Rekonstruksi Vaskular

Taufik Nur Yahya

Anatomi vaskular
Biologi vaskular
Instrumen
• Klem
• Needle holder
• Forsep
• Gunting
• Retraktor
Klem
• Atraumatik
• Penggunaan klam
• Ukuran sasaran vaskular
• Besar
• Sedang
• Kecil
• Fungsi
• Total oklusi
• Parsial oklusi
• DeBakey-Bahnson aortic aneurysm
clamp  Infrarenal aorta
• Fogarty aortic clamp (side-to-side
apposition of aortic wall) 
Infrarenal aorta; aortic grafts,
calcified aorta
• Lambert-Kay aortic clamp
(apposition of anterior and
posterior walls together) 
Infrarenal aorta
• Wylie hypogastric clamp  Iliac
arteries, especially hypogastric
arteries
• DeBakey peripheral vascular
clamp (angled handle)  Iliac
arteries
• Henly subclavian clamp 
Subclavian and common femoral
arteries
• Lemole-Strong aortic clamp 
Aorta; aortic grafts
• Satinsky clamp  Aorta, vena
cava
Needle holder
• Needle holders of various
lengths and shapes are available.
• The choice of needle holder is
often dictated by the size of the
needle used.
Forsep
• The forceps used during vascular
procedures typically have very fine,
noncrushing jaws, exemplified by
the DeBakey forceps.
• However, similar to vascular
clamps, vascular forceps can crush
a vessel wall if they are not used
appropriately and delicately.
• Fine-tip ring forceps or Jarrell
forceps are very useful during the
construction of vein bypasses to
infrapopliteal vessels.
Gunting
• Metzenbaum and Church scissors
are used for the dissection of blood
vessels.
• Stevens tenotomy scissors with
sharp tips are used for dissecting
tibial vessels.
• Special Potts scissors with various
angulations are used to enlarge
and shape arteriotomies and
venotomies.
• Right-angle clamps with various tip
sizes are used to encircle blood
vessels and branches
Retraktor
• Retractors can be self-retaining or
handheld. Self-retaining retractors
should be used whenever possible.
• The Omni- Flex vascular retractor (Omni-
Tract Surgical, St. Paul, Minn) is
frequently used for open aortic surgery,
whether transabdominal or
retroperitoneal
• Bookwalter retractor (Codman Johnson
& Johnson, Raynham, Massachusetts).
This retractor is often used when
conducting abdominal aortic
replacement through mini-laparotomy
incisions.
• The Weitlaner retractor is
commonly used for inguinal and
popliteal incisions
• In obese patients with significant
inguinal pannus, a Miskimon
retractor can be especially useful
because of its deeper and wider
blades, which provide a larger
retracting area.
• The Gelpi retractor is typically
helpful when conducting a first
rib resection through a
transaxillary approach for
thoracic outlet obstruction.
Suture material
• Monofilamen
• nonbsorable
• Sintetik
• Double-armed
• Jarum taper

Sering digunakan:
• Polypropylene
• Polybutester
• PTFE
Vaskular Eksposur
• Incisi kulit longitudinal diatas pembuluh darah, 2 cm lebih panjang di
masing-masing sisi
• Handling kulit dan jaringan sekitar  mencegah kompikasi luka
• Kontrol dan klem cabang-cabng pembuluh darah yang hendak
dioperasi
• Hati-hati dalam handling vaskular  sensitif terhadap trauma
• memicu aktivitas trombogenik di intima
• Hindari diseksi dan oklusi
• Ekspos sisi anterior dan
lateral, bebaskan dengan
jaringan sekitar
• Masukkan right-angle clamp
ke sisi posterior
• Kaitkan dengan vessel loop
Antikoagulasi
• Anikoagulasi dilakukan sebelum interupsi aliran darah
• Heparin 75-100 IU/kg diberikan secara IV 5 menit sebelum interupsi
• Monitor dengan ACT  target >250 s
• Jika diperlukan, re-dosing heparin untuk mencapai target ACT
• Jika pasien diketahui ada riwayat HIT  thrombin inhibitor (cth:
argatroban)
Kontrol bleeding
• Vessel loop
• Bulldog
• Balloon catheter
• Ligasi
• Vascular clamp
• Plak biasanya terletak pada
sisi dorsal
• Klem secara horizontal 
menghindarai rupture plak
Penjahitan vaskular
• All layer
• Penjahitan arteri:
inside-out 
menghindari diseksi
intima dan pelepasan
plak
Teknik repair

1. Repair primer

4. Bypass

3. Interposisi

2. Repair dengan patch

End-to-side anastomosis
Teknik Anchor
• In the anchor technique, the
anastomosis is constructed by first
placing a suture at the heel of the
conduit and the arteriotomy.
• The suture is tied, thus stabilizing and
anchoring the conduit at the heel of
the anastomosis.
• Suturing is continued on one side of
the heel to the toe, then halfway
down the other side of the
anastomosis.
• The anastomosis is completed by
suturing the other end of the heel
suture until it meets the previously
placed suture
Teknik Parasut
• In the parachute variation of the end-to-side
anastomosis, the sutures at the heel and the
apex are not initially pulled down or tied.
• Suturing is started a few millimeters from the
center of the heel. The conduit is typically
held with forceps a few centimeters from the
arteriotomy. This allows the placement of
sutures in deep areas without the conduit
obscuring or interfering with suture
placement.
• First, several bites are placed in the conduit
and the arteriotomy until the challenging part
of the anastomosis is completed. This usually
requires a total of three sutures on each side
of the center of the heel.
• Tension is then applied on both ends of the
suture, and the bypass is slowly pulled toward
the anastomosis, achieving a tight suture line
• Such a configuration allows the
maintenance of antegrade flow
in the native vessel at the level
of the proximal anastomosis.
• An end-to-side configuration at
the distal anastomosis allows the
maintenance of retrograde flow
through all patent branches
End-to-end anastomosis
• An end-to-end anastomosis is typically performed for replacement of
an arterial segment, such as an aneurysmal artery or a vessel that has
been transected by trauma.
• An end-to-end anastomosis is also constructed when a composite
bypass is needed or when preservation of retrograde or antegrade
flow is not essential.
• One technique involves placing
two diametrically opposed
sutures in an anterior and
posterior part of the vessel.
• The sutures are tied, and the
anterior part of the anastomosis
is constructed first.
• The vessels are then flipped 180
degrees, placing the posterior
wall in an anterior location for
completion of the anastomosis
• In the triangulation technique,
the anastomosis is divided into
three parts rather than two
parts, anterior and posterior
End-to-end anastomosis pada vasa kecil

• When constructing an end-to-

end anastomosis between two
small vessels, it is essential to
spatulate the anastomosis to
avoid compromising the lumen.
Side-to-side anastomosis
• A side-to-side anastomosis is rarely performed.
• create a side-to-side radiocephalic arteriovenous fistula for chronic
hemodialysis or a side-to-side arteriovenous fistula distal to an
infrainguinal prosthetic bypass as an adjunctive procedure to improve
graft patency by decreasing outflow resistance.10
• A side-to-side configuration can also be used in the construction of a
second anastomosis in a sequential bypass for limb revascularization.
Side-to-side anastomosis
• To perform a side-to-side
anastomosis, the vessels need to
be dissected and mobilized so they
lie adjacent to each other with
minimal tension.
• The anastomosis is created by
longitudinal arteriotomy or
venotomy where the walls come in
direct contact.
• The posterior wall of the
anastomosis is typically
constructed first.
Pitfalls
• Anastomotic failure is more likely to be caused by technical
imperfections than by the dimensions of the anastomosis.
• Twist, kingking  misalignment of vessel
• Buckle effect  the posterior incision in the conduit is not parallel to
its long axis
Daftar Pustaka
• Ascher E. 2012. Haimovici’s vascular surgery 6th Ed. West Sussex:
Blackwell Publishing
• Cronenwett J, Johnston K. 2014. Rutherford's Vascular Surgery 8th Ed.
Philadelphia, PA: Saunders/Elsevier
• McMonagle M, Stephenson M. 2014. Vascular Surgery At A Glance.
Oxford: John Wiley & Sons, Ltd
• Wahlberg E, Goldstone J. 2017. Emergency Vascular Surgery: A
Practical Guideline. Heidelberg: Springer-Verlag Berlin
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