CATASTROPHIC
SURGICAL EMERGENCIES:
VASCULAR
York N. Hsiang, MB ChB MHSc FRCSC
Department of Surgery
Vancouver General Hospital
CATASTROPHE…
• Noun
• Sudden, extensive, or notable disaster or
misfortune
• Reversal of what is expected
• Also called, cataclysm
NOT ALL CATASTROPHES
ARE EQUAL…
An Ohio nurse accidentally put a kidney in the
trash, prompting the University of Toledo
Medical Center to suspend its live donor
program as it investigates the incident (Aug
26, 2012)
NOT ALL CATASTROPHES ARE
EQUAL…
Bad Judgement
Bad experience
Good Judgement
Lack of knowledge
Unrecognized situation
Catastrophe
Preparation
Opportunity
Success
Case 1 – Postop Bleeding
• 0300 RN calls because of bleeding from surgical
wound
• 72 y/o M, 12 hours post axilloaxillary bypass
• RN describes a spurt of blood hitting the ceiling
• O/E HR 72, BP 140/90, patient calm, good pulses,
no hematoma, wounds dry
• What do you do?
Case 1 – Postop Bleeding
Discussion
• What is going on?
• Can you confirm this?
• How is this situation managed?
Case 1 – Postop Bleeding
What actually happened
• Resident went back to sleep
• Resident gets chewed out by Attending
following day
• On the next call night, the exact same thing
happens
• Resident notifies attending and graft is
excised
Case 2 – Post Op swelling
• 87 y/o M, ward patient,12 hours post R
carotid endarterectomy
• Sudden coughing episode leads to swelling
R neck
• Has difficulty talking, trachea deviated
• What do you do?
• There is a skin stapler removal kit next to
the bed. Should you use it?
Case 2 – Post Op swelling
Discussion
• How do you relieve airway obstruction?
• What do you think would happen if the
neck staples and s.c. sutures are taken
down?
• Can you stop massive bleeding?
Case 2 – Post Op swelling
What actually happened
• Resident thought he was offering the best
treatment by utilizing what he was told
• Staples and sutures removed
• Torrential hemorrhage ensues
• Patient sent urgently to OR with Resident
using his fist to slow the bleeding
• Patient dies of hemorrhagic shock
Case 3 - Sewing
• You and your vascular attending have been getting
along well.
• While closing the calf wound on a below knee in situ
fempop graft, your attending gets called away to help
with another case
• He asks you to close up, “but be careful not to injure
the vein graft”
• During your closure, you accidentally make a through
and through pass with a 2-0 vicryl suture through the
vein graft – blood is pouring out of the needle holes
• What do you do?
• What/when do you tell the staff surgeon what
happened?
Case 3 – Sewing
Discussion
• Stopping bleeding
– How do you stop bleeding in this case
– What type(s) of haemostatic suture(s) and/or
sealants do you know of?
• When to tell the Attending what just
happened
– Don’t tell if all works out
– Call right away and deal with the fall out
Case 3 – Sewing
What actually happened
• Resident tried digital compression
• When that failed, tried clamping the graft
• Unable to place a haemostatic suture,
Resident calls Attending
• After being chewed out, Resident watches
Attending close bleeding holes and learns
how to place haemostatic sutures
Case 4 - Plaque
• During a radical neck dissection, your staff points
out a heavily calcified carotid artery
• He encourages you to palpate it, and appreciate the
firmness of the plaque
• You take his recommendation and palpate the
plaque
• Postop, the patients wakes up with an ipsilateral
stroke
• What do you do?
Case 4 – Plaque
Discussion
• What do you do when you come across
things that are not part of your original
procedure?
• Is it OK to pinch the ureter with forceps or
slap the bowel to watch it contract?
• What does that achieve?
• Is it OK to massage an aneurysm?
Case 4 – Plaque
What actually happened
• Patient developed dense contra lateral
hemiplegia
• Resident observed Attending explain to
relatives that a stroke had occurred
• Resident learned to be more respectful of
organs not related to the primary operation
Case 5 - Access
• You have successfully punctured the right
internal jugular vein and threaded the
guidewire into the right atrium
• But, in your zeal, when advancing the
catheter over the guidewire, you pushed the
guidewire completely into the patient
• What do you do now?
Case 5 – Access
Discussion
• What do you do when you lose wire access?
• Should you place another line while waiting
for help to get this stray guidewire out?
• Should you remove this operatively or
percutaneously by snaring it out?
Case 5 – Access
What actually happened
• Resident got chewed out (again)
• CXR performed to determine whether wire
was still in subcutaneous tissue or entirely
within the major veins
• Half of the wire was still in the subcut.
Tissues, so formal cutdown to remove wire
• Resident learned the importance of never
losing wire access
Case 6 - Hypoxemia
• 93y/o, M in PAR 2 hrs. following open
AAA repair for ruptured AAA
• pO2 60 on 100% O2, CXR shows min.
change from preOp
• Anesthetist suggests TEE; latter shows large
PE in PA
• What would you recommend?
Case 6 – Hypoxemia
Discussion
• What are the causes of postop hypoxemia?
• What are the causes of postop hypoxemia
with a normal CXR?
• How do you diagnose PE?
• Is TEE a recognized diagnostic modality for
PE?
Case 6 – Hypoxemia
What actually happened
• TEE image shown to Cardiology who agreed that it was
likely a big PE
• Convinced that the patient had a life threatening PE,
Cardiac surgery consulted
• Patient taken back to OR stat for emergency pulmonary
embolectomy
• At OR, no embolus found
• This was a doctor’s relative
• There are reasons for diagnostic algorithms; one should
question why a clinical course that goes away from a
recognized algorithm should be pursued
• The TEE image of the “PE” is never seen again
Case 7 – Postop swelling
• 67 y/o M, 3 days following L fempop
bypass
• Has L thigh and calf swelling
• Hb stable
• What do you do ?
Case 7 – Postop swelling
Discussion
• What causes postop swelling?
• Why is the most common reason for postop
swelling in Vascular patients?
• How common is DVT in Vascular patients?
• What is the diagnostic test to determine
DVT?
• If an ultrasound is not immediately
available, what options do you have?
Case 7 – Postop swelling
What actually happened
• IV heparin started overnight while waiting
for US
• Following morning, patient has significant
swelling and ecchymoses over bypass sites
• Protamine given
• Primum non nocere; If your diagnostic
suspicion is low, wait for the results of the
diagnostic test
SUMMARY
• Catastrophes occur because of lack of knowledge,
lack of attention, or over thinking problems
• Admit your ignorance
• Ask for help when exposed to a new situation
• In the OR, ask Attending to show how they want
things done
• Do not deviate from usual diagnostic and
treatment pathways