Vascular Surgery Edited by G. Heberer and R.J.A.M. van Dongen With the Assistence of K.W. Jauch and H. Stiegler Foreword by D.C. Sabiston With Contributions by KAigner, KBalzer, M.G.M.H.Barwegen, RG.H.Baumeister H.M.Becker, D.P.vanBergeHenegouwen, RG.M.Biemans, E.Biemer U. Brunner, G. Carstensen, H. Denck, H. Denecke, RlA.M. van Dongen F. W. Eigler, F. Franke, F.P. Gall, KH. Ganger, R Giessler, 1 Greebe lD. Gruss, B. Gunther, G. W. Hagmilller, H. Hamann, R Haring G. Heoerer, H. Hess, A. Himer, A. vonHochstetter, F. Husemann H.Ingrisch, H.D. Jakubowski, K W. Jauch, W. Klinner, H. Kortmann H. Kuppe, KL. Lauterjung, H. Loeprecht, E. Martin, R May H.M. Mehdorn, H. Muller-Wiefel, L. Nieuborg, F. Piza, E. Pratschke D. Raithel, B. Reichart, H. Rieger, D. Ruhland, M. Schemper F.W. Schildberg, W. Schoop, K Schwemmle, E.-D. Schwilden, A. Senn W.-l Stelter, H. Stiegler, L. Sunder-Plassmann, O. Thetter, H.H. Thiele M. Trede, A. Valesky, E.-U. Voss, O. Wagner, A.Zehle With 660 Figures, Mostly in Color in 1457 Separate illustrations Springer-Verlag Berlin Heidelberg New York London Paris Tokyo Hong Kong Professor Dr. G. HEBERER Klinikum Grosshadern, Chirurgische Klinik und Poliklinik der Universitat Miinchen Marchioninistr. 15, D-8000 Miinchen 70 Professor Dr. R.J.A.M. VAN DONGEN Academisch Ziekenhuis bij de Universiteit van Amsterdam Academisch Medisch Centrum, Vaatchirurgie Meibergdreef9, 1105 AZ Amsterdam Zuidoost The Netherlands Title of the German Edition: GefaBchirurgie (Volume XI of Kirschnersche allgemeine und spezielle Operationslehre, edited by G. Heberer and R.J.A.M. van Dongen) © Springer-Verlag Berlin Heidelberg 1987 ISBN-13:978-3-642-72944-7 e-ISBN-13:978-3-642-72942-3 DOl: 10.1007/978-3-642-72942-3 © Springer-Verlag Berlin Heidelberg 1989 Softcover reprint of the hardcover 1s t edition 1989 Library of Congress Cataloging-in-Publication Data. Gefasschirurgie. English. Vascular surgery. "Translated from Kirschnersche allgemeine und spezielle Operationslehre, Band XI: Gefiisschirurgie" - T.p. verso. Includes bibliographies and index. 1. Blood-vessels - Surgery. I. Heberer, G. (Georg), 1920-- . II. Dongen, R.J.A.M. van (Reinier Johannes Antonius Maria) III. Aigner, K. (Karl), 1947- . IV. Title. [DNLM: 1. Vascular Surgery. WG 170 G2987j RD598.5.G4413 1989 617.4'13 89-11274 ISBN-13:978 -3-642-72944-7(U.S.: alk. paper) This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, re-use of illustrations, recitation, broadcasting, reproduction on microfilms or in other ways, and storage in data banks. Duplication of this pUblication or parts thereof is only permitted uiJder the provisions of the German Copyright Law of September 9, 1965, in its version of June 24, 1985, and a copyright fee must always be paid. Violations fall under the prosecution act of the German Copyright Law. The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product liability: The publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check its accuracy by consulting other pharmaceutical literature. Illustrations: I. Daxwanger, K. Finch, C. Hengerer, R. Henkel, H. Konopatzki, J. Kiihn, J. Pupp, A.A. van Horssen, B. Zimmermann Reproduction of the Figures: Graphische Kunstanstalt G. Dreher, Stuttgart 2122/3130-543210 - Printed on acid-free paper List of Contributors AIGNER, K., Priv.-Doz. Dr., Chirurgische Abteilung des Kreiskrankenhauses, Siegertshohe 1, D-8223 Trostberg BALZER, K., Dr., Evangelisches Krankenhaus, Chirurgische Klinik:, Tei- nerstr. 62, D-4330 Mulheim/Ruhr BARWEGEN, M.G.M.H., Dr., Sint Maartens Gasthuis, Tegelseweg 210,5912 BL Venlo, The Netherlands BAUMEISTER, R.G.H., Prof. Dr., Klinikum Grosshadern, Chirurgische Klinik und Poliklinik: der Universitiit, Marchioninistr. 15, D-8000 Munchen 70 BECKER, H.M., Prof. Dr., Gefasschirurgische Abteilung des Stiidtischen Kran- kenhauses Munchen-Neuperlach, Oskar-Maria-Graf-Ring 51, D-8000 Mun- chen 83 VAN BERGE HENEGOUWEN, D.P., Dr., St. Elisabeth-Ziekenhuis, Hilvarenbeekse- weg 60, 5000 LC Tilburg, The Netherlands BmMANs, R.G.M., Dr., Zilverstraat 12, B-2120 Schoten BmMER, E., Prof. Dr., Klinikum rechts der Isar der Technischen Universitiit, Abteilung fUr Plastische Chirurgie, Ismaninger Str. 22, D-8000 M unchen 80 BRUNNER, U. Prof. Dr., Departement Chirurgie, Klinik fUr Herzgefasschirurgie, Riimistr. 100, CH-8091 Zurich CARSTENSEN, G., Prof. Dr., Evangelisches Krankenhaus, Chirurgische Klinik, Teinerstr. 62, D-4330 Mulheim/Ruhr DENCK, H., Prof. Dr., Krankenhaus der Stadt Wien-Lainz, I. Chirurgische Abteilung, Wolkersbergenstr. 1, A-1130 Wien . DENECKE, H., Prof. Dr., Klinikum Grosshadern, Chirurgische Klinik und Poli- klinik der Universitiit, Marchioninistr. 15, D-8000 Munchen 70 VAN DONGEN, R.J.A.M., Prof. Dr., Academisch Ziekenhuis bij de Universiteit van Amsterdam, Academisch Medisch Centrum, Vaatchirurgie, Meiberg- dreef 9, 1105 AZ Amsterdam Zuidoost, The Netherlands EIGLER, F.W., Prof. Dr., Klinikum der Gesamthochschule, Chirurgische Klinik und Poliklinik der Universitiit, Abteilung fUr Allgemeine Chirurgie, Hufe- landstr. 55, D-4300 Essen 1 FRANKE, F., Prof. Dr., Waldkrankenhaus St. Marien, Chirurgische Klinik, Rathsberger Str. 57, D-8520 Erlangen GALL, F.P., Prof. Dr., Chirurgische Universitiitsklinik, Maximiliansplatz 1, D-8520 Erlangen GANGER, K.H., Dr., t, CH-Bern GmssLER, R., Dr., Aggertalklinik, Chirurgische Abteilung, Klinik fUr Gefasser- krankungen, D-5250- Engelskirchen GREEBE, J., Dr., Majella Ziekenhuis, Nieuwe Hilversumseweg 20, 1406 TE Bussum, The Netherlands GRUSS, J.D., Prof. Dr., Kurhessisches Diakonissenhaus, Gefasschirurgische Abteilung, Goethestr. 85, D-3500 Kassel GUNTIIER, B., Prof. Dr., Stiidtisches Krankenhaus Munchen-Neuperlach, 1. Chirurgische Abteilung, Oskar-Maria-Graf-Ring 51, D-8000 Munchen 83 Foreword In view of the extraordinary advances which have been made in the field of vascular surgery during the past 30 years, this English translation of Professors HEBERER and VAN DONGEN is a monumental achievement. In this unusually thorough, yet concise and superbly written monograph, the authors have brought the state of the art in this field to a new standard of excellence. In achieving this important task, they have sought the most outstanding vascular surgeons in Germany, the Netherlands, Austria, and Switzerland as contributors. Quite appropriately, this remarkable text begins with a review of the pioneers in vascular surgery whose contributions later proved to be fundamental to both the initiation and development of vascular surgery. The contributions of CARREL and GUTHRIE in perfecting the technique of vascular anastomosis, and the work of LERICHE in developing clinical arterial surgery are engagingly reviewed. Appropriate attention is also given the fundamental contributions of GOYANES in his first successful use of the saphenous vein graft to restore circulatory continuity following resection of a popliteal aneurysm in 1906. Well deserved praise is given another pioneer whose contributions are seldom given the credit which they deserve, specifically those of JEGER, whose monograph published in 1913 entitled "Die Chirurgie der Blutgef4fJe und des Herzens" is one of the most impressive and visionary documentaries ever written in vascular surgery. The editors next tum to an excellent chapter on anatomical aspects of vascular surgery. The illustrations in this chapter, as in all others in this text, are especially noteworthy for their clarity and the vivid impressions they make. Readers have come to regard this feature as a hallmark of Springer-Verlag publications. Fol- lowing are well described aCCQunts of the fundamentals of vascular hemodynam- ics and the general principles involved in the techniques of vascular surgery. In a very effective manner, the authors illustrate poor techniques often employed and contrast them with those which have been proven to be superior. This approach is particularly effective in emphasizing the importance of meticulous technique in determining the final clinical result. Very helpful, especially to young surgeons in training, are the sections on microsurgery and angiocardiog- raphy. The advances made during the past decade in percutaneous transluminal angioplasty are admirably described and convincingly illustrated with a summary of the current results obtained with this important technique. The various disorders of the vascular system amenable to surgical correction are systematically reviewed by recognized authorities in the field with carefully detailed descriptions of the indications for operation, preparation of the patient, diagnostic techniques, and operative approach in appropriate detail. The poten- tial complications of each of the procedures are presented as well as an updated discussion of modem management. In the closing words of the Preface, the editors state: "Let us hope that this manual, the product of more than 30 years of personal experience, will become a useful source of sound advice in the field of vascular surgery." This reviewer is convinced beyond doubt that this has been achieved in this praise- x Foreword worthy text. It can be confidently predicted that this monograph will become a worldwide standard by which all other similar works will be compared, and it is regarded as an essential text for all surgeons who practice vascular surgery. DAVID C. SABISTON, Jr., M.D. James B. Duke Professor of Surgery and Chairman of the Department Duke University Medical Center Durham, North Carolina, USA Preface In recent decades surgical procedures for reconstruction of the aorta, arteries, veins, and lymph vessels have undergone extensive development. Advances were made possible through the improvement of instruments and suture material, through progress in biologic and synthetic grafts, and through developments in anesthesiology and surgical techniques as well. The initial result worldwide was the almost precipitate growth of the field of vascular surgery. For a time, opinions changed rapidly on fundamental matters such as operative procedures and techniques, choice of grafts for the various vascular areas, and clinical indications. Since that time, however, operative techniques have been standard- ized to a considerable degree, and a manual of vascular surgery therefore seems called for (exclusive of the coronary vessels, which are dealt with in the volume "Heart Surgery')' The present volume, the German edition of which is Volume 11 of Kirschner's series of manuals, consists of contributions by the editors and their colleagues and by numerous experts on vascular surgery from Ger- many, The Netherlands, Austria, and Switzerland. In the General Section the preparation of the patient and indications for operation are discussed, as well as documentation and quality control. Surgical anatomy, instruments, and general operative techniques are clearly illustrated in comprehensive figures. Furthermore, general complications such as infection, bleeding, and reocclusion are outlined with particular emphasis on their preven- tion, early detection, and indication, as well as on the timing of reintervention. In the Special Section the operative treatment of diseases of the aorta and arteries of all body regions, as well as of veins and of lymph vessels are discussed, also indications, operative approaches, and operative procedures. The various steps of the operations are presented dynamically using clear multicolored sequences of figures. Microsurgical techniques and rare operative procedures are also taken into consideration. Alternative techniques of vascular surgery and angiology to overcome unexpected difficulties are also mentioned. We owe special thanks to our contributors for their much-appreciated colla- boration. The procedures of the various operative phases are explained by fig- ures and figure sequences, some of which cover an entire page. We are indebted to the artists, Mrs. I. DAXWANGER of Munich, Mr. J. KUHN and colleagues of Heidelberg, and Mr. A.A. VAN HORSEN of Amsterdam. We would also like to thank the staff of Springer-Verlag, especially Dr. H. GOTZE, Mr. W. BERG- STEDT, Mrs. I. LEGNER, and Mr. E. KIRCHNER, for the excellent preparation and appearance of the book. In addition, we would like to thank K.W. JAUCH, Munich, and H. STIEGLER, Munich, for their collaboration and their efforts in correcting the text. We are also indebted to Prof. Dr. H.H. LOHR, Hamburg, for preparing the index. Finally, we appreciate the translation into English by R. HATZ, Munich, R.K. TEICHMANN, Munich, and T. HAU, Wilhelmshaven, and thank Mr. W. POHL for the care he has taken in revising the text. We also thank Miss J. ESSLINGER and Miss C. DAEHNE for typing the manuscript. xn Preface Let us hope that this manual, the product of more than 30 years of personal experience, will become a useful source of sound advice in the field of vascular surgery. Munich and Amsterdam G. HEBERER R.J.A.M. VAN DONGEN Table of Contents General Section 1 History of Vascular Surgery R.J.A.M. VAN DONGEN. With 4 Figures. 3 2 Anatomy . . . . . . . . . . . . . 11 2.1 Surgical Anatomy of the Arteries B. GiiNTHER and G. HEBERER. With 15 Figures. . . . . . . . 12 2.2 Surgical Anatomy of the Veins B. GiiNTHER and G. HEBERER. With 1 Figure. . . . . . . . . 30 2.3 Surgical Anatomy of the Lymphatic System R.G.H. BAUMEISTER. With 6 Figures . . . . . . . . . 32 3 Hemodynamic Aspects in Vascular Surgery L. SUNDER-PLASSMANN. With 4 Figures .. 39 4 Technique of Vascular Surgery E.-D. SCHWILDEN and R.J.A.M. VAN DONGEN. With 55 Figures 47 5 Vascular Reconstruction. R. GIESSLER . . . . . 71 6 Microvascular Surgery. E. BUlMER. With 7 Figures 87 7 Conservative and Radiologic Measures. . . . . 99 7.1 General Procedures in the Management of the Vascular Surgical Patient. H. RIEGER and W. SCHOOP 99 7.2 Local Thrombolysis. H. HESS ..... 106 7.3 Percutaneous Transluminal Angioplasty H. INGRISCH. With 11 Figures . . . . 113 8 Intraoperative and Postoperative Assessment G.W. HAGMULLER. With 15 Figures .... 127 9 Documentation and Statistics O. WAGNER and M. SCHEMPER. With 7 Figures. 143 10 Postoperative Complications . . . . . . . . 157 10.1 Immediate, Early, and Late Complications Following Vascular Reconstruction and Their Treatment (Hemorrhage, Occlusion) K.L. LAUTERJUNG . . . . . . . . . . . . . . . . . .. 157 10.2 Infections in Vascular Surgery F. PIZA. With 4 Figures. . . 166 10.3 Anastomotic Aneurysms H.M. BECKER and H. KORTMANN. With 3 Figures . 173 XIV Table of Contents 10.4 Disorders of Male Sexual Function Following Operative Procedures in the Aortoiliac Region. O. THETTER, A. VON HOCHSTETTER, and R.J.A.M. VAN DONGEN. With 8 Figures. . . . . . . . . . . . . . . . . . . . . . 180 11 Anesthesia in Vascular Surgery H. KUPPE and E. MARTIN. With 1 Figure . 191 Special Section 12 Vascular Deformities. 207 12.1 Atypical Coarctation of the Aorta G. HEBERER and H. DENECKE. With 7 Figures. 207 12.2 Congenital Malformations of the Iliofemoral Artery J. GREEBE and R.J.A.M. VAN DONGEN. With 11 Figures 216 12.3 Congenital Arterial and Arteriovenous Dysplasia R.J.A.M. VAN DONGEN. With 3 Figures .... 223 13 Peripheral and Abdominal Arterial Injuries A. ZEHLE. With 12 Figures . . . . . . . . 233 14 Replantation of Peripheral Body Parts (Microreplantation) E. BIEMER. With 8 Figures 255 15 Arterial Aneurysms . . . . . . . . . . . . . . . . . 265 15.1 Arterial Aneurysms of the Extracranial Supra-aortic Branches and the Upper Extremities. D. RAITHEL. With 9 Figures 265 15.2 Aneurysms of the Lower Extremity H. DENECKE and E. PRATSCHKE. With 6 Figures. . . . 276 15.3 Visceral Arterial Aneurysms. D.P. VAN BERGE HENEGOUWEN and R.J.A.M. VAN DONGEN. With 6 Figures . . . . 284 15.4 Aneurysms of the Abdominal Aorta F.W. SCIDLDBERG and A. VALESKY. With 16 Figures. 294 15.5 Thoracoabdominal Aneurysms G. HEBERER and H. STIEGLER. With 16 Figures 311 15.6 Aneurysms and Ruptures of the Thoracic Aorta W.-J. STELTER and G. HEBERER. With 9 Figures. 331 15.7 Dissecting Aneurysms H.M. BECKER and K.W. JAUCH. With 6 Figures. 349 16 Acute Obstructive Disease of the Extremities H. DENCK. With 8 Figures . . . . . . . 361 17 Occlusive Disease in the Lower Extremities . 375 17.1 Aortoiliac Occlusive Disease M. TREDE and H.H. THIELE. With 15 Figures . 375 17.2 Chronic Occlusive Disease of the Femoropopliteal Artery F.P. GALL and F. FRANKE. With 13 Figures . . . . . 391 17.3 Chronic Occlusive Disease of the Lower Leg Arteries R.J.A.M. VAN DONGEN and F. FRANKE. With 9 Figures 403