Evaluation and Management of Peripheral
Annotation for Point E
An injury to a peripheral artery or vein that results in complete transection is first managed with minimal debridement back to healthy intima at both ends. The amount of tension necessary to perform an end-to-end anastomosis is then assessed. Should the tension be excessive, a decision must be reached on whether to divide and ligate branches of the vessel on both ends versus inserting an interposition graft. Because of the elasticity of arteries, sacrifice of proximal and distal branches will often gain up to 3-cm total advancement of both ends; however, sacrifice of the geniculate collaterals from the popliteal artery should be performed with caution. This is because they furnish important collateral flow to the leg should atherosclerotic occlusion of the superficial femoral artery occur later in life. Spatulated end-to-end anastomoses using 6-0 or 7-0 polypropylene suture are recommended for arteries that are less than 1 cm in diameter distal to the axillary in the upper extremity and distal to the common femoral in the lower extremity. The ends of a vessel with a diameter greater than 1 cm can be anastomosed using an interrupted or a continuous suture technique with stay sutures 120 degrees or 180 degrees apart.15,16 An end-to-end anastomosis performed under tension will result in an ‘‘hourglass’’ narrowing and bleeding from suture holes. When an end-to-end anastomosis cannot be performed, an interposition graft is inserted.