Vascular surgery
Closing with confidence in vascular surgery
Doppler ultrasound can provide a cost-effective tool in ensuring verification of vascular blood flow during vascular surgery, enabling surgeons to ‘close with confidence’. So, should the philosophy shift towards physiologic assessment first and imaging second?
How can we ‘close with confidence’? This is the key question faced by surgical teams when performing vascular procedures. Quality control is vital when performing surgery, if secondary intervention and re-operation are to be avoided. Reliable and safe verification of vascular blood flow, during surgical procedures, gives surgeons the reassurance they need that the procedure has been performed satisfactorily. But what is the optimum method for completion quality assessment and what is actually happening in practice? Currently, the main options available include pulse palpation; completion angiography; intraoperative Duplex ultrasound; Intraoperative Doppler and other technologies. The pros and cons of these various approaches are shown in Table 1.
The guidelines Both the European Society for Vascular Surgery and the Society for Vascular Surgery have produced guidelines on many vascular procedures, including managing acute and chronic limb ischaemia, carotid artery disease and mesenteric artery disease.1,2
All
recommend some sort of assessment after the arterial reconstruction has been completed, mostly suggesting that angiography or Duplex ultrasound are used. “Often guidelines do not describe the real- world complexity of our practice,” comments Mr Lukla Biasi, a Consultant Vascular Endovascular Surgeon at St Thomas’. “Guidelines are both a comfort zone and quicksand for surgeons; there is no ‘one size fits all’, and guidelines are often outdated, as they are the result of a long process of agreement and medical research,” he warns.
He calls on the surgical community to
improve the strength of evidence around international recommendations for completion quality assessment in vascular surgery and highlights a need to “introduce intraoperative Doppler into the narrative of the guidelines.” Mr Lukla Biasi points out that we also need
to be aware that catheter directed angiogram comes with a risk of complication itself (i.e. a 1% risk of stroke). “For acute ischaemia, the recommendation
is to try to integrate the procedure into a hybrid [theatre] setting, where we can perform open surgery, endovascular treatment and completion angiogram. In practice, this is not always the case. Often interventions are performed out of hours and not in the ideal setting. Performing a completion angiogram is not always feasible or time-effective, plus there is a risk of contrast-induced nephrotoxicity,” he explains. Before the advent of Doppler technology,
traditional methods of assessing blood flow required invasive procedures like injecting the vessel and taking X-ray pictures, which carries a risk of complications. The Dopplex probe, for example, offers a non-invasive alternative, reducing these risks significantly. It can provide immediate evidence of success in vascular reconstructive procedures. By confirming blood flow prior to closing, time and costs of a potential re-operation can be saved. This approach can offer surgeons real-time confirmation of vascular patency during operations, providing reassurance and eliminating guesswork. Doppler ultrasound can be used in a wide
range of clinical procedures, including carotid endarterectomy, femoro-popliteal bypass, femoro-distal bypass, arteriovenous fistulae, coronary artery bypass grafts, renal and hepatic transplantation, aortic aneurysm repair, cosmetic surgery and skin flap surgery.
Visualising pulse waveforms Professor Usman Jaffer, an Honorary Consultant Vascular Surgeon, Imperial College Healthcare NHS Trust, asserts: “People talk about ‘a must have’ or ‘a nice to have’. As shown by our data around peripheral arterial disease detection,3 in people with diabetes, Doppler is very much in the ‘must have’ category, rather than the ‘nice to have’.” Prof. Jaffer highlights an example of
how the technology is used during femoral endarterectomy. The common femoral artery, located in the groin, supplies blood to the thigh and calf. When this artery becomes obstructed with calcified material, or atheroma, it impedes blood flow, risking tissue damage and other serious health issues. Without precise and reliable tools to assess blood flow, surgeons can face challenges in confirming the success of procedures like bypasses and endarterectomies. Inadequate blood flow can lead to prolonged recovery times, increased risk of complications, or the need for
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