Churg Strauss Syndrome

Churg-Strauss syndrome, named for Jakob Churg, a Polish-American pathologist (19101966) and Lotte Strauss, an American pathologist (1913-1985), has an incidence of about 3 per million. The typical patient is usually male and in the fifth decade of life. Classically the syndrome is a triad of rhinitis and asthma, eosinophilia, and systemic vasculitis. Because of its makeup, there are a number of theories about the underlying pathophysiology. It may be a progression of an allergic phenomenon, or...

Inherited

Inherited hypercoagulable states account for 5 to 15 of patients with venous thromboem-bolism (VTE). The most common appear to be the factor V Leiden mutation followed by the prothrombin G20210A mutation of the pro-thrombin gene among the white population, but these are rare in Asians and Africans. Table 5.7 shows the overall incidence of the various inherited hypercoagulable states. These are estimates from several studies and vary with ethnic background and location. Factor V Leiden, also...

Acquired

The most common cause in this group of conditions is the antiphospholipid antibody (APA) syndrome (Fligelstone et al., 1995). These antibodies bind to plasma proteins that have a high affinity for phospholipid surfaces. The most common of these proteins are the lupus anticoagulant (LA), anticardiolipin (ACL) antibodies, and anti-b2-glycoprotein-1 antibodies (B2G). These are usually acquired. Lupus anticoagulant can be suspected if there is an elevated PTT, and ACL and B2G are detected only by...

Sclerotherapy

The role of sclerotherapy is controversial, with practitioner's views based largely on professional background and country of origin rather than on clinical comparative studies. Some scle-rotherapists believe they can treat all VVs, but most accept the superiority of surgery in the presence of main stem, SFJ, or SPJ incompetence. However, the advent of foam sclerosants may revolutionize the management of such disease. The aim is to place a small volume of sclerosant in the lumen of a vein empty...

Dressings

No particular dressing or topical agent has been shown unequivocally to significantly hasten CVU healing. However, they do have different physical properties, and the surgeon needs to have a basic grasp of the underlying science (and art) of wound care. Enzymatic agents (e.g., streptokinase-streptodornase) undoubtedly digest the constituents of slough. However, they are relatively ineffective against deep necrosis or hard eschar. There is evidence that they speed up healing, and may damage the...

Surgery for Recurrent Veins

Recurrent LSV VVs arise because of inadequate dissection of, or neovascularization at,the SFJ in the presence of a nonstripped or incompletely stripped LSV. Standard teaching is to approach the SFJ through nonoperated tissues (usually from a lateral approach that first exposes the common femoral artery) so that the CFV can be skeletonized of branches using nonabsorbable sutures for 1 to 2 cm above and below the junction. The top of the LSV is dissected from the mass of scar tissue so that it...

Factor Deficiencies

Hemophilia A and B represent 80 of inherited bleeding diatheses. These are both sex-linked recessive deficiencies affecting mostly males. Figure 5.1. The coagulation cascade. Under physiological conditions, tissue factor is not exposed to blood. However, after injury, tissue factor is exposed to blood and activates the extrinsic pathway by acting in concert with activated VII and phospholipids to convert factor IX to IXa and factor X to Xa.The intrinsic pathway includes activation of factor XII...

Peripheral Vascular Disease Lower Limb

This is the most common of all vascular conditions, accounting for the majority of the work load in any vascular unit. Clinically, this condition is best divided into two subcategories (1) patients with symptoms of claudication without any tissue loss or rest pain and (2) patients with rest pain or tissue loss, suggesting limb-threatening ischemia. In those patients with symptoms that are severe enough to warrant intervention, further investigation is justified. However, most claudicants do not...

Physical Examination

Varicose veins Note the distribution of varices and any surgical scars. Corona phlebectatica (ankle malleolar flare) One of the earliest skin manifestations of CVI comprises dilated intra subdermal veins at or just below the medial malleolus. Overlying skin is thin and fragile leading to a blue-bleb appearance. Trauma frequently leads to hemorrhage and ulceration. Lipodermatosclerosis The skin is brown (red or purple) and indurated due to hemosiderin and plasma protein deposition, leading to...

Vascular Risk Factor Modification in Peripheral Arterial Disease

The medical management of vascular disease must focus on modification of the following specific risk factors that promote the progression of the disease (1) platelet aggregation, (2) smoking, (3) obesity, (4) diabetes, (5) dyslipi- Figure 6.1. Mortality of peripheral arterial disease (PAD).The 5-year mortality of PAD is relatively equivalent to numerous cancers (prostate, breast, colorectal, and lung). Figure 6.1. Mortality of peripheral arterial disease (PAD).The 5-year mortality of PAD is...

Surgery

Surgery benefits only a small minority of patients with lymphedema. Operations fall into two categories bypass procedures and reduction procedures. The rare patient with proximal ilioinguinal lymphatic obstruction and normal distal lymphatic channels might benefit, at least in theory, from lymphatic bypass. A number of methods have been described including the omental pedicle, the skin bridge (Gillies), anastomosing lymph nodes to veins (Neibulowitz), the ileal mucosal patch (Kinmonth), and,...

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,...

Carotid Artery Aneurysms

Extracranial carotid aneurysmal disease requiring vascular surgical expertise is extremely rare. True carotid aneurysms are located either in the carotid bifurcation, internal carotid system or external carotid, in decreasing frequency of that order. Etiological factors are varied, but the most common include atherosclerosis, trauma, previous carotid surgery e.g.,endarterectomy , and carotid artery dissection. Historically, infection used to be the major culprit causing disease, but widespread...

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...