Open and Endovascular Operative Techniques and Complications
Open technique principles
Obtain proximal and distal control before opening the vessel. Choose conduit deliberately: autologous vein is preferred below the knee and across joints, while prosthetic is acceptable for aortic and above-knee reconstruction, often with a vein patch or cuff to improve compliance at the anastomosis. Endarterectomy requires the correct plane and a distal tacking suture. Tunnel grafts deeply, avoiding infection-prone subcutaneous paths and kinking.
Endovascular failure modes
Access complications include dissection, pseudoaneurysm, and hematoma, managed with closure devices or covered stents. Endoleaks after EVAR: type I (seal zone) and type III (fabric defect or modular disconnection) require treatment; type II (branch back-bleeding) is the commonest and is observed unless the sac enlarges; type IV is graft porosity and resolves spontaneously. Surveillance targets migration, limb occlusion, and sac expansion. After TEVAR, spinal cord ischemia is the feared complication - maintain mean arterial pressure above 90 mmHg, drain cerebrospinal fluid when deficits appear, and keep suspicion high for delayed paraparesis. Buttock claudication follows internal iliac coverage.
General complications
Compartment syndrome after prolonged ischemia or reperfusion, contrast-induced nephropathy, and prosthetic graft infection (usually staphylococcal, requiring explant and extra-anatomic reconstruction) all appear in questions. Radiation and contrast exposure matter in patients with chronic kidney disease; carbon dioxide angiography is an alternative.
Rule of thumb: treat a type I endoleak now; watch a type II endoleak until the sac grows.