Chapter 56 - Lower extremity arterial exposure

Question 1

vein that crosses over the proximal DFA

Answer 1

Lateral femoral circumflex

Question 2

femoral nerve in relation to femoral artery

Answer 2

lateral and posterior

Question 3

Lateral/distal approach to the DFA

Answer 3

1) starting 6-7 cm distal to the femoral pulse
2) parallel to sartorius (medial or lateral side)
3) dissect lateral to SFA and adjacent nerves
4) dissect between the vastus medialis and adductor longus
5) open raphe/fascia encountered
6) expose DFV and find artery deep to this

Question 4

Nerves inside the Hunter canal

Answer 4

1) sensory saphenous nerve

2) motor nerve to vastus medialis muscle

Question 5

Exposure of mid/distal SFA

Answer 5

1) knee flex 30 degrees
2) longitudinal incision parallel to anterior border of sartorius
3) avoid muscle blood supply from inferomedial edge
4) incision down to fascia lata
5) incise to expose sartorius
6) reflect muscle posteriorly to reveal Hunter canal roof
7) open fascia to expose SFA/FV

Question 6

Medial exposure of proximal popliteal

Answer 6

1) leg rotated on bump at knee
2) distal third of medial thigh along anterior sartorius at lower edge of vastus medialis
2) fascia lata incised
3) sartorius retracted posterior
4) deep fascia entered inferior to vastus medialis
5) spare branch of the saphenous nerve
6) dissect fat pad close to the femur

Question 7

Popliteal artery in relation to the vein

Answer 7

Anterior and medial

Question 8

Finding the proximal popliteal artery using muscle landmark

Answer 8

Palpate adductor magnus tendon

artery pierces the tendon to enter popliteal space

Question 9

Lateral exposure of proximal popliteal

Answer 9

Internally rotate leg and flex knee

1) incision in distal third lateral thigh
2) between iliotibial tract and bicep femoris
3) fascia lata incised posterior to where iliotibial tract joins lateral intramuscular septum
4) enter popliteal space between short head of biceps femoris and lateral femoral condyle
5) palpate neurovascular bundle in fat pad
6) do not injury common peroneal nerve

Question 10

Posterior approach to mid popliteal

Answer 10

1) prone
2) foota nd ankle on pad to slightly flex knee
3) S-shaped incision from medial to lateral
4) small saphenous identified
5) deep fascia entered
6) avoid sural nerve
7) tibial nerve identified
8) identify neurovascular bundle
9) protect common peroneal nerve along the biceps femoris

10) retract apart two heads of gastrocnemius muscles to expose distal popliteal

Question 11

Medial approach to mid popliteal requires division of these

Answer 11

1) tendinous attachments of medial head of gastrocnemius
2) division of sartorius tendon

reattach these

Question 12

Medial exposure to distal popliteal

Answer 12

1) knee flexed
2) one finger inferior to medial border of tibia start incision
3) crural fascia entered to get into popliteal space
4) semimembranosus tendon divided
5) medial head of gastrocnemius retracted posteriorly to reveal neurovascular bundle
6) dissect out artery

Question 13

Lateral exposure to distal popliteal

Answer 13

1) supine with leg internally rotated and knee flexed
2) longitudinal incision over head of fibula and extend distally
3) common peroneal nerve identified posterior to tendon of biceps femoris
4) divide tendon to reach fibula
5) detach attachments to the fibular head
6) remove proximal third of figula
7) identify popliteal artery

Question 14

AT exposure proximal and middle 1/3

Answer 14

1) vertical incision on anterolateral calf centered over planned anastomosis
2) palpate cleft between tibialis anterior and extensor digitorum longus on lateral calf with foot and ankle relaxed
3) incision over cleft 2-3 cm distal to figular head
4) avoid injury to peroneal nerve
5) blunt dissect to separate muscle bellies of tibialis anterior and extensor digitorum longus
6) Identify AT artery and vein in the cleft of the interosseous membrane
7) vessels line just on top of the interosseous membrane

Question 15

Distal AT exposure

Answer 15

separate tendons of extensor hallucis longus and extensor digitorum longus

Question 16

Options to tunnel an AT bypass

Answer 16

1) laterally subcutaneously through thigh then passing knee between the midpoint of the lateral femoral condyle and anterior to head of fibula
2) through interosseus membrane
3) through anterior shin/tibia

Question 17

TPT exposure

Answer 17

1) below knee pop exposure
2) divide soleus 1 finger posteror to tibial attachment
3) mobilize TPT vein first
4) peroneal artery is more deep and turns lateral

Question 18

Mid PT exposure

Answer 18

1) 1-2 finger posterior to edge of tibia or via GSV harvest
2) enter deep fascia and take soleus off tibia
3) PT vein superior to artery, isolate

Question 19

Distal PT exposure

Answer 19

1) incision posterior to tibia and anterior to Achilles tendon
2) encounter artery and vein

Question 20

Two exposures to the mid peroneal pros and cons

Answer 20

Anterior to PT - more veins

Posterior to PT - peroneal nerve encountered

Question 21

Lateral approach to the mid distal peroneal

Answer 21

Lateral incision along fibula
take out fibula
incise fascia

Question 22

Course of the AT artery at the ankle

Answer 22

1) lateral border of extensor hallucis longus
2) pass beneath inferior extensor retinaculum –> dorsalis pedis
3) runs parallel and immediately lateral to extensor hallucis longus tendon
4) runs between first and second metatarsal
5) gives deep plantar branch between heads of first itnerosseous muscle
6) connects with lateral plantar branch of PT

Question 23

Course of PT artery at ankle

Answer 23

1) found between flexor digitorum longus and flexor hallucis longus
2) enters foot after coursing beneath flexor retinaculum
3) travels with tibial nerve
4) divides into medial and lateral plantar arteries

Question 24

Exposure of DP

Answer 24

1) foot in relaxed position
2) longitudinal incision over DP just distal to extensor retinaculum
3) parallel and immediately lateral to extensor hallucis longus tendon
4) Dorsal branch of peroneal nerve (can be divided)
5) incision of deep fascia to identify artery
6) preserve division into lateral and medial tarsal arteries
7) preserve all branches

Question 25

Exposure of inframalleolar PT and plantar artery

Answer 25

1) flex knee and elevate foot
2) Curvilinear skin incision between medial malleolus and calcaneus
3) deepen tissue down to flexor retinaculum
4) divide fat pad and deep fascia
5) identify artery between flexor digitorum longus superiorly and flexor hallucis inferiorly
6) abductor hallucis can be divided to expose lateral plantar artery

Question 26

Exposure of obturator foramen

Answer 26

1) retroperitoneal exposure
2) dissection medial to EIV and posterior to pubic ramus
3) dissect obturator internus muscle
4) identify obturator membrane
5) tunnel through anterior medial portion of membrane

Question 27

Tunnelling obturator bypass

Answer 27

Between adductor longus and brevis anteriorly and adductor magnus posteriorly

Question 28

Obturatory artery and nerve in relation tot he obturator membrane

Answer 28

Neurovascular in posterior-lateral position

Tunnel via anterior-medial

Question 29

Course of the GSV

Answer 29

1) medial aspect of dorsal pedal venous arch
2) anterior to medial malleolus
3) cross tibia at junction of distal and middle third of calf
4) posteriormedial to femoral condyle at knee
5) medial ascension in thigh parallel to medial edge of sartorius
6) joins common femoral vein 4cm below inguinal ligament

Question 30

GSV lies close to this nerve

Answer 30

Saphenous nerve

anterior to GSV in calf

Question 31

Patency and infection with skip incisions vs continuous incision

Answer 31

VQI showed no difference

Question 32

exposure of SSV

Answer 32

vertical incision posterior to lateral malleolus after ultrasound mapping

Question 33

percentage of SSV that ascends into thigh without joining popliteal

Answer 33

25%

Question 34

Deep vein harvest steps

Answer 34

1) bump under knee with external hip rotation and flexed knee
2) longitudinal incision in thigh along border of sartorius
3) sartorius reflected laterally
4) incise fascia overlying abductors to expose SFA adn FV
5) preserve deep femoral vein; don’t leave stump