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Vascular surgeons are unique from other specialty surgeons as their focus is on a broad spectrum of blood vessels which is only exclusive of the heart and intracerebral vessels. With this anatomic scope are a variety of surgical approaches and treatment options that can be adapted to all situations. Each vascular open operation has the goal of identifying the inflow and outflow vessels that will then be locally reconstructed or bypassed to improve perfusion. Hybrid vascular surgery is a label that has been developed in the last two decades to refer to cases with an open and endovascular component, as endovascular surgery has taken root in the management of vascular disease especially for occlusive and aneurysmal disease. Its innovation has been led by vascular surgeons and knowledge of both open and endovascular techniques and is a necessity in the current treatment of vascular patients.
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Regardless of innovation, skillful management of the blood vessels is important as even minor errors can be relentless and unforgiving. As such, the basics of vessel dissection and anastomosis remain constant. This chapter will focus on the basic techniques of exposure, vessel control, endarterectomy, and vessel reconstruction. Specifics regarding conduits will be covered in Chapter 14. As the iliac vessels are often exposed with a retroperitoneal approach, vascular surgeons often have the unique opportunity to participate in spine surgery and thus the techniques of anterior spinal exposure are also presented.
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VESSEL EXPOSURE AND CONTROL
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Anatomic awareness is essential to all exposures. A majority of exposures have been developed by pioneers in vascular surgery using muscle-sparing paths in naturally occurring planes. Given the multitude of possible management options, there are a plethora of approaches with some locations having different options based on the situation. One example is the approach to the popliteal artery which is most commonly accessed from a medial exposure for a bypass or thrombectomy. However, when performing popliteal aneurysm repair, a posterior approach can be very effective. A specific incision may also be selected based upon the surrounding tissue structures or previous surgery. This is often a consideration when choosing the lateral or medial approach to the profunda femoris artery. In general, the extremity vessels are often in close proximity to other structures particularly peripheral nerves and associated veins. Central abdominal incisions, by contrast, have fewer options for locations. Truncal exposure requires a deeper knowledge of associated organs and tubular structures (bowel, ureter, lymphatics, etc.) in addition to variations in the abdominal wall. Arterial anomalies are more common with the trunk vessels. Redo surgery carries additional risk and complexity as the natural planes are often fused with scar tissue, rotational flaps, or synthetic material. Similar situations like radiation and infection can also affect the natural tissue causing radiation fibrosis, inflammation, and edematous phlegmons. Situational awareness and proper caution can minimize local injury and enhance outcomes. Despite these ...