AXILLOBIFEMORAL BYPASS

PREPARED

BY

IMELDA BATALLONES

AXILLOBIFEMORAL BYPASS

1.        DEFENITIONS

Axillofemoral bypass is a method of surgical revascularization used in the setting of symptomatic aortoiliac occlusive disease for patients without an endovascular option or who cannot undergo an aortofemoral reconstruction. The bypass depends on a healthy axillary artery for adequate inflow to the ipsilateral arm and one or both legs. This extra-anatomic reconstructive method is one of the options for managing patients presenting with infected aortic grafts or aortoenteric fistulae. Bypass patency rates are estimated to be 40-80% at 5 years.^{[1, 2, 3, 4]} Patency rates are influenced by the characteristics of the patients; claudicants generally have better patency than patients with critical limb ischemia.

2.        INDICATIONS

·            Symptomatic lower extremity ischemia (disabling claudication, rest pain, tissue loss), acute (thrombosed aortoiliac system) or chronic

·            Infected aortic grafts or prosthetics

·            Aortoenteric fistulae

·            Patients without endovascular options for management of their ischemic symptoms

·            High-risk patients with significant comorbidities that preclude inline reconstruction with inflow from the aorta (cardiopulmonary, multiple prior abdominal surgeries, prior radiation therapy to the abdomen, abdominal stoma)

·            Aortic coarctation

3.        CONTRA INDICATIONS

·            Diseased axillary or subclavian arteries

·            Extreme medical risks for surgery; ie, nonsurvivable acidosis in the setting of acute ischemia

NURSING CARE

A.     PREPARATION FOR SURGERY IN THE WARD

-         Prepare the skin at least 12 hours prior to surgery by throughout cleansing the lower abdomen and legs with germicidal soap.

-         Hair removal may shave to surgeon request

-         Have the patient prepare on the day before the surgery for the surgeon to mark his skin with pen

B.     PREOPERATIVE NURSING CARE – RECEPTION

1.     Received and identify the patient correctly by

-         ask  the patient name

-         checking patient identification band and conform with  file data.

2.     Received the endorsement form the ward regarding premedication, latest of blood investigations, X-Ray, or CT – Scan, Blood availability,

3.     Check the file, consent must be signed properly

4.     Check for any implants or jewelry, loose or removable teeth and presence of contact lenses.

5.     Be sure the patient is fasting minimum 6 hours

6.     Wheeled the patient to preoperative waiting area.

C.     ROOM PREPARATION IN OPERATING THEATER

1.     Major set and major  packet

2.     Hibitane 0,5% ,  bethadine

3.     Plain gauze

4.     Raytec gauze

5.     Abdominal swab

6.     Diathermi wire

7.     Blade no, 10 and 20

8.     Ligature vicryl No : 2-0, 3-0, 0,

9.     Suture material vicryl 2-0, 3-0, and vicryl 1or stapler for skin closing.

10.            Suction

11.            Bladder syringe

12.            Nylon tape

13.            Light handle

14.            Self retaining

D.   Anesthesia

-         Axillofemoral bypass is most often performed under general anesthesia as exploration of the axillary artery and tunneling of the graft proximal from the chest to the distal femoral landing site can be difficult to tolerate.

-         In cases where general anesthesia is contraindicated due to underlying cardiopulmonary disease, the procedure can be performed under local anesthesia with sedation.

E.   Equipment

·         Standard vascular clamps and instruments

·         Tunneling device (ie, Gore tunneler; W. L. Gore and Associates, Flagstaff, Ariz)

·         Polytetrafluoroethylene (PTFE) or Dacron-based aortic grafts (6-10 mm) of appropriate length and configuration for either a unifemoral or bifemoral reconstruction

·         Doppler ultrasonography device to assess blood flow intraoperatively

F.    Positioning

Perform the procedure with the patient positioned supine and prepare a wide sterile field from the neck to the anterior thigh (chest, flank, abdomen included). Place a rolled towel under the ipsilateral torso to allow good visualization of the lateral chest wall during tunneling of the graft. Sterilely prep the donor arm, which allows for intraoperative abduction of the limb to assess for graft lie following the axillary anastomosis.

INTRAOPERATIVE NURSING CARE

1.     Scrub Nurse

·          Works directly with surgeon within the sterile field, passing instruments, sponges and other items needed during the procedure.

·          Prepares and preserves a sterile field in which the operation can take place

·          Maintain sterility throughout the procedure

·          Awareness of the patient's safety

·          Undertake count of sponges and instrument with circulating nurse

·          Helps to apply dressing

2.     Circulating Nurse

·          Take the patient from waiting room areas, be sure to verify the correct identification of the patient by checking the identification band or by asking the patient complete  name.

·          Secure proper positioning to protect the safety and skin integrity of the patient under anasthesia.

·          Responsible for managing the nurse care of the patient within the operating and coordinating the needs of the surgical team with other care provider for completion of surgery

·          Observe the surgery and surgical team from broad respective and assists the team to create and maintain a safety and comfortable environment for the patient

·          Asses the patient's condition before, during and after the operation to ensure optimal outcome for the patient

·          Must be able to anticipate the scrub nurse,  needs and be able to open sterile packs, operate machinery and keep accurate record

·          Record patient data on register book:Name, hospital no, age, sex, nationality, ward, surgery, surgeons, anasthetist , type of anesthesia has  given, scrub nurse and circulating nurse.

·          Ensure specimen area properly and labeled, data completed : name , hospital number, age, sex, nationality , CID, unit surgeon, name of specimen , and specimen request must be filled and signed by surgeon and write on the specimen register book

·          Documentation

·          Hand over patient to recovery room.

PROCEDURE TECHNIQUE

1.     Exposure of the axillary artery

Make a transverse infraclavicular incision approximately 2 fingerbreadths below the clavicle. The pectoralis muscle is exposed and fibers are split superiorly and inferiorly. At this point, divide the pectoralis minor muscle insertion to allow for more exposure. The axillary fat pad, which contains the vein, artery, and brachial plexus, will be accessible. The axillary vein lies anterior to the artery and requires mobilization inferiorly to allow access to the artery. Isolate a 3-4 cm length of artery, which requires some branching vessels to be ligated and/or controlled.

2.     Exposure of the femoral artery

Obtain either unilateral or bilateral exposures of the femoral arteries depending on the revascularization needs. Use longitudinal or oblique groin incisions for the femoral exposure. Carry the incision along the femoral pulse at the level of the common femoral artery (inguinal ligament). Dissect subcutaneous tissues and enter the femoral sheath. The artery lies lateral to the femoral vein. Dissect the common, superficial, and deep (profunda) femoral arteries and control with vessel loops. Control and preserve circumflex branches.

3.     Tunneling of the graft

Perform subcutaneous tunneling prior to systemic heparinization. Use a graft tunneling device (eg, Gore Tunneler) to create a midaxillary tunnel, lateral to the nipple and above the abdominal fascia, from the axillary incision to the femoral incision. If required, create a femoral-to-femoral tunnel superior to the pubic bone for a bifemoral reconstruction. Pass the PTFE/Dacron graft(s) through the tunnel(s) with the use of the device and ensure there are no twists or kinks.

( Tunneling of the axillofemoral bypass (bifemoral configuration shown).

4.     Axillary anastomosis

Administer intravenous heparin prior to vascular control for the creation of the anastomosis. Perform proximal axillary anastomosis first. The axillary and subclavian arteries are considerably more fragile than the femoral arteries, so take care to avoid aggressive handling of these vessels. Use angled clamps (ductus, angled DeBakey, or mini profunda) to obtain proximal and distal control of the axillary artery. Perform a longitudinal arteriotomy and fashion a hood on the PTFE/Dacron graft. Then create an end-to-side running anastomosis. Assess graft inflow and distal axillary arterial outflow as the arm is abducted to ensure there is no tension on the anastomosis.

( Axillary anastomosis )

5.     Femoral anastomosis

There are many configurations to creating the distal femoral anastomosis depending on the needs of the patient. If a bifemoral configuration is required, construct the distal femoral-to-femoral anastomosis first and land on the distal axillary graft on the ipsilateral segment of the femoral-femoral graft. Otherwise, the contralateral femoral limb may come directly off the ipsilateral axillofemoral graft in end-to-side fashion. Premade axillobifemoral grafts also exist from several manufacturers.

Once the femoral vessels are controlled, create a longitudinal arteriotomy. Create the distal femoral anastomosis in an end-to-side fashion to an appropriate branch of the common femoral artery, most often being the common femoral artery itself. If there is significant disease of the superficial femoral artery, the anastomosis may need to be performed to incorporate the deep femoral artery. In general, spatulation of the anastomosis to the deep femoral artery is recommended. Concomitant endarterectomy of the femoral artery may need to be performed if significant disease exists on the distal target vessel.

POSTOPERATIVE NURSING CARE – RECOVERY ROOM

       A recovery room nurse provides constant care to patient immediately following the surgery. This may be a time frame anywhere from 30 minutes to a few hours until the patient is stable and out from the effect of anasthesia.  The recovery staff nurse must be:

1.     Ensure that the patient is breathing spontaneously, administers oxygen

2.     Assess the level of consciousness by orienting the patient by asking patient name, and any complaint

3.     Monitor vital signs such as BP, HR, Temp, Saturation, Respiratory Rate. Take not for any alteration and sign of complication

4.     React rapidly to signs of physical changes and inform the anesthetist

5.     Assess comfort level. Asking the patient about the level of pain and administer pain medication that had been prescribed

6.     Asses the patient dressing for drainage or bright red bleeding, report to the surgeon

7.     Make sure the patient is warm and comfortable

8.     Documentation

9.     Hand over to their respective ward after fully recovered from anesthesia.

COMPLICATIONS

·            A thorough preoperative assessment of the inflow vessel cannot be stressed enough.

·            Pay strict attention to sterile technique when handling prosthetic grafts.

·            A wide sterile field is necessary to allow for a thoracotomy, sternotomy, or laparotomy to manage intraoperative bleeding or other unexpected complications that can arise while performing the revascularization procedure.

·            Place axillary anastomosis as medially on the artery as possible (medial to pectoralis minor muscle) to avoid tension on the anastomosis when the arm is abducted.

·            Tunnel the graft along the midaxillary line to prevent kinking of the graft with torso flexion.

COMPLICATIONS OF SURGERY

·            Brachial plexus injury

·            Axillary pullout syndrome (disruption of the axillary anastomosis)

·            Graft thrombosis

·            Graft infection

·            Early graft thrombosis and delayed pseudoaneurysm of the graft (may be a sign of underlying graft infection)