Computed Tomography CT

Conventional CT was welcomed at the end of the 1980s as an alternative to angiography in the diagnosis of thoracic aortic rupture. Although initial reports were very enthusiastic, the relatively high incidence of both false-negative and false-positive findings indicated that conventional CT was merely a screening and not a diagnostic tool 47 . Helical or spiral CT was introduced in the mid 1990s and Gavant et al. 17 were among the first to report superior results. They compared spiral CT and...

In Microvascular Surgery

Microvascular Anastomosis

Fine work with reliable accuracy is made possible in microsurgery with the aid of an operating microscope or magnifying loupes, and the refined techniques and skills can be acquired only by many hours of practice. In this regard, training in the laboratory has proven a key factor before a surgeon can make a successful clinical contribution. Before participation in complex cases of complete or incomplete nonviable amputations, surgeons need to demonstrate adequate experience and skills acquired...

Info

Follow cannulation of the CCA using a guide catheter or a guide sheath. Then procedure is continued - if necessary and always under protection - with predilatation of the lesion, stent implantation and (also if necessary) postdilatation of the stent. When insertion of a brain protection device is impossible, predilatation of the lesion using a coronary balloon can be done in order to help pass the protection device distally to the lesion. When the procedure is finished, the protection device is...

Choice of Technique

Controversy continues about the optimal technique for repair because of concern about proximal hypertension and distal hypotension with the possibility of spinal cord ischaemia and the potential for lower limb paralysis. There are still strong advocates of the simple clamp and repair method, particularly in urgent situations. Techniques for distal perfusion include the use of passive shunts, partial or complete cardiopulmonary bypass and left heart by-pass (Biomedicus, Eden Prairie, Minn.)....

Fibromuscular Dysplasia

Arterial fibromuscular disease encompasses a heterogeneous group of nonatherosclerotic vascular occlusive and aneurysmal diseases. A principal forum of fibrodysplastic stenoses includes Perimedial dysplasia 2, 11, 17 . The first two are distinctly different pathological entities, whereas the latter two appear to represent a common disease in evolution. Compounding this classification are hypoplastic dysplastic vessels occurring as true developmental lesions. Various combinations of dysplastic...

Amputation of Extremities

The main goal of all vascular surgeons in the field of arterial diseases or trauma in the extremities is arterial reconstruction in order to save vitality and function. However, despite substantial improvement of limb-salvage rates in patients with peripheral vascular disease, extremity amputation can be, in some cases, the only possible treatment for a limb severely affected by trauma, infection, tumour, or at the last stage of ischaemia 8 . Many vascular surgeons have traditionally viewed...

Local Wound Complications Graft Infection and Morbidity

Local wound complications, e.g. haematoma, seroma and superficial wound infection, are not necessarily related to the femoro-femoral by-pass graft and can just as easily be related to dissection of the common femoral artery. Bifurcated devices may be expected to produce in the region of 8.4 local groin complications 21 , similar to the 11 experienced in Hinchliffes' cohort 25 . Yilmaz et al. 60 found that all wound or graft infections complicated femoral exposure through a longitudinal...

Or Pulse Volume Recording PVR

Any instrument measuring the change in volume of the limb during each cardiac cycle by a plethysmo-graphic sensor may be used for example, sphygmomanometer, mercury-in-silastic tube strain gauge or impedance captors. The pulse volume recording is obtained by a plethys-mograph connected to these devices placed at selected locations of the limb 26 . In addition a brachial cuff reflects the undampened cardiac contribution to arterial pulsatility. Comparing each PVR reveals an eventual significant...

Classification Systems

The Meggitt-Wagner classification (Table 8.1.2) has been widely accepted, and is the most utilized system. The original system has four grades (0-3) based on the depth of the ulcer, and two more grades (4-5) describing ischaemia 54 . A modification of the Wagner-Meggitt system is Depth-Ischemia classification, combining grades for both the depth of an ulcer (0-3) and ischaemia of the foot (A-D) 14 . The University of Texas (UT) classification system for diabetic foot wounds (Table 8.1.3) is...

Visceral Hybrid Procedure

The principle of this operation is the retrograde revas-cularization of the visceral and renal arteries via an abdominal approach to allow the use of endovascular stent grafts to exclude Crawford type I, II and III tho-racoabdominal aortic aneurysm in their entirety. Open repair with a subcostal incision is preferred for Crawford type IV aneurysms. The safety and durability of using retrograde by-pass grafts to supply the coeliac, superior mesenteric and renal arteries is controversial. The...

Medical and Interventional Vascular Contributions to the Development of Vascular Surgery in Europe and Worldwide

Christian Doppler was a mathematician born in Salzburg, Austria. In 1842 he wrote a paper entitled Concerning the colored light of double stars, the substance of which is now known as the Doppler effect. He hypothesized that the pitch of a sound would change if the source of the sound was moving. This hypothesis was tested in 1845. The Japanese Shige and Satomiga applied the Doppler effect to the diagnostic investigation of the cardiovascular system using ultrasound techniques. The resulting...

Disadvantages

The basic disadvantages of the shunt include a high rate of infection and thrombosis danger of being extracted, especially in uncooperative patients or children. A nonfunctioning shunt is possible due to an infection or recurrence of thrombosis a convolution of its parts or a stenosis around the lumen of the catheter due to an overgrowth of the intima. A rare complication is the creation of an aneurysm in the artery after removing the shunt.

Antiphospholipid Antibodies

Antiphospholipid syndrome (APS) is a commonly acquired cause of hypercoagulation. It appears in 1 to 15 of the population, this rate increasing with age (to 50 in patients over the age of 80 years) 28 . APS affects patients with lupus anticoagulant or anticardiolipin antibodies. These antibodies react with endothelial cells, platelets and phospholipids. Recurrent venous thrombosis is one of its clinical manifestations 20 . Thrombotic complications, estimated to be as high as 50 , have also been...

Peripheral Vascular Stent Infections PVSIs

Peripheral vascular stenting in combination with percutaneous angioplasty procedures has been the most common nonsurgical treatment of atherosclerosis in recent years, accounting for more than 400,000 implantations per year in the USA. The risk of infection is reported as being lower than 1 case per 10,000 procedures 65 . Fig. 14.1.2 Axial spiral CT slice in a patient with infected bifurcated aortofemoral graft during the arterial phase post iv contrast administration. A fluid collection with...

Treatment of Coeliac Artery Compression Syndrome

The surgical treatment of coeliac artery compression syndrome consists of decompression of the coeliac artery at the diaphragm by careful division of fibres and fibrous and nerve tissue. Fig. 6.1.2a Exposure of the aorta, coeliac artery, superior mesenteric artery and left renal artery and vein Fig. 6.1.2b Aorta has now been opened by a longitudinal incision showing the obstructed coeliac artery and superior mesenteric artery which will be treated by endarterectomy Fig. 6.1.2b Aorta has now...

Alternative Graft Option

If there is a lack of available or suitable GSV, which ranges considerably in the literature from 15 to 45 20, 81 , a search should be made for another vein source, such as the contralateral saphenous, the short saphenous, the superficial arm veins and the superficial femoral vein. These grafts could be used as single grafts or after the construction of a vein-to-vein composite graft 20, 32, 36, 37 . When the length of the vein graft is inadequate, composite PTFE-vein grafts may be a valuable...

Combined Transperitoneal and Retroperitoneal Procedures

The combined transperitoneal and retroperitoneal procedure presented here is described by Dion 12-15 . The main feature of the technique is creation of a peritoneal apron that retains the intestinal loops without reducing the size of the operating cavity. A 10-mm trocar is introduced at the level of the umbilicus to establish a pneumo- peritoneum at a pressure of 15 mmHg. The patient is then placed in the Trendelenburg position at 10 with the table tilted to the right. As initially described by...

Training of the Vascular Surgeon for Endovascular Procedures

BIASI, CLAUDIA PIAZZONI, GAETANO DELEO, ALBERTO FROIO, VALTER camesasca, angela LhOIA, grazia pozzi In the last two decades the most crucial event in the evolution of vascular surgery has been the advent of endovascular techniques. The introduction of endovascular therapies has had an extraordinary impact on vascular surgery, widening and transforming the horizons of vascular surgeons in many important ways. The number of endovascular procedures has increased in the last few years...

Factors Determining Extension of Dissection

Debakey Iiib

Biomechanical properties determining the extent and progression of aortic dissection include Quality and resistance of the aortic layers Kinetic energy of the bloodstream Cohesion force between wall components Tension within the false lumen. Fig. 4.2.5 Type B (DeBakey type IIIa) aortic dissection. Posttraumatic false aneurysm. DSA imaging during stent graft placement Fig. 4.2.5 Type B (DeBakey type IIIa) aortic dissection. Posttraumatic false aneurysm. DSA imaging during stent graft placement...

Carotid body tumour

FABRIZIO BENEDETTI VALENTINI, RITA MASSA, ANTONELLA LAURITO Carotid body tumour (CBT) is a non-chromaffin paraganglioma of the carotid body It originates from the mesodermal cells of the third branchial arch and from the neural part of the ectoderm crest 14 . CBT location is predominantly at the carotid bifurcation, but similar paragangliomas can be found They can also originate from the glossopharyngeal or the vagus nerve. In a few cases there is multicentricity of the disease such as multiple...

Special Remarks

It is most important to be aware of the fact that intermittent claudication is the first sign of popliteal entrapment and usually affects young patients. For this reason a high index of suspicion is of the essence. In our personal experience the youngest patient was 7 years old and presented with poststenotic dilatation and peripheral embolism. Intermittent claudication in the patient's history must always evoke the suspicion of popliteal artery entrapment or adventitial cystic disease....

Antegrade Complications

Distal progression without damage of side branches Distal progression with refenestration at sites that have no significant sequelae Distal progression with side branch (spinal, visceral, renal iliac) involvement (Figs. 4.2.7-4.2.17). Fig. 4.2.14 Lateral view of a long segmental aortic dissection. Thoracoabdominal aortic level. Periorificial subintimal compression of the coeliac trunk and superior mesenteric artery is seen Fig. 4.2.15 Sagittal view of a long segmental aortic dissection....

Angulated Aneurysm Neck

The angulated aneurysm neck is an essential parameter that directly influences accurate graft deployment at the proximal landing zone. However, if it is also short, thrombosed or calcified, an angulated neck may influence whether there is sufficient sealing of the aneurysm sac and stent graft fixation during the long-term follow-up. The degree of aortic arch angulation is also an important anatomical feature that has to be considered when selecting patients for graft surgery 13, 14, 23, 46 . In...

Distal Anastomotic Site Fig 723

The distal anastomotic site has no impact on the results of femorodistal reconstructions. As a rule, a tibial artery is used if its lumen runs into the foot without obstruction, though by-passes to disadvantaged outflow segments may be performed successfully. Generally, the peroneal artery is used only if it communicates with foot arteries. Although the ability of peroneal revascularization to perfuse the foot sufficiently has been criticized, many studies have demonstrated equivalent patencies...

Diabetic Neuropathy

The diabetic neuropathies are a heterogeneous group of conditions that may be sub-classified into various poly-neuropathies and mononeuropathies. The commonest forms of diabetic neuropathies are distal sensorimotor neuropathy (also called peripheral neuropathy) Distal Sensorimotor Neuropathy Peripheral Neuropathy Epidemiology Aetiology This affects about 30 of patients with both types of diabetes. Its prevalence increases with both age and duration of diabetes 91 . The onset of this type of...

Vascular Complication in Orthopaedic Patients

Damage to major arterial structures during various orthopaedic procedures related to both trauma and reconstruction is well-known and has been documented extensively in the orthopaedic literature 4, 12, 14, 37, 45, 46, 57 . Injuries to the major vessels may be of several types, involving either partial or complete interruption of normal blood flow. They can be the product of continuous pressure resulting in thrombosis or false aneurysm 3 or the result of acute complete or partial laceration...

Symptoms

The identikit of a patient with TAO is young, a heavy smoker, has severe rest pain and ulcers of the toes (Fig. 7.5.2), cyanosis and cold sensitivity of the fingers, is nondiabetic, has a presenting history of actual superficial phlebitis and has normal or negative inflamma-tory immunological markers. Typically the lower extremities are the first and more severely affected, but the upper extremities and mainly the fingers are also involved in most cases. Rather frequently, rest pain of the...

The Vast Majority of Patients do not Have a Pattern of the Disease that Requires Angioplasty that would Remain Patent

The results in the CLI series are much worse than in the SCLI IC series. Skin necrosis and ulceration may affect limbs with ankle systolic pressure > 60 mmHg and with short occlusions, often because of trauma, sepsis or venous stasis. These limbs are unlikely to show progressive deterioration and angioplasty is frequently effective in such patients. This condition should be termed SCLI. Once healing has been achieved, occlusion after angioplasty may not precipitate relapse 21 . There are...

Arteriovenous Grafts

It has been accepted worldwide that the classic internal A-V shunt in the arm constitutes ideal vascular access for performing chronic haemodialysis. When the vessels have been worn out by previous efforts or the veins are not competent, then it is necessary to use special synthetic grafts to bridge the gap between the artery and the vein as they are too far apart. These grafts cannot be the first choice for a vascular procedure in a new patient but must be used in patients who have a certified...

References

Ansel GM, Sample NS, Botti III CF et al (2004) Cutting balloon angioplasty of the popliteal and infrapopliteal vessels for symptomatic limb ischemia. Catheter Cardiovasc Interv 61(1) 1-4 2. Bauermeister G (2001) Endovascular stent-grafting in the treatment of superficial femoral artery occlusive disease. J Endovasc Ther 8(3) 315-320 3. Bell J, Papp I, Bradbury AW (2000) Bypass versus angio-plasty for severe ischaemia of the leg The BASIL trial. In Greenhalgh RM, Powell JT, Mitchell AW (eds)...

Other Risk Factors

Callus formation is the result of both increased plantar pressure and dry skin. The presence of callus is associated with a 77-fold increase in foot ulceration risk in patients with neuropathy. Regular removal of callosities results in a significant reduction in foot pressure and in prevention of ulceration 59 . The presence of foot deformities (claw toes, prominent metatarsal heads, hallux valgus, nail deformities) is associated with an increased risk of foot ulceration. The presence of other...

Clinical Judgement

The question that should be answered expeditiously during the clinical evaluation is whether an aortic dissection is responsible for the patient's symptoms. If yes, ascertain Signs of expanding aneurysm Signs of contained or free rupture alongside the dissected aorta Signs of side branch lesions Signs of unstable and impending side branch morphology Fig. 4.2.18a-c Morphology of side branch damage caused by aortic dissection. a Subintimal haemorrhagic cuff with lumen compression. b Partial tear...

Secondary Atherosclerotic Manifestations

Eversion Running

In the presence of secondary atherosclerotic manifestations, it might be possible to perform endarterec-tomy with removal of an appositional thrombus or an eversion procedure with re-anastomosis end-to-end. Fig. 7.6.3 Intraoperative situation with deviation of the artery behind the medial head of the gastrocnemius with vein and nerve running an orthotopic course Fig. 7.6.3 Intraoperative situation with deviation of the artery behind the medial head of the gastrocnemius with vein and nerve...

Duplex Scanning

Below The Knee Angiography

Very contributory it identifies the distal arterial lesions typical of TAO and rules out the presence of proximal disease. It helps also to exclude aneurysms (aortic, femoral and popliteal), ulcerated plaques, popliteal entrapment, etc. Venous disease can also be seen or confirmed. Fig. 7.5.3 MR angiography shows multiple arterial lesions below the knee with segmentary occlusions and corkscrew-like collateral circulation Fig. 7.5.3 MR angiography shows multiple arterial lesions below the knee...

Angiography

Angiography is traditionally cited as the gold standard in the diagnosis of thoracic aortic trauma. Digital subtraction angiography (DSA) is preferred and intravenous examinations should be avoided because it produces poor-quality studies in one-third of cases. When performed adequately, intra-arterial DSA can detect thoracic aortic injury with a sensitivity of 9599 and a specificity of 94-100 39 . False-positive results are most frequently related to a prominent ductus diverticulum or large...

Neighbourhood Grey Tone Difference Matrix

For each ROI, information about spatial changes in intensity can be obtained by looking at the difference between each pixel and the grey tones of its surrounding neighbours. A one-dimensional (1D) matrix can be estimated for each ROI, in which the ith entry corresponds to the summation of the differences between the grey level of all pixels with grey level i, and the average grey level of their surrounding neighbours. The size of the neighbourhood depends on the selected distance, i.e. a...

False Aneurysms or Pseudoaneurysms

In these cases treatment will depend on the aetiology. If they are small and asymptomatic, conservative treatment is recommended, since the rate of spontaneous resolution is high, above 70 34 . Should resolution not occur spontaneously, then selective compression of the aneurysmal neck is to be performed with ultrasound monitoring until thrombosis of the sac is achieved. Until 1991 symptomatic or large-sized femoral aneurysms were eligible for surgical repair, but now ultrasound-scan-guided...

The Case of Aortic Dissection

The pathophysiology, management and prognosis of aortic dissection are different from those of aortic an-eurysm. Untreated aortic dissection has a high mortality 4 . Recently, a consensus has evolved regarding the acceptable management of aortic dissections. For the acute Stanford type A dissection immediate surgery is recom- Fig. 5.4.5a-f Endovascular aneurysm repair (EVAR) for TAA with involvement of supra-aortic arteries - hybrid management. a, b Intraoperative angiography before and after...

Endovascular Treatment of Carotid Stenosis

THOMAS GERASIMIDIS, DIMITRIOS KARAMANOS, KONSTANTINOS KONSTANTINIDIS, ALEXANDROS MALLIOS Endovascular treatment of carotid stenosis using carotid angioplasty and stenting (CAS) was first implemented experimentally on dogs in 1977 33 . Since the early 1980s there have been reports of its implementation, mainly on patients suffering from fibromuscular dysplasia 18 and, later on, on patients with atherosclerosis and post-endar-terectomy restenosis 34, 41, 57 . Stenting was performed electively in...

Prothrombin Gene Mutation 20210A

This anomaly described in 1996 is caused by a mutation in nucleotide 20210 of the prothrombin gene (guanine replaced by adenine). The heterozygous state occurs in 1 to 4 of the general population and in up to 6 to 10 of subjects with venous thrombosis. The risk of thrombosis increases 2-3 times with respect to the population at large, and seems to be mediated by increased prothrombin levels 35 . It has even been suggested that prothrombin gene and factor V Leiden mutations occur in 63 of...

Complications of the AV Grafts

Vascular Graft

The most common complication of grafts is infection. In order to reduce or avoid infections, while placing the graft strict antiseptic rules must be followed and antibiotics administered to the patient. This tactic has significantly reduced the rate of primary infection of the graft. The puncture of the graft must be done carefully and 2-3 weeks must have passed from the date of placement to avoid haematoma. The haematoma is nutritive for the growth of microbes and contributes to the appearance...

Thoracoabdominal Refenestration

Carotid Endarterectomy Procedure Steps

This type of surgery in a selected subgroup of patients is indicated if no major aneurysm is present at the tear site, but dangerous distal side branch morphology is present. Through left thoracophrenolaparotomy along the 7th or 8th intercostal space and pararectal line, the thora-coabdominal aorta can be dissected. The removal of the dissected intimal membrane leaves double lumen at the thoracic aorta, decreases tension of the false lumen, creates a common cavity at the visceral segment...

I

Leg Edema Vesicles

Fig. 11.1.5 Isotope lymphangiogram showing enhanced uptake of isotope in enlarged left pelvic lymph nodes Filariasis is the commonest secondary cause of lymphoedema and is endemic in many tropical areas, particularly in Indonesia, India and China. The worm Wuchereria bancrofti enters the body in mi-crofilarial form through insect bites. The worm lodges in lymph nodes, where it matures and starts producing microfilariae which are released into the bloodstream and are thence transmitted back to...

Problems and Complications of Arteriovenous Fistula

Fistula Problems Pic

This complication is usually developed in a shunt which is produced in the wrist and its origin is unknown. Haemorrhage. This may take place immediately after the creation of the shunt and, in this case, we have to open it and ligate the vessel that is responsible. Later if there is a haemorrhage it is usually due to infection. Thrombosis. Thrombosis is divided into early and late. Thrombosis at the early stage of the procedure is unusual and takes place at a...

The Case of Aortic Bronchial and Enteric Fistula

Aorto-bronchial and aorto-enteric fistulas are rare but serious complications, which can develop from an aneu-rysm of the descending thoracic or abdominal aorta. The leading symptom is haemorrhage into the target organ bronchus (haemoptysis) or bowel (haematemesis, melena). Conventional surgery via thoracotomy or laparotomy is a risky procedure. EVAR of such potentially infected fistulas is an attractive alternative with excellent primary results (Fig. 5.4.6). Most authors postulate a good...

The Nursery of Vascular Surgery in Europe in the 1930s was the Ren Leriche School in Strasburg France

The identity of vascular surgery as a specialty in the major field of surgery, not only in Europe but also internationally, started emerging in the 1930s in the famous School of Ren Leriche in Strasburg. In this Clinic many young European surgeons and the American Michael E. De-Bakey had their training and were indoctrinated with the impressive ideas and experience of Leriche concerning the pathophysiology and treatment of arterial diseases. Among Leriche's pupils were Michael E. DeBakey (USA),...

The Oxidized LDL Hypothesis

Low density lipoproteins (LDL) are plasma particles that contain in association with protein several types of lip-ids with a predominance of phospholipids, free and es-terified cholesterol, for a total of about 1200 unsaturated fatty acid chains. In the presence of high levels of LDL - a well-recognized risk factor for developing atherosclerosis - influx of cholesterol and LDL into the intima is increased. In addition to binding to connective tissue elements (such as proteoglycans), accumulated...

Outcome

Endovascular reconstruction has certainly been met with enthusiasm and over the last 5 years there have been at least 12 papers presenting more than 5 cases (Table 4.3.5). In these series, all grafts were deployed successfully and there were no early conversions. The overall mortality (9.7 ) is quite high, which might be explained by the fact that virtually all deaths were due to concomitant injuries. One patient however died because of rupture of the ascending aorta on postoperative day 6 15...

Trauma of the Knee

What Supracondylar Amputation

Trauma of the knee joint holds a special place for two main reasons The potentially serious threat to limb salvage in the case of arterial injury. The policy formulated around the use of intraluminal shunts 1 , which has shown the way for exemplary close co-operation between vascular and orthopaedic surgeons. Simple or complex fractures around the knee joint and knee dislocation are sometimes associated with injury to the popliteal artery. Here the proximity of bone and artery is especially...

Specific Laparoscopic Instruments for Vascular Laparoscopy

Vascular Instruments

Specific laparoscopic instruments for vascular surgery include the following Potts laparoscopic scissors (Fig. 5.6.9) Two releasable clamps (Clamps B Braun) for occlusion of the iliac arteries (Fig. 5.6.10) Two laparoscopic clamps with 10-mm DeBakey-type jaws and safety ratchet for proximal and distal aortic clamping (B Braun-Aesculap or Storz-France) (Fig. 5.6.11) Fig. 5.6.9 Potts laparoscopic scissors (B Braun-Aesculap) Fig. 5.6.9 Potts laparoscopic scissors (B Braun-Aesculap) 5.6.5.1...

Studies Comparing MDCT and CT Angiography

Particular attention should be paid to the study of the axial native images including all the diagnostic information. 3D reconstruction and post-processing images are highly operator dependent. Inadvertent 3D manipulations could create or ignore pathological conditions. Fig. 1.5.1. Male 65 years, 76-mm-diameter infrarenal abdominal aortic aneurysm (AAA), stenosis of right common iliac artery. Postoperative CTA after endovascular aneurysm repair (EVAR) Fig. 1.5.1. Male 65 years, 76-mm-diameter...

Transperitoneal Route as Described by Alimi [2

The patient is placed in the dorsal decubitus position. The operating surgeon and first assistant stand on the left side of the table and the second assistant on the right. The procedure begins with a 10-mm peri-umbilical incision for placement of the viewing endoscope using the open-coe-lioscopy technique. The working trocars are placed along the same pararectal line in a triangular configuration with the viewing endoscope. The patient is then placed in the Trendelenburg position at 30 and the...

Acute Ischaemia Of Extremity

Abciximab 133 abdominal angina 407,417 abdominal aortic aneurysm 317 - endovascular repair 327, 343-347 abdominal aortic reconstruction, quality control 119 acidosis, after acute limb ischaemia 452 acute leg limb lower extremity ischaemia 449-457 acute peripheral arterial occlusion 449-457 amputation 438, 476, 485, 494, 497, 501, 502, 525-535, 583, 602, 603, 627 amputation, for upper extremity vascular trauma 259 anaesthesia 95 anastomosis 624 - end-to-side microvascular 626 anastomotic...

Platelets Fibrinolysis and DDimers

Patients with PAD have impaired fibrinolytic activity, manifested primarily as raised levels of the inhibitor of fibrinolysis, plasminogen activator inhibitor-1 (PAI-1). Six months of exercise training improved fibrinolysis. Physical activity lowers D-dimer levels, which may be a sensitive marker of the extent of atherosclerosis in lower extremity arteries 11 . High D-dimer levels are associated with poorer physical activity among individuals with and without PAD. Additional work is needed to...

Endto End Microvascular Anastomosis

Careful microvascular dissection under magnification is used to expose the selected vessel (Fig. 14.3.1). Magnification by a microscope is required when working with vessels less than 2 mm in diameter, while ocular loupes are valuable for the initial dissection and anastomosis of vessels greater than 2-3 mm in diameter. Proper exposure entails clearing enough room to perform the procedure and to be able to visualize enough of the proximal recipient vessel to verify its condition. Once the loose...

Popliteal Varicose Veins

Saphenopopliteal Junction

Fig. 10.1.1a-c Different types of varices. a Stem varicosis of greater saphenous vein. b Reticular varices in the area of the popliteal fossa, with pigmentation. c Telangiectasia due to venous stasis, agenesia of valves, deep venous thrombosis (post-thrombotic syndrome) or progressive primary varicosis. The most common cause is varicose disease. Varicose veins are dilated, tortuous and superficial veins occurring mainly in the lower limb area. Three types exist (Fig. 10.1.1) dilated saphenous...

Pathogenesis of the Neuropathic Ulcer

Neuropathic foot ulcers result from a combination of two or more contributory factors occurring together. The neuropathic foot, for example, does not ulcerate spontaneously. It is the combination of loss of protective sensation and either extrinsic factors (e.g. walking barefoot, ill-fitting shoes, foreign bodies in the shoes) or intrinsic factors (peripheral vascular disease, foot deformities, callosities) causing minor or major trauma that ultimately result in ulceration. Neuropathy is the...

Initiation of Atherosclerosis and Role of Endothelial Dysfunction

Platelet Smc

Atherosclerotic lesions develop progressively with a succession of events leading to the constitution of mature lesions named atheromatous plaques (Fig. 1.2.1). These lat- 1.2 Development of Atherosclerosis for the Vascular Surgeon Table 1.2.1 Products released by endothelial cells Table 1.2.1 Products released by endothelial cells Fibronectin, laminin, collagen (type I, II, III, IV), proteoglycans NO, prostacyclin (PGI2), prostaglandin E2 (PGE2), angiotensin-converting enzyme (ACE),...

Are all Statins the Same

Statins are of proven efficacy in secondary prevention in high-risk groups such as PAD patients. However, we do not know if all statins are equally effective. This question can only be answered by head to head comparison trials that incorporate clinical endpoints. Potential differences between statins can conveniently be considered in the context of LDL-C lowering potency, and So far, head to head comparisons clearly show that some statins are considerably more potent, in terms of LDL-C...

Wtz R References

Barone JE (2001) Routine perioperative pulmonary artery catheterization has no effect on rate of complications in vascular surgery a meta analysis. Am Surgeon 67 674-679 2. Basse L et al (2000) A clinical pathway to accelerate recovery after colonic resection. Ann Surg 232 51-57 3. Boersma E et al (2001) Predictors of cardiac events after major vascular surgery - role of clinical characteristics, dobu-tamine echocardiography and beta-blocker therapy. J Am Med Assoc 285 1865-1873 4. Boylan JF et...

Descending or Retrograde Phlebography

The main objective of this technique is the study of venous valve function and evaluation of venous reflux in both the deep and superficial venous system, and for detailed study of insufficiency at the sapheno-femoral and sapheno-popliteal junctions. The initial technique of descending phlebography was through puncture of the femoral vein with the patient standing it was developed subsequently by Cid dos Santos 18 to study sapheno-femoral incompetence and abnormal patterns of venous reflux in...

Antegrade Femoral Access

The antegrade femoral technique through the ipsilat-eral common or superficial femoral artery provides access, for diagnostic or endovascular purposes, to the femoro-popliteal and tibio-peroneal arterial segments. It is obtained through an antegrade, flow-directed percutaneous approach proximal to the femoral pulse with orientation of the needle appropriate for entry into the common femoral artery. Care should be taken to avoid dissection and to orientate the guidewire in the proper direction...

Brooks Marcus J MD

Mary's Hospital London, UK E-mail marcus.brooks btinternet.com Cairols, Marc, MD Servei d'Angiologia I Cirurgia Vascular Hospital Universitari de Bellvitge University of Barcelona Barcelona, Spain E-mail mcairols csub.scs.es Camesasca, Valter, MD School of Medicine University of Milan-Bicocca San Gerardo Hospital Monza, Italy E-mail valter.camesasca inwind.it

Eversion Carotid Endarterectomy Technique

Right Carotid Endartectomy

SARATZIS Carotid endarterectomy CEA is well established as a stroke-preventing treatment. Since the 1960s, two different techniques have evolved, namely conventional and eversion carotid endarterectomy, which is a modified version of the original method. 1. Conventional endarterectomy is the most common option for carotid bifurcation endarterectomy. It involves a longitudinal arteriotomy extending to the internal carotid distal to the lesion, and arteriotomy...

Deep Venous Thrombosis

HEIKKINEN, JUHA-PEKKA SALENIUS The following three factors, primarily postulated by Virchow, are most important in the pathophysiology of deep venous thrombosis DVT 10 Abnormalities of blood coagulation disorders Abnormalities of blood flow stasis . There are multiple risk factors for DVT, but the independence and magnitude of each are unclear 10, 11, 12, 34 Surgery hip or knee arthroplasty, cancer surgery in the abdominopelvic area, neurosurgery Immobilization...

Literature

In 1996 Nitecki et al. 36 presented a series of 29 consecutive patients with an inflammatory aneurysm, who were matched in a case-control fashion to a group of 58 patients with noninflammatory aneurysms. The two groups had comparable characteristics of age, gender and cardiovascular risk factors. Fig. 5.3.4 Spiral CT indicating inflammatory aortic aneurysm with contained rupture at the posterior site arrow Fig. 5.3.4 Spiral CT indicating inflammatory aortic aneurysm with contained rupture at...

Arteriography

Arteriography provides detailed visualization of the arterial segments and is an essential tool for planning revascularization by conventional or endovascular techniques. Noninvasive technology combining new vascular imaging modalities with flow assessment has reduced the diagnostic importance of arteriography, which is re- Fig. 1.6.3 Lower limb arteriography by direct femoral access Fig. 1.6.3 Lower limb arteriography by direct femoral access garded in modern vascular practice as the first...

Technique of Carotid Endarterectomy

Carotid Thromboendarterectomy

Carotid endarterectomy CEA can be performed under general or regional anaesthesia and requires full cardiac and blood pressure monitoring. Transcranial Doppler is a major adjuvant for Identifying embolic events microembolic signals, MES that may occur during surgical dissection. Deciding whether to use shunt when the operation is performed under general anaesthesia. Assessing function and cerebral flow post-operatively. Persistent MES after carotid declamping and or in the recovery room may...

Jean Louis Petit

Jean-Louis Petit 1731 was the first surgeon to study hae-mostasis 38 . The famous English surgeon Sir Astley Cooper, at Guy's Hospital, made two important contributions a successful ligation of the common carotid artery for aneurysm in 1805 and in 1817 his attempt to treat an aneurysm of the iliac artery by ligation, for the first time, of the aorta above the bifurcation. He was also the first to use the ex-traperitoneal approach to the abdominal aorta, which was reintroduced by C. Rob in 1963...

Aneurysms of the Extracranial Carotid Arteries

DANIEL MENEZES, MARIA JOS BARBAS, J. GOUL O 2.5.1 Definition and Historical Background Carotid artery aneurysm can be defined as a more than 50 localized increase of carotid calibre diameter when compared to reference values Internal carotid 0.55 0.06 in men and 0.49 0.07 in women Carotid bulb 0.99 0.10 in men and 0.92 0.10 in women. Unlike occlusive or ulcerated atherosclerotic lesions carotid aneurysms are quite uncommon, with very few cases reported in the literature, which influences the...

European Vascular Surgical and Angiological Societies and Congresses

Since the 1970s the following events have played an essential role in the development of European vascular surgery. The European Society of Vascular Surgery ESVS was founded by leading vascular surgeons R. Greenhalgh, Sir Peter Bell UK , P. Fiorani Italy , H. Mhyre Norway , H. Van Urk The Netherlands and others. The inaugural meeting of the Society was held in May 1987, with the first President being Hans Myhre, during the International Symposium of the Charing Cross Hospital in London it was...

Mcq Vascular Surgery

Diabetic patients have an increased propensity to develop a variety of infections, which are often more severe than in the general population. They include urinary tract infections, cholecystitis, external ear infections, fungal and skin and soft tissue infections. Foot infections are probably the commonest and most important of them, being responsible for more hospital days than any other complication of diabetes 66, 67 . Diabetic foot infections pose a potentially serious acute medical...

Georgopoulos Sotiris E

First Department of Surgery Athens University Medical School Athens, Greece E-mail sgeorg med.uoa.gr Professor of Vascular Surgery Head of the Fifth Surgical Clinic Aristotle University of Thessaloniki Hippokrateio Hospital Thessaloniki, Greece E-mail gerasimi med.auth.gr 4th Department of Internal Medicine and Infectious Diseases Athens University Medical School University General Hospital ATTIKON Athens, Greece First Urology Department University of Athens Medical School, Laiko Hospital...

Elongated Aortic Aneurysms

Aortic aneurysms are frequently associated with severe elongations and angulations. In these cases the endovas-cular devices are not easy to push upwards and to handle during the deployment. Intra- and post-procedural problems are not rare. The curved delivery system is under tension and graft deployment may be problematic 11, 39, 40 . This usually arises in aortic arch or descending aortic aneurysms that have c- or s-shaped elongations Fig. 5.4.4 . This occurrence is further worsened if the...

Mitropoulos Fotios MD PhD

Department of Cardiothoracic Surgery University of Athens School of Medicine Attikon Hospital Center Athens, Greece E-mail fotiosmitropoulos yahoo.com Hospital Clinico Universitario San Carlos Madrid, Spain E-mail rmoreno.hcsc salud.madrid.org Ittingen, Switzerland E-mail nachbur bluewin.ch Department of Vascular Surgery University Hospital Gasthuisberg Leuven, Belgium E-mail Andre.Nevelsteen uz.kuleuven.ac.be Biomedical Simulations and Imaging Laboratory Faculty of Electrical and Computer...

Distal Arterial Disease Thrombangiitis obliterans TAO Epidemiology Aetiology

Thrombangiitis Obliterans

TAO or Buerger's disease is a vasculitis of unknown aetiology that can be defined as a nonspecific inflammatory and occlusive arteritis primarily affecting the midsized and small-calibre vessels of young men who are heavy smokers 28 . Fig. 3.1.8 Male, 34 years old, smoker, ulcerations on right thumb and left index finger, atypical Raynaud's syndrome on both upper extremities It differs from other vasculitis in that the serological makers of inflammation and autoantibody formation are either...

Introduction

Noninvasive vascular laboratory findings remain important in the diagnosis of peripheral arterial disease PAD . In many circumstances they are as accurate as invasive imaging and have the advantage of being quick and inexpensive. The two basic modalities of evaluation are the indirect methods ankle brachial pressure index, Doppler wave forms, treadmill exercise that provide location and functional severity of disease, and the direct method of evaluation, colour duplex imaging CDI , which...

Who Through their Pioneering Work Developed Vascular Surgery in their Continent with International Influence

Clarence Crafoord, Director of Cardiovascular Surgery at the Karolinska Hospital in Stockholm, was a pioneer in performing pulmonary embolectomies and in 1944 performed the first successful correction of coarctation of the aorta. After the excision of the stenotic segment of the aorta he performed an end-to-end anastomosis, using Carrel's triangulation technique 9 . In Russia V. F. Gu-dov, in 1945, designed and applied clinically the first vascular suturing apparatus 54 . Joao Cid dos Santos,...

Conical Aneurysm Neck

A further morphological parameter that is a challenge for EVAR is a conical neck. The definition of conical aortic neck differs greatly, from the very simple Blum's definition cone-shaped, divergent walls from proximal to distal to the very sophisticated Albertini's neck coefficient, which is calculated by the following formula D arctan Ds-Di l -180 n, where D is the diameter and l is neck length 8 . The conical aortic neck is a challenge to all aspects of EVAR, which is contraindicated if...