Vascular Surgical Tech Set Ups

Patients are usually sedated or injected with a local anesthetic. Sometimes they are put under general depending on their circumstances.

The surgeon will cut the skin over femoral artery in the groin. Once they dissect down to the artery, they will insert a wire into the femoral artery and pass it up to the aneurysm.

Contrast dye will be used throughout the case so that they can see where they are under x-ray for visualization.

A tube will then be placed over the wire. This is preparing for the graft to be inserted which is the next step.

A sheath is used to insert the graft. Once they see the graft is in the correct spot, the sheath will be removed and the graft will expand into the surrounding artery.

The incision can be closed.

Tips:
The open abdominal AAA set should be close by in case the surgeon cannot do it the way they originally planned.

Have balloons and pigtail sheaths available just in case.

Have contrast dye, heparinized saline, and regular saline on your back table and flush all the wires you get and keep them flushed each time they are used.

Wear lead to protect you from x-ray.

Have ties and clips at the ready in case the surgeon quickly needs them.

Positioning: The patient will be positioned with their neck extended and their head turned away from the operating side.

A 15 blade on a #3 knife handle will be used to make an incision medially to the sternocleidomastoid muscle. The surgeon will dissect down through the fat using bovie, metz and debakey pickups.

Dull Weitlaners, Gelpis, and Beckman’s are all popular retractors for Carotid Endarterectomy surgery.

Several vascular branches will be ligated, so free ties need to be available. Vessel loops may also be used around the carotid. Some wet raytecs will be placed on the vessel while heparin is given.

Vascular clamps such as a Cooley Derra or a DeBakey will be used to clamp the artery proximal and distal to the plaque.

The artery will be opened and both ends of the plaque will be seen. Each clamp will be taken off while a bypass stent is placed while the artery is being patched up after removing the plaque.

A freer elevator is commonly used to remove the plaque, and all 11 blade will be used to cut the atheroma.

The artery can be patched with a variety of different materials. The doctor will choose what they want.

At the end of the case, ultrasound will be used to verify proper flow through the artery.

Tips: You should always have rubber shods on some mosquitos and irrigation to squirt on the physician’s hands while tying suture during vascular cases.

This is a L carotid endart, which is removal of plaque in the carotid artery. This is a very complex surgery because you are essentially going to be stopping blood flow to the brain so not many people can do them. So mainly what it intails is opening up the carotid and removing the plaque to allow for better blood flow by placing a carotid patch over it to increase the width of the artery.

A phlebectomy is done to remove varicose veins. It can be done under local or general anesthesia depending on the doctor’s preference and the patient’s tolerance.

The doctor will make an incision either with an 11 blade, or a large gauged needle.

A phlebectomy hook is used to dissect to the vein. Once it is dissected, a fine mosquito will be used to clamp onto the vein. Make sure you have raytecs available.

Most doctors make incisions that are small enough to not be sutured closed.

The surgeon will make their incision using a 15 blade loaded onto a #3 knife handle. It will be a pretty big incision along the arm. The bovie will then be used with your adson pickups to dissect down to the basilic vein. As they get deeper, they will switch to either gerald or debakey pickups, and will also use either metz or tenotomy scissors, and different sized weitlaners to help mobilize and view the vein.

Small and medium clips should always be loaded in the clip appliers, suture should always be ready (usually 6-0 or 7-0 prolene and silk ties), vessel loops should be loaded on hemostats ready to be passed, and booties should be placed on the tips of at least two mosquito clamps to hold the suture.

The basilic vein will eventually be completely free from all of the surrounding nerves and tissue. It will look like a really long, fat spaghetti noodle. The doctor will then want heparinized saline in a syringe with a cannula loaded onto it. They will insert the cannula into the vein and irrigate it to check for any holes along the vein.
They will then use an arm tunneler to make a superficial tunnel under the skin, attach the vein to the end of the tunneler, and pull it through. It can then be anastomosed to the brachial artery or proximal radial or ulnar artery using usually 7-0 Prolene suture and a castroviejo needle driver.

Closure can then begin using usually a 5-0 Vicryl under the skin, adson pickups, and a ryder needle driver.

I have the setup in order, from left to right. Start with 15blade and Adsons and then disect down with bovie and Metz. Switch to debakeys and fine debakeys as asked. 3-0 silk ties to tie off branches as you come across them. Once finding the artery and vein, vessel loops will go around them with a right angle and a clamp to hold them in place. Then little bull dogs and shods are used to clamp them off as you get ready with your 11 blade and Potts to make the cut and get ready for anastomoses. If it is in the wrist 7-0 prolene is used with a hemostat that has a bootie on it. The suture is loaded with a Castro and gold forceps are used to help with suturing. If it’s up past the elbow, just the size of the suture changes to a 6-0 prolene. Make sure to wet drs hands as he goes to throw a tie into the prolene. Once the anastomoses is compete the bulldogs are pulled off and checked for any bleeding, if none is shown, closing begins with a 3-0 vicryl SH and then followed with a 5-0 vicryl p3 per drs preference. Patient is dressed with dermabond and given tubigrip