There is a growing case complexity in vascular surgery and we must prepare trainees in an environment of reduced autonomy and increased scrutiny on outcomes.1 These pressures have led to a focus on operative preparation and teaching outside of the operating room. Many current models of vascular surgery lack the anatomic relevance and use of vascular control techniques required for successful complex operations.2,3 Using a proprietary soft-embalming technique pioneered at our institution, we successfully created a high-fidelity isolated limb perfusion model of a femoral artery to popliteal artery bypass with saphenous vein harvesting for vascular surgery training. This study established the technical feasibility and clinical relevance of perfused models of deceased donors in vascular surgery. First, the fluid osmolality of the embalming solution was calculated and a sodium chloride perfusion solution was created to provide a similar osmolality and reduce tissue edema while perfusing organs. Subsequently, an isolated lower limb perfusion was performed using arterial-to-arterial access (Figure, A). A direct cannulation of the femoral artery (inflow) was performed with a Bio-Medicus 20 French arterial cannula (Medtronic) and limb isolation was achieved with a tourniquet placed above the cannulation site (Figure, B). Distal access (outflow) was achieved with a 14-gauge catheter (Becton, Dickinson and Company) in the dorsalis pedis artery (Figure, C). A standard roller pump (Medtronic) was used to perfuse the limb at 200 mL/min for the duration of the procedure. The high-osmolality perfusion solution demonstrated good performance in the soft-embalmed vasculature of the deceased donor with no major gains in leg edema, as demonstrated by the suture-marking leg circumference (Figure, A). A standard open saphenous vein harvest and femoral to popliteal artery bypass was performed in the perfused model of the deceased donor. After initiating limb perfusion, the greater saphenous vein was easily identified and a standard open harvest was performed. A skin incision was made and 15 cm of greater saphenous vein was exposed and harvested. Next, the popliteal artery was exposed by making a standard medial thigh incision along the anterior border of the sartorius muscle. Atraumatic vascular clamps were placed proximally and distally on the dissected popliteal artery, and an arteriotomy was created in the anterior wall of the vessel (Figure, D). The popliteal artery exposure was anatomically appropriate and required good hemostatic and atraumatic dissection techniques. The saphenous vein graft was incised along its posterior aspect, spatulating the vein. The vein conduit was good quality with a realistic feel and consistency. The distal anastomosis to the popliteal artery was constructed with a running 6-0 Prolene suture. Before completing the suture line, the back bleeding, forward flushing, and irrigation of the anastomosis was performed with a perfusion solution (Figure, E). After completing the anastomosis, there was good hemostasis present with no perfusate leaking.
Mehaffey JH, Charles EJ, Yarboro LT. Novel Deceased Donor Perfusion Model for High-Fidelity Simulation in Vascular Surgery. JAMA Surg. Published online May 17, 2017. doi:10.1001/jamasurg.2017.0849