Today we finished a femoral endarterectomy and femoral posterior tibial bypass, for chronic lower limb ischemia cased be plaques blocking the blood vessels. The operation from hell would be a fitting name. In vascular surgery when things go bad it can make life very difficult.
The first half of the operation went nicely but after we moved to the finishing anastomosis, the connection from the large upper arteries to the small lower arteries via a vein. There seemed to be a problem with the arteries of the lower leg and foot. After completion and bandaging the wounds there was no blood flow to the foot.
Here in lies the problem. In a country like this the facilities are sometimes sub-optimal. The Palestinians are very sophisticated and advanced. They have very nice operating theaters, however there is some equipment they have to make do without. The goal of this mission trip, that will do the most good, is for us to come see the facilities and see what is missing. On the next trip we will be able to bring the equiptment that the patients need to provide optimal care. So what we are going to do is make list of supplies and try to bring as much of it back for Dr. Ihab and the rest of the Palestinians.
After we determined there was no flow to the foot we reopened the incision. In the optimal circumstances we would do intrapretive angiography of the lower arteries to see where the occlusion was. This was not an option for us. They have a C-arm for the Xray however the tables are not radiolucent. We opened up the graft, we threaded a catheter down the distal arteries for the embolectomy and removed several small clots. We had reasonable outflow so we closed again.. no flow.
We opened again, went more distal with the graft passed an area of stenosis, plaque, and possible small dissection in the artery. We reattache the graft more distal. We closed… no flow. Our final option was to use more vein and take the graft further down the leg in hopes of getting circulation to the foot and save the patients limb. We anastamosed the graft to the posterior tibial arter deep in the calf, preformed another embolectomy and closed. After 9.5 hour operation we were had a good anatomist, and good runoff. We got a the pulse in the posterior tibial with a good biphasic doppler wave. Unfortunately the dorsales pedis was not as strong, but it was audible.
This patient has very treatable disease and the people here have the knowledge to treat. We are going to make a list of things that we will bring back and to Rafiti Hospital and the people of West Bank.
- Angiography equipment
- basic endovascular equipment
- Webster cannulae
- tunneler for fem pop bypass
- balloon occluders and catheters
- artificial graphs and patches
- Silk ties!!
- Sclerosant-polidocanol solution
- fogarty clamps
- ultrasound equipment
- papaverine vaso dialator
- a full team: Two nurses, and an Anesthisiologis