REPAIRING BLOOD VESSELS

EQUIPMENT Arterial clamps. A very fine needle holder, and fine dissecting forceps such as Adson’s or finer. Half circle round–bodied atraumatic needles (or better, a micropoint needle). 4/0 monofilament sutures or finer. Magnifying spectacles, such as the Bishop Harman loupe. Heparin (50 mg or 5000 units in 100 ml of saline), or use the citrate solution from a blood transfusion bottle or bag.

WOUND TOILET Do this carefully, and remove all dead or dying tissue from the patient’s wound. If he has a fracture, allow its fragments to overlap while you repair his artery. Enlarge his wound as necessary, so that you can really get at his injured vessel easily, and inspect it.

TORN ARTERIES

If the patient’s artery is only partly divided, or is cut longitudinally, you may be able to suture it directly.

If It has been nearly cut across, you may be able to anastomase its cut ends.

If a length of it is bruised or torn, you may have to cut out the ragged piece and bring clean cut ends together for anastomosis.

If its cut ends are ragged, excise them, so that you can bring two clean–cut ends together. You may be able to excise 2 cm or more and still bring the ends together. If they will not come together, you will have to insert a saphenous vein graft, as described in the next section.

If the adventitia (which looks like filmy cobwebs) projects beyond the other coats, trim it away. If you leave it, it will promote thrombosis in the suture line.

If there is a gap in one wall of the artery, you may be able to repair it with a saphenous vein patch graft, as in B, Fig. 55-3.

MOBILIZE THE ARTERY Arteries are elastic, so you will probably be able to free enough of the artery above and below the wound to let you work on it. Apply arterial clamps or Rummel tourniquets above and below the wound. In an emergency, ask your assistant to press the artery between his finger and thumb. Inject heparin into it on the far sides of each clamp or tourniquet.

Try to preserve any reasonably sized branches, because these will help to maintain the collateral circulation if the repair fails.

REPAIR Put something behind the injured vessel, such as a piece of gauze or half a glove, so that you can see what you are doing as in Fig. 55-4.

CAUTION! Before you start the repair, allow the artery to bleed from both ends to remove any clot that may have formed. This will wash out the heparin, so inject more through fine catheters.

Squeeze any clot out of the cut ends of the artery and drip a few drops of heparin onto each of them.

Bring the cut ends of the artery together with two stay sutures at opposite sides. Two more at the top and bottom may help. Use these to steady the artery and rotate it, where necessary.

Either use horizontal mattress sutures to evert i ts cut edges, or use continuous sutures. Place them about 1 mm apart or less and 1 mm from the cut edges. Place the knots on the outside. Drop some heparin solution onto the artery while you suture it.

CAUTION! Place the sutures carefully and avoid dog ears or the anastomosis will leak.

When the suture is complete, release the distal clamp first. This low pressure retrograde flow will show up any leaks. If necesary, stitch them.

Then press the anastomosis lightly with gauze and gradually release the proximal clamp. The repair will bleed, but the bleeding will usually stop spontaneously in a few minutes. If necessary, put in more sutures.

If the repair leaks, press it with a gauze pack for a few minutes. Blood may clot in the leaks and block them.

If you are successful there will be a pulse in the artery distal to the repair.

CAUTION! Cover the repair with living muscle or subcutaneous tissue. Don’t leave it exposed while waiting for delayed primary closure (54.4). Rotate a flap over it, or partly close the wound.

TORN VEINS Sponge holding forceps are useful in grasping a torn vein because they take large bites and flatten it. If possible use lateral occluding clamps which will let you see the edges of the tear and insert an everting layer of fine continous sutures.

Failing this, press firmly on the vein above and below the tear. This will empty it and show you the hole outlined against its posterior wall.

If all else fails, occlude the vein above and below the tear, and tie it.

POSTOPERATIVELY (ALL VASCULAR INJURIES) Splint the patient’s limb in the position of least tension on his injured vessel, and then gradually straighten it over several days. If there is a fracture, you have at least 10 days in which to align the bony fragments before they unite in the wrong position.

Figure 55.5: A SAPHENOUS VEIN GRAFT. A, the incision to expose the saphenous vein. B, the length of saphenous vein is being reversed, so that any valves it contains do not obstruct the blood flow. The grafted vein sewn in place and its side branches tied off. Kindly contributed by Peter Bewes.