drape. Confirm that blood has been ordered and is available, and have the patient's imaging in the room.

Setup: a major laparotomylaparotomylap-uh-ROT-uh-meeSurgery that opens the abdomen through a large cut to reach the organs inside.lapar/o abdomen-tomy cutting intoFull entry Close set, a major vascular set, vessel loops, umbilical tapes, jaw covers, vessel clips, pledgets, topical hemostatic agentshemostatichee-moh-STAT-ikStopping bleeding; also, a product or agent used to stop bleeding.hem/o blood-stasis stopping, standing still-ic relating toFull entry Close and thrombinthrombinTHROM-binAn enzyme in the blood that turns fibrinogen into fibrin, the threads that hold a blood clot together.thromb/o clot-in substanceFull entry Close, IV saline and heparin, and the surgeon's choice of graft, with long Penrose drains or straight Robinson catheters for the tunnels, and the surgeon's tunneling device. Have several graft sizes in the room, unopened, for the surgeon to choose from.

Key steps:

1. A long midlinemidlineMID-lineAn imaginary line down the center of the body; also, a type of IV catheter placed in a vein of the upper arm.Full entry Close laparotomy. The aorta is exposed up to the renal vein, with the duodenumduodenumdoo-uh-DEE-numThe first, short part of the small intestine, just after the stomach.Full entry Close moved aside, and down to its lower end.
2. Both groins are opened, and the common, superficial and deep femoral arteries are freed and looped. The groin wounds may be covered with sterile towels while the abdomen is worked on.
3. A tunnel is made on each side from the groin up to the aortic bifurcation, by finger, with a long clamp or with a tunneler. A Penrose drain or Robinson catheter may be drawn through each tunnel, its ends clamped with hemostatshemostatHEE-moe-statA clamp with finger rings and a locking ratchet used in surgery to grasp and close off bleeding vessels.hem/o blood-stat stopping, standing stillFull entry Close so it cannot slip back.
4. Heparin is given, and the aorta is clamped just below the left renal vein. The aorta is divided, its lower stump oversewn, and the graft sewn to the upper end, end to end, with a continuous polypropylene suturesutureSOO-cherA stitch, or the thread used to stitch, that holds the edges of a wound or incision together.Full entry Close. Pledgets may reinforcereinforceree-in-FORSTo repeat and support teaching or care that has already been started, so the client remembers and follows it.Full entry Close a fragile aorta.
5. Each limb of the graft is drawn down through its tunnel to the groin. The common femoral artery is clamped, with bulldogs on its branches, and opened; the limb is cut to length, beveled and sewn end to side with a double-armed 5-0 or 6-0 polypropylene.
6. Just before each join is finished, the clamps are let off briefly to flush clot and air out of the graft, and the suture line is flushed with heparinized saline; a small basin catches the blood.
7. The surgeon closes the peritoneumperitoneumpair-ih-toh-NEE-umThe thin membrane that lines the belly cavity and covers most of the organs inside it.peri- aroundton stretched-eum a structureFull entry Close and fasciafasciaFASH-ee-uhA sheet or band of tough connective tissue that covers and separates muscles and organs.fasci/o bandFull entry Close at the back of the abdomen over the graft, then the abdomen and both groins, layer by layer.

Wound class: I, clean.

After surgery: the ICU or surgical unit, with DopplerDoppler ultrasoundDOP-ler UL-truh-soundAn ultrasound that uses sound waves to hear or show blood flowing through vessels or the fetal heartbeat.Full entry Close checks of the circulation in the legs through the first 48 hours.

Femoropopliteal bypass

What and why: a femoropopliteal bypass carries blood around a blocked stretch of the femoral artery, from the femoral artery in the groin to the popliteal artery at the knee. The graft is the patient's own great saphenous vein or a synthetic tube. When the popliteal artery is diseased too, the lower end goes to a tibialtibiaTIB-ee-uhThe large inner bone of the lower leg, between the knee and the ankle; the shinbone.tibi/o tibiaFull entry Close artery below the knee (a femorotibial bypass), which may need microvascular instruments.

Diagnosis: arteriography maps the blocked femoral artery and the arteries below the knee, and a duplex ultrasound scan can check before surgery that the saphenous vein is good enough to use.

Position, prep and drape: supine, the hip turned out and spread a little, with the knee bent. The whole groin and leg are prepped and draped, with the other leg prepped when its vein may be needed. The incision lines and the pedal pulses are marked on the skin.

Setup: a basic minor set and a vascular set, Gelpi and Weitlaner retractorsretractorrih-TRAK-terA surgical instrument that holds back tissue or organs so the surgeon can see and reach the operative site.Full entry Close, a tunneler, umbilical tapes or vessel loops, and supplies for an angiogramangiographyan-jee-OG-ruh-feeAn imaging test that shows blood vessels by injecting a contrast dye and taking x-ray, CT or MRI pictures.angi/o vessel-graphy process of recordingFull entry Close during the operation.

Gelpi RetractorOn 36 setups

Key steps (reversed vein):

1. An incision along the inner thigh below the groin exposes the common femoral artery, and moist umbilical tapes or vessel loops go around the common, superficial and deep femoral arteries.
2. A second incision on the inner side of the knee, above or below it, exposes the popliteal artery, which is looped; an angiogram may check that it and the arteries below are open.
3. The saphenous vein is exposed through one long incision or several short ones, its side branches are tied with fine silk or clipped, and the length needed is removed. Because of its valves, the vein is reversed, so the end that was at the groin is sewn to the popliteal artery. Keep the vein moist in the solution the surgeon orders, which may be heparinized saline with papaverine.
4. The graft is passed through a tunnel from the knee to the groin, without kinks or twists.
5. Heparin is given, the femoral artery is clamped and opened with a #11 blade and Potts scissors, and the upper end of the graft is sewn on with fine vascular suture. Keep heparinized saline ready to irrigateirrigationeer-ih-GAY-shunWashing out a wound, body cavity, tube or eye with a steady flow of liquid.Full entry Close both sites.
6. The knee is bent, the popliteal artery is clamped and opened, and the lower end is sewn on. Before the last stitches, the femoralfemoralFEM-er-ulRelating to the thigh or the femur, the thigh bone.Full entry Close clamp is opened for a moment to flush out air and debris.
7. All the clamps come off, the joins are checked for leaks, and the flow is checked by angiogram, Doppler or IVUS before the wounds are closed.

Taking the vein through small incisions, with an endoscopicendoscopicen-doh-SKOP-ikDone with an endoscope, a thin tube with a light and camera passed into the body.endo- within-scopic viewingFull entry Close vein harvesting system, is chapter 41's.

In situ bypass: in situ means in its natural place. The saphenous vein stays in its bed, its narrow lower end sewn to the popliteal artery and its wide upper end to the femoral artery. Its valves are cut with a valvulotome passed through it, and its side branches are tied or clipped so they cannot act as small fistulasfistulaFIS-choo-luhAn abnormal passage between two organs or vessels, or between an organ and the skin.Full entry Close.

Femorofemoral and axillofemoral bypass: when an aortic operation is undesirable, an extra-anatomic bypass, run outside the normal path of the arteries, carries blood from one good iliac and femoral artery through a tunnel under the skin across the pubispubisPYOO-bisThe front part of each hip bone, low in the pelvis; the two meet in the middle at the pubic symphysis.pub/o pubisFull entry Close to the other femoral artery (femorofemoral), or from the axillary artery down to the same side's femoral artery (axillofemoral).

Wound class: I, clean.

After surgery: the pedal pulses are checked often; a pulse that fades or disappears can mean the graft has blocked. Swelling of the operated leg is common afterward, and some numbness of the lower leg may follow; blockage of the graft and infection are the main complications. Patients are taught foot care, to stop smoking and to report any change in the color, warmth or feeling of the leg.

16Embolectomy and thrombectomy

What and why: an embolectomy removes an embolusembolismEM-buh-liz-umThe blocking of a blood vessel by a mass carried there in the blood (an embolus), such as a clot, fat or an air bubble.embol/o plug-ism conditionFull entry Close that has lodged in an artery; a thrombectomy removes a thrombusthrombosisthrom-BOH-sisThe forming of a blood clot (a thrombus) inside a blood vessel or the heart.thromb/o clot-osis conditionFull entry Close, a clot that formed where it sits. Both open the vessel and pull the clot out, usually with a balloon embolectomy catheter, to restore the flow before the tissue beyond dies, and both can save a limb or a life. About 80 percent of emboli that travel to the peripheral arteries lodge in a leg, about half of all of them where the common femoral arteryfemoral arteryFEM-er-ul AR-ter-eeThe large artery that carries blood to the leg, running through the groin and down the thigh.Full entry Close divides, which is why a leg clot is usually removed through the groin. The usual causes of the clot are atherosclerosisatherosclerosisath-er-oh-skluh-ROH-sisA buildup of fatty deposits (plaque) inside the walls of the arteries.ather/o fatty pastescler/o hard-osis conditionFull entry Close, a heart that throws emboli, surgery on large vessels, and trauma such as a hip fracturehip fracturehip FRAK-churA break in the upper part of the thigh bone, near the hip joint.Full entry Close.

Diagnosis: angiogramsangiographyan-jee-OG-ruh-feeAn imaging test that shows blood vessels by injecting a contrast dye and taking x-ray, CT or MRI pictures.angi/o vessel-graphy process of recordingFull entry Close, duplex Doppler ultrasoundDoppler ultrasoundDOP-ler UL-truh-soundAn ultrasound that uses sound waves to hear or show blood flowing through vessels or the fetal heartbeat.Full entry Close and MRImagnetic resonance imagingmag-NET-ik REZ-uh-nunts IM-uh-jingAn imaging test that uses a strong magnet and radio waves to make detailed pictures of the inside of the body.Full entry Close show where the clot is and guide where the incision goes.

Anesthesiaanesthesiaan-us-THEE-zhuhLoss of feeling or sensation, often brought on by drugs so that surgery or a procedure can be done without pain.an- withoutesthesi/o feeling, sensation-ia conditionFull entry Close and position: general or regional anesthesia; supine, prepped and draped for the clot's location, most often a leg.

Setup: a laparotomylaparotomylap-uh-ROT-uh-meeSurgery that opens the abdomen through a large cut to reach the organs inside.lapar/o abdomen-tomy cutting intoFull entry Close or general set, a vascular set, vessel irrigationirrigationeer-ih-GAY-shunWashing out a wound, body cavity, tube or eye with a steady flow of liquid.Full entry Close tips, Frazier suction, 30 and 60 mL syringes and heparinized saline, irrigation catheters, vessel loops and topical hemostatic agentshemostatichee-moh-STAT-ikStopping bleeding; also, a product or agent used to stop bleeding.hem/o blood-stasis stopping, standing still-ic relating toFull entry Close. Embolectomy catheters in several sizes are in the room but are opened only when they are needed.

Key steps (femoralfemoralFEM-er-ulRelating to the thigh or the femur, the thigh bone.Full entry Close embolectomy):

1. A groin incision exposes the common femoral artery and its branches, and vessel loops go around them.
2. HeparinheparinHEP-uh-rinAn anticoagulant drug, given by injection or IV, that keeps blood clots from forming or growing.Full entry Close is given, the vessels are clamped, and an arteriotomy is made with a #11 blade and lengthened with Potts-Smith scissors; have suction ready at the arteriotomy.
3. You prepare the embolectomy catheter the surgeon names. The surgeon passes it beyond the clot with the balloon down, inflates the balloon, and slowly pulls the catheter back, drawing the clot out of the artery. Passes are made toward the heart and down each branch, and the surgeon checks that each branch bleeds back well.
4. Have a vascular clamp ready to hand the moment the catheter and clot come out, so the bleeding is controlled.
5. The artery is flushed with heparinized saline through a small irrigating catheter. An angiogram, angioscopy or Doppler checks the result.
6. The arteriotomy is closed with 6-0 or 7-0 nonabsorbable vascular suturesutureSOO-cherA stitch, or the thread used to stitch, that holds the edges of a wound or incision together.Full entry Close, and the wound is closed.

Specimen: the clot is kept as a specimen.

After surgery: once blood flows again into muscle that has been without it, the muscle can swell inside its fasciafasciaFASH-ee-uhA sheet or band of tough connective tissue that covers and separates muscles and organs.fasci/o bandFull entry Close (ischemiaischemiais-KEE-mee-uhToo little blood flow to a part of the body, so the tissue does not get enough oxygen.isch- hold back-emia blood conditionFull entry Close-reperfusion injury), causing compartment syndromecompartment syndromekum-PART-ment SIN-drohmA buildup of pressure inside a closed group of muscles that cuts off their blood supply.Full entry Close. The surgeon may open the fascia at the same operation (a fasciotomyfasciotomyfash-ee-OT-uh-meeSurgery that cuts open the fascia, the tough tissue around a group of muscles, to relieve pressure inside it.fasci/o fascia, a band of connective tissue-tomy cutting intoFull entry Close), and afterward the limb is checked often for the signs chapter 11 teaches. Dying muscle also releases myoglobin and potassium into the blood, which are watched.

Wound class: I, clean, when no infection or dead tissue is present.

Venous thrombectomy

A deep vein thrombosisdeep vein thrombosisDEEP VAYN throm-BOH-sisA blood clot in a deep vein, most often in the leg or pelvis.thromb/o clot-osis conditionFull entry Close in the iliaciliacIL-ee-akHaving to do with the ilium, the large, wing-shaped upper part of the hip bone.Full entry Close and femoral veins may be dissolved through a catheter, or removed in an open venous thrombectomy: a balloon catheter is passed up the femoral vein under fluoroscopyfluoroscopyfloo-ROS-kuh-peeAn x-ray method that shows moving pictures of the inside of the body in real time.fluor/o glowing (from the fluorescent screen)-scopy looking, viewingFull entry Close to pull the clot out, and any narrowing left in the iliac vein is opened with a balloon and, if needed, a stentstentstentA small tube, often of metal mesh, placed inside a vessel or duct to hold it open.Full entry Close; like the other planned vascular operations, it is Class I.

Venous StentOn 1 setup

17Access for hemodialysis

Chapter 34 teaches kidney failurerenal failureREE-nul FAYL-yerLoss of the kidneys' ability to filter waste and extra fluid from the blood.ren kidney-al relating toFull entry Close and hemodialysisdialysisdy-AL-ih-sisA treatment that removes wastes and extra fluid from the blood when the kidneys can no longer do it.dia- through, apart-lysis separation, looseningFull entry Close, in which a machine filters the blood. Dialysis needs strong blood flow through large needles, often 15 to 17 gauge, placed again and again. An ordinary vein cannot take that, so the surgeon builds an access. For urgent dialysis, a double-lumenlumenLOO-menThe open space inside a tube, such as a blood vessel, the intestine or a catheter.Full entry Close dialysis catheter can be placed in a large vein and used at once.

Arteriovenous fistula

An arteriovenous fistulaarteriovenous fistulaar-teer-ee-oh-VEE-nus FIS-chuh-luhA connection made by surgery between an artery and a vein, usually in the arm, to give access for hemodialysis.arteri/o arteryven/o vein-ous relating tofistula an abnormal passage between two body partsFull entry Close (AV fistula) is a direct connection between an artery and a vein made by the surgeon. The vein, filled with arterial blood under pressure, grows wide and thick-walled over the following weeks (it matures), until it can take the dialysis needles. It is the standard access: it uses the patient's own vessels, and it is preferred over an external shuntshuntSHUNTA passage that moves blood or other fluid from one place to another, either made by a surgeon or present in the body.Full entry Close, which carries a high risk of clottingclottingKLOT-ingThe process by which blood thickens into a gel to plug a damaged vessel and stop bleeding; also called coagulation.Full entry Close and infection. A working fistulafistulaFIS-choo-luhAn abnormal passage between two organs or vessels, or between an organ and the skin.Full entry Close has a buzz you can feel, the thrillthrillTHRILA buzzing or vibrating feeling felt with the fingertips over a blood vessel or the heart.Full entry Close, and a continuous rushing sound you can hear, the bruitbruitbroo-EEA whooshing or blowing sound heard with a stethoscope over a blood vessel.Full entry Close.

Of the four ways to join the artery and vein, sewing the end of the vein to the side of the artery is used more and more, and side-to-side joins less. Surgeons start as far out on the arm as they can and move up the arm with each new fistula. The classic first fistula, the Brescia-Cimino fistula, joins the radial artery and the cephalic vein at the wrist; later ones join the brachial artery to the cephalic or basilic vein in the upper arm. The basilic vein lies deep, under the fasciafasciaFASH-ee-uhA sheet or band of tough connective tissue that covers and separates muscles and organs.fasci/o bandFull entry Close of the upper arm, so for a basilic fistula it is also moved up near the skin where needles can reach it (a transposition).

Before surgery: the fistula may be made ahead of need, when the kidney function falls far enough that dialysis is near, so it has time to mature. The veins and arteries of the arm are checked first, often in the vascular lab with ultrasound, because the veins vary from one person to the next.

Position, prep and drape: supine, the arm (often the nondominant one) out on an armboard. The prep may include the hand, arm, chest and axilla, and the arm is draped free. Local anesthesialocal anesthesiaLOH-kul an-es-THEE-zhuhNumbing medicine applied to or injected into one small area, so a procedure there is not felt while the person stays awake.Full entry Close is common.

Setup: a minor plastic set and a peripheral vascular set, vessel loops, mosquito clamps with jaw covers, a small self-retaining retractorretractorrih-TRAK-terA surgical instrument that holds back tissue or organs so the surgeon can see and reach the operative site.Full entry Close, and loupes for the surgeon.

Key steps (radiocephalic fistula):

1. An incision with a #15 blade over the radial artery and the cephalic vein in the forearm.
2. The vein and the artery are freed, with vessel loops around them and small bulldogs or vascular clamps on each side of the planned join.
3. An arteriotomy is made in the radial artery with a #11 blade and lengthened with Potts-Smith scissors, and the surgeon may widen the artery with vascular dilatorsdilatorDY-lay-terAn instrument used to stretch or widen an opening, canal or passage in the body.Full entry Close: have them lined up from smallest to largest, and say the size of each one as you hand it.
4. The vein is clamped, divided and tied off at its far end, and the near end is opened (a venotomy).
5. The vein is sewn end to side onto the artery with 6-0 or 7-0 polypropylene; the surgeon may inject a little heparinheparinHEP-uh-rinAn anticoagulant drug, given by injection or IV, that keeps blood clots from forming or growing.Full entry Close into the join just before the last stitches.
6. The clamps come off, and the surgeon gently feels the join to confirm blood flow. The wound is closed in layers and dressed with a nonadherent pad and dry gauze.

Arteriovenous graft

When the patient's own veins will not do, an arteriovenous graftarteriovenous graftar-teer-ee-oh-VEE-nus graftA soft synthetic tube placed under the skin to join an artery to a vein, used for hemodialysis access.Full entry Close bridges an artery and a vein with a tube, usually PTFE, laid in a tunnel under the skin; the Core Curriculum's "shunt" includes it. A bovine artery or a vein graftgraftGRAFTTissue or a man-made material moved into place in surgery to replace or repair a damaged part.Full entry Close can be used too. A graft does not need to mature and can be used at once, though waiting about 2 weeks lets its joins heal first. A loop (U-shaped) graft joins an artery and a vein that lie close together; the usual sites run from the brachial artery to a vein at the elbow or to the axillary vein. A tunneler lays the graft in the fat just under the skin.

Once the arm sites are used up, most surgeons place the graft in the thigh, looped from the femoral arteryfemoral arteryFEM-er-ul AR-ter-eeThe large artery that carries blood to the leg, running through the groin and down the thigh.Full entry Close to the great saphenous or femoralfemoralFEM-er-ulRelating to the thigh or the femur, the thigh bone.Full entry Close vein, where it stays open about as well but becomes infected more often.

Wound class (a fistula or a graft): I, clean.

After surgery: a fistula or graft can narrow, most often where it joins the vein, and then clot; that is its most common problem, and it is usually treated by another procedure, such as a patch angioplasty or removal of the clot. Bleeding, infection, an aneurysmaneurysmAN-yuh-riz-umA weak spot in the wall of an artery that bulges outward like a balloon.aneurysm a widening (Greek)Full entry Close or pseudoaneurysm, and heart failureheart failurehart FAYL-yerA long-term condition in which the heart cannot pump enough blood to meet the body's needs.Full entry Close from too much flow can also occur. In steal syndrome, the access draws so much blood away from the hand beyond it that the hand becomes ischemicischemiais-KEE-mee-uhToo little blood flow to a part of the body, so the tissue does not get enough oxygen.isch- hold back-emia blood conditionFull entry Close; the access may have to be tied off or revised. Patients guard their access closely, as chapter 34 teaches.

18Venous access

Some patients need a large vein for weeks, months or years: for antibiotics, chemotherapyantineoplastican-tee-nee-oh-PLAS-tikA drug used to treat cancer by killing cancer cells or stopping them from growing and dividing.anti- againstneo- newplas growth, formation-tic relating toFull entry Close and hemodialysisdialysisdy-AL-ih-sisA treatment that removes wastes and extra fluid from the blood when the kidneys can no longer do it.dia- through, apart-lysis separation, looseningFull entry Close, the uses the Core Curriculum names, and for IV nutrition and blood draws. A central venous cathetercentral venous catheterSEN-trul VEE-nus KATH-uh-terAn IV catheter whose tip sits in a large vein near the heart, used for long-term drugs, fluids, nutrition or blood draws.Full entry Close (central line) is a soft tube whose tip lies in the superior vena cavasuperior vena cavasuh-PEER-ee-er VEE-nuh KAY-vuhThe large vein that carries blood from the head, neck, arms and upper chest back to the right atrium of the heart.superior uppervena veincava hollowFull entry Close near the right atriumatriumAY-tree-umOne of the two upper chambers of the heart, which receive blood coming back to the heart.atri/o atrium-um noun endingFull entry Close, entered through the skin into the subclavian, internal jugularjugularJUG-yuh-lerRelating to the neck, especially the large veins in the neck.Full entry Close or, less often, the femoralfemoralFEM-er-ulRelating to the thigh or the femur, the thigh bone.Full entry Close vein; its outer end may have two or three lumenslumenLOO-menThe open space inside a tube, such as a blood vessel, the intestine or a catheter.Full entry Close.

• Tunneled catheter: part of the catheter runs in a tunnel under the skin between the vein and an exit site on the skin. Common ones are the Hickman, the Broviac and the Groshong. They are for long-term therapy, with one lumen or several.
• Non-tunneled catheter: for short- or medium-term therapy.
• Peripherally inserted central catheterPICCpik (said as one word)Peripherally inserted central catheter: a long, thin IV tube put into an arm vein with its tip in a large vein near the heart.Full entry Close (PICC): a thin tube put into a vein of the upper arm and guided up to the superior vena cava, for weeks or months, such as a course of antibiotics.
• Port: a reservoirreservoirREZ-er-vwarA place where germs live and multiply, such as a person, animal, water or soil.Full entry Close implanted under the skin, usually of the upper chest, joined to a catheter in a central vein. Its self-sealing silicone dome is entered through the skin with a special noncoring needle, which does not cut out a core of the dome. A port can stay for months to years, and when it is not in use the patient lives normally, with nothing outside the skin.

Central lines are placed with strict aseptic technique in interventional radiology or the OR, guided by fluoroscopyfluoroscopyfloo-ROS-kuh-peeAn x-ray method that shows moving pictures of the inside of the body in real time.fluor/o glowing (from the fluorescent screen)-scopy looking, viewingFull entry Close or ultrasound. Every central line carries a risk of bloodstream infectionbloodstream infectionBLUD-streem in-FEK-shunAn infection in which bacteria or fungi are growing in the blood.Full entry Close; among the long-term devices, a fully implanted port carries the lowest.

Before surgery: electrolytes and clottingclottingKLOT-ingThe process by which blood thickens into a gel to plug a damaged vessel and stop bleeding; also called coagulation.Full entry Close studies are checked, any earlier central lines are asked about to help choose the site, and ultrasound can find the vein. A single preoperative dose of antibiotic is given.

Anesthesiaanesthesiaan-us-THEE-zhuhLoss of feeling or sensation, often brought on by drugs so that surgery or a procedure can be done without pain.an- withoutesthesi/o feeling, sensation-ia conditionFull entry Close, position, prep and drape: usually moderate sedationmoderate sedationMOD-er-it seh-DAY-shunA drug-induced state of relaxed, lowered awareness in which the client still responds to voice or light touch and breathes on their own.Full entry Close or local with monitored anesthesia care, as an outpatient. Supine, the arms tucked, often in slight TrendelenburgTrendelenburg positiontren-DEL-en-burg puh-ZISH-unA position in which the client lies on the back with the bed tilted so the head is lower than the feet.Full entry Close to fill and widen the vein, with the head turned away. Hair is clipped, and a wide chlorhexidine prep covers the side of the neck and the chest, under the full sterile barrier: a drape that exposes the area over the collarbone and breastbone up to the chin.

Setup: the catheter or port kit, with its introducer needle, guidewire, dilatordilatorDY-lay-terAn instrument used to stretch or widen an opening, canal or passage in the body.Full entry Close, peel-away sheathsheathSHEETHA covering that wraps around a structure; in procedures, a short hollow tube left in a blood vessel to pass catheters through.Full entry Close and tunneler; a minor instrument set; contrastcontrastKON-trastA dye or other substance given before an imaging test so body parts show up more clearly.Full entry Close, the C-arm and its drape; heparinized saline.

Central Venous Catheter KitOn 31 setups Implantable Port KitOn 1 setup

Key steps (port in the internal jugular veininternal jugular veinin-TUR-nul JUG-yuh-ler vaynA large vein deep on each side of the neck that carries blood from the brain, face and neck back toward the heart.Full entry Close):

1. The vein is checked with ultrasound, then entered through a tiny skin nick with a small needle under live ultrasound, by the modified Seldinger technique (chapter 22), and a guidewire is passed; a micropuncture set may be used first.
2. A small dilator makes a track over the wire.
3. A 3 to 4 cm incision two fingerbreadthsfingerbreadthFING-ger-bredthThe width of one finger, about 1 to 2 centimeters, used as a quick bedside measure.Full entry Close below the collarbone opens a pocket on the fasciafasciaFASH-ee-uhA sheet or band of tough connective tissue that covers and separates muscles and organs.fasci/o bandFull entry Close of the pectoralis muscle, and a tunnel is made under the skin from the pocket to the neck.
4. The dilator is swapped over the wire for an introducer with a peel-away sheath. The catheter goes in through the sheath and is placed with its tip in the right atrium under fluoroscopy; the sheath is split and peeled away. Hand the catheter coiled and tip first, and help steady it while it goes in.
5. The catheter is cut to length and pushed onto the port's hub, and a slide-on boot locks it there.
6. The port is drawn back and flushed to check that it runs freely, its position is checked on fluoroscopy, and it is stitched to the pectoralis fascia with nonabsorbable monofilament.
7. The pocket and the skin are closed with absorbable suturessutureSOO-cherA stitch, or the thread used to stitch, that holds the edges of a wound or incision together.Full entry Close, and the port is filled with a dilute heparinheparinHEP-uh-rinAn anticoagulant drug, given by injection or IV, that keeps blood clots from forming or growing.Full entry Close solution.

A tunneled catheter goes in the same way, but its outer end comes out through an exit site, and a small cuff around it, left in the tunnel, grows into the tissue and holds it. It is stitched to the skin for about 2 weeks while the cuff takes hold.

Medications: heparin in low strengths flushes and fills a port or catheter; count it as heparin given into a vein. Have the right strength and label it clearly, because heparin vials that look alike hold very different doses.

Wound class: I, clean.

After surgery: a pneumothoraxpneumothoraxnoo-moh-THOR-aksAir in the space between a lung and the chest wall, which lets part or all of that lung collapse.pneum/o air, lungthorac/o chestFull entry Close, a lung collapsed by a needle that strayed into it, is ruled out with a chest x-ray, which may be taken in the OR. Other complications are puncture of the subclavian artery and a catheter tip in the wrong place, such as up the jugular veinjugular veinJUG-yuh-ler VAYNOne of the large veins on each side of the neck that carry blood from the head back toward the heart.Full entry Close.

Port Placement13 instruments · 2 photos

19Vena cava filter

What and why: a vena cavavena cavaVEE-nuh KAY-vuhOne of the two large veins that return oxygen-poor blood from the body to the right atrium of the heart.Full entry Close filter is a small metal device, shaped like an umbrella without its fabric, placed in the inferior vena cavainferior vena cavain-FEER-ee-er VEE-nuh KAY-vuhThe large vein that carries blood from the lower body back to the right atrium of the heart.inferior lowervena veincava hollowFull entry Close to catch clots on their way from the leg veins to the lungs. It is made of titanium, stainless steel or nitinol, opens out against the vein wall, and may be permanent or temporary. It is used when:

• a patient with a venous clot cannot take anticoagulantsanticoagulantan-tee-koh-AG-yoo-luntA drug that slows the blood's ability to form clots.anti- againstcoagul/o clotting-ant an agent that doesFull entry Close, as after recent surgery or a bleeding stroke
• a patient survived a massive pulmonary embolismpulmonary embolismPUL-muh-nair-ee EM-buh-liz-umA blockage of an artery in the lungs, usually by a blood clot that has traveled there from elsewhere in the body.pulmon/o lung-ary relating toembol/o plug-ism conditionFull entry Close and another would be fatal
• clots keep forming in spite of anticoagulants
• the risk of a pulmonary embolism is high

It is placed through the skin, under fluoroscopyfluoroscopyfloo-ROS-kuh-peeAn x-ray method that shows moving pictures of the inside of the body in real time.fluor/o glowing (from the fluorescent screen)-scopy looking, viewingFull entry Close, in the catheter lab or the OR, with local anesthesialocal anesthesiaLOH-kul an-es-THEE-zhuhNumbing medicine applied to or injected into one small area, so a procedure there is not felt while the person stays awake.Full entry Close or moderate sedationmoderate sedationMOD-er-it seh-DAY-shunA drug-induced state of relaxed, lowered awareness in which the client still responds to voice or light touch and breathes on their own.Full entry Close. Several designs exist, and a kit made for the chosen route, femoralfemoralFEM-er-ulRelating to the thigh or the femur, the thigh bone.Full entry Close or jugularjugularJUG-yuh-lerRelating to the neck, especially the large veins in the neck.Full entry Close, must be opened.

Position and prep: supine on a bed that x-rays pass through, imaged at the level of the renal veins. The right femoral vein is the usual route, because the left femoral vein's path makes threading harder; for a jugular approach the head turns to the left. The circulator makes sure the local anestheticlocal anestheticLOH-kul an-es-THET-ikA drug that blocks feeling in one part of the body without making the person unconscious.Full entry Close, the contrastcontrastKON-trastA dye or other substance given before an imaging test so body parts show up more clearly.Full entry Close and heparinized saline for flushing the filter's kit are in the room.

Key steps:

1. The groin is prepped, draped and numbed, and the vein is entered with a needle, often 18-gauge.
2. A guidewire is passed under fluoroscopy up past the renal veins.
3. Every lumenlumenLOO-menThe open space inside a tube, such as a blood vessel, the intestine or a catheter.Full entry Close of the device is flushed with heparinized saline, and the sheathsheathSHEETHA covering that wraps around a structure; in procedures, a short hollow tube left in a blood vessel to pass catheters through.Full entry Close or dilatordilatorDY-lay-terAn instrument used to stretch or widen an opening, canal or passage in the body.Full entry Close goes over the wire.
4. The introducer catheter, carrying the filter preloaded in a capsule, goes up to the planned spot below the renal veins, and the filter is pushed out, where it opens; its place is checked on fluoroscopy.
5. The introducer and wire come out, and pressure is held on the site until it stops bleeding, about 5 to 15 minutes in the references; a pressure dressing goes on.

The patient lies flat for some hours afterward so the site does not bleed, keeping the leg straight after a femoral insertion. A retrievable filter has a small hook at its top: through a sheath in a jugular or subclavian vein above it, the surgeon snares the hook and draws the filter up, and it folds closed into the sheath like an umbrella; an angiogramangiographyan-jee-OG-ruh-feeAn imaging test that shows blood vessels by injecting a contrast dye and taking x-ray, CT or MRI pictures.angi/o vessel-graphy process of recordingFull entry Close then checks the vena cava.

Wound class and complications: Class I. Bleeding at the site, a pulmonary embolism, a filter that moves or becomes infected, clot in the vena cava, and a filter that pierces the vein wall, causing bleeding behind the peritoneumperitoneumpair-ih-toh-NEE-umThe thin membrane that lines the belly cavity and covers most of the organs inside it.peri- aroundton stretched-eum a structureFull entry Close.

20Vein ligation and stripping

What and why: the operation ties off (ligates) the great or small saphenous vein where it joins the deep vein and removes the diseased length of it, with its varicose branches, to relieve the pain, swelling and tiredness of the leg and to prevent ulcersulcerUL-serAn open sore where the skin or the lining of an organ has broken down.Full entry Close.

Diagnosis and anesthesiaanesthesiaan-us-THEE-zhuhLoss of feeling or sensation, often brought on by drugs so that surgery or a procedure can be done without pain.an- withoutesthesi/o feeling, sensation-ia conditionFull entry Close: duplex ultrasound shows which veins and valves have failed. Stripping is usually done under general anesthesiageneral anesthesiaJEN-er-ul an-es-THEE-zhuhDrug-induced loss of consciousness and feeling over the whole body, so a person feels nothing and is not aware during surgery.an- withoutesthesi/o feeling, sensation-ia conditionFull entry Close.

Before surgery: before the patient comes to the OR, the surgeon has the patient stand and marks the varicose veinsvaricose veinVAIR-ih-kohs VAYNA swollen, twisted vein just under the skin, most often in the legs, in which the valves do not work well.varic/o swollen, twisted vein-ose full ofFull entry Close on the skin with a markermarkerMAR-kerSomething that can be measured, such as a substance in the blood, that shows a disease or body process is present.Full entry Close that will not wash off in the prep, so every varicose vein can be seen and removed.

Position, prep and drape: supine with the legs slightly apart, often tilted head down during surgery (TrendelenburgTrendelenburg positiontren-DEL-en-burg puh-ZISH-unA position in which the client lies on the back with the bed tilted so the head is lower than the feet.Full entry Close) to drain the veins; the small saphenous vein, behind the calf, may need the prone position. The leg is draped so the knee can be bent and lifted.

Setup: a minor set, Weitlaner retractorsretractorrih-TRAK-terA surgical instrument that holds back tissue or organs so the surgeon can see and reach the operative site.Full entry Close, #11 blades, skin hooks, mosquito clamps, vein strippers with several sizes of olive (acorn) tip, and elastic bandages. Confirm the size of acorn with the surgeon, and keep the long, very flexible stripper from sliding off the field.

Internal Vein StripperOn 1 setup

Key steps:

1. An incision in the upper thigh, parallel to the groin crease, and a Weitlaner.
2. The saphenous vein is found and its branches are tied twice with silk and divided. The vein is traced up to where it enters the femoralfemoralFEM-er-ulRelating to the thigh or the femur, the thigh bone.Full entry Close vein (the saphenofemoral junction) and tied there.
3. A second incision near the ankle exposes the lower end of the vein, which is tied and divided.
4. The stripper is threaded up the inside of the vein from the ankle to the groin. The acorn is screwed on, the vein is tied tightly to the stripper just below it, and the stripper is pulled out, turning the vein inside out as it comes. As the surgeon pulls, the assistant or the scrub presses along the leg.
5. Branches are removed through many tiny incisions, 2 to 3 mm long, a technique called stab avulsion.
6. The groin is closed in layers, the small incisions with suturessutureSOO-cherA stitch, or the thread used to stitch, that holds the edges of a wound or incision together.Full entry Close or staples, and the leg is wrapped firmly in elastic bandages.

Medications: none are routinely needed on the field.

Specimen: you remove the inverted vein from the stripper as the specimen.

Endovenous ablationablationab-LAY-shunA procedure that destroys a small area of tissue, often with heat or cold, to stop it from causing a problem.Full entry Close: a newer outpatient alternative seals the vein from inside instead of removing it, with laser energy through a fiber-optic catheter placed under ultrasound, under the laser safety rules of chapter 20.

Wound class: I, clean. Most patients go home the same day; bleeding, a hematomahematomahee-muh-TOH-muhA collection of blood, often clotted, that has leaked out of the blood vessels into the tissue.hem/o blood (here as hemat-)-oma swelling or massFull entry Close, infection and recurrencerecurrencerih-KER-ensThe return of a disease or symptom after a period when it had gone away.re- againcur run-ence state ofFull entry Close are the main complications.

After surgery: the patient walks, avoids long sitting and standing, keeps the legs raised when sitting, and wears the bandages or stockings as told.

21Vascular trauma

Chapter 11 teaches trauma care and how penetrating and blunt injuries harm the body; this is the vascular part. An injured major artery can cost a limb or a life, so its repair is urgent. In the United States most peripheral vascular injuries come from penetrating violence, gunshots and stab wounds.

• Penetrating trauma: a bullet's track and its breaking up can injure vessels far from the entry wound, and shotgun pellets scatter widely. A knife cuts a vessel partly or completely.
• Blunt trauma: crushing, as in a vehicle or industrial accident, or a broken long bone pressing on the vessels, blocks the flow to the limb. A sudden stop at high speed can split the layers of the aorta (a dissectiondissectiondy-SEK-shunA tear in the inner layer of an artery wall that lets blood split the layers apart; also, the cutting apart of tissue in surgery.Full entry Close).

The hard signs of an artery injury are absent pulses, active bleeding, a limb that is plainly ischemicischemiais-KEE-mee-uhToo little blood flow to a part of the body, so the tissue does not get enough oxygen.isch- hold back-emia blood conditionFull entry Close, a hematomahematomahee-muh-TOH-muhA collection of blood, often clotted, that has leaked out of the blood vessels into the tissue.hem/o blood (here as hemat-)-oma swelling or massFull entry Close that keeps growing, and a thrillthrillTHRILA buzzing or vibrating feeling felt with the fingertips over a blood vessel or the heart.Full entry Close or bruitbruitbroo-EEA whooshing or blowing sound heard with a stethoscope over a blood vessel.Full entry Close over the wound; a patient with them usually goes straight to the OR. In the emergency department a Foley catheterindwelling urinary catheterin-DWEL-ing YUR-ih-nair-ee KATH-uh-terA tube passed through the urethra into the bladder and left in place to drain urine into a bag.Full entry Close may be passed into the wound and inflated as a tamponade to hold back the bleeding.

Setup: a vascular setup with general surgery instruments and every major vascular supply: the drugs, solutions, hemostatic agentshemostatichee-moh-STAT-ikStopping bleeding; also, a product or agent used to stop bleeding.hem/o blood-stasis stopping, standing still-ic relating toFull entry Close, vessel loops and Fogarty catheters to clear clot from damaged vessels, with orthopedicorthopedicor-thuh-PEE-dikHaving to do with the bones, joints, muscles, ligaments and tendons, and the branch of medicine that treats them.orth/o straightped/o child (the field began with straightening children's bones)-ic relating toFull entry Close and amputationamputationam-pyoo-TAY-shunThe removal of all or part of a limb or other body part, by surgery or by injury.Full entry Close instruments available. Get the suturessutureSOO-cherA stitch, or the thread used to stitch, that holds the edges of a wound or incision together.Full entry Close ready as soon as you know which vessel will be repaired, both single-armed and double-armed. Unless the surgeon names others, start with 2-0 and 0 silk ties on right-angle passers. Chapter 25 teaches loading needle holders ahead in trauma, with the needle tips left in their packet.

The repair: the surgeon exposes the injury, controls the bleeding with clamps or pressure, then repairs the vessel, directly, with a patch, or by bypassing the damaged part; blood and fluids are replaced, and bone or metal fragments that threaten more injury are dealt with. In a patient too unstableunstableun-STAY-bulDescribes a client whose condition is changing quickly or is hard to predict.Full entry Close for a full repair, a temporary shuntshuntSHUNTA passage that moves blood or other fluid from one place to another, either made by a surgeon or present in the body.Full entry Close, a tube placed inside the injured artery, restores blood flow to the limb until the patient can return for the definitive repair. This is vascular damage control. A severely mangled limb, or an injury to a major nerve and vessel bundle together, may lead to amputation instead, which chapter 39 teaches. Compartment syndromecompartment syndromekum-PART-ment SIN-drohmA buildup of pressure inside a closed group of muscles that cuts off their blood supply.Full entry Close threatens after the flow returns, and a fasciotomyfasciotomyfash-ee-OT-uh-meeSurgery that cuts open the fascia, the tough tissue around a group of muscles, to relieve pressure inside it.fasci/o fascia, a band of connective tissue-tomy cutting intoFull entry Close may be done (chapter 11).

Wound class: a fresh traumatic wound is Class III, contaminated (chapter 11).

22Microvascular surgery

Microsurgery is any operation done under magnification, through loupes or the operating microscope; microvascular work joins vessels about 1 mm across, in replantation, plastic and reconstructive surgery, trauma, urology and neurosurgery. Chapter 38 teaches the scrub's part (the spring-handled microinstruments, the microvascular clamps marked A or V, suturessutureSOO-cherA stitch, or the thread used to stitch, that holds the edges of a wound or incision together.Full entry Close of 8-0 to 12-0, gentle irrigationirrigationeer-ih-GAY-shunWashing out a wound, body cavity, tube or eye with a steady flow of liquid.Full entry Close and suction, and tissue kept moist and away from the table's edge), and chapter 23 the operating microscope.

Micro Vascular Needle HolderOn 4 setups Micro Vascular ClampOn 2 setups Magnifying LoupesOn 21 setups

23Wound classes and care after vascular surgery

Almost every planned vascular operation is Class I, clean, because no tract is entered. A fresh traumatic wound is Class III, and an infection already present, such as an infected graftgraftGRAFTTissue or a man-made material moved into place in surgery to replace or repair a damaged part.Full entry Close or infected gangrenegangreneGANG-greenThe death of body tissue because its blood supply has been lost or because of severe infection.Full entry Close, is Class IV. The scrub's part in preventing infection matters especially here, because an infected graft can mean losing a limb or a life: the antibiotic goes in on time, the graft stays off the skin, and sterile techniquesurgical asepsisSUR-jih-kul ay-SEP-sisPractices that keep an area or object completely free of microorganisms; also called sterile technique.a- withoutsepsis decay, infectionFull entry Close holds.

Everything on the field, the back table and the Mayo standMayo standMAY-oh standA small tray on an adjustable stand placed over or beside the patient during surgery to hold the instruments used most often.Full entry Close included, stays sterile until the patient has left the room. Bleeding from an anastomosisanastomosisuh-nas-tuh-MOH-sisA connection between two tube-shaped structures, such as two ends of bowel or two blood vessels, made by surgery or found naturally.Full entry Close may need another stitch, and a new neurologic deficit in the OR after a carotidcarotidkuh-ROT-idHaving to do with the carotid arteries, the two large arteries on each side of the neck that carry blood to the head and brain.Full entry Close endarterectomy means the incision is opened again to check the repair.

Watch for these after vascular surgery, and report them at once:

• Bleeding: at an anastomosis, a groin puncture or a sheathsheathSHEETHA covering that wraps around a structure; in procedures, a short hollow tube left in a blood vessel to pass catheters through.Full entry Close site; a growing hematomahematomahee-muh-TOH-muhA collection of blood, often clotted, that has leaked out of the blood vessels into the tissue.hem/o blood (here as hemat-)-oma swelling or massFull entry Close.
• A blocked graft or vessel: a pulse that fades or disappears, or a limb that turns pale, cold, numb or painful.
• Compartment syndromecompartment syndromekum-PART-ment SIN-drohmA buildup of pressure inside a closed group of muscles that cuts off their blood supply.Full entry Close after flow returns to an ischemicischemiais-KEE-mee-uhToo little blood flow to a part of the body, so the tissue does not get enough oxygen.isch- hold back-emia blood conditionFull entry Close limb: swelling and severe pain, with the other signs chapter 11 teaches.
• Stroke and nerve injury after carotid surgery: a new weakness, confusion or trouble speaking, or a tongue that points to one side.
• Infection of the wound or the graft.
• Kidney injury, after contrastcontrastKON-trastA dye or other substance given before an imaging test so body parts show up more clearly.Full entry Close or aortic surgery.

Patients go home with teaching tailored to the operation: wound care, the signs of graft failure and infection, foot care after a leg bypass, how to take an anticoagulantanticoagulantan-tee-koh-AG-yoo-luntA drug that slows the blood's ability to form clots.anti- againstcoagul/o clotting-ant an agent that doesFull entry Close safely, and above all to stop smoking, which harms both the vessels and wound healingwound healingwoond HEE-lingThe body's process of repairing damaged skin and tissue.Full entry Close.

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