Rutherford's 065: Autogenous Grafts Including Vein Harvest, Surgical and Endoscopic скачать в хорошем качестве

Rutherford's 065: Autogenous Grafts Including Vein Harvest, Surgical and Endoscopic

#AutogenousGrafts #VeinHarvest #VascularSurgery #Rutherfords #LegBypass #CLTI #PAD #Endothelium #GraftFailure #IntimalHyperplasia #DuplexScan #Anastomosis This video, referencing Rutherford's Vascular and Endovascular Therapy, delves into autogenous vein grafts, utilizing a patient's own veins for leg artery bypass procedures. These are considered the gold standard for critical limb-threatening ischemia (CLTI) and claudication, consistently showing better outcomes than synthetic grafts. The Great Saphenous Vein (GSV) is typically the primary choice, although arm veins or the small saphenous vein can serve as alternatives if the GSV is unsuitable. Preoperative duplex ultrasound mapping is essential for detailed assessment of vein size, location, and quality, significantly improving surgical planning and reducing complications compared to older methods like venography. Studies indicate that veins smaller than 3-3.5mm diameter are associated with lower long-term patency rates, though smaller sizes might be necessary for CLTI patients with limited options. Vein harvesting demands meticulous, gentle handling to protect the delicate endothelial lining, which is crucial for preventing clot formation and future narrowing (intimal hyperplasia). The "no touch" technique minimizes direct instrument contact. After harvest, the vein is carefully cannulated and distended with buffered solutions, preferably not plain saline, and typically includes heparin to prevent microclots. Adjunctive agents like papaverine or a GTN/verapamil combination can help prevent vasospasm and protect the endothelium. Harvest techniques include traditional open incision, skip incisions, and endoscopic methods. While endoscopic harvest is common in cardiac surgery, it has a steep learning curve and mixed results regarding graft patency in peripheral bypasses, though it may reduce wound complications in experienced hands. Grafts can be configured as reversed, non-reversed (requiring valve lysis), or in-situ (left in place, valves lysed, branches interrupted). Different valvulotomes are used to disrupt the one-way valves. Branch interruption in non-reversed or in-situ grafts prevents arteriovenous fistulas that can steal arterial flow. Anastomoses, or connections, are typically made from the common femoral artery to tibial or peroneal arteries in the lower leg. Graft failure presents at different stages: early (within 30 days, usually technical issues), midterm (30 days to 2 years, primarily intimal hyperplasia), and late (after 2 years, often due to atherosclerosis progression or ongoing hyperplasia). Intimal hyperplasia is a biological response to surgical trauma and arterial pressure, causing smooth muscle cells to proliferate and thicken the vessel wall. Intraoperative checks like angiography or duplex ultrasound verify graft patency. Long-term surveillance combining clinical exams, ABI measurements, and duplex ultrasound is recommended to detect issues before complete failure. Antiplatelet therapy, rather than routine anticoagulation, is generally prescribed post-bypass. The success of these procedures relies on meticulous technique, biological factors, and diligent long-term monitoring.