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PREOPERATIVE DIAGNOSES:
1. Arteriosclerosis obliterans.
2. Gangrene, right foot.

POSTOPERATIVE DIAGNOSES:
1. Arteriosclerosis obliterans.
2. Gangrene, right foot.

PROCEDURE PERFORMED:
1. Right proximal superficial femoral to mid-posterior tibial in situ bypass.
2. Right transmetatarsal amputation, fifth toe.

ANESTHESIA: Spinal.

SITE OF PROCEDURE: Main OR.

GROSS FINDINGS: The patient is a 61-year-old black female with peripheral vascular disease. She gives a history of rest pain. She developed an ulceration along the right lateral foot at the level of the metatarsophalangeal joint. On admission, the patient began experiencing progressive pain. The patient was admitted during the blackout. She was placed on IV antibiotics. As soon as possible, angiography was performed. I also saw the patient. The patient was cleared for surgery.

Intraoperatively, the proximal superficial femoral artery was widely patent with a good pulse, soft and suitable for proximal anastomosis. The saphenous vein was a fair quality, open throughout its course from the groin down to the mid-calf. The posterior tibial artery at the level of the mid-calf was soft and free of atherosclerosis. The tissue above the fifth metatarsophalangeal joint was necrotic. The skin changes were also present.

OPERATIVE PROCEDURE: The patient was taken to the OR suite and placed in supine position after spinal anesthetic was administered. The patient's right lower extremity was prepped and draped in appropriate manner. A longitudinal incision was created parallel to the inguinal ligament. This was deepened through the subcutaneous tissue and fascia, utilizing both blunt and sharp dissections. Distal femoral artery, proximal superficial femoral artery and deep femoral artery were isolated encircled to the vessel loop. The dissection was carried medially where branches of the saphenous vein were ligated with #4-0 silk ligature prior to dividing them. The saphenofemoral junction was isolated. Then with a series of longitudinal incisions over the course of the right greater saphenous vein, the vein was isolated. At the level of the mid-calf after isolating the greater saphenous vein, the incision was then deepened through the fascia. Utilizing both blunt and sharp dissections, the posterior tibial artery was isolated.

The patient was administered 5000 units of aqueous heparin. After allowing adequate circulating time, Satinsky clamp was placed across the saphenofemoral junction. The saphenous vein was controlled with a vascular clamp and saphenous vein was amputated off the vein. Then the defect in the common femoral vein oversewn with continuous running #6-0 Prolene suture tied upon itself. This closure was hemostatic. The valve at the saphenofemoral junction was excised. The vein was spatulated. The superficial femoral artery was controlled with vascular clamps. A longitudinal arteriotomy was created along the anterior wall. The proximal anastomosis was then performed in an end-to-side fashion with interrupted #6-0 Prolene suture. Flow to the anastomosis was permitted. A good pulse was present within the proximal vein.

Attention was then turned towards the mid-calf. The saphenous vein was ligated with silk suture. Transverse venotomy created. A LeMaitre valvulotome was then passed, proximally withdrawn, dividing the valves and permitting good flow into the bypass. A good pulse was present. The graft was flushed with heparinized saline and controlled with a vascular clamp. A tourniquet was then placed just below the knee. The right lower extremity was elevated and exsanguinated. The cuff was inflated. This permitted hemostasis and control of the posterior tibial artery without applying clamps. The vein graft was cut to shape in length. A longitudinal arteriotomy was created along the exposed posterior tibial artery. An anastomosis between the vein and the artery was then performed in an end-to-side fashion with interrupted U-clips anchoring the vein to the artery with interrupted #6-0 Prolene suture. Prior to completing the closure, the cuff was deflated. Flow into the lower extremity was permitted. One additional suture was required for hemostatic closure.

A large branch at the level of the mid-thigh was accessed with an #18 gauge Argon needle and held in place with silk ligature. Through this, angiography was performed. The distal anastomosis was patent just beyond it. There was a short allograft deformity suggesting spasm. I did flush the graft with heparin and papaverine. I did expose the portion of the posterior tibial artery beyond the distal anastomosis. When the angiogram was repeated, the allograft deformity was suggesting indeed that this was spasm.

The wounds were copiously irrigated with antibiotic solution. Sponge, needle, and instrument count were correct. All surgical sites were inspected. Good hemostasis noted. The right groin incision was closed in layers with absorbable sutures. Stainless steel clips were utilized to approximate the skin. The thigh incision was also closed in a similar fashion. The calf incision was closed in single layer fashion with interrupted #3-0 nylon suture utilizing an interrupted vertical mattress stitches of #3-0 nylon suture.

The incisions were then covered. Attention turned towards the ischemic aspect of the foot. Utilizing sharp dissection, a circumferential incision was created about the right fifth toe. This extended proximally to include an area of necrotic skin. This was deepened to the soft tissues. The soft tissues were then elevated off the metatarsal with a periosteal elevator. The fifth metatarsal was transected with a bone cutter. The edges were shortened and smooth with the rongeurs. Bleeding was controlled with #3-0 chromic suture. The wound was irrigated with antibiotic solution. Bacitracin was placed within the wound. The sterile dressing was applied. The patient tolerated the procedure well. She returned to the recovery room with a good pulse within the bypass. The quality of the right posterior tibial ______ continuously improving. I did discuss the operative findings and procedure with the family at length.

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