Complications, risks, and consequences
Estimated frequency
Most significant/serious complications
Vascular complications
Bleeding or hematoma formation
Wound (small)
20–50 %
Wound (large)a
0.1–1 %
Graft associated (if graft is present)a
1–5 %
Vascular injury (femoral/popliteal artery or vein)a
0.1–1 %
Arterial wall dissectiona
0.1–1 %
Embolization (thrombus, gas, or atheroma)a
0.1–1 %
Peripheral limb ischemia (trash foot/leg)a
0.1–1 %
Deep venous thrombosis/pulmonary embolus
0.1–1 %
Pseudoaneurysm (false aneurysm)a
0.1–1 %
Limb amputationa
<0.1 %
Arteriovenous fistulaa
<0.1 %
Limb compartment syndrome (may necessitate fasciotomy)a
<0.1 %
Infection
Wounda
<0.1 %
Systemic sepsisa
<0.1 %
Neural injurya
1–5 %
Sensory (ilioinguinal, femoral nerve/lat. cut. nerve thigh)
0.1–1 %
Motor (femoral)
0.1–1 %
Contrast-related complications (overall)
1–5 %
Allergic reactions (mild urticaria, mild asthma, itching)
1–5 %
Anaphylactic reactions
<0.1 %
Contrast-induced nephropathy
0.1–1 %
Rare significant/serious problems
Organ ischemia (brain, abdominal)a
0.1–1 %
Gas gangrene or necrotizing fasciitisa
< 0.1 %
Cardiac events, respiratory failure, multisystem organ failure, deatha
< 0.1 %
Less serious complications
Skin necrosis or skin ulcerationa
0.1–1 %
Seroma/lymphocele formation or lymphatic fluid leak
0.1–1 %
Limb edema (long-term swelling)a
<0.1 %
X-ray radiation burnsa
<0.1 %
Blood transfusiona
0.1–1 %
Perspective
See Table 3.1. Significant puncture site complications occur with a frequency of 0.1–1 %. Small hematomata are common, but rarely do they require surgical intervention. Large hematomata may lead to skin necrosis. Pseudoaneurysm and arteriovenous fistula formation are less common. Dissection also occurs with a frequency of 0.1–1 % and may occur at the puncture site or more distally from a catheter. These do not usually result in clinical complication especially if they are retrograde dissections but may lead to vessel occlusion. Embolization may occur due to air bubbles, thrombus formation on the catheter or from cholesterol embolization due to catheter manipulation in atheromatous vessels. This may lead to ischemia or blue-toe syndrome depending on the distal vascular bed (e.g., stroke, renal failure, gangrene) and the size of the embolized particles. Contrast-related complications include allergic reactions, which are only very rarely anaphylactic in nature, or contrast-induced nephropathy. Nephropathy can be avoided by careful checking of renal function pre-procedure, while limiting contrast dose and optimizing hydration. Contrast-related allergies can cause rash, nausea and vomiting, respiratory compromise, cardiac arrhythmia, hypotension, myocardial infarction, cardiac arrest, and death. Nephropathy can be avoided by good preoperative hydration and limiting contrast dose and by better awareness of renal status using preoperative renal function testing. Radiation burns are very rare. All complications are more common as the complexity of the intervention increases, and for groin procedures, related complications increase with larger sheath sizes. Bleeding risk is increased where thrombolytic agent infusions are used. Lymphocele or lymph leakage is usually minor.
Major Complications
The major risks include bleeding, large hematoma formation, skin necrosis and false aneurysm formation, which may necessitate further surgery. Distal ischemia of a vascular bed is less common but may be devastating, depending on the location and underlying pathology, including stroke, gut ischemia, bleeding or perforation, and limb ischemia perhaps requiring amputation. Severe allergic reactions, including anaphylaxis, to radiographic contrast can occur and may rarely require resuscitation and ICU care. Acute renal failure may occur following renal arterial embolization or contrast agent-induced renal toxicity. Thrombosis or embolism often increases the relative risk of further complications. Severe limb edema is a very rare complication. In patients with vascular disease, the risk of cardiorespiratory compromise (e.g., myocardial infarction, cardiac failure, cardiac arrhythmias) and embolic events is increased, which may rarely lead to multisystem organ failure and death. The frequency and range of the complications increase proportionately with the complexity of the angiographic intervention, and with groin procedures and larger catheter sheath sizes.
Consent and Risk Reduction
Main Points to Explain
Discomfort
Bleeding*
False aneurysm*
Allergic reactions
Distal embolization*
Further surgery
Risks without surgery
*Dependent on catheter size and site
Temporal Artery Biopsy
Description
Local anesthesia or general anesthesia may be used. The aim is to expose and biopsy a part of the superficial temporal artery for diagnosis/exclusion of temporal arteritis. A preauricular incision is made in the hairline along the line of the artery to expose the temporal artery. A 4–7 cm segment is biopsied between clamps, inclusive of any pathological region if identifiable, and the ends are ligated with absorbable suture. The skin is closed.
Anatomical Points
The location of the temporal artery is relatively constant, but the branching and tortuosity may vary considerably, especially more distally at the hairline where the biopsy is usually performed. The superficial temporal artery lies superficial to the temporalis muscle fascia, but deep to the superficial fascia (which may be well developed at this site). The parietal branch can be given off early or later, and either the main trunk or parietal branch is usually chosen for the biopsy. The auriculotemporal nerve (branch of trigeminal V cranial n.) travels with the superficial temporal artery for much of its course and is at risk of injury.
Table 3.2
Temporal artery biopsy: estimated frequency of complications, risks, and consequences
Complications, risks, and consequences | Estimated frequency |
|---|---|
Most significant/serious complications | |
Infection | 0.1–1 % |
Bleeding and hematoma formation | 0.1–1 % |
Less serious complications | |
Thrombosis | 0.1–1 % |
Failure to locate the temporal artery | 0.1–1 % |
Failure to sample the diseased arterial segment | 5–20 % |
Superficial temporal nerve injury (sensory loss) | 1–5 % |
Neuroma | 0.1–1 % |
Wound scarring (poor cosmesis) | 1–5 % |
Perspective
See Table 3.2. Temporal artery biopsy is a small surgical procedure where most complications are relatively uncommon or less significant. However, bleeding, hematoma formation, infection, failure to locate and biopsy the diseased artery and nerve injury are sometimes problematic.
Major Complications
The major complications are rare and are related to the wound itself, namely, bleeding, hematoma formation and consequent infection, sometimes resulting in wound dehiscence. Failure to locate and biopsy the diseased artery may necessitate repeat surgery and inadvertent auriculotemporal nerve injury or even biopsy of it can occur, notably when obscured by bleeding from the vessel or its small branches, which can bleed profusely.
Consent and Risk Reduction
Main Points to Explain
Discomfort
Bleeding
Failure to locate artery
Failure to biopsy disease
Nerve injury and numbness
Infection
Further surgery
Risks without surgery
Arteriovenous Fistula Surgery
Description
Local anesthetic or local block is usually used. General anesthesia may be required for more extensive and revisional procedures. The aim is to create a superficial, straight segment of arterialized vein for hemodialysis access. The cephalic vein is the first choice and the anastomosis should be as distal as possible provided the artery and vein are of adequate caliber. It is important to ensure that the vein is patent, usually by flushing with heparinized saline. The cephalic vein is usually divided and sutured end-to-side to the radial artery via a longitudinal arteriotomy. Side-to-side or end-to-end anastomoses can also be performed. If performing an upper arm fistula, the same principles apply, but the incision in the artery should be small, so as to limit the risk of a “steal” phenomenon, particularly in the elderly or diabetic patient.
Anatomical Points
The first choice of vessels is the radial artery and cephalic vein in the forearm. The cutaneous branch of the radial nerve is in the vicinity and small branches may be inadvertently divided. If using the radial artery, it is important to ensure the presence of the ulnar, usually by Allen’s test or duplex ultrasound if there is any doubt. Lack of a complete palmar arch may compromise vascularity of the hand. An upper arm brachiocephalic fistula is the next choice with other options being an ulnar-basilic forearm fistula, a transposed basilic vein to brachial artery in the upper arm, a saphenous loop in the thigh, or using prosthetic material to bridge between an artery and a vein. Prosthetic material currently remains the last choice for grafting. The brachial artery may have a high division such that the anastomosis at the elbow is onto either the radial or ulnar artery. It is important to assess the vein to ensure patency. Veins may not be present, e.g., upper arm cephalic, or may be damaged.
Table 3.3
Arteriovenous fistula surgery: estimated frequency of complications, risks, and consequences
Complications, risks, and consequences | Estimated frequency |
|---|---|
Most significant/serious complications | |
Infection (overall)a | 1–5 % |
Wound | 1–5 % |
Systemic sepsis | 0.1–1 % |
Bleeding or hematoma formation | 1–5 % |
Steal phenomenon/brachial fistulaa | 5–20 % |
Acute fistula thrombosisb | 1–5 % |
Secondary problems | |
Secondary patency | |
1 year | 70–80 % |
5 year | 50 % |
Subacute bacterial endocarditis | 0.1–1 % |
Embolization | 0.1–1 % |
Fistula rupture | 0.1–1 % |
Rare significant/serious problems | |
Fistula not usablea (anastomosis too small, peripheral vein previously damaged, subclavian vein stenosis from previous central venous lines) | 0.1–1 % |
Significant aneurysm formationc | 0.1–1 % |
Cardiac failure | 0.1–1 % |
Fistula thumb (blue hot painful thumb with varicose ulceration)a (notably with side-to-side anastomosis) | 0.1–1 % |
Acute ischemic neuritis of median nerve in upper arm fistula | <0.1 % |
Acute ischemia (solitary supply; negative Allen’s test)a | <0.1 % |
Gas gangrene/necrotizing fasciitis | <0.1 % |
Multisystem organ failurea | <0.1 % |
Deatha | <0.1 % |
Less serious complications | |
Numbness dorsum of thumb | 1–5 % |
Skin necrosis | 0.1–1 % |
Wound dehiscence | 1–5 % |
Delayed wound healing (including ulceration) | 1–5 % |
Wound scarring (poor cosmesis)a | 1–5 % |
Seroma/lymphocele formation | 1–5 % |
Residual pain/discomfort/neuralgia | 1–5 % |
Perspective
See Table 3.3. The worst complications for the patient are either acute hand/limb ischemia or thrombosis of the fistula. Acute ischemia of the distal limb is extremely rare and is usually due to clot or spasm of the artery. It requires immediate exploration. Acute thrombosis of the fistula may be due to poor vessels, anastomotic technique, or hypotension. It should also be explored as soon as possible to try and salvage the fistula. A rare but important complication is acute ischemic neuritis of the median nerve. This may respond to immediate ligation of the fistula.
Major Complications
Postoperative acute fistula thrombosis may be due to a stenosis in the vein, low blood pressure, or technical problems. Acute loss of fistula function requires immediate exploration. Postoperative bleeding can occlude the fistula from external pressure (often due to a slipped ligature on the distal end of the vein). Steal phenomenon is more common in upper arm fistulae, the elderly, and diabetics. It is important in brachial artery fistulae to limit the size of the arteriotomy – it should be <75 % of the proximal arterial diameter. Stenoses can develop at anastomotic sites, curves, and valves. Revisional surgery is often necessary at some point. Division of radial nerve branches may lead to numbness over the dorsum of the thumb. Later secondary problems include shunt thrombosis, bacterial endocarditis, embolization and fistula rupture. Infection may occasionally be severe and lead to dehiscence and even systemic sepsis.
Consent and Risk Reduction
Main Points to Explain
Discomfort
Bleeding
False aneurysm
Fistula failure
Distal ischemia
Infection
Further surgery
Risks without surgery
Brachial Embolectomy (Including Graft Embolectomy)
Description
General or local anesthetic may be used. The aim is to gain entry to the brachial artery usually at the inferior cubital fossa, upper arm, or axilla to pass a balloon catheter proximally and distally beyond the embolus or thrombus to be able to draw embolic material retrogradely back through the arteriotomy to remove it and restore patency to the distal vessel(s). A vein patch may be needed to close the artery. An angiogram may be performed to ensure patency and infusion with a thrombolytic agent may be used. The arteriotomy and skin are then closed.
Anatomical Points
The site and extent of the embolus/thrombus will largely determine the site of arteriotomy and the vessels that need to be embolectomized. The arterial anatomy of the larger vessels of the upper limb is relatively constant; however, the size of the embolectomy catheter in proportion to artery size will determine the distal extent of the embolectomy.
Table 3.4
Brachial embolectomy: estimated frequency of complications, risks, and consequences
Complications, risks, and consequences | Estimated frequency |
|---|---|
Most significant/serious complications | |
Bleeding or hematoma formation | |
Wound | 5–20 % |
Return to theater rate for evacuation of hematoma | 1–5 % |
Graft associated (if graft is present)a | 1–5 % |
Dissection of vessel wall and/or false aneurysma | 1–5 % |
Re-thrombosis/blockagea | 1–5 % |
Further embolizationa (thrombus or atheroma) | 5–20 % |
Rare significant/serious problems | |
Infection | |
Wounda | 0.1–1 % |
Systemic sepsisa | 0.1–1 % |
Neural injurya | 0.1–1 % |
Sensory (lateral cutaneous nerve of arm/forearm, brachial plexus) | |
Motor (brachial plexus) | |
Peripheral limb ischemia (trash hand/arm)a | 0.1–1 % |
Limb amputationa | 0.1–1 % |
Deep venous thrombosis/pulmonary embolus | 0.1–1 % |
Vascular injury (axillary/brachial artery or vein)a | 0.1–1 % |
Gas gangrene/necrotizing fasciitisa | <0.1 % |
Limb compartment syndrome (may necessitate fasciotomy)a | <0.1 % |
Less serious complications | |
Skin ulcerationa | 0.1–1 % |
Wound dehiscence | 0.1–1 % |
Seroma/lymphocele formation | 1–5 % |
Lymphatic fluid leak | 1–5 % |
Arm edema (long-term swelling)a | 0.1–1 % |
Wound scarring/deformity – poor cosmesis | 0.1–1 % |
Blood transfusiona | 0.1–1 % |
Wound drainage tubea | 1–5 % |
Perspective
See Table 3.4. Local wound problems, hematoma, infection, and scarring are probably the most common complication of the arteriotomy and embolectomy surgery. Nerve problems are rare but can cause chronic pain on occasions. Severe complications are relatively rare but include re-thrombosis/embolism, inability to remove the embolus, and amputation. Bleeding is a risk because all patients require postoperative anticoagulation to prevent further embolization. This risk is further increased when thrombolytic agent infusions are used.
Major Complications
The major risks are bleeding, hematoma formation and failure to remove the embolus which can result in ischemia and amputation. Recurrence of thrombosis/embolus can occur and increases the relative risk of further complications. Severe arm edema is a rare complication.
Consent and Risk Reduction
Main Points to Explain
Discomfort
Bleeding*
False aneurysm*
Further thromboembolism*
Further surgery
Risks without surgery
*Dependent on catheter size and site
Femoropopliteal Embolectomy (Including Graft Embolectomy)
Description
General or local anesthetic may be used. The aim is to gain entry to the femoropopliteal artery usually at the groin, but occasionally the mid-thigh or popliteal fossa, to pass a balloon catheter beyond the embolus or thrombus to be able to draw embolic material back through the arteriotomy to remove it and restore patency to the distal vessel(s). A vein patch may be needed to close the artery. An angiogram may be performed to ensure patency, and infusion with a thrombolytic agent may be used. The arteriotomy and skin are then closed.
Anatomical Points
The site and extent of the embolus/thrombus will largely determine the site of arteriotomy and the vessels that need to be embolectomized. The arterial anatomy of the larger vessels of the lower limb is relatively constant; however, the size of the embolectomy catheter in proportion to artery size will determine the distal extent of the embolectomy.
Table 3.5
Femoropopliteal embolectomy (including graft embolectomy): estimated frequency of complications, risks, and consequences
Complications, risks, and consequences | Estimated frequency |
|---|---|
Most significant/serious complications | |
Bleeding or hematoma formation | |
Wound | 1–5 % |
Graft associated (if graft is present)a | 1–5 % |
Dissection of vessel wall and/or false aneurysma | 1–5 % |
Re-thrombosis/blockage/embolizationa | 5–20 % |
Vascular injury (femoral/popliteal artery or vein)a | 0.1–1 % |
Infection | |
Wounda | 5–20 % |
Systemic sepsisa | 0.1–1 % |
Neural injurya | 1–5 % |
Sensory (ilioinguinal, femoral nerve/lat. cut. nerve thigh) | 1–5 % |
Motor (femoral) | 0.1–1 % |
Limb compartment syndrome (may necessitate fasciotomy)a | 5–20 % |
Limb amputationa (dependant on total ischemic time) | 5–20 % |
Acute renal failure | 1–5 % |
Cardiac complications (e.g., arrhythmias, failure, ischemic events) | 1–5 % |
Rare significant/serious problems | |
Peripheral limb ischemia (trash foot/leg)a | 0.1–1 % |
Deep venous thrombosis/pulmonary embolus | 0.1–1 % |
Gas gangrene/necrotizing fasciitisa | <0.1 % |
Less serious complications | |
Skin ulcerationa | 0.1–1 % |
Wound dehiscence | 0.1–1 % |
Seroma/lymphocele formation | 1–5 % |
Lymphatic fluid leak (esp. groin incisions) | 1–5 % |
Leg edema (long-term swelling)a | 1–5 % |
Wound scarring/deformity – poor cosmesis | 0.1–1 % |
Blood transfusiona | 0.1–1 % |
Wound drainage tubea | 1–5 % |
Perspective
See Table 3.5. Local wound problems, hematoma, infection, and scarring are probably the most common complication of the arteriotomy and embolectomy surgery. Nerve problems are uncommon but can cause chronic pain on occasions. Severe complications are relatively rare but include re-thrombosis/embolism, inability to remove the embolus, and amputation. Bleeding risk is increased where thrombolytic agent infusions are used. Lymphocele or lymph leakage is not uncommon.
Major Complications
The major risks are bleeding and hematoma formation and failure to remove the embolus which can result in ischemia and amputation. Recurrence of thrombosis/embolus can occur and increases the relative risk of further complications. Severe leg edema is a rare complication.
Consent and Risk Reduction
Main Points to Explain
Discomfort
Bleeding*
False aneurysm*
Further thromboembolism*
Further surgery
Risks without surgery
*Dependent on catheter size and site
Mesenteric Arterial Embolectomy
Description
General anesthetic is used. The aim is to gain entry to the superior mesenteric, celiac, or very rarely inferior mesenteric artery usually during laparotomy to pass a balloon catheter proximally and distally beyond the embolus or thrombus to be able to draw embolic material back through the arteriotomy to remove it and restore patency to the distal vessel(s) and bowel. A vein patch may be needed to close the artery. An angiogram may be performed to ensure patency and infusion with a thrombolytic agent may be used. The arteriotomy and skin are then closed.
Anatomical Points
The site and extent of the embolus/thrombus will largely determine the site of arteriotomy and the vessels that need to be embolectomized. The arterial anatomy of the larger vessels of the mesenteric circulation is relatively constant, but the smaller vessels may vary considerably; however the size of the embolectomy catheter in proportion to artery size will determine the distal extent of the embolectomy. Mesenteric arteries tend to be thinner walled than systemic vessels and are more fragile, being liable to rupture. The anatomy of the vascular supply may be significantly altered by atheroma, even with occlusion and reversal of flow with blood supply coming from other vascular channels.
Table 3.6
Mesenteric arterial embolectomy: estimated frequency of complications, risks, and consequences
Complications, risks, and consequences | Estimated frequency |
|---|---|
Most significant/serious complications | |
Bleeding or hematoma formation | |
Wound | 1–5 % |
Graft associated (if graft is present)a | 1–5 % |
Dissection of vessel wall and/or false aneurysma | 1–5 % |
Re-thrombosis/blockagea | 1–5 % |
Further embolizationa (thrombus or atheroma) | 5–20 % |
Vascular injury (mesenteric/femoral/popliteal artery or vein)a | 1–5 % |
Graft dehiscence/leakage/rupturea | 1–5 % |
Infection | |
Wounda | 0.1–1 % |
Systemic sepsisa | 5–20 % |
Colonic ischemia/necrosisa | 50–80 % |
Myocardial impairment/failurea | 5–20 % |
Pulmonary impairment/failurea | 5–20 % |
Renal impairment/failurea | 5–20 % |
Gastrointestinal hemorrhage (ischemic gut)a | 1–5 % |
Abdominal compartment syndrome (may necessitate re-laparotomy)a | 1–5 % |
Small bowel obstruction (adhesions or ischemia)a | 1–5 % |
Trash kidneya | 1–5 % |
Multisystem failure (renal, pulmonary, cardiac failure)a | 5–20 % |
Deatha | >80 % |
Rare significant/serious problems | |
Gut injury/perforation (traumatic)a | 0.1–1 % |
Neural injurya | 0.1–1 % |
Sensory (subcostal, ilioinguinal, iliohypogastric) | |
Motor (lumbosacral plexus) | |
Pancreatitis | 0.1–1 % |
Peripheral limb ischemia (trash foot/leg)a | 0.1–1 % |
Deep venous thrombosis/pulmonary embolus | 0.1–1 % |
Gas gangrene/necrotizing fasciitisa | <0.1 % |
Limb compartment syndrome (may necessitate fasciotomy)a | <0.1 % |
Less serious complications | |
Skin ulcerationa | 0.1–1 % |
Wound dehiscence | 0.1–1 % |
Lymphatic fluid leak/chylous ascites/fistulaa | 1–5 % |
Paralytic ileus | 50–80 % |
Leg edema (long-term swelling)a | 0.1–1 % |
Orchitis/testicular atrophya | 0.1–1 % |
Wound scarring/deformity – poor cosmesis | 0.1–1 % |
Incisional hernia formation (delayed heavy lifting or straining) | 0.1–1 % |
Blood transfusiona | 0.1–1 % |
Wound drainage tubea | 1–5 % |
Perspective
See Table 3.6. This condition often initially presents with vague initial symptoms and signs, and delayed diagnosis is common, such that if established gut ischemia is present with sepsis, mortality is likely. When diagnosed expediently, the clinical picture is often of severe abdominal pain with minimal clinical signs, atrial fibrillation and episodes of recurrent embolization. Multisystem failure and death is the usual outcome due to the fact that most patients are elderly with significant comorbidities and that the diagnosis is often made late. Local wound problems, hematoma, infection, and scarring are probably the most common complications of abdominal arteriotomy and embolectomy surgery. Nerve problems are uncommon but can cause chronic pain on occasions. Severe complications are relatively rare but include re-thrombosis/embolism, inability to remove the embolus, and mesenteric ischemia. Mesenteric ischemia may cause serious bowel complications with or without the further surgery. Bleeding risk is increased where thrombolytic agent infusions are used.
Major Complications
The major risks are bleeding, hematoma formation and failure to remove the embolus which can result in ischemia and mesenteric ischemia. Bowel resection may be required. Recurrence of thrombosis/embolus can occur and increases the relative risk of further complications. False aneurysm can occur at the femoral or brachial puncture site(s). Bleeding, perforation, and stenosis of the bowel may occur, requiring further surgery. Multisystem organ failure is related closely to preexisting ischemic time, comorbidities, and age, often resulting in death. Many of the major complications arise from the underlying disease state and comorbidities with the typical patient being elderly, having an embolic history, cardiac arrhythmias (usually AF), with severe abdominal pain and few signs, presenting late with established gut ischemia.
Consent and Risk Reduction
Main Points to Explain
Discomfort
Bleeding*
False aneurysm*
Further thromboembolism*
Further surgery
Risks without surgery
*Dependent on catheter size and site
Carotid Endarterectomy
Description
General or local anesthetic may be used. The aim is to expose the carotid artery(s) to perform an arteriotomy to remove atheromatous plaque, debris, and thrombus from the luminal aspect to improve flow through the carotid vessels. The carotid vessels are clamped above and below the obstructing stenosis and the arteriotomy performed between. The carotid blood flow may be bypassed around the operative site with the use of a shunt, intraoperatively, to preserve perfusion of the brain and other distal tissues. The arteriotomy is frequently closed with a vein patch and continuous monofilament sutures. The skin is often closed with continuous absorbable suture.
Anatomical Points
The carotid arterial anatomy is relatively constant with the carotid bifurcation at approximately hyoid cartilage/C3 vertebral level. The extent, nature, and degree of the carotid stenosis usually dictate the site and surgical approach. The arterial anatomy can also be altered by the atherosclerotic disease process to some degree, affecting the vascular tortuosity.
Table 3.7
Carotid endarterectomy: estimated frequency of complications, risks, and consequences
Complications, risks, and consequences | Estimated frequency |
|---|---|
Most significant/serious complications | |
Infection (overall) | 1–5 % |
Wound | 0.1–1 % |
Graft associated | 0.1–1 % |
Systemic sepsis | 0.1–1 % |
Bleeding or hematoma formation – overall | 1–5 % |
Early: wound/graft associated/false aneurysm | 1–5 % |
Late: graft failure tear dissection, etc. | 0.1–1 % |
Vessel/graft thrombosis/blockage | 0.1–1 % |
Carotid restenosis (intimal hyperplasia or atheroma) | 5–20 % |
Cerebral ischemia/hemorrhage/thrombosis (CVA, TIA, RIND)a | 1–5 % |
Myocardial impairment/failurea | 1–5 % |
Pulmonary impairment/failurea | 1–5 % |
Neural injury (paresthesia and/or muscle weakness)a | |
Sensory (overall) | >80 % |
Cervical plexus – neck/chest/facial numbness | >80 % |
Lingual V – tongue numbness, sympathetic Horner’s syndrome | 0.1–1 % |
Motor (overall) | 5–20 % |
Neuropraxia (temporary) | 5–20 % |
Nerve division (permanent) | 0.1–1 % |
(including facial VII, weakness; hypoglossal XII, tongue weakness; accessory XI, shoulder weakness; vagus X, voice changes; glossopharyngeal IX, swallowing difficulty; phrenic nerve injury, diaphragmatic paralysis) | |
Death | 1–5 % |
Rare significant/serious problems | |
Acute respiratory obstruction | 0.1–1 % |
Renal impairment/failure | 0.1–1 % |
Multisystem failure (renal, pulmonary, cardiac failure) | 0.1–1 % |
Deep venous thrombosis/pulmonary embolus | 0.1–1 % |
Epilepsya (LA and hypoperfusion) | 0.1–1 % |
Pneumothoraxa | 0.1–1 % |
False aneurysm formation | <0.1 % |
First bite syndrome | <0.1 % |
Less serious complications | |
Skin ulceration | 0.1–1 % |
Psychological changesa (often subtle) | 20–50 % |
Seroma/lymphocele/chylous/lymphatic fluid leakage/fistula (right lymphatic or thoracic duct injury)a | 0.1–1 % |
Facial/neck swelling | 5–20 % |
Hyperesthesia | 1–5 % |
Blood transfusion | 0.1–1 % |
Wound dehiscence | 0.1–1 % |
Wound scarring/deformity (poor cosmesis) | 0.1–1 % |
Wound drain tubea | 5–20 % |
Perspective
See Table 3.7. Local wound problems, hematoma, infection, and scarring, are probably the most common complications of carotid arterial surgery. Nerve problems (especially neck and ear numbness from injury to the cervical plexus) are not uncommon but can cause chronic pain on occasions. Permanent clinically significant cranial nerve injuries are rare. Severe complications include TIAs, stroke, myocardial infarction and death but fortunately are relatively uncommon.
Major Complications
The major risks are acute bleeding and hematoma formation which may produce life-threatening respiratory obstruction requiring immediate surgical drainage to relieve the pressure. Embolization or thrombosis can result in TIAs, RINDs, and stroke which are significant sequelae and potentially catastrophic. Intimal hyperplasia and atheroma causing carotid restenosis is a significant late problem. False aneurysm is another complication of surgery to the vessel wall in the medium to late term. Subtle cerebral injuries causing psychological changes are relatively common and are determined by how closely examinations are performed. Some changes may represent those present but missed in the preoperative assessment. Injury to the facial nerve can be permanent and cause permanent facial paralysis, particularly affecting the corner of the mouth causing dribbling. Further surgery may be required for correction of this. Numbness of the neck is occasionally a significant problem for some patients, especially with shaving or application of cosmetics. Pneumothorax and lymphatic (chylous) leak are extremely rare but can occur with low cervical dissections. Lymphatic sinuses are extremely rare, but suture granulomas can be troublesome and may require excision. Wound scarring and deformity are rarely a problem but may require revision surgery.
Consent and Risk Reduction
Main Points to Explain
Discomfort
Bleeding
False aneurysm
Stroke
Carotid restenosis
Infection
Further surgery
Risks without surgery
Femoropopliteal Bypass Surgery (Including Femoro-tibial, Femoro-distal Bypass Surgery, and Femoro-femoral Crossover Graft Surgery)
Description
General anesthetic is usually used, but spinal/epidural anesthesia can be used. The aim is to bypass the obstructing lesion(s) in the femoral or popliteal artery. If iliac obstruction is present, a femoro-femoral crossover graft from the patent contralateral femoral or iliac artery may be required. Vein is currently the preferred conduit, usually using ipsilateral long saphenous vein (LSV), but synthetic graft material can be used. Vertical incisions are generally made in the groin and lower thigh/popliteal fossa or more distally for access as required according to the site of obstruction and the relatively normal caliber vessels for anastomosis.
Anatomical Points
The iliac and femoral arteries are relatively constant; however, the profunda femoris artery, the muscular perforators, and the location of division of the popliteal artery into its branches (anterior, posterior tibial and peroneal) are moderately variable. This latter division may occur anywhere within the popliteal fossa or below, and each branch leaves the artery at different levels. Angiography should usually map the divisions adequately. Pathology may cause stenosis, absence, and differing collateral circulation, which may alter anatomy significantly.
Table 3.8
Femoropopliteal (−tibial) bypass surgery: estimated frequency of complications, risks, and consequences
Complications, risks, and consequences | Estimated frequency |
|---|---|
Most significant/serious complications | |
Bleeding or hematoma formation | |
Wound | 1–5 % |
Graft dehiscence/leakage/rupture (early)a (including dissection of vessel wall; false aneurysm) | 1–5 % |
Late delayed bleeding (graft erosion) | 0.1–1 % |
Femoro-cutaneous fistula | <0.1 % |
Early graft thrombosis/blockagea | 1–5 % |
Late graft failure (tearing, dissection, etc.)a | 0.1–1 % |
Embolizationa (thrombus or atheroma) | 1–5 % |
Arteriovenous fistula (in situ saphenous vein bypass grafts) | 1–5 % |
Limb amputation (short term)a | |
Claudicants | 0.1–1 % |
Critical limb ischemia | 1–5 % |
Limb amputation (late)a | |
Claudicants | 1–5 % |
Critical limb ischemia | 5–20 % |
Infection | |
Wounda | 5–20 % |
Graft associateda | 0.1–1 % |
Systemic sepsisa | 0.1–1 % |
Wound dehiscence | 1–5 % |
Seroma/lymphocele formation or lymphatic fluid leak | 5–20 % |
Myocardial impairment/infarction/failurea | 1–5 % |
Cerebral ischemia/hemorrhage/thrombosis (CVA, TIA, RIND)a | 1–5 % |
Neural injurya (overall) | 1–5 % |
Sensory (femoral nerve/lat. cut. nerve thigh/sciatic/saphenous) | |
Motor (femoral) | |
Deatha | 1–5 % |
Rare significant/serious problems | |
Limb compartment syndrome (may necessitate fasciotomy)a | <0.1 % |
Vascular injury (femoral/popliteal artery or vein)a | 0.1–1 % |
Peripheral limb ischemia (trash foot/leg)a | 0.1–1 % |
Deep venous thrombosis/pulmonary embolus | 0.1–1 % |
Gas gangrene/necrotizing fasciitisa | 0.1 % |
Less serious complications | |
Skin ulcerationa | 0.1–1 % |
Femoral (or prevascular or inguinal) hernia (late)a
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