Thoracofemoral Bypass: A Retroperitoneal Approach

CHAPTER 1

Hi, my name is Benjamin Pearce. I'm an associate professor at University of Alabama Birmingham. And today we have a case for you of a retroperitoneal approach to a thoracofemoral bypass. And this is a 52-year-old gentleman who has a significant history of familial hypocholesterolemia and early onset atherosclerotic disease. He actually suffered for several years from what was likely buttock and hip claudication, but was misdiagnosed with low back disease. He sought multiple opinions and actually on workup for spine surgery, was found to have significant coronary disease and had to undergo a recent coronary bypass graft. At the time, they attempted to do a heart cath from the femoral vessel and realized the patient had an occluded aortic segment. CTA reveals a normal-looking thoracic aorta, a heavily-diseased perivisceral aorta, especially beginning at the level of the SMA but patent SMA and renals. He then has complete occlusion of the aorta as well as both iliac systems and reconstitutes the femorals via the epigastric collaterals. I discussed at length with the patient, the relative means of revascularization. He does not seem to be a good candidate for endovascular therapy, both due to the extent of disease as well as his youth. In addition, I think that he would best be served with a thoracofemoral bypass. In his case because of the visceral disease, I would like the opportunity to be able to interrogate this with ultrasound during the case and if need be actually perform an aortic endarterectomy if there is indication during the operation. He doesn't meet criteria for this currently as he has does not suffer from hypertension, nor is he having any mesenteric ischemic symptoms. Further, this would leave his thoracic aorta clean for potential future operations given his youth and potential need for revisions as we go down the road. So we're gonna approach this through a retroperitoneal incision today. In a modified decubitus position. We'll plan to do bilateral femoral exposure and then we will focus the case on the construction of the proximal anastomosis as well as the tunneling in the modified decubitus position. And we look forward to having a good result.

CHAPTER 2

we're in the modified right decubitus position with the pelvis as flat as possible and the shoulders at about 30 to 45 degrees to allow us to have access to the supraceliac aorta for a thoracofemoral bypass but still have access to the groins. He's gonna actually need femoral endarterectomies as a part of his procedure. And then I like to go in about the ninth or 10th - eight, or ninth, or 10th inter-space depending on how his abdomen looks when he lays. So, I'm just counting here his 11th space, 10th space, ninth space. It looks a little low. We'll go eight for him. And then we take, bring the incision down. Paramedian, low enough to allow us to make the tunnel across to the right groin from the retroperitoneal plane. So something like that. All right, that's what we'll start with. Make a little bit more gentle like that.

CHAPTER 3

Okay, so we're gonna start with the femoral incision, so we decrease the amount of time that his viscera is open. Make sure we have an outflow. Knife to Dr. Oakland, please. I like to make just a little bit of an elliptical incision. They tend to heal better. But we'll go below the crease. He's skinny, and that way we can make sure we get the profunda and the SFA out. Can I have a pickup? Can I have the cerebellar? You can feel in there. Pretty calcified, right? Can I get my headlight plugged in, please? I'll take a Metz. So I always like to see the inguinal ligaments. More of this, please. Thank you. Can I have the cerebellar? Scissors. Good question. Looks - the water's going through them good. Yes sir. Yeah, they're doing great. Thanks my man. Appreciate you. Bovie. Split the inguinal ligament a little bit, so we can see the crossing vein. Vein of Goertz as it was known where I trained. Can you have the blunt Weity, please? Forceps. Nope, got it. Scissors. It looks on this one, we're doing endarterectomies, so we're \gonna make sure we get out the proximal SFA and the profunda, separately. So we can tow down onto the SFA. Metz and right angle. Fine right angle. Did you find the main vein already? Oh, you can see a little branch there. On my side, I'm gonna need your help once you guys are ready. Yeah, with everything else because it's up under the inguinal ligaments. Thank you. Did y'all pull a red rubber in case you wanted that. We will need the red rubber for sure, at least one if not two. Scissors? Can I have my Bovie back? So toe in. Yeah, and pull up a little bit. Fine right angle. Another one there, Bailey. Hold that. Thank you. There you go. I'll take that fine right angle back. 3-0 silk. I'll take the first little vein branch that goes over the profunda so we can make sure we can get a good soft spot to clamp. Nice profunda, soft. Can I have a - yeah. Sorry, everything's elevated. All righty. Soft spot to clamp there. Get her Mr. B. Hold on. Okay. Hold on. She said hold on. You can relax but not all the way. Do you wanna divide the vein or you don't? I mean I just, I divided this little gintsy thing up here, but there's nothing else down there. So there's that tunnel. You agree? It looks pretty, pretty good. Make a pretty decent tunnel there. Yeah, whatever it was was up here. You can see that thing you tied actually. But I agree. I don't think you need to do much more. Sweep all that stuff up. Do you have beaver? There's some real bleeding in there. This retroperitoneum is a little sticky back there. Lemme have a - hold this for a second please. Potts forceps? Cool, like so, good. I saw it when I first put that in there but whatever it is must not be too bad. Let go for a second. Let me see. Yeah, okay, good. Hold right there. That makes - that makes more sense. All right, you can come out. Let me see you over on this side. Let me have the appendiceal on this side. I'll take the Adson right angle. Here's the big vein here. DeBakey forceps. So I like to double ligate this so when we tunnel, we don't rip it. Thank you. Gimme a medium clip, Bailey. Can I have a blue - or small vessel loop as well. Yeah. Hemostat. Regular medium clip. Scissor. Borrow you for a second. Thank you. Can Isabelle have a pickup? Here we go. We got a good tunnel started there. That looks nice. All right. Okay. What's that? Billy gave you all of them, huh? You're really long. So that's a, yeah, switch your hands if you need to. Metz. I'd take a little bit more down your profundo so we get to a good soft spot. Do you have a cerebellar? Right angle. That first vein branch there. Beautiful. 3-0 silk. Give her the fine right angle, maybe. Oh, she's got it. Nevermind. Another one of those silks. Can I get more 3-0 ties, please? Good. Feel there. Better. You can clamp it down there for sure. This feels nice. Yeah. There's just a little plaque right at the bifurcation, which is why we're gonna plan on doing the... Scissors. Right angle. 3-0 silk. Scissor. Well that feels good. Nice. SFA's good. Big branch right there. Profunda branch is right there. We may be able to just clamp right above both of them. Let's put that around both of them so we... There you go. All right. Moist lap. Take the tension off the skin. Relax that little loop. All right, good deal. All right, let's do it. Make the little gentler line.

CHAPTER 4

On the inside line there. Bovie to me. Yeah, nice. Okay. Give her a Bovie too. Just come down to the intercostals. You don't have to get into the chest yet. So when we're making a thoracoretroperitoneal incision, so we have the ability to go into the left chest if we need to to clamp or even do our anastomosis. And it lets us, if anything else, we take the diaphragm down to get more exposure around the proximal aorta. It looks like he has a very nice, soft supraceliac aorta. That'd be good Inflow. I also wanted to do this incision in case we decide we need to do something about his visceral segment, although he has some plaque in his perivisceral aorta, he's completely asymptomatic, with no hypertension, no mesenteric ischemia. So even though there's some plaque, he doesn't have any indication for an aortic endarterectomy. So we're just gonna make sure we'll be able to do the assmosis and make sure we don't injure anything. We can duplex all the vessels at the conclusion. Let's see. Keep it safer. Try and stay outside the rectus this time. Forceps. Yeah, it's not that - pretty lateral, isn't it? Let's see what that is. Let's see if we can get into the retroperitoneum over here and then we can come at it from your side. We may already be in the peritoneum, let me see. I'm not going through the transversalis yet. A little bit more. Just come through here. Let's find the retroperitoneal plane. Let me have an Adson right angle? There we go. Now we're in the peritoneum. Let's see if we can tease this off. Give her a 2-0 Vicryl. Just put a little stitch in this while we're looking at it. It's tearing pretty easy. At the end of the day, that's not the end of the world. But we like to repair these when we see them. So see, we're trying to stay out of the peritoneum and in the retroperitoneal plane here. So we just made a little rent in the peritoneum, which is again not the end of the world but, but if you stay in here, that just tore. I'll just leave it be. It can make closing it all a lot easier too. Let me have an Allis. Good. So we're just teasing the peritoneum away. Give her the Bovie. So we keep opening - I'm gonna pull the rectus muscle to me. We'll stay paramedian here. She's got the peritoneum down. Good. Very nice. Close to being able to make your tunnel, huh? Might as well use the whole incision. All right, Kocher. Another Kocher.

CHAPTER 5

All right, put the light in here and then we'll start teasing this away. Get the ureter up and make our tunnels. Just a little blunt dissection and here comes iliac vessels, ureter is - see the ureter up in here Isabelle? Colon's coming up. The ureter is gonna be in there somewhere. Iliopsoas muscle, right? Gonadal vein there. Iliac vessels, chronically occluded. See? Ureter right on top of it. So see the ureter right here? And that's the iliac - external iliac artery, common iliac artery. All right, good times. We'll work up this way a little bit and we'll come back and make our tunnels. Bovie, long tip. Potts forceps. Burn these little things as we go so we don't let them ooze the whole time. Good. Good. Let me see the Bovie, Bailey. Buzz me. And let's worry about getting the rest of this down. Okay, we're getting behind the kidney now. Like usual, with former smokers, he's barrel-chested enough that I think we're just gonna take down the diaphragm a little bit. All right. Let's just count one more time. 11th space, 10 rib, 10 space, nine rib. We'll go right in here, huh? Yep. Stay on the top of the rib below so that we know we're not gonna get any neurovascular bundle. Do you have the stapler loads for the diaphragm? The endo GIA Good. That's gonna come like right over here. Okay. Yeah, come right up into the cartilaginous part right here. Just kind of follow it along. Good. Okay. Let me see the plastic tip sucker. Stay right on top of that rib. Plastic tip sucker. Good. Okay. Yep. Let me have the Adson right angle. Okay. We'll do the diaphragm here. So we're gonna take some of the diaphragm just to give ourselves better visualization up high. Do you have the stapler? Thinned out, huh? It's pretty thinned out. This is a little trick we learned from Dr. Beck where we use the endo - GIA to give us a nice cut on this diaphragm so we can put it back together later. Let me see a Kelly? Why don't you open it. Just kind of sweep it up. Feel the rib space here. That's that one. Oh, he's really stuck into his chest there. Do you have that - another load of the stapler. Okay, good. For the chest tube. In the chest. Yeah. Make it easier to put the chest tube in, anyway. Good. This diaphragm is sticking a little bit right here. Put the retractor in in a minute as we start getting the spleen up. Let me have Adson right angle. And get that sort of separated. Get us back in the proper space there. Put my finger in there now. Cut that. Bovie, yep. Good. Good. Nice. Do you have a sponge stick? Here's the tip of the spleen there. Yep. Getting around the spleen. A lot of this is just by feel. Okay, let's put the retractor in and we'll be ready. All right, I like to use the Omni-retractor. Here we go. Three clips, please. Move this down just a little bit. Moist lap and a Mayo body wall. Do the same thing on the other side. All right, Bailey, can we slide? Okay, give me that stapler one more time. All right. See if you can work on this wall a little bit. Getting the diaphragm off. Right Angle and some scissors. That's the spot, right? Perfect. That's beautiful. That's what we were looking for. Hold that diaphragm back, yep. Let me see that Adson right angle. It's always the last little bit that's the stickiest, you know? Let me get this in there. Let's see if you can get a little bit more up this way. Scissors to her - see right there? Get us back in the right spot. Almost. That's right. We're almost at the top of the spleen, there. Table down, please. All the way to the ground. That's good. All righty. In the peritoneum a little bit there. Not the end of the world. Scissors. That's right. Push on that. Just gotta come up on the crus here, and let's come back down here - Bovie. We'll just keep... Start working the kidney up. Let me have a big right angle. With the other Bovie. Long-tip Bovie. All right, I'm gonna get all that off so we can get back to the top. Uh huh. Right on my finger. That's good. Let me have a big right angle. That's the spleen there, huh? These are some of the peritoneal attachments to the spleen, just being persnickety. Let me have that right angle back. Okay, go ahead and take this. It'll be all right, it's just peritoneum. Get a long Bovie in there, and then we'll get some retractor down on that diaphragm here in a minute. Good. Long tip Bovie. Good. You put that NG in, right? Yep. Good. No. No, no. I can't - I just wanna know so I can feel for it, actually. I'm getting up to the crease here. Feel, here comes the aorta. All right, roll the table towards me, please. A little bit more. That's good. Let me have a moist towel. Let me have a big right angle. This diaphragm is not wanting to give up the ghost, is it? Bovie. That may have been the last of it. Huh? It's all just more of that same. Maybe a little vein in there, huh? Good eyes. That's gonna be our crus, right there. Right above that we're gonna be able to sew. All right, let's see if we can get the retractor in better now. Help each other out. Let me see the fence? The slightly smaller fence We can try putting - let me have a Kelly for the machine now. I need a step. I need to do a little bit more work here just to get it over so we can see the left renal. A big right angle. I'll take a pickup and the long Bovie. You have the long Bovie. I do. You're right. This should be the left crus, right here. There's one of those lumbar veins. 3-0 silk. That's probably the left renal artery, there. It's hard. See? Right there is left renal artery. So we're gonna work above that. Let me see the big right angle? Let me have an Adson right angle. It should be diaphragm, left crus of the diaphragm. Yep. We'll come go that way a little bit. Good. Pull that towards you again. Trying to find the best spot here. Okay. It's like either too high or too low with my loops. Let me put my finger in there and feel it. That's aorta. I feel like we're not quite medial enough on that crus. Lock that. We have the medium, slotted. I'm pulling that back through. Okay, lock it. Good. Forceps. Big right angle. Good. All right. Bovie right - yep, you got it. Nice. Scissors. Get us the hockey stick, I just want to see where we get free of the disease. You know what I mean? Lock this again. Good. Forceps, big right angle. Get that. Hold your side. All right. We gotta get enough to get a clamp on there. Forceps. You should start seeing SMA or celiac down here, so... That's probably celiac, right? We'll just look with the - this actually looks like good aorta to sew to. Get a little bit of that. Yep. All right, put a renal vein retractor in there and really get that over. Renal vein retractor. Okay, try that. And it slipped out. What can we do to get that a little bit easier to see? You want to put another renal vein on this side? That's what I'm thinking. I just gotta get this one to hook. Yeah, we need the other renal vein. Let's see if you can hook. We need a squirt, Bailey. And she's got it. Nevermind. Good. Let me see the other one now. Scissors. You still want this? Pickup. Yeah, we will in a second. Got it. That's gonna be our spot, huh? 0-1 is not quite this long or this is it? I think that's it. We only have two. Okay. Good. Let me see the Kelly back. Quick fit - and see if anything else is thin enough to fit in there and we'll be ready to roll. Good. Nice. Alright. We'll just make sure we're above all that plaque and we'll come out. We gotta come down and make our tunnel over here too. The tunnel to your side is pretty much done, right? Can you see it?

Right at the top. Looks good. So we're just looking at him with the ultrasound and making sure - he had a lot of visceral disease, so we're making sure where we're gonna clamp is not gonna impact... That's the celiac, there. We're just confirming that where we're gonna clamp the aorta is free of disease. So that's supraceliac aorta. It looks really clean. There's the celiac coming off right there. So we're well above that. And then the next branch is the SMA, right there. Most of his disease started kind of at or below the SMA. His renals were patent and he doesn't have any renal vascular hypertension, so we're not gonna go messing with that stuff today. That's his renal artery. Left renal artery there. But this all looks really good, so we've got a good spot. We're just gonna make our tunnel and then we're gonna clamp and go. Let me have forceps. I'm gonna have you give 12.5 g of mannitol, and then we'll give heparin, okay? Satinsky clamp. Umbo tape, yep. This part's just gonna be - we could get that under this retractor. I think that would let the teeth of that thing come in in the right spot. Lock this one. Good. That'll be it right there, huh? Okay.

CHAPTER 6

What's that? The gut side? Yeah, are you doing this side? It's done. Yeah, I mean... Go from this side. Go from... Let me just feel it. I thought I felt it earlier. There we go. So tunnel over the external iliac, under the ureter on the left. A little more of a challenge on this other side today. Good. Let's see... Bovie. We're just gonna make the tunnel to the right leg now, so we're just gonna get the aortic bifurcation out. That ureter stays up. Dr. Pearce - the 4 or the 3.6? 4. So you can get whatever, it may bleed there. Can you get a suction as well. Adson right angle. All right. Here's distal aorta. Put your fingers on it. Feel how hard that is? Pretty crazy.

We're gonna do 12 g of mannitol. You can go ahead and give that now. Can I get some more laps, please? We're just gonna have to sweep it like we do when we do - there we go. Sticky. He's sticky in the retroperitoneum. Let's move this for a second. Let me have the handheld wide deaver. Okay, good. That's left. And here's right. Where my finger is. Good. Feel that hard cord? Yeah. Good. I just have tiny short fingers. Yep. Lemme see. You did a good job. Let's see. You got all the ureter up over here. Yep. Yep. That is the right spot. Gonna stay on top of it. So we know the ureter goes up. There's the iliac bifurcation. Lemme take a quick look in here. There it is. He's sticky back here, you see? Yep. What is that? That's the Kocher, you can take that out. Let me just make sure we're okay. There's a little bleeding in there. Make sure that's okay before we give heparin. Give her a medium clip. Good. Little thing right there you can buzz.

Good. All right, open it. You got the 16-8 graft open? Give him five. You got the 16-8 graft open? It's open. All right. 5,000 heparin, guys. Let me know when it's been 3 minutes.

CHAPTER 7

Let's look up here and make sure we're gonna be able to get our hands in there. You able to get your hand in there to sew? We will try with the 4-0 SH suture. 4-0, okay. But we may have to go to HS 6, so have one of those up ready too. We don't want to end up short and a little bit more to get to the right side. All right, really good, huh? Okay. Yeah. Glad we didn't try to endarterectomize his aorta, it's a mess. He's really sticky, you know? Yeah. And we'd have to - we'd have to plow through all that stuff. That's what I was saying look at the scan. It looked like it was all inflamed, and I was like we're gonna get ourselves in trouble if we try to dig all that out.

Let me have a pickup? Okay, you're clamped. Feel for a pulse. Feels good. since you clamped, you tell him. 11 blade.

You're gonna have to do probably this half, and I'll do the top half because we're working forehand. Let me have hep saline on an olive tip. It looks good. Can we get the metal tip sucker? Let me have the punch?

Give him the punch. Sorry, let just get this clean. How about a side-biting clamp, Clark? Clean. Clean. Looks pretty good, huh? A little bit more graft. Let me have one more punch. We have slightly more graft. Let me have a white towel too. Then we have... It's a little close to the…

Bulb. So just have to have a little bit on the graft more than the artery, okay? SH suture to her. Forceps. Bring that up. I like it. Just bite underneath it, it'll be okay. Beautiful. That's how you do it. Nice. Yep, that's it. Beautiful. Love that. Put you on the same side. Want me to try? Yeah, let's parachute it. That's okay. You wanna keep going towards you, okay? Check a little bit more graft. Coming here, there's more graft than artery. Come up on that little hump. Yeah, that'll work. I like that. Good. Okay. Good. Can you get a 4-0 RB ready, too? Yeah, and we may - we can switch to an RB if we need to for the next level. Let me help you out. Travel up. Yeah, that's good, like that. The suture's a little short too. Okay. The hardest part is that part right in that heel that once you get on the side you're gonna be burning. Look towards the edge a little bit. Like right up here. Yeah, I like that. Good. I like that. Give her a - or here, you can take this shod. You can keep going forehand I think, okay? Is he doing okay? Good. Yeah, he's doing great. You gotta U-stitch back in. Go real close to it. Good. You may want to backhand it - yes. I like it. Oh it's gonna be so good. Okay. That's good. No, that's good. I like that. Don't travel too far from your last one. This is where you're kind of U-ing it in. Yeah, that's good. That's good. I like it. Oh yeah, that looks beautiful, doctor. The wrong one? I was looking at the wrong one to travel judgment distance. One more, and then we'll parachute it down. One more? I think so, if you can. Okay. Good. I'll take a shod. Start to... Start getting it down. How's it look? Down firm? Good. Okay, let me try that RB and see if it'll be a little bit better angle. Just kind of push down. Yeah, that's good stuff. Shod. We can do your side first I think, and if the retractor's in your way, I can do the backhand too. That looks good. You can just keep it forehand I think. Yeah, I like it. Nice. That's good. Good. Good. Make it pop back into the wound. There it is. You're good. I'm trying to give you the view. Problem with the RB, it gets you a better, tight angle to get in there, but it doesn't drive through quite as easily to grab it, you know? I like what you're doing there. Okay. Just don't travel too far then. I don't want to let go with my left hand because I got you kind of set up here. You know what I mean? That was good, huh? That was good. So for those watching the video, like I said, we did a 4-0 SH in the first one, but I think our angle is a little bit underneath his barrel chest so it, we use a little tighter curved needle on this one, and she's got it rocking and rolling. Would be nice for good luck. Yeah. Bailey, you're gonna need to put some heparinized saline in a bulb syringe, okay? Make sure this one's nice and snug - the one you're parachuting. Driver. Like so, good. Let's see, what is - oh, I'm stuck up here. I was like what is that? That's me. So a little extra graft, like I thought, but not bad. We'll just travel here a little bit and then back. Not so far on the aorta. Make up the difference. Probably going to put a repair stitch up there. Can I have an HS-7 double-loaded with a pledget? And you can put it on a Castro. I said loaded on a Castro. Yep, good. We're gonna flush out the end of the graft, so no need to flush now. We can go ahead and finish it. Push right there. Yep. Needle please. Wet my hands. Shod? And a bulb syringe or? And a bulb syringe, in a minute. Let me have that stitch first. Let's put this repair stitch in. Yep. I think…

See it's splitting, right there. Where? Right here. Yeah. Oof. All right, I'll take - yeah, but get a 4-0 RB double-loaded also, please. Can I have a pickup? Got it. Better to fix this now. You know what I'm saying? We need a free pledget next. Let me... Try and get a bite. Free pledget. That one cinched it up pretty nice. Bring a little closer, please. There you go, perfect. Let go. Cut this. Wet my hands. Thank you. Okay, cut. Let me see that RB with the double-loaded pledget, please. Thank you. Let me have another one of those HS 6. Same thing. Maybe too much of a needle angle here. Looks like I got it. You see the artery, right? Free pledget. Cut the needle. Here you go. Let's have that bulb syringe, please. And I'll take a Fogarty soft jaw clamp. Okay, you begin. I need a 6-0 on a - see your side. Your side looks okay. It's all my side. I was torquing too much, or what? I'll take that 6-0. I saw two spots. Nice, so that's right here. Free pledget. Make sure I didn't lock that. Looks good. Gonna be a pro with that move. Huh? Cut. I'm trying. Yeah. No, it's not easy to do. The needle like... That's what I'm saying. Scissors. I should have tried to felt this side, I guess. And cut these other ones too. Here's some needles back. Do you have one more? All right. About to be a moment of truth here. You can see bubbles coming out here. I don't see any other holes though. Let me have that bulb syringe back for a second. Hep saline? Mm hmm. It's just up there at the top. Let me see that HS? Oh here it is, right here. Hold that one for me, please. Thank you. Follow there. Free pledget. Needle off. Scissors. All right, let me dry lap. Let me have a Fogarty shodded clamp on the other one.

We're gonna test your proximal clamp, okay? We're not, may get a little bit of your SMA flow back, although it's only been partially clamped the whole time. So, here we go. Suck in there. Let me have a 6-0, I mean a HS-6, not a 6-0. HS-6. You don't have to pledget this one. I just have it. Is your side okay? I don't know. This side is definitively not okay. Let me anchor this with a pledget I guess, and then we'll run it down. Let's have a pledget. Wet my hands. I'll take a shod. Shod that one. Wet the driver. You got it. Don't pull super hard. Just kind of snug. Aorta just seems like it's splitting on the needle holes a little bit. He's got some problem. You know, that's about as hard as we need to be. Kind of a bowed suture on me now to kill it, right? Let me go through the pledget here before I pull it up. Maybe, maybe not. That's okay. Let's just tie it. I think we need to put one in the heel too. Cut. There's your needles. A little loose there. We can pull it up in a second. Let's anchor this one. Free pledget. Cut this needle. Get me a nerve hook next. Nerve hook. Don't cut it yet in case we can tie to it. Let's see your side. Okay, let me have a fine right angle and a 3-0 silk. Here's this back. Yeah, and get this one. You got it? I got it. Forceps. Cut the other one too. Let me have the dry lap. All right, you got the aorta back. What do you think? Not bad, huh? Good. Okay.

Let's have the hockey stick. Let's just take a quick look at the aorta, make sure we didn't do anything damaging with the clamp. All right, so here's the anastomosis wide open and then we're gonna go down and look at the aorta below. There's the celiac and SMA. The celiac looks fine. I don't see any problem there. Good. I don't see anything in the aorta itself. It looks good, right? There we go. No crack. All right, good. Let's have a sterile doppler.

All right, and let's take a listen. Good. Good. All right. The viscera sounds good. Let's have the bulb syringe with hep saline. Here you go. And a bucket to her.

I'll take a - I'll take actually that. I got you pinched. We're gonna flush these. Tell me when you're ready. Ready. Uh huh. Good. How long since we gave the heparin? Heparin was 43 minutes ago. Okay, you can add a thousand now. Hep saline. Let's flush. Flush that out there. You got it. Ready? Good. Good. Nice. Okay. The thousand is given. Thank you. You wanna put some of that Evarrest stuffed around there? Yeah, sure. That stuff's cool, right? Yeah. Open one of those Evarrest things. And I'll take heavy scissors. Looks good, doc.

CHAPTER 8

Let me have the DeBakey tunneling clamp, please. See it? Yeah. Let me have the hemostat. Okay. Get your clamp there. Good. Good. Hemostat - oh, I got it right here. I got the Evarrest. Ooh, I like - what are you doing? Just wait, just wait. Ohh. This is the right side, right? Yes, correct. I was just gonna put a couple strips around it, but I see what you're stepping in here. You could lift it up a bit. Forceps. Look at that, huh? Very cool. Dry lap. Love it. We'll go say goodbye to that for a while. Let him have his ribcage back. Just make sure he doesn't bleed when you get the retractor out when we're tenting something over it. It looks really good, doctor. Relax on the bowel. Let me have a clean towel. Flatten the bed, please. Like, just level, left to right. That's good. Can we have a cerebellar? Let's do my side. It's a little harder side of the two. Let me have a blunt Weitlaner. Is it still in your way? A little bit. Okay, let me have a small profunda clamp. Another small profunda. Soft. Do you have a penguin clamp. Okay, 11 blade.

Potts scissors. See, he's got noodly arteries. Let me have the Freer.

All right, we're doing an endarterectomy here. We're gonna try to preserve that. profunda obviously very important. We - do you have a Jake? This is almost like some sort of embolus that lodged here or something, you know, see how smooth it is? Yeah. Can I have the plaque elevator? Do you have plaque cutting scissors or fine Potts? They're bigger Potts. Do you want some squeezy Potts? We're okay. We're gonna have to evert this a little bit. Big old booger, huh? Let's see if I can get it from my side here. Okay, Adson right angle. Can I have another pickup? Famous last words, the Dr. Jordan Maneuver. I don't quite have it free there. Here we go. Specimen. Right femoral plaque. We actually want to attack this so that we can retrograde flow into the pelvis, right? I know which side. I think that's pretty smooth there. Look inside. Hold that. It's just because of the decubitus thing. Hep saline. Do you have a 7-0 BV tacking suture, please. Do you have any like - like finer-tip of one of these And I'll take a moist lap to put over these clamps, please. Is he gonna - is it okay to bring a table up just a fraction. Yep. Tie this. Table up a little bit. There's needle. Pinch. That's good. Thank you. Heed the needle. That one. Hep saline. Can I see? Hold this side just right there. Let me have an Adson right angle. Right there.

Okay, heavy - let me have a marker actually, please. Purple marker. Straight scissors. We'll do 5-0 C1. All right, that was a legit booger in there. Yeah. Here's yours. I'll take a right angle. Pass that one to me. Forceps. Got it. Thanks Joe, all right, let's make up some time here. Okay, I'll take this. You pinch back there. Good. Try not to hurt your neck too much. Shod. These DeBakeys seem rough. Try these. These seem nicer? I thought that was a kitten. That noise. It's the bear hugger, right? Yeah. Shod. Same thing. 5-0 C1. Shod. Keep going. There it goes. Good news. I like it. Let me move this one up. Sorry, screwed you, there you go. Sorry. Sweet. Okay, we cut one of our needles, please. Empty driver. No. Yeah, it's all good. Can you see? Let me have the other DeBakeys, please. There we go. Common now. That's it. Do you want one on the other side of that? Yeah. All right. Okay. Just take what we got and we can fix it on the other side. Just flush before we get tied up. Hmm, back flushed a little bit. All right, go for it. Oh, yeah. Hep saline. cut. Wet my hands. All righty. Let me take it off the pelvis first then you can give me that one, okay?

All right. Go for it. Let me see the sucker. All right, you're off? Yep. Sterile doppler. All right, I'm giving you a leg back, okay? Go ahead. I can pinch it here. Open. Okay, good. Scissors. Here you go. Needle. Let's have a new net. We'll look at this with the hockey stick at the end. Dry lap. Let me have the - here we go. All right.

CHAPTER 9

All right, moment of truth. Here comes the other leg, okay? 6-0 BV. Go ahead and cut that if you want. There's a little branch on the profunda. Oh, gotcha, needle on your Mayo. Wet my hands. Sterile doppler while she's sewing this last thing. Can I help show it to you, or you got it? Suction. Don't go anywhere. Good. This is from the feet. I need some room. I need heavy scissors. Oh, the feet aren't prepped. Are they? Forgot, he's in a different position. All right, well I'm gonna come listen over there. Give me another drape. Good times. It's okay. All right. Ooh, DP's palpable. Very nice. You can turn it off. All right, let's take a look with the hockey stick and let's start drying up. All right, we're gonna look at the ultrasound again guys. There's the anastomosis. Looks wide open. Proximal SFA. Look at that. Huh? Looks good, doesn't it? Profunda. A little plaque there. Let's see. Here it is. It looks good. I think we were looking at a ligated branch. because see that looks good. There's a little branch underneath it, but that's SFA upper right and profunda down at the bottom, and they both look fine and come together there. That looks good. All right, let's look at this side. Irrigation. Proximal SFA looks really good. The profunda looks good too, despite us pulling that big old booger out of it. See, looks nice and clean. Yeah, looks great. All right, let's take a look back in the belly.

CHAPTER 10

Can I have the cell saver with the Yankauer. Clear one. And we'll take the Mayo body wall back, please. And you just get in here. No problems in our tunnel. Ureters up above - that looks good. Nice to close whatever that hole is. Okay, let me have a bucket of warm irrigation. Do we have any of that powder, the stuff that smells like potatoes or birthday cake? Get the light in there and see if we can figure out how to close the peritoneum back over the stomach. The spleen looks okay, right? I don't see anything bleeding. May not be anything we can do about it at this point. Let's hook up the chest tube. Can we get some warm irrigation?

You can do either. The surgicel powder's fine. How much heparin did he get total? 3000. Give him a test dose of protamine. If he tolerates it, give him 50 of protamine, please. Ready to put the chest tube in? Yeah. We gotta put at least one above where we're gonna close, right? Love it. Dry lap.

I'm trying to put up - put your hand like, you know, he's not fully lateral so you gotta go a little bit lower there. Here you go. Here you go. And the Bovie. I'll take it a DeBakey. Get the other Bovie, please. And touch me. She'll take a Kelly. You want me to move the retractor anyway? No, that's okay. I don't feel you, doc. I'm above. Oh, now I do. Can you see? Not quite, almost. Oh, move your hand for a second. I think I got it. Yeah, hold on. Do you have a malleable, please? Let's see. There it is. Okay. Good. Going posterior, looking good. Good. Beautiful. Oh, I love it. Give her a stitch. Let me know when the protamine's in, okay? Do you have a another silk? All right. It looks dry. It looks really good. It looks like all retroperitoneum falls back over it. So I think we're good. There's a good tissue between the graft and the abdomen, you know what I mean? I'm happy with that. I'm not gonna hold. What's that? Is it ripping again? I mean it's not mission critical. It didn't hold the first time we did it. Needle back. You got scissors? Excellent. Let's look at the spleen one more time. Capsule of the spleen looks okay There's no blood pouring out of there either, you know? Waste sucker. One more bucket of warm irrigation. Looks pretty dry in there. Does look good. Just make sure the graft is, like I said, all covered with peritoneum and not viscera. That feels good. Let me have a malleable and an 0 Prolene. Can you make the bed reflex? Takes a little tension off while we're closing this.

CHAPTER 11

Ferris, we're gonna close the diaphragm here with an 0 Prolene. Can I have a Rich. I'll take the Ferris. On the big one? I'm in there. Cut that. I like to lock these. It just keeps it from sliding back on us. Let me lock it. There's a little bit stapled up to the edge of the intercostal. There it goes. I think so. Yep, perfect. All right, let's have the rib stitch, please.

Put one in up here. Back to here. And maybe one here and then we'll put one on the end. Does that work? Yep. Give her a Ferris and a big needle. Let's go right on top of that rib. I just want you to look inside, make sure you don't get the lung. You should be good down here, right? Good. Good. You gotta go well down the lower, right? Oh shoot. You gotta go low so you're on top of the - the vector is down. Sorry. Okay. Yep, go ahead. Because you don't wanna hit the bundle, right? Okay, good. Cut her needle. Hemostat. Let me have - do you have like a 0 Vicryl? It looks okay. She'll take another big stitch. You need to take some of the diagram off of there. Bovie. Come right through that. Come right on my finger. Down a little lower. Get this band there. Right down here. Okay, good. Okay, good. Good. That's perfect. That's how you do that. Snap. There's a way to do that. We almost got it. Cut that. Let's see. Let me just look real quick there. Do you have an 0 Vicryl? Can I have a lap? Needle. A what? A lap. Cut that. That's good. Let's get a little bit more of the diaphragm, and we'll do that one more big stitch on the end of that rib. Okay? Cut this. Squirt her hand. Can we have one of those Tevdek sutures, please. Can I have a straight hemostat? Show me how to do it. Look at that, see? Teamwork makes the dream work. You just can't let the old man do the part he's not used to doing. That's the wrong one. Huh. All right, good. You want to tie them? Good. Yeah, go ahead. You can cut that for me. Cut that? Good. That looks - came together nice this time, didn't it? Just a short tail on these. Not much. Give her some heavy scissors. Those are really nice scissors. Okay. All right.

Loop PDS, please. He's relaxed, right? Okay. Moving or? No, no, no, I'm just make sure - we gotta get his abdominal wall back together, so... Can we set up the chest tube? Yep. Do you have a single-armed PDS? I'll just take it. You wanna do two layers? Yeah. Give her the single. We'll use the double last. Here's the upper fascia. It goes to here. Malleable. Got it. Yep. Good. Let me have an Army-Navy. Let me show you that edge, you can see. Okay. Good, do you have heavy scissors? Good. Okay, we'll do a two-layer closure. Posterior fascia. And then the anterior, which is the more strength layer with the PDS suture. Can you hold this back? Do you want tie towards yourself? What's that? Wanna tie it towards yourself - yeah, I like that. Tie towards yourself. I like it. That's good. Watch your hand there. Good. Looking good. To what? Peritoneum. Excuse me, do you have peritoneum? I wanna make sure I don't. Oh, for sure. There you go. Cut the needle. I'll take a loop PDS next. Cut it. That's the stuff. All these hernia hero bites, huh? That's the new new thing. You want me to take? Oh no, no. You're doing the right thing. That's what all the books say, right? Half centimeter bites, half centimeter travels or whatever. All right Isabelle, let that sort of relax and start to fall over, yeah. I'll take a Ferris. Can you follow Isabelle? Yes. Make sure you get, I think, the catch is tracking back. Yeah. Good. Yep. And when you get up over the ribs, you transition it and you get this whole sort of muscle here. You take it all the way to the back of the incision. We'll put Isabelle to work with those loops sewing some - well I was gonna say she can run this and then run a subcuticular, and then you and I can do the groins. No, but I like that... Sewing the aorta is good, and that was a good lesson we learned that that thing split a little on us. He probably has some sort of, you know, arteriopathy of some sort, right? But we handled it not under arterial pressure and it, it looked really good, you know? Just goes to show, enough pledgets... But it's better to know that problem before you take the clamp out. Yep. We're gonna need a running... You're holding tension on that, right? A running 2-0 Vicryl, and a running 3-0 Vicryl, and then a 3-0 Monocryl if we have it. Can I get a 3-0 Monocryl? You got one more, or you wanna do - go ahead and tie it to itself. Now what you do is throw in one backhand. Scissors. Can I get some irrigation?

Cerebellar? All right Isabella, run a Scarpa's layer, 2-0 Vicryl, anchored here. Run it all the way through. And then do a deep dermal with a 3-0 Vicryl, and then a subcuticular. You know what I'm talking about? So Scarpa's fascia is the middle fascia inside the fat, right? So run that closed, and then you can run a deep dermal and a subcuticular. This looks good. Give her some irrigation, please. And I'll take a 2-0 pop. We like to close the groins in layers to get rid of the dead space with interrupted figure-of-eight Vicryl.

CHAPTER 12

So hopefully that case was enlightening for you. I know that I learned a lot myself doing it. The exposure itself went relatively straightforward in the retroperitoneal plane, and you had a very nice normal supraceliac aorta. I'd like to highlight the interrogation of the anastomosis before giving back full arterial pressure. The patient actually has a relatively soft normal aorta and had some evidence of microtearing from the suture line due to our parachute technique. Before we fully revascularized and pressurized the proximal anastomosis, I was able to repair it with pledgeted sutures and limit any blood loss. And it looked really good at the end. And I'd also like to highlight that I have become very routine in using on-table duplex ultrasonography to interrogate any anastomosis I do and also to rule out any complications from clamp sites, especially in the perivisceral aorta. As seen, the proximal anstomosis was widely patent. The celiac and SMA were uninjured by the clamping, and the patient had excellent flow into his visceral segment at the end of the case. The femoral anastomoses went very well. We had to do a pretty extensive endarterectomy on both sides, potentially due to a combination of atherosclerotic plaque, plaque rupture, and maybe even some embolus when his aorta occluded. We had great flow and triphasic signals at the end. Ultimately, this is a really great case. The tunneling in the modified decubitus position should be something else highlighted as getting underneath the ureter and finding the right common iliac, and then tunneling as normal for an aortofemoral bypass is really important. But getting that graft in the proper tunnel so we're underneath the ureter and don't cause downstream problems with urinary retention or obstruction. At the end of the case, the patient closed up very nicely, and I think we'll have a really great result.