A Iliofemoral Venous Thrombosis

A 72-year-old man was admitted in the late evening because of a turgid, white, painful left leg. Over the course of 4 months, he had lost 8 kg of weight (from 82 to 74 kg) his height was 175 cm. There were general symptoms, such as tiredness, slight nausea, lack of appetite and increasing apathy. Over the last 12 h, he had been increasingly confused and aggressive. He had been bedridden for 3 weeks but had refused to see a doctor. There was no history of psychiatric disease, focal...

Bypass to the Popliteal Artery

Calligaro and Matthew J. Dougherty A 62-year-old overweight postal worker presented with complaints of cramps in his right calf. He stated that this reproducible pain occurred each time he walked 50 yards and resolved upon sitting down. He denied tissue loss or rest pain. His past medical history was significant for hypertension, hypercholesterolemia and tobacco use, as well as coronary revascularization. On physical examination, he had bilateral carotid bruits,...

Commentary

The question of the optimal format for population screening for AAA remains unanswered. Many studies have attempted to identify high-risk populations in order to reduce healthcare costs and maximise the yield. Simon et al. 1 have demonstrated a prevalence of AAA of 11 percent in male patients aged 60-75 years with a systolic blood pressure greater than 175 mm Hg. No patients with uncomplicated hypertension had an AAA. Claudication was the only cardiovascular complication associated...

Congenital Vascular Malformation

A 10-year-old girl presented with a history of recurrent painful swelling of the left knee with mild ecchymosis. The latest episode of tender swelling of soft tissue along the left knee was preceded by a direct blow to the area during a ball game. In addition, she has had an abnormally grown left lower limb with scattered multiple soft tissue masses throughout the limb since birth. Physical examination revealed diffuse swelling of the entire left limb, which was longer and larger than the...

Management of Patients with Carotid Bifurcation Disease

A 72-year-old white male was referred for evaluation and management following the finding of an asymptomatic carotid bruit, picked up on routine physical examination by his primary-care physician. The patient was asymptomatic with respect to ocular or hemispheric ischaemic events. His risk factors included a 30-year history of smoking one pack of cigarettes a day, which he quit a year ago. He had hypertension that was controlled well by two drugs. He had no history of coronary artery disease,...

Lower Limb Claudication due to Iliac Artery Occlusive Disease

A 63-year-old hypertensive man presented in 1990 with a history of pain developing in his left calf and thigh after walking 100 metres. During the preceding 3 months, following the introduction of a beta-blocker for newly diagnosed hypertension, the distance he could walk at a normal pace had reduced from 200 metres. The pain ceased almost immediately after stopping walking and appeared again after the same interval. A systemic enquiry was unremarkable. He was noted to be an active and...

Preface to the Second Edition

The authors' principal objective in the first edition of Vascular Surgery was the presentation of the principles of vascular and endovascular surgery through interactive real life clinical scenarios. The success of the first edition has been gratifying. We have received many suggestions for additions and changes from vascular trainees, specialists, and teachers at various institutions in Europe, the United States, and other parts of the world. These comments have been well received and have...

Question 1

The work-up of this patient presenting with symptoms of vertebrobasilar ischemia and MR evidence of infarction in the posterior region must include Fig. 31.1. MRI showing cerebellar and brainstem infarctions. ffl Fig. 31.1. MRI showing cerebellar and brainstem infarctions. ffl

Question 2

Identify which of the following statements are true or false. A. Premenopausal women have a higher prevalence of varicose veins. B. Age, gender, parity, race and occupation are factors contributing to the development of varicose veins. C. Leg oedema is a prominent feature of varicose veins. D. In the presence of a varicose long saphenous vein (LSV), the saphenofemoral junction is always incompetent. E. Cutaneous telangiectases are only ever associated with varicose veins. F. Patients with...

Question 3

This patient's father has long suffered with post-thrombotic chronic venous insufficiency, and she expresses a strong desire to avoid post-thrombotic complications. However, she does not want to accept the risks of bleeding associated with thrombolytic therapy therefore, she asks for your treatment recommendation. Your best recommendation to this patient would be A. Intravenous heparin for 5 days, followed by oral anticoagulation with a warfarin compound. B. Heparin (unfractionated or...

Question 4

Is it relevant to monitor renal function in this patient Yes, because about 33 per cent of PAD patients have atherosclerotic renal artery stenosis 4 . It is therefore important to consider the presence of this condition, especially if the renal function tests are abnormal. There is evidence that renal and vascular disease progress in parallel 22 . Increased plasma creatinine levels are associated with a higher risk of vascular events, even if these values are in the upper end of the reference...

Question 6

How would you further examine the circulation non-invasively or invasively B. Ankle pressure measurements and pulse wave recordings. C. Treadmill test with pressure measurements. D. Duplex scanning of distal arteries. E. Magnetic resonance angiography. F. Digital subtraction angiography. The toe pressures were 73 mm Hg on the right side and 29 mm Hg on the left side. A selective angiography was obtained the next day (Fig. 23.2).

Question 8

The best treatment for this condition is A. Begin strong diuresis to counter the right heart failure. B. Place the arm in a sling and elevate it to reduce the existing edema from the operation. The patient is reassured that edema following pacemaker insertion of these devices is usually self-limited and will soon resolve. C. The defibrillator is removed and replaced in the right subclavian vein. D. A fistulagram venogram is performed. This will determine the etiology of the edema and may offer...

Question 7

Which of the following is now the preferred intervention A. Aorto-bifemoral bypass graft with revascularisation of both internal iliac arteries. B. Left aorto-uni-iliac bypass graft with revascularisation of the left internal iliac. C. Right femoral to left femoral cross-over graft. D. Percutaneous transluminal angioplasty. E. No intervention - claudication and impotence are a good way of protecting the heart. A percutaneous approach was used a hydrophilic guidewire passed easily through the...

Raynauds Phenomenon

A 38-year-old female patient presented to the rheumatology clinic with a 3-week history of a painful fingertip ulcer. The pain was so severe that it was keeping her awake at night. For 20 years (since her teens) her hands had been turning white then purple in the cold weather, going red (with tingling) when rewarming. Her feet also felt cold. Her family doctor had told her that this was Raynaud's phenomenon, which was very common. However, each winter her symptoms seemed to be worsening, and...

References

The etiology and treatment of varicose ulcer of the leg. Surg Gynecol Obstet 1917 24 300-11. 2. Bauer G. A roentgenological and clinical study of the sequels of thrombosis. Acta Chir Scand 1942 86. 3. Lees TA, Lambert D. Patterns of venous reflux in limbs with skin changes associated with chronic venous insufficiency. Br J Surg 1993 80 725-8. 4. Hoare MC, Nicolaides A, Miles C. The role of primary varicose veins in venous ulceration. Surgery 1983 82 450. 5. Sethia KK, Darke SG. Long...

Question 5

Which of the following are acceptable corrective options for limb-threatening steal following proximal access construction Fig. 39.1. a The operation before the creation of the corrective procedure. b The corrective procedure with ligation of the artery just distal to the AV graft take-off and the venous bypass from a point proximal to the inflow to a point just distal to ligation (DRIL procedure). A, brachial artery AV, axillary vein BV, basilic vein G, arteriovenous PTFE graft VG, vein graft....

Neurogenic Thoracic Outlet Syndrome

A 30-year-old woman presented with complaints of pain in her neck, right shoulder, right trapezius, right anterior chest wall, right arm, elbow, and forearm occipital headaches every other day numbness and tingling in all fingers of the right hand, worse in the fourth and fifth fingers aggravation of her symptoms when elevating her arms, especially to comb or blow dry her hair or drive a car weakness of her right hand and dropping coffee cups and coldness and color changes in her right hand....

Qustion

There is no clear indication to offer any treatment. B. Offer injection sclerotherapy. C. Offer below-knee compression stockings. The patient was advised that the disease progression is very slow. However, the varicosities are likely to deteriorate with age and therefore it is likely that some active measures would need to be taken. Patient compliance and some change in lifestyle, along with conservative measures such as compression stockings, seem to provide symptomatic relief in the...

Chronic Critical Limb Ischemia

An 85-year-old male with a history of diabetes, hypertension, hypercholesterolemia, coronary artery bypass, and active tobacco use presented with a gangrenous right first toe. The patient stated that he had no history of trauma to the area, and complained of rest pain in the foot. The patient had been in otherwise good health since his coronary artery bypass 12 years ago. On physical examination, the patient was in no physical distress. The patient had a well-healed median sternotomy scar....

Erectile Dysfunction due to Aortic Disease

A 60-year-old married man presented with sudden onset of erectile failure about 1 month previously. This occurred in the absence of critical life changes, psychological stress, or known intercurrent illness. Initially, the patient was seen by a general practitioner and treated with sildenafil in incremental doses up to 150 mg. This had only a minor effect ejaculation was maintained but erections remained insufficient for penetration. Risk factors consisted of mild hypertension controlled by an...

A Management of Upper Extremity Lymphoedema with Microsurgical Lymphovenous Anastomosis

Corradino Campisi and Francesco Boccardo A 59-year-old woman presented with an 8-year history of oedema of the left arm. Initially, the oedema appeared in the upper arm. The patient was treated with combined decongestive physiotherapy (manual and mechanical lymphatic drainage), bandaging and exercises three to four times over a 12-month period. Despite these measures, the oedema extended as far as the forearm and hand (Fig. 47a.1), and she had several episodes of erysipeloid lymphangitis. In...

Aortofemoral Graft Infection

A 66-year-old man, an ex-smoker with hypertension and hypercholesterolemia, had undergone a Dacron bifurcated aortic graft and bilateral ureteric stents for an inflammatory aortic aneurysm with ureteric obstruction at another hospital 4 years previously. The left limb of the graft had been anastomosed to the common femoral artery and the right limb to the common iliac bifurcation. Postoperatively he had suffered a mild groin wound infection, which had healed with antibiotics. At follow-up he...

The Obturator Foramen Bypass

Staxrud A 62-year-old man presented with a 2-week history of continuous pain in the left lower abdomen radiating to the groin. For several weeks, he had complained of general malaise, including tiredness and poor appetite, and diarrhoea once or twice per day. His general practitioner palpated a pulsating, tender mass in the left groin and referred him to the department of vascular surgery at the nearby university hospital. Three years previously, he had been...