Femoral Endarterectomy for Severe Peripheral Arterial Disease

CHAPTER 1

My name is Anahita Dua. I am a vascular surgeon at the Massachusetts General Hospital and Assistant Professor of Surgery at Harvard Medical School. I'm director of our Peripheral Artery Disease Center and Limb Evaluation, Amputation, and Prevention Program, and associate director of our Wound Care Center, director of our vascular lab, and the director of our director of our lymphedema program. I today did a femoral endarterectomy on a patient that had very severe lifestyle-limiting claudication, who previously had had an angiogram done of that right side that noted to have a very significant stenosis in the femoral artery going into both the SFA which is the artery that feeds the anterior aspect of the leg and the profunda. So he was really getting minimal flow down to the toes. The major steps of this particular procedure involve first identification of where the artery lies, which is halfway between the pubic bone and the ASIS, and basically making an incision longitudinally across the spot, identifying the femoral artery, then placing clamps after heparinizing the patient, making an incision in the femoral artery that extends usually down onto the SFA or the profunda, ensuring that you have taken the large crossing vein that is the quote, "vein of pain" that is proximal over the femoral artery. Then removing all of the plaque within it and suturing a patch on top of it so that we don't narrow it once we're done, removing clamps and ensuring that there's excellent flow throughout the area that you have done the patch on top of. After this, we achieve hemostasis and then close the groin in multiple layers.

CHAPTER 2

Go ahead and give her the knife. Okay, just through the skin, I like to keep it as dry as possible. Incision. From here to there. Better than it was. Stay right in the middle. Yeah, I was just getting to that. You said you like it dry, so. That I do. Okay. Come up here. Yes. Yes it is. Right in the middle. Excellent. Watch that vein right there. All right, go ahead and yeah, get those little edges there. Okay. I didn't know you were a lefty. I am. One of the best kept secrets of the MGH. Yep, perfect in there. Can we both have DeBakeys, please? And could we have two 3-0s? And if we could please also have two - a medium and small clips available. Okay. Another 3-0, please. Yep. Lovely. There you go. I'll take a medium. Or just give me a small clip, please. Do you tie and clip? Mmmhmm. Belt and suspenders. People say, oh, you don't trust your knots. And I'm like, well, yes. Let's go with that. Another one, please. Thank you. It's like, why not for a vein like that? Yeah, it's gonna cause you trouble, right? Why not, just to make sure? Two Weitaners, please. Now, I'm gonna have a feel here. Yep. And get a sense of exactly where, it's like right down the middle, exactly where the artery is, right? So go ahead and hold to your side there, up, yep. Lovely. There's another vein there. See right there? Probably part of the same drama. So we can come to that in a second. Let that come to my side. Lovely. Yeah. Excellent. Up here, yep. Mmmhmm. I'm gonna hold this to my side. Grab a little less tissue. There you go. Yeah, a little bit more than that. More, less! More, less! Okay. Weitianer, please. Do you have the smaller ones by chance? Yeah. Have a feel right there. Thank you so much. Lovely. I like to stay right down the middle. So let's go here, layer by layer. Nice, clean layer means nice, clean closure. Let's see what this is here. Okay. Thank you. Come right down the middle here. Can I have the right angle again? We'll take this right there. Let's have a 2-0 this time, please. And then a medium clip, please. Thank you. All right. One more. Sure. Drier, please, to me. I think we can do that with the Bovie. Yeah. So what I'm doing here is really ensuring that we can see the ligament and then what I like to do is come lateral to really get the tissue off the ligament to get a nice spread, but yep. Hold a little bit less. Right there. Yes. Lovely. There is a very big vessel in this particular patient. Yep. It's right here. Have a feel, right there. Feel it? And you roll it with your fingers. Yeah. Yep, lovely. Let's take this too, right there. Yep. Lovely. Mmmhmm. Can you put the table down at all? Does it go down? Woah, that makes a huge difference, thank you! Yeah, absolutely. I will be heparinizing by the way, just so you know. How much does he weigh? Okay. Not yet. But when the time comes, it'll be 8,000. Yes, when the time comes. Not yet. So let's shift down there. And I'm kind of, as I'm feeling, I'm getting, like, kind of getting a sense of where we need to be. And it's more towards me a little bit, like, right in this area. So that's why we clip and tie. Can I have a dry, please? I think that's the same one. Mmmhmm. I see what you were talking about with that noise. It's making like a weird, buzzing noise. Yeah, very funny noise. Okay. Put your fingers right there, Armani, have a feel. Feel that there? Right there. And there's the vein on the side there. May I have a Schnidt, please? Thank you. Armani, I'll switch with you. Go ahead and take the Bovie. Come right on top? Not yet, but yes, eventually. Go ahead. Don't pass point at all. Hi, buddy. So vein. Yeah. Which means artery is right here. Lovely. Have a feel. Lovely. Yep. Just be gentle there. Yep. Keep our tips up. Little bit of fibrotic tissue from the angiogram that we did recently. That's what's going on. And so we're going nice and slow. Yep, but I did it from the opposite side. Okay. So it's up and over. So we're not gonna find like... So it shouldn't be. No. A little plaque of... No, shouldn't. Just a little bit more slack. Okay, hold on a second. Yeah. come through this. Change the angle for your camera. Have a quick feel. I can feel the calcium too. Are you gonna want a patch? Oh yeah, for sure. Bow and pericardial patch, please. What size? A 0.8 by 8 should be okay. Can I borrow this from you for a moment? Now we're gonna have to find- Go ahead and let go of that for a second. We're gonna have to find... The edge of the ligament? Yep. And the vein of pain when the time comes. This is what I meant by taking it kind of off the ligament. Yeah. Giving us a nice room, some space here. So, like, this is where we're gonna put our retractor to do this. But once we kind of get down here, and like I said, you know, there's a little bit of abnormal anatomy. But have a nice feel. You can feel right smack in the middle. So we came right down properly. You feel that? You can feel it too. All the way up here. Okay, so let's come a little more distally. So yeah, just hold right there. Just not on the vein. There we go. See this guy? Yeah. That's our friend. Go ahead. Even though, like, we know we did an angiogram, but I don't usually expect it on the exterior like that. Well, he's also got really bad plaque. So it's, like, classically inflammatory. I mean, feel that. Just have a feel of that big rock. Yeah. Go ahead. You know, that's pretty serious. So go ahead. You want to put your finger up here, feel this rock? And come a bit distal here. And he has a huge branch that's a collateral that goes off, you know, kind of not... And you could see it in the ultrasound, even. Go ahead and take them off. Stay more towards your side there. Yeah. Lovely. Try not to park on that. No, that's great. You're fine. Come through this. Excellent. She's right about this Bovie being kind of a weirdo. Do you guys...? Let me just take this from you. So I've got my finger in the plane. Okay? With my finger in the plane, I can have a feel. I see where I want to be, because you know there's always, like, and you've already noticed this with this guy. Big crossing veins. Right? Never good. And when you get to the profunda, like SFA too, there's always one vein that's, like, right underneath. Yeah. So I'm just opening up, you know, using the whole length of my incision, I know we're gonna be a bit distal 'cause on this guy, as you know, we know we gotta go a little distal because... Can we pause for one second to change the Bovei? Oh yeah, sure. We'll let you know. It's much better. Yeah, thank you. Thank you. What was that? So it was the Bovie or? It was the box. It was the box. Interesting. Top one needs to be... All right, so let me... You see it? Yeah. Right there. Yep. So we'll stay away from that guy. So put your finger here. Feel the trajectory of it all the way. We're gonna expose that whole thing. Go ahead and have a feel. And then you too, all the way. Come down all the way. Yeah. Feel it? Now we're gonna go on the hunt, the SFA profunda hunt. And in his case, the little collateral guy too. So we're good as our big, important things. Can I have a Schnidt, please? Yes. Thank you. And go ahead and take the Bovie. I do like the Bovie. I think it does a really good job with dissection, Give me a Bovie dissect. Go ahead and come through that. Just layer by layer. To the point where, you know, you need to switch over. Yeah. There we go. And so for that collateral, are we gonna preserve it? Oh yeah, absolutely. You know, I just want to - that's why I want to find it. It's pretty big too, like, it won't be a... I mean, yeah. Go ahead and come through that. It's not gonna be easy to miss. No. Okay, let's... See how tiny this vessel is, right? Yeah. It's very diminutive, even on the angio. Okay, do me a favor. Buzz me. Okay, stop there. Now, come through that nice and slow. Lovely. You've had your day there. I don't like to come too deep. I don't want to put like a... This, you see this guy right here? Yeah. This is one of those huge branches. Yeah. So we're gonna leave him alone. Do you want me to put a vessel loop around them or? Yes, oh yes. And then there's always an an opposite side too. Yeah. So we'll find both those guys. We'll save 'em both. But let's get out everything before we make any big decisions about - I never take anything before - go ahead and kind of stay on your side there. Nice. Okay. So I'm gonna hold on top of the artery. You hold there. Now remember, the vein is gonna be stuck to, right? There he is. Oh yeah. You want me to get it myself? It's a naughty boy. Oh no. Oh no. You're good. You're good. Go ahead. Hold that towards you. Kind of falling away. Yeah. Right down the middle. Beautiful. Yes. Lovely. Yeah, that's the vein. See the vein there? And the artery. And this is the artery. Yep. And so we're gonna just get the vein away. We just don't want that guy in our face. Gotcha. This is nice. Let's come to now this side. So you hold on top of the artery. Lovely. And this is where I've gotta be extra careful, because... Go ahead and come through there. That's where, like, you know, there might be collaterals, whatnot. Go ahead and hold towards you. Lovely. Excellent. Okay, dry please. You need the femoral endarterectomy. May I take that again? So then again, I kind of do the same thing where I put my finger, have a feel. Especially when I'm kind of past, like, I know the vein is behind my nail there. So I'm like, I feel safe. Yeah. You know? I'm not gonna plow into something important. I'm not digging, I'm just kind of pushing. Exactly. Okay. So that's one. So you see the vein all the way down there? And where you see this caliber of vessel gets small is usually where the profunda is going to be. So that's what we'll go hunting for now. Now, this is very rigid. The SFA all the way down and there was quite a way. So we may have to go a little bit further. It might be a longer patch, you know? Yeah. It is what it is. But his big deal is his profunda. That's what, when I took him for his last angio, that's what I, like, made better, so to speak. Okay. So now what I'm gonna have you do. Yep, exactly. If you could hold that up towards you. Right there. Excellent. Yep, keep holding it. Lovely. And if you could hold right there for me. Yeah, it's tough. It's just so rigid, you know? Definitely can feel the scar tissue as you were saying. There we go. So now I'm gonna give this to you. It's a little bit bigger there, though. Like it's almost... It's still. Now put your fingers like this and hold it and feel how rigid it is all the way down. Feeling calcium. Calcium. Oh yeah, have a feel. Have a feel. You should feel too. Go ahead. So the most important thing is the proximal. You know? And then, well, kind of equally important is the profunda. So go ahead and hold that towards you. Right. So I'm gonna, yeah, and pull. Exactly. Give me a nice plane. I like to Bovie dissect. I like to hold like that. And this is something one of my mentors taught me. So I'll do this. But remember when I tell you, there's always a vein that's, like, right underneath... Just a moment. Let me just grab this guy for a second. There's always a, yeah, hold that towards you. Excellent. There's always a vein between the- Yeah. See and that's it. Is that one of the collaterals right there? I think it is because I don't think we've found the - it's not impossible that's the profunda. But probably not. Off at an angle, I would expect. Go ahead and pull that towards you. Excellent. Keep holding. Lovely, lovely. I'm coming up here. Yep, you keep holding. Great job. All right. I'll take this from you. Yep, and you hold the- Kind of see if the vein is right there. Yeah, you'll even- You don't want to... Come across, like, with the Bovie there. Oh yeah. Wow, okay. I know. Impressive. Impressed? I mean, not always, but - can I have a right angle, please? Do you have the duo dissector? Is it on your? Yeah, give me that. So that's what I... I like to use this. This is the instrument. Do you want a vessel loop? Yes, please. Bigger? Do you see it? This is how I - I invented this as a resident. Yeah. And the way that I like to do it is it kind of spreads. You see that? So it's, like, right in the plane. Did you see that? Yeah. So like, now it's opened, exactly the plane. Right? Like it? So now I know - I mean, you gotta be careful. But that's how it works. But like, I now know the spot and then I know, look, that's probably where the profunda is. But also because you're right up under there, like on the vessel, you know, there's a slim chance you'll get into anything else if you're in the correct plane. Exactly. Exactly. And see, so I'm holding up with this dissector and I spread. So what's that? What? I'm sorry? That one right there, coming off? Oh, there's a little collateral. Well, big collateral. But yeah, that's why. So I got this idea when I was... Thank you very much. You're welcome. When I was a resident doing a hernia repair, actually. I saw somebody doing the spermatic cord with the fingers and it's tearing and I thought, wouldn't it be nice if you just had one thing in a plane? You know, and you don't get much bleeding or anything. And then that's a really nice plane. Now see, we're completely, in my opinion at least. So there's another branch there. So this is the profunda. You see that? Two branches and we're gonna preserve everything. We're gonna preserve this, this, this, and this. Now, some people may want to just put the - Can I have a Metz, please? Some people may want to just put one clamp on the profunda. The problem in this particular patient's case is we want to be a little distal, right? Yeah, exactly. Thank you very much. We want to be a little bit distal on each vessel so we can protect it. There's one of those little veins coming off. Yep, yep. Exactly. See this guy? That's the guy I'm talking about. Him and him. Yep. They're so naughty. Yeah, there you go. Excellent. May I have... So I'm gonna come from the other side now, underneath. And I don't know if you can see that, but there's a huge- Do you see that profunda? Yeah. That's the guy that, you know... So let's see what's the best way to do this. May I have a right angle? So I wouldn't use the- I mean, the Dua dissector thing is too big for this. I wouldn't be stupid enough to put it there. But I'm sorry. You okay? Yep, may I have... Yep, go ahead. No, please. Excellent. Excellent job. Yep. So go ahead and take this towards you. Okay. I'm gonna take this towards me. And now, let's see if we can get in this plane. So we treat this as two separate bits. Now, remember there's a vein in there. And you know what? If you get into the vein, you just- Go ahead and put that there. You just hold pressure. Yes, please. And we're gonna Potts it. So we're gonna go around again. Okay? So I'm gonna have you hold that and give that to me. Lovely. Go ahead and give it to me. Yep. Exactly. And now I'm gonna give it back to you. You, there you go. You got it. Lovely. Go ahead and don't pull on it. Just put a vessel loop on it. Would you mind getting us some thin vessel loops, please? Yeah, go ahead and give me one of those. So let's put one on here. And then we'll do that proximal. He's not gonna need much. And go ahead and pull up on that. There you go. Exactly. That gives me a nice view of it. Thank you. And I'll bring this towards me. Wait a second. I don't think we. Thank you. Thank you. Thank you. All right. This guy, it's a ways down. Like, it's totally rigid. You know? You're worried about a distal clamping zone? Exactly. We can do it distally. And we don't want to follow the plaque. We'll see what it does. I'm like, I'm quite far. I'm like all the way here. Yeah. And it's still, there's is a clamp site there, like right where my finger is, which if you look is right here. Put your finger right there. It's not great, but it is a little bit of a clamping zone. I mean, he's really... His profunda is really his dominant. Yeah. May I have another- That's why we can't lose any collaterals. May I have another thin vessel loop, please? Thank you. Go ahead and take that for me. Give me the tip only. Yep. There you go. We gotta get this guy here. Yep, exactly. Dry, please. Yes, please. And then we'll do that proximal. Not too tight. Just enough so I can get the - Yeah, there you go, and give me the other end there. Put a snap on that. All right, so now let's go to the proximal. Really important. We will take an appendiceal, please. So now let me see. So here, there's some posterior plaque, which is like a cup, right? All the way up. Hold like that. If you could just hold it right there, Armani. So now what we need is to find the vein of pain, which is - you always want to take it. It's usually crossing. So I don't see it here. Again, I like the Bovie dissection. No. It's not there. Yep. Hold on tight to that. Uh-huh. It's usually right on top of the artery. But sometimes it's in this mess too. And let's get that light. There we go. Just watch everyone's heads. No, you're fine. Mmmhmm. Still looking, still looking. Suction, please. It's okay, this is going to be a big endarterectomy. Potentially a little slower. Or I just do a side to side type thing. We'll see. There it is. See him. Look how big that guy is, huh? Way up there. Yeah. But that's a good marker of kind of like where you should be. Yeah. You know? It tells you, you know, where you need to be. Now this part's super important. So I'm under it, right. Now we gotta get through it. So, I'll have you come up for a moment. Let's work. So we know where he is. We know what we gotta do. So first things first. Mmmhmm. We don't have to do any that thing actually to... This is another branch. Remember I told you there's always two branches. There's the other guy. So we'll get that one. Right angle, please. You want to be completely controlled. And there is a soft spot where I have my finger. Okay? So I want you all to take your finger. It's literally right, literally right where the vein of pain is, which is always what happens. You now, go ahead and put your finger in there. That's the clamping spot. Slide up until you feel the soft spot. You feel it? No, exactly. Small vessel loop. Yep, there you go. Lovely. Hold onto that. Oh, right here. Yeah, and then go ahead. You got it? Okay, so we are nice and far up. I'll take that Adson back in now, please. Will you do me a favor here, Armani? Yes. Once we get this in, go ahead and hold the one that's up here. Yep, just hold that. Not tight. Just enough for me to get the Adson-Beckman around. There you go. Yeah, out of the way. Exactly right. There we go. See that? So that's much cleaner. Much nicer. Let's put the one, so this one comes to this side. This one's like that, and this one's kind of like that. You see that layout? Good. Lovely. So now let's go after him. First of all, a Bovie. So this is what I meant by the lateral edges. So if you look, this is the inguinal ligament, but this is just like fibrous tissue that can be opened to give you a little bit of a lateral space so that you can really get in there. I'll take that appendiceal, please. And then now we're gonna tie off the vein of pain. Two 2-0 ties perfectly done and then big clips. Hmm. So first I'm gonna have you - You see how nice it comes into your view there? Yeah. So stay right there. So you hold onto that, I'll tie my side then I will take it and you tie your side. Right angle, please. Thank you so much. And then, up here is where we are going to put our eventual clamp and, you know, and I like to come and really dissect to know that there's no other branches. But I know that this is probably it. Now, this vain of pain, see how nicely we're around it? May I borrow this from you? Thank you. Okay, so to begin with, I'm gonna tie this down. People try to not do this part. Ah, it's so high. Let it go. But what if someone else operates on this patient in the future? The expectation would be maybe that the vein of pain is gone. I'm gonna switch with you in a second, Armani. Give you the other side to tie. Medium clips? Large, please. Okay, so. I got you, Armani. You hold it, bring it towards you. Okay. There you go. Yep. Tie it down. go ahead and bring it over here. Yeah, go all the way down with your finger, so that you're not pulling the vein towards you, 'cause that rips it. Yeah, there you go. Nice. Very nice. Nice and tight, okay? Nice and tight. Yep, push past the knot. Large clip. A large clip. Would you mind holding this again for me? You hold kind of like this. Another, and then I'll take two mediums. So kind of put the large ones on the outside, and I'm gonna put two mediums kind of in the middle. Keep holding what you got. Take a look now, all of you. Go ahead and stick your finger in there. That's, like, exactly our clamp site. It's like a marker. So feel the hard and then feel the soft. So, Armani, I'm gonna have you hold this for me again. Can I have a Metz, please, and a DeBakey? So what I'm gonna do now is just get around it, that's it. Just right here, okay? And then we'll say that's gonna be our clamp site. And I like to use the C-clamp. Yes, which is the... I'll show you in a moment. You want me to loop around it or no? Oh yeah, absolutely. I always do. I'm going to need a big vessel loop. So that you've got a nice - yeah. Katherine, can I have you just please suction for me while I do this? Just use the other one, the smaller one. Can we have a big vessel loop at the ready as well, please? Yeah, I think this is another branch here, potentially. Right there. It's possible. Right here. You see this guy? Yeah. Yeah, and I'll take a right angle, please. Little bit bigger one than - let's see if this will work. Do we have any bigger vessel loops? Do we want something bigger than this or? The vessel loop, you mean? Yeah, I think that's what they think you're asking for. Oh no, no, no. I need a bigger right angle. Oh, we meant a bigger right angle. Oh. Sorry. Armani, if you could hold like that for me. Okay, bigger right angle. All right, I'm nice and clear on both sides which is the most important thing. This is like... They have the bigger one. Okay, let me see. Thank you very much. Yep. There we are. All right, vessel loop, please. I'll take a snap. All right, I'll have you put that right here. And then what I do is I hold both sides up to give me my plane again, which is right there. Let's see. Yeah. And that's gonna be our clamp site. So, lovely. So we are set. I like to have the vessel loop. So we have our proximal control. Very, very important. And when the time comes, basically the story is going to be the entirety of this area. How far on the SFA we go, we'll have to see. Hopefully we'll be able to get a lot out. You know, can I see that? Yeah, let me see the 0.8 by 8, because I don't know... We're gonna take it out. It might... Be too... Short. Do we have anything longer than 0.8? I know we've got thicker. Do we have longer? We don't, right? So this is 0.8 by 8. The other one's 2 by 9. So it's wider. And longer. A little bit longer. Yeah, it's a little bit longer, right? But it's just 0.9? Or? No. It's 2 by 9. 2 by 9? That might be. I think it's mostly the length, you're just going to get 1. Yeah, the length is what I need, and that's why I'm wondering how much I'll get more out of it. There is like a big patch for cardio. I've seen that huge - yeah, that's, like, really big. You either get like that, or... Or like... I know what I'd pick normally, but... I'll grab the other to see. Yeah, let me just see. I'm just debating, you know? Can I have a ruler? Because you can see that's quite a stretch, you know? Quite a stretch. So... Let's see. 3 inches. 3 inches. Is there centimeters on the back? We can do that too. You don't want to convert it? I mean, we might just... An 8, or you need bigger? I think maybe the 9. That might be. Yeah, the 9 might be - just to be safe. Okay. I think, the 9. Let's do that. Let's do that just to be safe. And then may I have... So the other thing we need to do is just put a vessel loop around here. If I could have the suction a moment. You know, right here? So we're just cleaning this up. Nothing crazy. Just cleaning it off. Just so that if we need to slide down, it's easy. I think, you know, I mean, it kind of opens up like in this area. The other option is, you know, do what we need to do up here and then an anterograde stick of the patch work on this area. I would rather not put a bunch of stents, you know, knowing that they're gonna in this rigidity, especially in such a small artery. But, let's see.

CHAPTER 3

Would you mind giving him 8,000, I think what I wanted, yep. Yeah, would you give him 8,000 of heparin? And then could you tell me in 3 minutes what an ACT is, please. And then we'll get ACTs every 3 minutes to keep him at a... Every 30 minutes, right? Every 30 minutes, exactly. Yeah, 3 minutes first, then every 30 minutes. To keep him at 250, please. Can I have a right angle? Yeah. A small one, please. Yeah. Vessel loop, please. Once he gives that, then we will clamp and open and go from there. Can I have one more Weitlaner, please? I think the inflow is probably okay, frankly, but we'll find out. Go ahead and hold this for me. So you feel how it's like, it's more of a in and up. Okay. Right? Like that. Okay. tell me if you need to take a break. That's completely fine. See this guy? DeBakeys, please. Thank you. Yeah, right there. This guy. You'll just take it off later? Yeah. It's pretty big, I gotta say, actually. Can I have a right angle? Yeah, let me have a... I don't like the idea of taking anything, you know. I don't want to, oh, sorry. Let me have that from you a second. There you go. Like that. Okay? And then a blue vessel loop, please. And then what I typically do with this is I will put it like that. Okay. You'll see in just a moment what I mean. Gotcha. All right. Lovely. I have the patch. Great. Tell me when it's been three minutes. I'll take the C-clamp. Which one? Yes, it's like this. But do you have one that's tighter? So like this, but tighter. Tighter? Yep. It really looks like a C. This is my favorite clamp for doing femorals because this is a little big, but I'll show you the tighter one, because you can put it on. No, it really looks like a C. It's, like, really quite a tight loop. Okay. Let me see. Go ahead and hold onto that. Yeah, hold on tight, because this might just be a little bit too big. See what I like to do? So I come around. Yeah, there we are. And then I'll push up. Has it been 3 minutes on the heparin? 2.5. I'll take two profunda clamps, please. All right. So. All right, we're clamping. Let me make sure that's a soft spot, which it is. And... That's two clicks. Okay. I'll leave it right there. And then what I typically will do is - DeBakeys to me - I will unloop this. Okay. Just one loop. And keep it like that, so we're ready if we need it. But this is our clamp, so let's not shake or move this. Now come all the way down, basically locking each one of these to the table. This is the next one. You know, actually go ahead and release that one. So this one kind of comes around. Do you see this? Like, it's a little stuck underneath here. So I'm gonna pull it through here, and then lock it up top. There we go. You see that? Yeah. And we can pull that and kinda lock it there. Just right on the thing. This is kind of our big gun. Might even need its own clamp. See? And that was one of the profunda. We can do this one too. And I'll take a profunda clamp from you, please. Thank you. Actually, you know what? Would you have the Fogarty inserts? Give me the Fogarty angle, because there's a lot of calcium here. So the inserts are nice for that. And then what we'll do is come a little bit lower and two clamps, okay? Let me have a feel. I do not feel a pulse, which is good.

CHAPTER 4

Can I have an 11 blade now? And they're more defined. Thank you. Go ahead and grab the suction. Get into a soft spot to begin with. Potts, please. Knife down to you here. Thank you. You saw the knife, right? I gave that back to you there. Yeah, I have it. Lovely. Ooh yeah, that's really tight. You see? Yeah. Really tight. So the key is you want to be in the lumen. Yeah. Which I believe is here, but that's getting into plaque here. So let's come this way too. Really get a sense of it. Notice how I stayed away from the profunda. I did not start there. Yeah. And now I'm coming down onto the SFA area. Yep. Suction for me. I'm basically trying to find the plane and cut. Let's do the same thing up here. So you gotta wonder, is that the lumen here? You see this? Mmmhmm. Versus, yeah. You see that? See how that's, like, jotting out? Okay, so let me continue to go up and to what would be - you want to just give a little bit of a spot where you're gonna be able to do your - So yeah, suction there. Now, may I have the Freer elevator, please?

So everyone take a look at this. You know, you can see how rigid, ugly. Eww. Yeah. So now, the key is that you want to use the Freer to push the wall away from the plaque versus make a hole. I'll show you a little bit of that. We'll both take Gerald's please. So you gotta find where it actually is starting. This looks like it probably, you see there's two planes right there? Yeah. Likely it. I'll take a Gerald's, please. I think I have a Gerald's in my kit, if you look at my kit. Yeah, I think this. So I'm pushing the wall away. I always will err on the side of keep more plaque than thin the wall too much. Than thin the wall. Oh yeah, absolutely. That is totally the answer, too. You see how it's making a little bit of a spot here? I'm gonna come down. This is where it's really bad. It's lending itself to it there, but... And I will take a DeBakeys as well. Let's just keep 'em both here. Yeah, just little. I need a little bit more rigidity to hold on. So you go ahead and hold the wall for me, just real gentle. Okay? It's real easy to get, like, you can hold it. Yeah, it's okay. It's real easy to get just, like... Too aggressive? Super excited and aggressive, yeah, which is, you know, as you should 'cause it's exciting. It's also my personality to get, you know, just so wild. Me too. Now do me a favor and come here. You see how this is kind of like..? Exactly. Yeah. So now what I'm doing is turning up. I'll take a right angle, please. What I like to do is very similar to what you saw before. So basically, the key with this though is that you're in the right plane. It's very easy to be in the intima. So what I do is just real gentle. Oh look, there I am. Yeah. And then I spread. Okay. Right? Yeah. And I spread it and I'm like, okay, I'm in the right plane here. Spread down, you know? And then do you come across it to get two pieces or do you just see how far... Oh no, I do try to get two pieces. But you see in this particular case how it's giving it to me a little bit? Yeah. So I'm just like, okay. And I'm pushing the wall away. I'm pushing the wall away. But I don't want to get into it. You see how it's like kind of... Yeah. Now I'm at the profunda area. So this is super careful, because remember, there's a couple... Couple branches. Couple branches there, right? Now, we can always come back and clean it up, but we don't want to, like, cause trouble. Yeah. Especially given that it's his dominant flow. Correct. Correct, correct. So we're coming down. We're coming down. I'm just making a plane. Making a plane. Starting to give it to me here a little bit. You know what I mean? Yeah. But like, I'm trying not to - you see, you would be in like a totally different plane if you just tried to... Yeah. So I'm coming down. I'm peeling it like a banana, and it's giving it to me there. Great. All right. Now this is super important, because if you get into the wrong plane here, you get a little flap, goes up, occludes your inflow. You're done. So you don't want to get psycho here, but you need to be able to get enough out. So, what I like to do - may I have the Freer, please? It's a dance with the clamp up here. So first thing first. Kind of give me as much as I can get from there, 'cause the idea is that it's just gonna kind of peel out. Just suction for me right there, if you could. Lovely. Right there. Yeah, yeah, yeah. Excellent. Okay. So now, what I'm gonna do is release the clamp and get sprayed with blood. Put it down again. Okay. Suction for me. So I've released a little bit more with every move, and I put the clamp higher. That's the key. See how much higher we are than we were previously? Yeah. Why? Because I want to get to a point where I take it and I'm happy with the inflow. Yeah. So I'm gonna take the Freer again, please. Thank you so much. And remember, this thing goes all the way up. So at some point you gotta make a call. You know? I'm not gonna go, I can't go all the way up. But I have a clamp site, which means that there's a spot, which in theory should be - yeah. A soft spot. Right. Is up like that. Oh my god. See this? So see how it did this, what we call, quote, "feathering"? And you can, if you touch it, touch that piece. So that's intima right there. Yeah? Feel that soft, soft piece. Feel a soft piece here. And so if you look at it, plaque attached to a piece of intima. And ideally, you know, this chunk, I mean, this is, you could build a house out of this. Right? So now, we go and we have to clean up. Let's give that back. We should take a picture of that for the patient. I'm sure he'd like to see it. He's a very sweet man.

So now: movement of truth. Right? Let's look at what this is gonna be. Everyone back up. That's not bad. Okay. Two clicks. I never go crazy. A little bit of blood loss, not gonna hurt anybody. Just be careful with this. And I'll take some heparin saline, please. Oh, heparin saline, please. I'm just... I'm sorry? 242. 242. Will you give him 2000 more of heparin? I like to keep him at 250.

Okay, so now, I like the proximal. But we want to look at the end point, make sure it's not terrible, okay? Thank you. Thank you. And when you use the suction, just be a bit careful about Rubbing up against this too hard. Yep. Yes. Go ahead and suction. Any itty-bitty bits like that, we want to take out. Okay. Yeah. Out you come, buddy. Out you come. You're out of here. Yep. Yep. Go ahead and suction. And suction, suction, suction. Okay. More of this. May I take this again for a second? Some people are really crazy about, like, I want to get in that little layer. I want to make sure. I mean, you don't need to do that and you shouldn't do that. You don't need to do that. It's because if you thin it out, you have a whole other problem. So let me just up here. I just want to see what my end point looks like. So I'm looking into the vessel, right? So looking into it, you see it, right Armani? Yeah. Can I have that heparin saline? Thank you. So what I'm doing now is I'm gonna shoot some fluid in here. Go ahead and suction for me. I just want to see if anything is lifting. That's what I'm looking at. That's gonna potentially get in there and... Embolize. Yeah. And I really don't - I'm taking this stuff out. Just you don't get overly aggressive. Exactly. You just don't need to. Also, you are gonna attack some when you do your patch. You don't need to. I mean, could you argue like - this? Like, do I need to take... I mean, it's pretty stuck, you know. Do I need to take it? But yes, in real life, I mean, technically this is the real artery wall. Yeah. But is this gonna limit his flow? Is it going to cause trouble? Is it going to embolize? Those are the questions I ask before I start peeling away, you know, and causing more trouble, right. This stuff will all lock down when I suture to this thing. Suction please. Yep. And then I'm taking any bits. You know, bits needs to go. And anything that's pretty stuffed down, you're just... I don't mess with, yeah. Like, is he going to have essentially normal flow down now, especially if I'm gonna patch this too. You know? It's not like, but yes, you don't want anything that's gonna lift. That's the most important thing, 'cause blood could dissect, you know. See in this plane right here? Yeah. So yeah. I'm gonna clean that up. I'm gonna take it off the edges. See the clean artery underneath? Mmmhmm. But look, it's pretty rigid. Again, you know, like if it's not giving it to me. Like look. See, that had cut into the intima there. That's not ideal. Right? So that's a sign that, hey, leave me alone. I don't need to be messed with. You can even take a Potts and cut this. You don't need to pull it off like, you know what I mean? Now I'm just showing off. Can I have a little bit of heparin saline, please?

So that was the proximal. Now let's go to the distal and deal with that end point. Okay, 'cause this is again, very important, right? Inflow, outflow conduit. Tenets of vascular surgery. This is not even properly pulled up, but... So first of all... Pull it up or? Let's not do that yet. What I'm doing first is seeing if we got everything we needed to from the profunda, then we will come mess with the SFA. Okay, so for right now... I'm just taking out these little chunks that are dangling, and then we'll see what we've got left over. Again, this is gonna lock down. Just be - you're right on the profunda there, which is fine. No, you're fine. Just hold that up right there. I liked what you were doing. Remember also, this is... Yeah. See this little piece kind of floating around? You want no jellyfish, jellyfish-free zone.

Okay now, go ahead and release what you have. Okay, now we're gonna play a game. It's called the profunda game. So we're gonna see - does the profunda light up? So I'm letting out the first branch, and look at that. It back-bleeds, okay? That's branch number 1. I'm gonna put it back. And that's why I like to do each branch because you can check... Individually. Did you get everything? You know? So, this is the second one. This is gonna be fine. Here. Yep. Go ahead and suction. That's not a profunda branch. It's a collateral. This is the other profunda branch here. Okay, ready? Yeah. I gotta release it here. Okay. Suction. You always give it a second. Suction. Yeah. Great. Great. Okay, so let that be. Now, SFA time. And once you've checked everything, you're ready to do your patch.

Okay. Let's see what this SFA does. Releasing it. Okay. A little bit of back-bleeding. I like that. I like that. That's not bad. This is from the SFA here. So let me see what happens if I just pull up on it. Yeah, the posterior plaque. So we don't have to use the Fogarty anymore. We can just do this. But we gotta go up, down, up, down, up, down to make sure our end point looks good. Because he does have on my angio pretty nice flow actually here. So the danger is when you're putting your patch in, you accidentally suture that hole closed thinking it's the- So I think the smartest thing to do is, may I have a Potts? Gonna find a nice end point. So we know that there's a lumen here. So the question is, where is it? So yeah, hold up right there. Exactly. I think it's here, esque. Yep. Hold that for me. And we don't want to go chasing it. Yeah. Now what I'm gonna do is take a look to see where does the blood come from when I release it. Okay, and it's lower down. It's almost from here. Yeah. Yeah. Okay, so keep holding. Yep, yep, yep. Schnidt, please. All you really need is for your end point to be okay where you're suturing, you know. So I'm just taking this right here. You're almost like everting some of that flap out. Mmmhmm, exactly. Because it's almost like this is the lumen, you know? Like right here. Yeah. Right. If that's the lumen, then all you want to do is just basically, you see how my Schnidt is going in? And yeah. See? Like clearly so. So I'm pulling some of this stuff out. You see that little, like, cork of garbage? Is it perfect? No. And can it cause more trouble? Yes. Because I can accidentally close the lumen distally. You know? But you also do need to have something you can sew to intelligently. May I have a Freer, please? We're almost done. Oh wow. See how it's slowly- Another Schnidt, please. Now the problem is when I do this. I mean, this thing goes on forever. So you see that? Yeah. Same sort of thing. I let it feather, right? But, now did I screw it up? You know? Did I ruin our lumen? No, I didn't. So we have a channel. I don't expect to see a torrential amount of back-bleeding. There was no blood going into it. But now I'm happy. I have blood that can get in. I have blood that can get out. I have two end points I can suture to. Profunda's open. SFA's open. Branches are open. We can do our patch. See, you know, keep our blood pressure up. So it's good. It's at 135/35. You don't want very low blood pressure because you want the leg to perfuse, and then we can see what the next steps are. Okay, all right. All right.

Yeah. May I see heparin saline just before we do that, please? Thank you. You're gonna check for jellyfish? Yes, jellyfish check. Jellyfish check. Some jellyfish here. But they're attached, so that's okay. Can I have a DeBakey, please? Again, you know, that would horrify some people. Oh my god. What are you doing? It's gonna embolize. It's gonna... I mean, it's attached, so. You know, again, your job is to not make things worse. We have to suture that off, I think. Yeah. See, this is very attached here. Yeah. Let's not... Mess with it too much. Smart to mess with. Yeah. Yeah. There we go. Just want to get, again, this stuff. Got that right there. Yeah. Yep, yep, yep. But then, otherwise just kind of move out that guy or no? Mmhmm. Oh yeah. But you can see how this would... Be very tempted to keep going. Yeah, and even just, like, plucking it. Like jellyfish and eyeball wax, the threading. These are the best ways to, you know. Let's come down here. Would you take a Gerald's? Yep. And just hold the edge of this towards you like that. Exactly. And I'll take some more of the heparin saline, please. So I'll hold it here. Yeah, you do what you're doing. Because you see, the problem with this is if you don't take it fully out, you could peel it down like peeling off wallpaper. And then it can occlude your profunda hole. You know? I also assume it's thrombogenic. Yes. Yes it is. This is all gonna get sutured up. All gonna get sutured up, and you're gonna suture it there. All right, we'll take the patch please. Sorry. No worries. Maybe that right here. See this? For a dissection flap. Sometimes if you have a piece that's, like, right at the end points, you can tack it down too. We don't have that issue today. But that is an option as well.

CHAPTER 5

Thank you. This is a nine. Oh yeah, this is only a little bit - SNH, too. So yeah, that's definitely gonna be fine. Okay, so first things first. We put it down. Marking pen, please. So, smooth side goes down, rough side goes up. I like to just, you know, just make it simple. Another scissors, please. Yep. Hold it way back here. Just right in the middle. Yep, and stretch it towards you. Lovely. You don't wanna make this too patulant either because it can - it can thrombose. It's just like sitting there doing nothing. Yeah. You know, that's no good. By patulent, you mean redundant material? Yeah, yeah. Like, you know, a big, huge thick. Right. You don't need to do that. You may think that when you look at how big that hole is, but those walls move. Go ahead and keep you're holding. Yeah. Should we orient it that way? We are gonna use a... A 7-0, or a...? Let's do 5-0. All right. Not 5-0, what's the thing Conrad used to use, where it was like a HS4, maybe. It was a 5-0, but it had a needle hole that, like, or maybe they only have that where I, the other place I work. Do you have any other kinds of 5-0s? What is it? HS1? HS4, I thought it was. Or needle, maybe. The suture's smaller, or bigger, or... Yeah, remember that? Yeah. I always liked that. I always thought that was kind of cool. Would you hold that for me? May I have the heavy scissors now, please? Yeah, I think HS was hemostatic. Just hold it straight like that. Thank you. Yeah, that's the one. Little arts and crafts. Okay. Let me take a look. Yeah, there's an HS7. Is that? Would that be a 6, then? Yeah, that's nice, isn't it? That's what it looks like. And I am gonna try out... Fancy casters. These are titanium casters. May I? Yeah. Okay, hold on. Okay, here you go. Thank you. All right so, I'm gonna need a splash in a second. So Armani, put your hand right there. Don't let this thing move. Yep. Thank you very much. Lovely. Ashley, you got it? Don't move. So, just in, one stitch. Okay. Now, Armani, pick up the patch. Okay. Yeah, lovely. Bring it down. You can use it with the... Yeah, just use yours. Just bring it down all the way. There you go. Lovely. Okay. Big splash to me. Armani, just hold it with your pickups there. Big splash. Big splash. Big splash. There you go. All right. Yeah. Okay. There we go. Shod, please. Shod to Armani. All right, Armani. Lovely. You can let go of the patch. Great job. Go ahead and shod this one towards you. We'll take this piece. Follow on this is super key. So I'm gonna have you use your... Yep, exactly. You're doing it great. Armani, switch hands. There you go. Okay. And you'll go back and forth, back and forth. Now don't let it coil in front of me at all. So hold it back a little bit further. Maybe, like, there. Yes. Lovely. Just enough for me to get in. And I always take the first 5 or so in 2 bites. Always, always. Okay? Go ahead and release. Now the trick is, there's a special way to make sure that it lays down real nice. And that's bringing the patch 90 degrees. Just watch the clamp, yeah, 'cause that's the classic issue that it... Okay. Yeah, don't pull too tight. But you're doing great. I mean that's... And again, I'm like almost, almost right at my spot. Yeah. And I'm going to bring this 90 degrees to make it lie down exactly. That way you don't have to do that thing where you're pushing, you know, the loop to make sure it lies flat and it's all over. So watch again. I'll show you. So keep the loop outta my face. So come all the way up. Yeah, there you go. And it becomes less and less as you move down. Yeah, totally. So I'm ready to go again. Oops, that was my fault. No, that's fine. Yep, hold up for me. I'm gonna attack some of this plaque. All right. And then I'm gonna bring this 90 degrees, and it's down again. Lovely. Hold on to it again. So when you're saying that 90 degrees it's, like... Up, straight. Like, straight up. Okay. Exactly right. Yep. Nice follow. Okay. Nice and tight. So what you want to do is - you're pulling it towards you like this. What you want to do is - So switch hands. So now you're with this hand. Exactly. Exactly, beautiful. Not too tight. Not too tight. The tightness only comes once you... All right. Yes. Now you see how you're splaying this towards you? Yeah. And then I go 90, go ahead and let go, 90 degrees. See how it lies down perfectly, right? And every time, I flatten it out again. So you want to have your - either you can do it. Like, I can do it, or I can have my partner do it. Obviously, you. So this one. Try to protect that plaque. Got it. And I'm not worried. It's not gonna narrow. I mean, that's a huge patulent area. But sometimes it's really tight, you know. Or if you've not gotten enough plaque, you can imagine, you know, those sorts of scenarios. You just want to kind of get the edge. Yep. Try to do a few more. We'll have you come out of that corner. So there's a branch here, so our first branch. So it's a little bit thick. That plaque is real nicely tightened down. I want to make sure I get patch, and I want to make sure I get artery. And again, 90 degrees really allows it to lay. Up there. Yeah. Nice and tight. Nice and tight. Uh-huh. Shod, please. So go ahead and give me your shod, Armani. Oh no, I'll take hers. So Armani, I'm gonna throw the first two up top and then I'll have you do the rest. Yeah, and I can see it really nicely, too. Also paranoia. The usual. So I come about halfway and then, you know, we'll keep moving down. Hold up a little bit. Give me that little... 'Cause by you holding straight up, I can, you know, the tent that... Yeah, exactly right. Yeah, you see how nice and clear and obvious it is? Yeah. Yeah. Hold tight. You see this circle? You want to come a little bit further? There you go. In classic attending fashion, I just told you I do all the first 5 in 2 bites and then did it in one, but... So I'm pulling back on the patch to kind of flatten it out. Yes. Pull up nice and tight 'cause that makes it not leak at the end. Could you airplane the table towards Armani, please? Nice and tight. Ah. There we go. Here you go. Take it. Okay. So I'm gonna hold tight for you. If you feel like you need to take it in two, that is completely fine. Then, so you still come about there. Little bit closer. Little bit closer. Yeah. Bang it across. Yes. Perfect. These are smooth. Isn't it? I know. Amazing, right? Yeah. Don't torque it. Straight out. There you go. Perfection. Good job. Pull up. This is what it's like to have my casters? This is right. All right, go ahead. Close to your last bite. Up there? Yeah. And straight across. Yep, and you can sometimes lift that and put it on your needle. There you go. Take it. Beautiful. Release. Yep. Push it through. Beautiful. And take it. Let me take some more. So you have it a little bit far back. Come a little bit closer and angle a little bit 45 degree. That'll help you a lot. Just a smidge. Yeah, yeah. Try that. ACT is 237. 237. Could you give 3000 of heparin, please? 3000? All right. Yes, please. There in that groove? Yep. Get it. Yes. I love it. Nice job. Mmhmm. Watch that clamp. You don't want to wiggle it. It's hard. I mean, it's in your face. But, you know. 3000 heparin. Okay. You want me to travel a little more or? Yeah, you can do a little bit. Just a smidge, though. You don't want to, like, really... Especially, yeah. And I'm gonna hold this straight, so you want to just come straight across. So you don't want to angle it all, you know, 'cause that's how you make it kind of even. Yeah. Straight across. Yes, straight across. So I'm gonna pull out over here. Yes, yes, yes. Perfect. Can take a little less light on the artery. But that's okay. That's fine. Nothing's gonna happen. Okay. Try closer. Yeah. Right there. Bring it across. Yes. Perfect. That's a weird angle. It is. Oh yeah, it is, it is. There's no question about that. Take it. There's something - I think it's just the - maybe it's the profunda. Whatever. Okay, go ahead. Right across. Okay? Yeah. Mmhmm. Yep. Perfect. Okay, keep going. I want you to come to like here esque. That leg's fine, but you see how far back you are on the patch? Okay. Because it'll do this. See that crimping? Yeah. So just like you're sewing these lips shut. See the two sides? Yeah. Just get the edges 'cause now you're kind of into that thinner area that we were. Closer. Closer. There you go. Use your pickups to lift and put on your needle. Ah. Sorry. Yes. take it. Beautiful. Release with your left hand. Yeah. 'Cause you want to release the artery as soon as you can, otherwise it pinches. Like that? Yeah, I gotcha. Here you go. Nice deep, nice deep, deep, deep, deep, deep. Yeah, there you go. From - oh, release your thing. Don't twerk it. Push forward. No, push forward in the back. There you go. Lovely. See, Armani, give me this one moment. Let just take a couple shots from my end to flatten out 'cause my side, you know what's happened? Is my side is no longer locked. Go ahead and take this over here. Okay. Yep. Hold onto that. Pull down and show me the - and come out a little bit. Yes. So, it's more, like, right across. Yeah. You know, and then I'm just getting us back on a equal... And then what I'll do is come on my side, come down a little bit, and then we'll start the bottom. Okay. So I guess I can follow. Okay. Come out a little bit. Yes, show me the... Like that. Yes. You see how I can, like, really see where I need to be? Yeah. Yeah. Okay. Go ahead and shod this. Yeah, shod that. Thank you. Heparin saline, please. I'll probably take this chunk of stuff right there. Go ahead. Suction. Lovely. Now hold out here. Great. So this is very easy for me because you've already tacked on your side. But, you know, you see how it's a little bit... I took that hiccup. Hold out and a little bit higher up. Beautiful. And what'll happen is when we release all of these... Yeah, hold tight. When we release all of these vessel loops, there'll be a little bit of laxity, too. You know, right now, it's because it's tense. Yeah. Hold on. That one hiccuped. Yep. Hold out. There you go. So notice how I'm pulling outward to make it land like this. Yeah. Mmhmm. You got it? Uh-huh. May I have the shod, please? Thank you so much. We'll need another suture. So, let's take a look-see now now. Let's take a look over here. Let's readjust the light so it's kind of focused in this area. May I have a Freer for a second? Let me just see. Thank you. And if you would just take your Gerald's and just hold that over for a moment. Let me see if I can just get this stuff off. I mean, it's pretty, pretty stuck on there. I gotta say. There we go. Yep. Suction if you wouldn't mind. Yep, yep, yep. Yep. Almost. Maybe just this last bit. There we go. Okay. Heparin saline, please? Yep. Suction. May I have the suture, please. Okay, so I'll take this one more second and what I'm gonna have you do, Armani, is just kind of hold right here. Now, we gotta get the whole thing. It's very easy not to get the wall, okay? It's very easy to just sort of get the edge, so. Go ahead. I'm just taking that out. So I want you to just hold like kind of right there. Other hand. Switch hands if you can. And I'm going to first of all check the length here. Does this need to be cut? Actually, I think we're pretty good. So, same sort of story with a single suture. So I'm gonna give you this end here. You go ahead and hold like that. I'll need a squirt in a second. Do you think we're going to angio? I don't think so. It depends on what it sounds like at the end, and we'll run PVRs Okay, cool. If it's good. Normally, if I angio, I like to actually put the wire in like, around this time. Yeah, because I like to be right in the lumen. You can imagine if you stick the patch, which you can do, but you could get into that plane up top. It's kind of a pain, but we'll see. That was purely, like, if we didn't have good inflow. Armani, I'll have you just hold the other side of this open for me, please. Yeah, there. Nice. And I'm gonna hold here. And remember, we gotta get like all the way in. Yep. You see that? Yep. But this is where we have to be super careful. We can't take big bites because you don't want to get anywhere near - I mean, the profunda is there, but I don't think that's an issue. I'm just saying in general, you know, good surgical hygiene. Go ahead and give me a big splash, please. Go ahead and just hold the patch in place there with your pickups. We'll see. I mean, you know, famous last words. Depends on what the angio shows at the end. Armani, if you'll hold with your left hand. Yeah, what you got. Lovely. And we've gotta be super careful. Your side's the more important one. You've got the profunda. Yes. So come around. There you go. Lovely. Okay, hold that. Do me a favor with your pickups. Pick this up for me. Excellent. Yeah, just gently. You know, again, kind of the important piece here. It's very easy. You can imagine to suture the other side. I mean, see? That's the lip of the other side there. Optimized your visualization. Mmhmmm. Release there. Lovely. Hold that. Oops. More further back then. Go ahead and give me this. So notice how I lifted straight up in the air. Uh-huh. And then... Take that one in two. Go ahead and take the suction in your other hand, and just get me right there in the, you know, right here. Gentle. The gentle pull. A little bit less. Yeah. 'Cause I want to be able to get in here, you know? Yeah. And suction for me. 'Cause I want to make sure I'm getting those edges. You see? So, like, the intima is, like, way back there. Yeah. That's what we need to get. We cannot not get that. Yeah. So what I'm gonna have you do, if you could hold. Can I get a Gerald's? I'm gonna take it in two. Yeah. Hold that. Exactly. Can someone else suction? You hold that. Yep. Towards you. Yeah, I can see his intima's way down there. Yep. It's deceptive. It is, right? If you don't get that along with the adventitia, it can blow in your face. Like, when you release your clamps. You've got a big hole there, really? She's like, oh my god. That's a huge bite. Not really, 'cause you're just getting a bunch of schmutz. But the intima is the most important with the adventitia. 'Cause what I'm gonna do is hold up the other side, you know, like this. Yep. You hold tight. Other hand. There you go. Hold tight. But you see how the dissection is so - you know, once you've got everything out, you're not messing - otherwise, you're messing with your clamps, you're messing with your... I like to do one more. You go slightly down. Beyond, yeah. Exactly right. To kind of... Really. Can I get a scissors, please? Hold tight. Hold tight. A scissors. Hold nice and tight. I think this is the last one. That's how you kind of build in reinforcement there. Mmhmm. And it also probably will take a little tension off for now. Okay, if you cut this off for me? I'm gonna give that to you. And if I could get a big splash, please. I think this flow is coming from the SFA, so I'm going to fully, you know. So I'm gonna put that down for us. We'll be back with the Fogarty, and then when we're getting close to your end, we'll flush everything. Right. Which is a good sign though. Yeah, it's a great sign. Exactly. I mean, let's see what his PVRs look like. Yeah, they actually look pretty okay, pre-op. That's 'cause I, you know, I had ballooned him here. That's why it looked like that when we opened it. Let me see. Where is this? Yeah, I think it is that. So can I have the Fogarty clamp back, please? So we'll just kind of do this for now. And may I have the needle driver? Thank you so much. Yeah, they're fancy, right? So I'm coming a little bit more distal than you would think. Yeah. Because I want to get into that actual SFA space. Okay. Yeah, and kind of turning towards you, like, 90 degrees, really turning towards you. Saying... All right, I'll do one more, and then you take over. Here you go. Take us home, of course. Take, like, grab onto this part. Kind of hold it to it. Yeah. And then I will do this for you. Yep. You see that? And you kind of want to... Yep. Right across. Yes, beautiful. Yep. Excellent. Yep. Pull up. And then kind of, you see how it's just aligning for you. Come a little bit closer and not so far back. On the patch, that is. Yeah. But then deep in there. Exactly. Maybe. Yeah, yeah, yeah. Yes. A little deeper on the patch. There you go. Yeah. Now, once you're in the middle, it's kind of okay. It's more just the center. Yeah. And, you know, you're holding the artery. Yes, I know. So, you'd be amazed how much tension you push down, you know, not realizing. So just be mindful of it. You can do it. Just CT surgery, they don't like it. To touch the artery. But we're much more lenient, you just have to be... Our vessels are also a little bit bigger. Yes, yes. Yep. Yep. Take it. Beautiful. A little bit closer. A little bit closer. Yep. Yes. Perfect. There you go. So now what I'm gonna do is hold both. Yes. And then you kind of just align it. So let me have that. Yep, there you go. Just just come right across. Bang, bang, bang. Like a sewing machine. You know? Except I grabbed my needle too far back. We're not close to ACT, are we or? I just sent it. Oh, lovely. Okay. Great, great, great. That might be the last one. We'll see. Okay. We're gonna need 2-0 times 2, Vicryl. I got 'em. And closer to the last one. Monocryl. Monocryl, exactly. Dermabond? Dermabond. All right, cool. When do you do what? I'm sorry. For veinous. Usually if it's a redo, that's a common phenomenon. A little bit closer. Or just like if they're - have a hard body habitus, we're just worried about... Sometimes, you know, in that case - I Dermabond though, you know, so - one more and we'll flush. Okay. It's been flushing the whole time, which is great. Do one more, kind of close to you. Okay, to give us room for the... Uh-huh. This patient is allergic to Aspirin? Supposedly, yes. Yeah. Okay. Does everyone hear that? So he'll be on Plavix postoperatively. And probably 2.50 Xarelto is what I'll do for him. Okay. So, this is what we're gonna do. I will have this just kind of loaded. So what I normally do is... Yeah, just watch your hand here, Katherine, okay? This is a loaded needle. All right. I will take this from you. Okay, so first thing first. Let's release this. Good? Mmhmm. Okay. Heparin saline, please. Well, lost that. Yeah. No, we're just saying we lost it. All right, let's check the profunda now. We just have to - can I have a... There we go. There we are. See that? Yep. Lovely. Okay, Katherine, I'm just gonna have you just gently hold this if you don't mind. Just real gentle, right there. Yeah. Love it. All right, lovely. All right. I'm gonna come off with this one here. Same story. A little bit of this. Yep. Okay. Yep. There it is. Okay, great. Katherine, can I give you this one? Same sort of thing, just real gentle. Okay? All right, now everyone back off. Great. Okay, that was inflow. And then, you don't check these? No, I normally don't, 'cause, yeah, it's gonna be fine. And then watch your hand here. Loaded needle. Please. We'll come under Katherine's hand. Okay, Katherine, release the profunda's. Yeah, just release 'em. You can just keep 'em like that. But Armani, will you hold this one up for me like that? Yes. Okay. Just hold onto all that guys. I like to have a little bit of flow, but not so much that it's gonna rip. Just to fill it. I don't want a big air bubble. Suction right here for me, Armani. And hold tight to what you got. Okay? Mmhmm. See, it's already starting up. Can we have the doppler up, please. We're gonna give you the leg back. My anesthesia colleague Are they here? Jonathan? What's up? I'm gonna give you a leg back in a second. It's gonna be a big drop, probably. I don't know if you want to just... I'm gonna give you the leg back. Scissors, please. So I just want to keep his blood pressure. I mean, I don't give him a ton of stuff, but I just want to drop his blood pressure 'cause I want him to not thrombose. Can I have a splash, please? So just so you know, it's coming. Want to keep him normal blood pressure. Release the proximal, please. Real gentle. Yeah. Let it fill. Just let it be. Let it be, let it be. I just took off those clips. Yeah, yeah. You just opened it, right? Yeah. Okay. Not bad. We're gonna need a couple of 6-0s, please. Maybe not, but we'll see. And you sent an ACT already, right? Yep. Great. Looking pretty good. Right there. Could you run a - let's give it a couple minutes and then we'll run a PVR. Scissors, please. Thank you. I'm gonna give this to you. Okay, so let's release these. Sorry? ACT 254. 254. Lovely. Okay. Did you say you wanted a PVR? In just a moment here. So just release this one too. So anyone else not released? I don't think I'm holding anything. Okay. Can I see this a quick second? I'm just looking up top here, actually. Could you get your appendiceal? We don't have a lady finger. I keep throwing things off the table, sorry. It's okay. I think it's right there. So what I like to do, first of all, we'll need one fix it stitch here for sure. And then, yeah, see that there? Okay. So, let's do this. Yep. Hold that for me. Can we fix the light, please? Okay. Lovely. Suction for me, Armani. Here. What I like to do. Do you reclamp it or? I do. Okay. Because it could tear otherwise. You're still gonna have a little bit. Yeah, you don't go all the way. No. And I like to do a figure of eight, personally. Okay. I'm gonna need a cut, please, in a second. Yep, to relieve the pressure. Okay. Okay, scissors, please. If you could cut this off for me. Thank you. I'll need one more 6-0. Splash to me. Go ahead and come out of there. Suction. Come out of there. One more 6-0. Okay. You want it there, or do you want me to move? Let me see. Come out of there a moment. Could you cut this for me, please? I'll give this needle back to you. Come over here to my- Like, just grab this. See this right here. Grab that. I'm gonna ask for 30 of protamine for this patient in a second. All right. I'm gonna release this again. Okay, so right here's the issue. Yep. Oh, I'm sorry. Thank you. Needle to you down here. Splash to me. Thank you.

Could you give 30 of protamine, please? Yep. And I'll have that TachoSil in postage-sized stamps, and the doppler, please. The other thing I like to do is I check my patch with the back of a DeBakey, always. You want it to, like, if you see anything that sprays in your face, that happens in longer patches and, you know, if there's a size mismatch. Things like that. So just basically checking for a little tiny hole... Exactly. Mmmhmm. Or that you know is gonna just like keep oozing, keep oozing, keep oozing sort of thing. It can create a slow drip. Exactly. Scissors, please. 30 of protamine. Thank you. I'm gonna give this to you. Here's this to you. Thank you so much. I'll take a dry. Yeah, we'll take this one out. Let's do it like super carefully. Suction for me. This is why I don't like it so big. Yeah. You know? So I'm trying to... There you are. Go a little up here. Yeah. That'll probably go away with the protamine. Just make sure there's nothing coming out of that corner. Mmhmm. So... You're basically challenging it. Mmhmm. Pressing down on it. Suction for me. And I will take a piece of Surgicel. And could we do PVRs? Let's do PVRs. Sure. Just one second. I'll take that piece of Surgicel first, and we'll do the PVRs, and... Just a full one. Yeah, thank you. It'll come out in a second. Thank you so much. You tell me when you've given the 30 of protamine, fully. It's almost all the way in. Thank you. So 250 ACT, which is what this patient was, is a full - go ahead. You ready? Yep. And then we'll take the doppler. Protamine is in. Thank you.

CHAPTER 6

Looks good. Good. So we always check the PVRs at the end just to compare, you know? That looks great. And may I have the doppler, please?

Okay, if we could just turn the doppler on, please. So SFA. Sounds good. It's a little branch here. There's that little itty-bitty branch. Now we want just suction for me. We want to hear the profunda's. Sounds great. So that's the profunda. And then this is the main.

And I like to listen up above the patch too, 'cause that's where your clamp site is, and that's where drama can happen. Can I have the appendiceal? Bad drama. Go ahead and hold that. This is way up. Here, one second. Or I can do it. I can see it. So that's our clamp site. So we're just checking. I'm just moving it up, and I'm happy with that. You know, like, I don't want a scare later on today. Yeah. Thank you very much.

CHAPTER 7

Hold this, actually, just a moment. Right there. There's something here. Yeah, right there. See this? Yeah. This guy. Is it from the... It's right at the edge. Yeah, right there. Yeah. I wonder if it's a... No, it think this is coming from the branch, you know? I'll take a piece of TachoSil, please. Here you go. Thank you. If you could cut that into four. So I love this stuff. TachoSil is a nice hemostatic agent. You leave it in. You can't wet it, because when you wet it, it starts. So, yep. So it's a yellow part towards the blood. Thank you. Thank you so much. DeBakey's, please. Cardiac. And trauma. Yep. Totally. Leave that there. Thank you. See right there? Yeah. So what we'll do is something scary. DeBakeys, please. Suction for me. Something scary? Something scary. Suction right here. It looks like this guy. Yeah, right above it. A little collateral leaking through. In these situations, it doesn't take much for me to just say I'm gonna shut it down. You know, because I don't want... It's coming from the side of it there. Yeah. For it to turn into something? I have it. Yeah, exactly. 6-0, please. Here. Nah, that's good, thank you. Oops, sorry. No worries. Maybe not. I mean, you gotta make sure you're dry, you know? A little action right here. Up there in the corner? Yeah, it looks like it. See it? Yeah. Put a clip across it or? I'm thinking. Yep. You know what? Actually, we'll take two 3-0s. It's just not worth it. Yeah. It's just not worth it. You know, he's got beautiful flow. This is not the end all be all, but it absolutely will be if he bleeds. I don't think it's so bad. I mean, there are a lot of people that probably would leave it. We don't even have to cut it. We can just tie it off. I'll take one more, please. Yep. Do you want a clip? Actually, yeah. Why don't we just do a clip. Because we're not gonna cut it, so... What size? Medium, please. Thank you. Thank you. We did it. Dry, please. Are you on anything or is he doing okay? He's on a little phenylephrine, but that will come off soon. All right. Could I please have... So I always check if there's any bleeding anywhere else. For example here, you know. See that? Yep. Coming from this guy. Would you grab a DeBakeys for me and just grab him. DeBakeys. Hematoma can cause a lot of infection obviously. Yeah, just grab that. Pull up. Yep. Very nice. Because we're gonna anticoagulate to some extent right after this. Now, did we do anything to the inguinal ligament? Not really. Looks great. You know, we didn't open it. We didn't do anything to it. So we don't have to close it. Otherwise, you would use 2-0 to just kind of…

CHAPTER 8

Can I have a 2-0 Vicryl, please. And again, we'll take the appendiceal for her. And a pickups for me and a Weitlaner. Yeah, like right here. So, it's just to tell me. I like to close in multiple layers, really tight. Gotta watch that vein. But I do close the sheath. Scissors, please. And the femoral sheath. Some people don't. I think one of my partners doesn't close, right? Somebody. Who doesn't close the femoral sheath? Abe does. Yeah, most people will. What's the harm, you know? It's a good thing, But some people don't do it. I really like to. So let me ask you, Ashley, if you were doing this and you hit the vein, what do you do? Put some pressure. Stick your finger on it. Yeah. Do you take your stitch out? No? You don't. Let it be. It'll just make it worse. So just pull it through, actually, if anything. And stop bleeding. Depends on how deep you are, obviously. I was gonna say, which vein are you we talking about? Are we talking about a small crossing vein or are we talking about, like, femoral? - [Anahita] No, no, no. Small crossing vein. But even though, you know, depends on what you- I mean, you shouldn't hit the... Like, that would be, I guess anything's possible. But... If it's a small crossing vein, you would leave or stitch in, and - won't you essentially tamponade it with your next stitch in? Right, exactly. Okay so, I'm gonna close this. Go ahead and release what you got there, Ashley. Next 2-0, please. There we go. 4-0 Monocryl, please. Do you want another 2-0? Sorry? Do you want another 2-0? You know, we'll probably use a 3-0 after this. 3-0. Okay. So for this patient, I like to keep, especially with patch, in someone who's been manipulated and stuff, I like to keep antibiotics for the time that they're here. So that's gonna be at least a couple of days. You just want Ancef or? Sorry? Yeah, just Ancef, please. Just continuing on Ancef? Exactly. just keep him bed rest today. Okay. With bathroom privileges or no? You know, he'll have his Foley. Oh yeah. So, probably not. No, nevermind. Go ahead. If you could take that fully out. Midnight antibiotics and then... Just not 90 degrees. Yeah, exactly right. Exactly right. Keep his - I mean, he shouldn't dump his blood pressure and stuff. He wanted to perfuse this leg. Otherwise, continue on meds. Give him... Scissors, please. Monocryl. Yes. Give him his Plavix today, for sure. Is he not on Plavix? I think he's on it. But I just wanted to make sure you didn't want me to like... You can load him. If he's on it, then you can just give him the 75. Okay. But do make sure he gets it today. Okay. Please. Yeah, I'll order it. Get one in the PACU. That'd be great. So we'll just let this dry. Once this dries all the way, a little Telfa and Tegaderm. And that's it. Done.

CHAPTER 9

Now that we've had a very successful case, there were a few things that were unique about this particular patient. First, he had a significant amount of calcium. So it was not in a single location. It was all the way through from his external iliac down into the profunda and into the SFA. So one of the critical aspects of this procedure is ensuring that you have a good site where you can clamp. So we felt essentially where the pulse was the strongest and where there was a soft spot within the patient's artery to clamp the SFA, the profunda, and basically the external iliac, because we had to go deep into the pelvis to find a nice clap site, which we were aware of from looking at the angiogram prior to the case. But obviously in real life when we're doing it, it's always a little higher than you expect. So very importantly, we made an incision such that we were not struggling to get good proximal control. That's fundamental. And we were able to move our clamp essentially a centimeter up and down in a soft spot so that we had nice proximal control and we were able to suture without any issues. The other thing that's unique in this patient is because he's had arthrosclerosis for so long and a blockage in that SFA and profunda, he had a number of very large collateral vessels. They were in fact so large that they were almost the size of the profunda branches. So instead of taking those branches or, you know, dangerously making them bleed by getting into them, we were prepared to find each one, which we did, and we placed a vessel loop around each one and were able to preserve all but one that we ended up taking that was very small and at the proximal aspect of his incision. So, those were really the key differences in this case versus others. Otherwise, the patient had a very straightforward femoral endarterectomy and a successful PVR check at the end, which is essentially ensuring that there's blood down to the ankle.