Chronic Venous Disease

Inspection with the patient standing is one of the most important aspects of the examination of chronic venous disease. The dilated veins of superficial disease are frequently obvious. Other signs of importance include swelling, hemosiderosis of the skin of the malleolar area, lipodermatosclerosis, atrophie blanche, and ulceration (Fig. 2.10). Deep venous disease may be less obvious and present simply with chronic swelling of the limb. In later stages, all of the above signs may be present....

Differential Diagnosis of Leg Ulcers

Many vascular patients present with ulcerations. There are three major types of leg ulcers venous, ischemic, and neuropathic (Table 2.2). Ischemic ulcers tend to be very distal in the vascular tree and painful. Venous stasis ulcers tend to occur in the region of the medial malleolus and have associated brownish discoloration of the skin (lipatodermatosclerosis) and edema. Neuropathic ulcers tend to occur in diabetic patients under pressure points. Patients with diabetes present particular...

Arteriovenous Fistula

Most clinicians agree that the most durable form of vascular access is the AVF. The preferential site is between the cephalic vein and the radial artery at the anatomical snuffbox, or the wrist, in the nondominant upper limb, the Table 13.1. Preoperative planning for autogenous or nonautogenous arteriovenous fistula (AVF) placement Consider patient age, projected life span, time to initiation of dialysis, dominant hand Elicit history of previous access attempts subclavian vein cannulations...

Definition and Pathophysiology

Lymphedema may be defined as abnormal limb swelling due to the accumulation of increased amounts of high-protein ISF secondary to defective lymphatic drainage in the presence of (near) normal net capillary filtration (Szuba and Rockson, 1997). In order for edema to be clinically detectable, the ISF volume has to double. About 8L of lymph is produced and, following resorption in lymph nodes, about 4L enters the venous circulation. In one sense, all edema is lymphedema in that it results from an...

The Epidemiology and Etiology of Atherosclerosis

Clement Darling III, and F.G.R. Fowkes The underlying disorder in the vast majority of cases of cardiovascular disease is atherosclerosis, for which low-density lipoprotein (LDL) cholesterol is recognized as a major risk factor. Evidence from epidemiological and clinical studies continues to improve our understanding of the pathogenesis of atherosclerosis. Atherosclerosis contributes to myocardial infarction, stroke, and peripheral vascular disease. Despite major advances...

Clinical Assessment

In most cases the diagnosis of primary or secondary lymphedema can be made, and the condition differentiated from other causes of a swollen limb, on the basis of history and examination without recourse to complex investigation. Unlike other types of edema, lymphedema characteristically involves the foot. The contour of the ankle is lost through infilling of the sub-malleolar depressions a buffalo hump forms on the dorsum of the foot, the toes appear square due to confinement of footwear, and...

Treatment

Mild to moderate limb ischemia that does not warrant invasive revascularization can be followed with serial examinations. An ABI determination is obtained at the initial visit to establish a baseline, as this measure may improve with exercise or deteriorate with progression of disease. The emphasis in treatment of these patients is on risk factor modification to prevent progression of disease and concurrently increase longevity, and a walking program to encourage exercise and increase exercise...

Buergers Disease

This eponymous disease, named for Leo Buerger, an Austrian-born American physician and urologist (1879-1943), is also known by the more descriptive term thromboangiitis obliterans. It is an occlusive disease of the small and medium-size arteries of the extremities, which it affects in a segmental fashion. It primarily affects young people, with a median age of 34 years. Initial descriptions by Buerger noted a strong predilection of the disease for men, affecting 2 of 500 cases that he reported....

Endovascular Repair of Renal Artery Stenosis

In addition to open surgical repair for symptomatic RAS, renal artery angioplasty with or without stenting offers a less invasive method to correct the anatomical stenosis. Although still a matter of great debate, it is clear that angio-plasty with or without stenting may offer at least short-term improvement in blood pressure and, in certain circumstances, renal function. Although this option is especially appealing for patients, it is certainly necessary to further evaluate and better define...

Primary Lymphedema

It has been proposed that all cases of primary lymphedema are due to an inherited abnormality of the lymphatic system, sometimes termed congenital lymphatic dysplasia. However, it is possible that many sporadic cases of primary lymphedema occur in the presence of a near normal lymphatic system and are actually examples of secondary lymphedema for which the triggering events have gone unrecognized. These might include seemingly trivial but repeated bacterial or fungal infections, insect bites,...

Pros and Cons of Regional Anesthesia and General Anesthesia for Carotid Endarterectomy

The advantage of general anesthesia goes beyond keeping the patient motionless. The brain's metabolic demand is usually reduced with general anesthesia, and thus acts as a protective mechanism against ischemia. The disadvantages of general anesthesia in carotid surgery include the need to routinely place a shunt or the use of EEG or stump pressure monitoring to selectively shunt. The decision to shunt is sometimes determined preoperatively in cases of contralateral occlusion, history of...