Photographic Atlas of Reconstructive Arterial Surgery

347 Pages·1970·19.847 MB·English

by  Reinier J. A. M. Van Dongen M.D. (auth.)

PHOTOGRAPHIC ATLAS
OF RECONSTRUCTIVE
ARTERIAL SURGERY
PHOTO GRAPH I C ATLAS
OF RECONSTRUCTIVE
ARTERIAL SURGERY
REINIER J. A. M. VAN DONGEN M.D.
Head of the department of surgery
Hospital 'De Goddelijke Voorzienigheid'
Sittard, The Netherlands
with a foreword by
PRO F, J. eiD DOS 5 A N TOS M. D.
H.E.STENFERT KROESE N.V.jLEIDEN 1970
Copyright 1970 by H. E. Stenfert Kroese N.V., Pieterskerkhof 38, P.B. 33, Leiden, The Netherlands
Softcover reprint of the hardcover 1s t edition 1970
Published simultaneously
in the United States, its possessions, and Canada by Springer-Verlag New York Inc., 175 Fifth Avenue, New York/NY 10010.
673-2660
in Japan by Nankodo Company Limited, 42-6, Hongo 3-chome, Bunkyo, Tokyo, 113 Japan
Library of Congress Catalog Card Number: 71-109114
ISBN-13: 978-94-011-6419-1 e-ISBN-13: 978-94-011-6417-7
001: 10.1007/978-94-011-6417-7
All rights reserved
No part of this book may be reproduced by print, photoprint or any other means without written permission of the publisher
FOREWORD
Direct surgery on arteries was born at the turn of the nineteenth and twentieth century. However, it
was only during the last twenty-four years, that this new chapter of clinical surgery could be weil
established, owing to diverse kinds of minds and hands. The result is that limbs, organs, functions, and
lives have since then been saved in increasing numbers. We may now consider that the main impulse of
this new phase is over. But the material of wh ich the chapter was built is still defective, incomplete, or
inadequate, and therefore surgeons and many other men will still have to spend a lot of sagacity and
vigour to give this chapter its proper arrangement. Principles evolve, methods are modified as a result of
technical progress, surgeons' solid opinions on a particular matter give way to other distinct but equally
solid opinions on the same matter. These are the reasons why the moment we are living in is a wonderful
one. As always in Iife, the great flame burns more intensely when one finds himself at the verge of
attaining so me proposed design.
The first phase of dream and failure has given way to a more structured ground on wh ich the final
battle must be fought. Such a battle is taking place right now. To find our way amidst this uncertainty, we
need landmarks to help us chart our course, and these are best provided by an author's report on his
direct experience. This is the kind of work we need the most - individual productions, offering to us
ideas, principles, techniques, details, devices, impressions, proposals, and revisions.
Books based on general information are useless or destined to lose most of their fugitive value before
the ink used to print them has had a chance to dry. But personal books based on the personal experience
of authors of integrity always remain valuable and will always be useful to the reader whether or not he
puts their contents into practice. Personal books become an inexhaustible source of suggestions for
the reader; they open doors or engender strong personal reactions against the author's opinions.
The present volume is the achievement of an experienced man. There are many such men in the world,
but Van Dongen's experience is sustained by one all too rare quality - clarity of mind. This clear mind
enables him to explain and interpret the work of a minutious hand throughout many possible technical
combinations. In their turn they are criticized in a simple and systematic way. And the reader may take
as much time as he likes to consider this weil presented and invaluable material.
An atlas is usually intended to be looked at, with a minimum of attention to the legends. It does not seem
to me that this atlas should be treated in the usual way. Although the special technique used for the
illustrations is highly effective and facilitates enormously a quick appreciation of the subject in question,
the text is in no way inferior to the pictures and in its conciseness throws light on problems and doubts
which are present at the moment.
In his preface, Van Dongen speaks of providing general surgeons with a guide to reconstructive arterial
operations. Although he himself qualifies the broad meaning of this purpose, I think it would not be
too much for someone else to express his own feelings about so delicate a question. The many sectors
into which surgery is divided may or may not be considered as specialities, but in their early phases they
must be treated as such. And since they are in the process of being built up, standardization is per force
still unattained. The architects of these sectors may quite weil be general surgeons (as it is the case with
vascular surgery) but it seems to me that in matters concerning surgery of arteries only men who wish
to dedicate a good part of their professional lives to this work should decide to enter this field in the
present moment. Otherwise, it is likely that many common errors will result from inexperienced hands and
still more from inexperienced minds. This would inevitably slow progress in the field. Later on, when its
main aspects have been sufficiently defined, arterial surgery may be incorporated into general surgery.
This is what has happened in the past with gastric surgery, biliary surgery, esophageal surgery, pulmonary
surgery, and many others, even perhaps, urology. Although anyone of them may be selected as a 'special
ity', they have all become part of general surgery. I weil know that views and opinions on this matter
differ widely, and I hl;lVe no wish to reopen the controversy here. I have no great fear about general
surgeons taking over arterial surgery; because there are two important factors to keep them weil away
V
from this uncertain and treacherous field, one being artenal surgery itself and the other the patients
requiring this kind of treatment.
As a general surgeon who has devoted a large part of his life to the vascular system, I am certain that the
book for which I have been given the honour of writing the introduction will not only be extremely
useful to vascular surgeons but will also become an exellent support for general surgeons, young and
old, provided they are determined to carry on their activity in this new field, spending a lot of time to
acquire quality, and feel themselves possessed of the inquisitive spirit needed to improve our actual
and far too insufficient knowledge. Then, they may all become arterial surgeons besides being general
surgeons.
Lisbon, Casa da Rosa, July 1969 J. Cid dos Santos
VI
PREFACE
In the Netherlands, as in most other countries, vascular surgery is not yet aseparate specialty. Vascular
surgery is usually performed by general surgeons who take a special interest in it. They have to find
time for the lenghthy diagnostic and operative procedures in the vascular field, apart from their
already busy general surgical work. Because this book is intended for those surgical colleagues who
are forced to divide their time and attention between general surgery and vascular surgery, and for
cardiologists, internists, radiologists and residents in surgery who wish to orientate themselves about the
possibilities offered by reconstructive vascular surgery, the form of an atlas was chosen, with the accent
on visual presentation and a bare minimum of text.
This photographic atlas is arecord of experience gained by the author in the course of more than
2600 reconstructive vascular operations performed in aperiod of twelve years. During these years there
have been frequent changes in the views on 'ideal' methods of reconstruction. Failures occurred and
stimulated the search for better procedures, the soundness of which was tested experimentally. In
addition, gratefully use was made of the experience of others, such as were known from the literature
or through personal communication. In this way the material came to exhibit considerable range of
variation - variation which had to be expressed in this photographic atlas because it is the author's con
viction that, in vascular surgery, there exists no 'method of choice'. No fixed rules can be given for the
reconstruction of arteries. Variation is the only rule. In each individual ca se, the method to be preferred
must be selected on the basis of clinical and aortographic data, operative findings and the surgeon's
personal experience.
The most common patterns of arterial obstruction are depicted in this atlas. An attempt has been made
to do justice to the various possibilities of reconstruction in so far as they could be applied in the author's
surgical department, and to delimitate their indications.
This photographic atlas is not an operative manual. The basic principles of vascular diagnosis and
surgery are supposed to be known. Nevertheless, a description is presented of the surgical approaches
which in certain reconstructive procedures merit preference. Moreover, a number of new personal
techniques and procedures, and some improvements of conventional methods, so far not published
elsewhere, yet used for many years with good results, are described in detail.
The objects of this book - to provide the general surgeon and all those who have an interest in vascular
surgery with a guide to the wide variety of reconstructive vascular operations - precluded in advance
the depiction and description of the surgical treatment of aneurysms of the aortic arch, because abnormal
ities of this type can be treated only with the aid of extracorporeal circulation. All the operations described
in this book can be and were performed without special devices, and in particular without extracorporeal
circulation. Hypothermia was used in the treatment of some aneurysms of the abdominal aorta, but it is
the author's conviction that these aneurysms can be treated equally weil without resorting to hypothermia.
Acknowledgement is due to all who have helped directly or indirectly vithile this book was in preparation.
Above all, the author would like to express his gratitude to Miss R. de Zwart for her high-class photo
graphic work. Without her assistance and indispensable efforts it would have been impossible to
accomplish this atlas in this form.
In addition the author is indebted to his assistants for their interest and co-operation in the treatment of
vascular patients. They gave much of their time in discussions, operations and post-operative care.
Acknowledgement is due also to my friend Dr. E. Lokin for his support in reviewing the manuscript.
It is to be hoped, that this book, which is the result of co-operation and the enthusiastic support of all
colleagues of the Departments of Surgery and Roentgenology and many others of the hospital staft,
might arouse interest in vascular surgery in a still wider circle and could serve as a supplement to the
manuals already available in the field of vascular surgery, for the benefit of the reader and his patients.
Sittard, December 1969
VII
CONTENTS
THE SEGMENTAL NATURE OF PERIPHERAL OBLITERATIVE ARTERIAL DISEASE/1
CHAPTER 1- RECONSTRUCTIVE SURGERY IN CHRONIC OBLITERATIVE DISEASE OF THE
SUPERFICIAL FEMORAL ARTERY /5
1. Extensive occlusion of the superficial femoral artery / 6
1.1. Discarded femoral bypass procedures / 7
1.2. Autogenous saphenous vein bypass graft / 10
1.3. Composite saphenous vein graft. Combination of saphenous vein bypass graft and disobliteration
with venous patch graft angioplasty / 12
1.4. Composite saphenous vein bypass graft. Combination of ipsilateral and contra lateral saphenous
vein / 16
1.5. Thromboendarterectomy with venous patch graft angioplasty / 18
1.6. Closed-Ioop endarterectomy / 20
2. Segmental obstruction of the superficial femoral artery / 23
2.1. Thromboendarterectomy and Iimited intimectomy with autogenous vein patch graft angioplasty /24
2.2. Autogenous vein graft. Bypass operation and exclusion arterioplasty with proximal end-to-end
anastomosis / 32
2.3. Reconstruction using a prosthesis / 34
2.4. Autogenous vein bypass graft in combination with proximal endarterectomy / 36
2.5. Treatment of stenosis at the origin of the superficial femoral or the profunda femoris artery / 40
CHAPTER II-RECONSTRUCTIVE SURGERY IN POPLITEAL OCCLUSIVE DISEASE/43
1.1. Endarterectomy with vein patch graft angioplasty / 48
1.2. Closed-Ioop endarterectomy / 50
1.3. Autogenous saphenous vein bypass graft / 52
1.4. Exclusion arterioplasty with autogenous vein graft / 52
1.5. Resection and replacement by venous autograft / 54
CHAPTER 111-RECONSTRUCTIVE SURGERY IN EXTENSIVE OCCLUSION OF THE FEMORO
POPLITEAL ARTERY / 57
1.1. Autogenous saphenous vein bypass graft / 60
1.2. Bilateral autogenous saphenous vein bypass graft / 60
1.3. Composite saphenous vein bypass graft. Combination of ipsilateral and contralateral saphenous
vein / 62
1.4. Combination of proximal endarterectomy with venous patch graft angioplasty and distal saphenous
vein bypass graft / 64
VIII
CHAPTER IV - R ECONSTRUCTIVE SU RG ERY I N CO M MON FEMORAL OCCLUSIVE DISEASE / 67
1. Bilateral stenosis of the common femoral artery bifurcation treated by disobliteration and vein
patch graft angioplasty / 70
2. Bilateral obstruction of the common femoral artery treated by thromboendarterectomy and vein
patch graft angioplasty / 70
3. Occlusion of the common femoral artery and stenosis of the external iliac artery / 72
3.1. Open and closed-Ioop endarterectomy with synthetic patch graft angioplasty / 72
3.2. Endarterectomy and vein patch graft angioplasty / 74
4. Occlusion of the common femoral artery and its bifurcation; treatment by disobstruction and Y
shaped vein patch graft angioplasty / 76
5. Occlusion of the common femoral arteryand inoperable occlusive disease of the femoropopliteal
artery; reconstruction of the inflow tract of the profunda femoris artery / 78
CHAPTER V-RECONSTRUCTIVE SURGERY IN EXTERNAL ILiAC OCCLUSIVE DISEASE/81
1. Stenosis of the external iliac artery / 84
1.1. Endarterectomy and patch graft angioplasty / 84
1.2. Side-to-side anastomosis between hypogastric artery and external iliac artery / 84
2. Extensive occlusion of the external iliac (and common femoral) artery / 86
2.1. Prosthetic bypass graft / 86
2.2. Prosthetic bypass graft through the obturator foramen / 88
2.3. Combination of proximal prosthetic bypass graft and distal endarterectomy with venous patch
graft angioplasty / 90
2.4. Endarterectomy with proximal synthetic and distal autogenous venous patch graft angioplasty / 90
2.5. Autogenous saphenous vein graft / 92
·2.6. Closed-Ioop endarterectomy / 92
CHAPTER VI-RECONSTRUCTIVE SURGERY IN UNILATERAL COMMON ILIAC OCCLUSIVE
DIS EAS E /95
1.1. Disobliteration and prosthetic patch graft angioplasty / 98
1.2. Resection and replacement by prosthetic graft / 100
1.3. Partial resection and exclusion arterioplasty with prosthesis / 102
1.4. Bypass reconstruction / 102
CHAPTER VII-RECONSTRUCTIVE SURGERY IN EXTENSIVE THROMBOSIS OF THE COMMON
AN 0 EX TE R N ALl LI A C ARTE R I ES / 105
1.1. Prosthetic exclusion arterioplasty / 108
1.2. Combination of proximal prosthetic substitution and distal endarterectomy with synthetic patch
graft angioplasty / 110
1.3. Combination of proximal prosthetic replacement and distal endarterectomy with venous patch
graft angioplasty /112
1 .4. Crossover bypass with prosthetic graft / 114
1.5. Crossover bypass with venous autograft / 116
IX
CHAPTER VIII-RECONSTRUCTIVE SURGERY IN AORTOILIAC OCCLUSIVE DISEASE/119
1. Stenosis of the aortic bifurcation treated by endarterectomy and patch graft angioplasty / 124
2. Stenosis of aortoiliac arteries / 126
2.1. Disobliteration and synthetic patch graft angioplasty on both sides /126
2.2. Disobliteration and synthetic patch graft angioplasty on both sides (continued) /128
2.3. Endarterectomy in combination with synthetic patch graft angioplasty on one side and venous
patch graft angioplasty on the other side / 130
2.4. Disobliteration and Y-shaped patch graft angioplasty /132
2.5. Disobliteration with patch graft angioplasty on one side and bypass graft on the other / 134
2.6. Bypass reconstruction with bifurcated tube / 136
2.7. Resection and replacement by prosthetic bifurcation / 138
3. Occlusion of aortoiliac arteries / 140
3.1. Resection and replacement by prosthetic bifurcation / 140
3.2. Resection and prosthetic replacement with distal end-to-side anastomosis / 142
3.3. Bypass operation / 144
4. Coarctation of the aortic bifurcation treated by resection and replacement / 146
CHAPTER IX - R ECONSTRU CTIVE SU RG ERY I N I LI 0 FEM 0 RAL OCCLUSIVE D ISEAS E / 149
1. Elective revascularizing procedures of the profunda femoris artery / 152
1.1. Prosthetic aortoprofunda bypass graft / 152
1.2. Combination of proximal prosthetic replacement and distal endarterectomy with venous patch
graft angioplasty / 154
1.3. Endarterectomy with proximal synthetic and distal venous patch graft angioplasty / 156
1.4. Autogenous saphenous vein graft / 158
1.5. Crossover bypass with venous autograft / 160
1.6. Closed-Ioop endarterectomy / 162
2. (Aorto-) iliopopliteal bypass procedure / 164
2.1. Resection and replacement of the aortic bifurcation; bypass of the iliofemoral artery and endar
terectomy of the common femoral artery / 164
2.2. lIiopopliteal composite saphenous vein bypass graft / 166
CHAPTER X-RECONSTRUCTIVE SURGERY FOR ASCENDING THROMBOSIS OF AORTOILIAC
ARTE R I ES / 1 69
1. Ascending thrombosis of the aortoiliac arteries with partial patency of the subrenal aortic segment
(Types A and B) / 174
1.1. Resection and replacement of the obstructed aortic bifurcation; endarterectomy of the infrarenal
part of the aorta combined with patch graft angioplasty / 174
1.2. Resection and replacement of the obstructed aortoiliac arteries; endarterectomy of the infrarenal
aortic segment and left common femoral artery combined with patch graft angioplasty / 176
1.3. Aortoiliac bypass operation; treatment of the common femoral arteries by endarterectomy and vein
patch graft angioplasty / 178
X
2. Ascending occlusion of the aortoiliac arteries to immediately below the level of the renal arteries
(Type C); treatment by resection and prosthetic replacement using an infrarenal aortic anastomosis/
180
3. Ascending occlusion of the aortoiliac arteries with associated stenosis of one renal artery (Type D) /
184
3.1. Resection and prosthetic replacement of the aortoiliac arteries; left-sided nephrectomy /184
3.2. Resection and prosthetic replacement of the aortoiliac arteries; revascularization of the left kidney
by means of splenorenal anastomosis / 186
3.3. Resection and prosthetic replacement of the infrarenal aorta and aortic bifurcation; re-implantation
of the post-stenotic renal artery into the prosthesis with interposition of a synthetic graft / 188
3.4. Resection and prosthetic replacement of the infrarenal aorta and aortic bifurcation; re-implantation
of the post-stenotic renal artery into the prosthesis with interposition of a splenic artery segment!
190
3.5. Resection and prosthetic replacement of the aortoiliac arteries; autogenous vein bypass graft
between endarterectomized subrenal part of the aorta and post-stenotic renal artery / 192
3.6. Resection and prosthetic replacement of the aortoiliac arteries; re-implantation of the post-stenotic
renal artery into the endarterectomized subrenal part of the aorta with interposition of an auto
genous vein graft / 196
4. Ascending occlusion of the aortoiliac arteries with associated stenosis of both renal arteries (Type
E) / 198
4.1. Aortoiliac bypass operation using parts of the autogenous splenic artery as renal branches / 198
4.2. Resection and prosthetic replacement of the aortoiliac arteries; insertion of two autogenous vein
bypass grafts between endarterectomized subrenal part of the aorta and post-stenotic renal arteries/
200
CHAPTER XI-RECONSTRUCTIVE SURGERY OF ARTERIAL ANEURYSMS/203
1. Aneurysm of the femoropopliteal artery / 206
2. Aneurysm of the common femoral artery / 208
3. Aneurysm of the infrarenal aorta / 210
3.1. Resection and replacement by prosthetic bifurcation / 210
3.2. Resection and replacement by prosthetic bifurcation with suprarenal aortic clamping / 212
4. Multiple aortic aneurysms with kinking of the pre-aneurysmal portion of the aorta / 214
5. Ruptured aneurysm of the infrarenal aorta / 216
6. Aneurysm of the infrarenal aorta and aortic bifurcation / 218
7. Aneurysm of the aortic bifurcation / 220
8. Aneurysm of the infrarenal aorta with associated stenosis of one renal artery / 222
8.1. Resection of the aneurysm and prosthetic replacement; transaortic endarterectomy of the stenotic
renal artery / 222
8.2. Resection of the aneurysm and prosthetic replacement; insertion of autogenous vein bypass graft
between subrenal part of aorta and post-stenotic renal artery / 224
XI