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Upper arm loop grafts
Many forearm loop grafts have multiple outflow interventions before failure. These angioplasties and outflow stents create inflammation around the vein just above the antecubital area. This inflammation makes arterial exposure difficult for a standard upper arm graft configuration. Accordingly, surgeons may avoid this area by performing an upper arm loop graft, which originates and terminates in one high arm incision. Upper arm loop grafts are also used for high bifurcation of the radial and ulnar arteries and when prior access grafts make other configurations difficult. Surgeons appear to place these upper arm loops routed with one limb running subcutaneously parallel to the brachial artery, placing half of the loop in an awkward position for cannulation.
Dr. Showalter is clinical assistant professor of surgery, Florida State University Medical School, Tallahassee, and attending vascular surgeon, Sarasota Vascular Specialists.
Many forearm loop grafts have multiple outflow interventions before failure. These angioplasties and outflow stents create inflammation around the vein just above the antecubital area. This inflammation makes arterial exposure difficult for a standard upper arm graft configuration. Accordingly, surgeons may avoid this area by performing an upper arm loop graft, which originates and terminates in one high arm incision. Upper arm loop grafts are also used for high bifurcation of the radial and ulnar arteries and when prior access grafts make other configurations difficult. Surgeons appear to place these upper arm loops routed with one limb running subcutaneously parallel to the brachial artery, placing half of the loop in an awkward position for cannulation.
Dr. Showalter is clinical assistant professor of surgery, Florida State University Medical School, Tallahassee, and attending vascular surgeon, Sarasota Vascular Specialists.
Many forearm loop grafts have multiple outflow interventions before failure. These angioplasties and outflow stents create inflammation around the vein just above the antecubital area. This inflammation makes arterial exposure difficult for a standard upper arm graft configuration. Accordingly, surgeons may avoid this area by performing an upper arm loop graft, which originates and terminates in one high arm incision. Upper arm loop grafts are also used for high bifurcation of the radial and ulnar arteries and when prior access grafts make other configurations difficult. Surgeons appear to place these upper arm loops routed with one limb running subcutaneously parallel to the brachial artery, placing half of the loop in an awkward position for cannulation.
Dr. Showalter is clinical assistant professor of surgery, Florida State University Medical School, Tallahassee, and attending vascular surgeon, Sarasota Vascular Specialists.
'Walk out the snot'
Balloon embolectomy revolutionized the treatment of acute thromboembolism involving peripheral arteries. However, an often overlooked method that actually may be more beneficial is to "walk out the snot."
This may sound somewhat disgusting but as can be seen from the accompanying photograph, the surgeon can often retrieve the entire clot from the main artery including extensions into collateral vessels.
In this picture of a patient undergoing femoral embolectomy with this technique, we retrieved a cast of the entire superficial femoral artery as well as the peroneal and posterior tibial arteries and two major collaterals.
The technique is simple. With proximal control of the inflow artery, the visible clot is gently pulled out of the arteriotomy in a slow but deliberate fashion, hand over hand. Often back bleeding will aid in pushing the specimen out of the arteriotomy. The maneuver is very similar to what children do when they feel the need to empty their nostrils! (No adult would do that – would they?)
Retrieval of a specimen like the one in the photo will usually reassure the surgeon that there will not be more thrombus left behind.
The technique also prevents possible arterial injury from a balloon catheter. For both reasons a postcompletion arteriogram may sometimes be avoided.
Dr. Showalter is clinical assistant professor of surgery at Florida State University Medical School and attending vascular surgeon, Sarasota Vascular Specialists.
Dr. Samson is clinical professor of surgery at Florida State University Medical School, attending vascular surgeon, Sarasota Vascular Specialists, and the medical editor of Vascular Specialist.
Balloon embolectomy revolutionized the treatment of acute thromboembolism involving peripheral arteries. However, an often overlooked method that actually may be more beneficial is to "walk out the snot."
This may sound somewhat disgusting but as can be seen from the accompanying photograph, the surgeon can often retrieve the entire clot from the main artery including extensions into collateral vessels.
In this picture of a patient undergoing femoral embolectomy with this technique, we retrieved a cast of the entire superficial femoral artery as well as the peroneal and posterior tibial arteries and two major collaterals.
The technique is simple. With proximal control of the inflow artery, the visible clot is gently pulled out of the arteriotomy in a slow but deliberate fashion, hand over hand. Often back bleeding will aid in pushing the specimen out of the arteriotomy. The maneuver is very similar to what children do when they feel the need to empty their nostrils! (No adult would do that – would they?)
Retrieval of a specimen like the one in the photo will usually reassure the surgeon that there will not be more thrombus left behind.
The technique also prevents possible arterial injury from a balloon catheter. For both reasons a postcompletion arteriogram may sometimes be avoided.
Dr. Showalter is clinical assistant professor of surgery at Florida State University Medical School and attending vascular surgeon, Sarasota Vascular Specialists.
Dr. Samson is clinical professor of surgery at Florida State University Medical School, attending vascular surgeon, Sarasota Vascular Specialists, and the medical editor of Vascular Specialist.
Balloon embolectomy revolutionized the treatment of acute thromboembolism involving peripheral arteries. However, an often overlooked method that actually may be more beneficial is to "walk out the snot."
This may sound somewhat disgusting but as can be seen from the accompanying photograph, the surgeon can often retrieve the entire clot from the main artery including extensions into collateral vessels.
In this picture of a patient undergoing femoral embolectomy with this technique, we retrieved a cast of the entire superficial femoral artery as well as the peroneal and posterior tibial arteries and two major collaterals.
The technique is simple. With proximal control of the inflow artery, the visible clot is gently pulled out of the arteriotomy in a slow but deliberate fashion, hand over hand. Often back bleeding will aid in pushing the specimen out of the arteriotomy. The maneuver is very similar to what children do when they feel the need to empty their nostrils! (No adult would do that – would they?)
Retrieval of a specimen like the one in the photo will usually reassure the surgeon that there will not be more thrombus left behind.
The technique also prevents possible arterial injury from a balloon catheter. For both reasons a postcompletion arteriogram may sometimes be avoided.
Dr. Showalter is clinical assistant professor of surgery at Florida State University Medical School and attending vascular surgeon, Sarasota Vascular Specialists.
Dr. Samson is clinical professor of surgery at Florida State University Medical School, attending vascular surgeon, Sarasota Vascular Specialists, and the medical editor of Vascular Specialist.
