Vascular surgery
occlusion causing resistance at the bottom end. What you want to see is a pulse that ‘comes up’ and then ‘goes down’, because it’s flowing away.” Prof. Bosanquet points out that a surgical
probe is more effective in decision-making than palpating with a finger: “We know that a pulse is not good enough – you should use a Doppler, so that you can see, hear and evidence that there is flow past the surgery. This week, I have performed an emergency operation, two major revascularisations and two big cases – I used the Doppler to complete every single one. I don’t see it as anything other than being standard practice, now.” The probe ensures that patients are not
sent to recovery with a failing graft, offering rapid, reliable, and easy-to-use confirmation of successful blood flow. This confidence in the probe’s effectiveness is crucial for the surgical team’s decision-making and patient outcomes. He gives the example of a case study in which he needed to get blood flow down both of the patient’s legs. At the end of the procedure, blood was flowing satisfactorily down one side, but for the second limb, the picture was less certain. In this situation, he needed to decide whether to use a plastic tube from the ‘good side’ to the ‘bad side’, or whether the flow was in fact adequate. “To decide if I have achieved sufficient flow, I
looked at the foot. I felt the pulse, but I also used the Doppler. What I found was that, although there was a very faint pulse, it was not sufficient – I needed to go on to do more. If there is a problem, you can fix it on the table. “The winners are the patients, as you can give them the best operation,” Prof. Bosanquet continues. “If a graft fails in recovery, and you have to bring the patient back, not only is that a significant burden to the patient, but you’re essentially doing an emergency case – when everyone should be moving on to the next patient. That’s where the savings are; you’re not bringing patients back to theatre,” he comments. The technology has other useful applications
in vascular surgery – Prof. Bosanquet explains that Doppler ultrasound can prove helpful in locating a vessel when dealing with anomalies. He cites a case where a bypass graft was inadvertently tunnelled through a muscle, which caused it to pinch each time the knee was bent. “If you’re looking in the middle of a muscle
and not at the normal anatomical place, the vessel may not be immediately apparent. In a challenging scenario such as this, the surgeon can direct the Doppler probe at different angles and different locations to help them identify exactly where the abnormally placed artery is located,” he explains.
Pulse palpation The pros of pulse palpation (within the operative field, in the distal limb) include: l Immediate l Free, easy to do, simple l Part of standard surgical teaching
The cons of pulse palpation include: l Difficult/impossible to palpate distal pulses in certain circumstances
l Can be present despite occluded graft l No way of ascertaining graft at risk l Subjective
Completion angiography The pros of completion angiography include: Detects technical issues immediately (e.g. stenosis, poor flow). l Allows intraoperative corrections l Provides documentation for quality assurance
The cons of completion angiography include: l Adds time to the procedure l Adds/increases radiation exposure l Risk of contrast-related complications (e.g. nephrotoxicity)
l Higher cost and resource use
Intraoperative Duplex ultrasound The pros of Intraoperative Duplex ultrasound include: l Non-invasive and radiation-free l Real-time haemodynamic assessment l Detects residual flow abnormalities
l Useful in carotid endarterectomy (CEA) l Portable and repeatable
The cons of Intraoperative Duplex ultrasound include: l Operator-dependent accuracy l Limited anatomical detail l Inconsistent evidence on long-term outcomes l May miss subtle defects in deep or calcified vessels
Intraoperative Doppler probe assessment The pros of intraoperative Doppler probe assessment include: l Immediate feedback on blood flow – confirms graft patency and vessel perfusion
l Audible and visual signals enhance surgeon confidence
l Non-invasive and sterile – single-use probes reduce infection risk
l Useful in small vessels - micro-Doppler ideal for vessels <2-3mm
l Portable and easy to use – direct application to vessels
The cons of intraoperative Doppler probe assessment include: l Limited anatomical detail – cannot visualise vessel structure
l Operator-dependent interpretation – requires experience
l No quantitative flow data – qualitative assessment only
l May miss subtle abnormalities in deep or calcified vessels
Table 1: The pros and cons of the different approaches used for completion assessment
Post intervention assessment Discussing post intervention assessment, Dr. Leigh Ann O’Banion, Associate Clinical Professor in the Department of Surgery, University of California San Francisco, Fresno Branch Campus, comments that, “The success of the first operation matters the most. You need to leave the operating theatre knowing you have performed a technically perfect operation. There are various ways you can do that – one is a post intervention Doppler assessment, which allows audible feedback distal to the intervention (including monophasic, multiphasic, water hammer). An interoperative Doppler assessment is the perfect way to start, once you have completed your bypass.” She comments that it is important for less experienced surgeons to practice listening to the sound of the triphasic signal to ensure they are familiar and ‘tuned’ into the different
Doppler signals they will hear. However, she adds that it is also important to see the waveform, where possible. “Having completion Duplex ultrasound can
also be really valuable to gaining a better understanding of the haemodynamics... “We need to think about ultrasound in the
same way for open procedures, as we do for endovascular. Sometimes, it can be quite challenging to identify the location of the pathology, but you get a little more information than the Doppler alone.” Dr. Leigh Ann O’Banion says that she uses completion angiogram for tibial cases, tenuous vein, or if there is a concern with the clinical examination. However, angiograms can be misleading, she points out: “You may think the outflow doesn’t look good, but when you complement the angiogram with interoperative Duplex, you may find it is just spasm,” she
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