Wednesday, November 28, 2007

i must have a target on my head

Now that I'm on the vascular service, we're doing lots of endovascular procedures, which is where we gain access to the arterial system at a location remote from the site of disease and use various wires, stents, and balloons to treat arterial (or sometimes venous) disease elsewhere. At the end of the case, there is a hole of varying sizes in the artery where our access was. There are all kinds of devices that have been developed to close this hole with a stitch or clip or whatever. Like all devices, sometimes they fail. When that occurs, we resort to the old fashioned way... hold pressure for a very long time.

A known complication of endovascular procedures is formation of a pseudoaneurysm which is when there is a leak in the artery and an inflammatory capsule forms around the flowing blood. The risk of this happening is increased if the patient requires systemic anticoagulation (for a heart valve, for example) or if there is a hematoma.

We were recently doing a groin exploration for just such a complication. We were carefully dissecting around the pseudoaneurysm, keeping in mind that the only thing separating us from a blood volcano was a thin wall of inflammatory tissue. Our dissection was almost complete... POP!

Right. You guessed it. All over me. It's was quite funny, actually. Not as bad as the last time, but messy enough to require me to wash my face and neck and change my shirt. My attending generously held pressure over the common femoral while I cleaned up so I wouldn't miss anything. With the exception of the anesthesiologist and my attending, the rest of the operating room staff was the same as the first blood bath. After that first one, which is already legendary around here, I vowed that I would handle the situation differently. And I did.

The rest of the case was uneventful. Cleaned out the capsule, gained control of the artery with a fogerty, repaired the hole with a few 5-0 prolenes in a figure-of-eight fashion, closed. The patient is great and going home today.

These two instances by two different attendings leaves me wondering, is this just how vascular is? If not, I may set a record for being sprayed with blood in the residency. I have three more months, so I'm sure I'll find out.


make mine trauma said...

Vascular is the service I like the least, tiny fragile little vessels, tiny fragile little suture, tiny fragile little instruments. I wear size eight gloves. Tiny and fragile are two things I don't mix well with. And yes, the most blood letting I've seen is always in vascular. The surgeons are often covered in arterial spray or venous splash before the case is over.
I don't assist on a lot of vascular but if I have to, make mine a AAA please.

Sid Schwab said...

Good job.

The thing I disliked most about vascular was, in many cases, the futility of it. The tedium and frustration of sewing to smaller and smaller vessels in vain attempts at salvage. I did a moderate amount in training; never did any in practice.