References

Expert panel on detection evaluation, and treatment of high blood cholesterol in adults. Executive summary of the third report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III). JAMA 2001 285 2486-97. 2. Haffner SM, Alexander CM, Cook TJ, et al. Reduced coronary events in simvastatin-treated patients with coronary heart disease and diabetes or impaired fasting glucose levels....

Question 4

Which of the following statements regarding the indication of renal artery repair (RAR) for RAA is correct A. There is an indication for RAR only in cases of symptoms other than hypertension. B. There is no reason to perform RAR in women of childbearing age if there is no arterial hypertension. C. There is a good indication for RAR if a concomitant RAS is found. D. There is a good indication for RAR only if the RAA is larger than 5.5 cm. E. There is an indication for RAR in patients presenting...

Question 8

Close the venotomy and anticoagulate, since a common iliac vein stenosis is frequently observed due to normal vascular anatomy. B. Close the venotomy and perform an AV fistula. C. Perform angioplasty and insert a self-expanding stent if recoil occurs. D. Operatively expose the common iliac vein and perform an endovenectomy and transpose the vein above the right common iliac artery. Fig. 46b3. a A completion phlebogram following iliofemoral thrombectomy shows stenosis of the left common iliac...

Commentary

Renovascular disease is responsible for hypertension in around 1 per cent of all patients with high blood pressure. The definition of renovascular hypertension is, however, complicated by the complex and sometimes unclear relation between morphological alterations in the renal artery and the physiological effect of the stenosis. Hypertension is seen in 10-15 per cent of the adult population, and a renovascular cause varies between 0.2 and 5 per cent of those with hypertension most often, a...

Question 3

Once the objective diagnosis of vertebral artery dissection is made in a patient with vertebrobasilar symptoms the next step is A. Anticoagulation with heparin, then Coumadin. Fig. 31.3. Postoperative carotid arteriogram showing a saphenous vein bypass from the distal cervical internal carotid to the vertebral artery beyond C1. Fig. 31.3. Postoperative carotid arteriogram showing a saphenous vein bypass from the distal cervical internal carotid to the vertebral artery beyond C1. Reprinted from...

Question 1

At this juncture the physician's most appropriate course of action is A. Refer the individual to a surgeon for hemoaccess. B. Refer the individual to a nephrologist to refine diagnosis and initiate specialty care. It is not time to initiate dialysis. C. Refer the individual to a nephrologist who will refine diagnosis, and determine if there is a reversible cause for the renal insufficiency. D. Refer the individual to a nephrologist who will evaluate the etiology of the renal insufficiency and...

Cardiovascular Risk Factors and Peripheral Arterial Disease

Daskalopoulou and Dimitri P. Mikhailidis A 62-year-old man with intermittent claudication was referred for vascular risk factor modification. He had no history of myocardial infarction (MI) or stroke. He was smoking 20 cigarettes day. His family history was negative for premature vascular events. He was not taking any medication. He was advised to start aspirin 75 mg day, but he stopped taking these tablets because of stomach discomfort. The patient's total cholesterol was 228 mg dl...

Vertebrobasilar Ischemia Embolic Mechanism

A 51-year-old male experienced over a period of 6 months a major stroke and several transient ischemic attacks (TIAs) of vertebrobasilar distribution. The original episode consisted of loss of balance, loss of coordination, and loss of the left visual field while driving a bus, which resulted in a road accident. Since then, he had experienced four additional episodes of aphasia and paraparesis lasting for 4-5 h. A diagnosis of vertebral artery dissection was made at the local hospital and he...

The Optimal Conduit for Hemodialysis Access

Zickler and Joseph M. Caruso A 42-year-old type 1 diabetic of normal weight has recently progressed to chronic renal disease. Insulin-dependent diabetes mellitus (DM) has been managed by the same primary care physician for the preceding 12 years glucose control has never been a problem in this cooperative and well-educated individual. The renal failure was initially managed with appropriate adjustments to diet and medications the presumptive diagnosis is diabetic...

B False Aneurysm in the Groin Following Coronary Angioplasty

A 70-year-old female with a history of hypertension developed chest pair and was admitted to a local hospital. Heparin was administered intravenously. Later that day, she underwent coronary angiography, which showed a critical stenosis of the left anterior descending artery. The lesion was treated with angioplasty and stent placement. The right femoral artery sheath was left in place overnight, and heparin was continued. The following morning after stopping heparin, the sheath was removed and a...

Question 6

What is the likely aetiology of this man's erectile dysfunction In the intervening 10 years the patient had resumed smoking and had undergone a coronary artery bypass graft for unstable angina. Two years following the bypass his angina had recurred. A coronary angiogram showed that two of three vein grafts had occluded, and that his left ventricle function was poor (28 percent ejection fraction). On examination his left femoral pulse was weak, the distal pulses were absent in the left leg and a...

Question I

Which of the following statements regarding impotence is incorrect A. Most cases respond to medical treatment, i.e. intracavernous injection or oral therapy. B. Chronic smoking may render the patient refractory to medical treatment. C. Impotence may be due to atheroembolism into penile arteries. D. Impotence may relate to stretching of the nerves by aneurysm. E. Impotence may be due to pelvic arterial occlusive disease. Because of the findings of enlargement of the aneurysm and evidence of...

Abdominal Aortic Aneurysm

Jean-Pierre Becquemin and Alexandre d'Audiffret A 59-year-old man presented with an abdominal aortic aneurysm (AAA) discovered on duplex scan examination of the abdomen. The AAA was 60-mm large and extended to the left common iliac artery. The patient was otherwise asymptomatic, with no abdominal or back pain. His medical history was significant for hypertension controlled by bitherapy, non-insulin-dependent diabetes diagnosed 5 years previously, claudication with a walking distance of 400...

E

Ecchymosis, 377 Eccrine sweat glands, 299 Echocardiogram normal, 5 pulmonary embolism and, 441-442 transthoracic, 225 Echocardiography aortic dissection and, 62 normal stress protocol of, 4 stress test and, 6 Echo-duplex, 273 ECST. See European Carotid Surgery Trial EIA. See External iliac artery Electrocardiogram, 35 Embolic ischaemia, 277-281 Embolic occlusion, 97 of left popliteal artery, 112 Embolic phenomena, 102 Embolism acute, 98 arterial, 107-113 external carotid artery and, 275...

H

Haematemesis, 339 Haematuria, 76 Haemofiltration, 58 Haemorrhage inspection of, 119 obvious, 120 vascular surgery and, 121 Haemorrhagic bullae, 434-435 Haemostatic factors, 138 Hamburg classification, 383, 391 paragangliomas of, 267-276 rotation of, 283-284 Heel ulcer, 367-368 debridement of, 368 subtotal calcnectomy and, 369 Hemangioma, 391 Hemispheric stroke, 253 Hemoaccess, 346 distal sites of, 356 hemodialysis and, 348 loss of, 351 optimal, 350 Hemodialysis, 39 AVF and, 362 hemoaccess and,...

Question 2

Preoperative medications lifestyle changes that should be added to the patient's regimen to reduce his overall cardiovascular risk based upon randomized prospective data include C. Angiotensin-converting enzyme inhibitors. Percutaneous angiogram of the right lower extremity demonstrated moderate right distal superficial femoral artery stenosis with distal occlusion. The popliteal appeared to be severely diseased with occlusion of the tibioperoneal artery and proximal anterior tibial artery. The...

Case Analysis Quiz

A number of imaging examples are shown in Figs 3.5-3.8. Analyse the anatomical suitability of each case for the possibility of endoluminal graft repair of the AAA. In particular, determine the favourable and unfavourable features shown. Fig. 3.5. Aortic angiogram showing a very favourable anatomy for endovascular repair the neck is straight and long, without irregular features of the wall. In addition, the aneurysm sac is straight, and both iliac arteries are non-aneurysmal and relatively...

Dissection Stanford B

A 54-year-old woman was admitted to another hospital with the provisional diagnosis of a myocardial infarction (MI). She experienced a sudden chest pain. Some hours later, she developed paraesthesia in both legs, which improved spontaneously. Subsequently, she felt abdominal discomfort and developed diarrhoea and vomiting. The patient had been normotensive throughout her life, but now she required five different antihypertensive drugs to stabilise blood pressure. Some laboratory data were...

Question 5

For choosing a suitable endoluminal graft, one must A. Take the graft that resembles your measurements most closely. Fig. 3.1. a Contrast-enhanced CT scan at the level of the neck of the aneurysm, immediately below the renal arteries. The neck has a maximum diameter of 19 mm on this image and has no irregular features, such as mural thrombus or atheromatous plaque. b Contrast-enhanced CT scan at the level of the sac of the aneurysm, showing a typical target appearance due to the presence of...

Thoracoabdominal Aortic Aneurysm

Hollier and Julius H. Jacobson II A 72-year-old white male presented to his primary-care physician with a history of left chest pain for the past month. The pain was dull and constant, and radiated to the back, medial to the scapula. He denied new cough or worsening shortness of breath. He had no recent weight loss, and his appetite was good. He has a history of hypertension that was currently controlled medically. He had a smoking history of 60 packs a year. In...

Question 7

Which of the following statements about complex vein repair are true A. Complex vein repair should never be undertaken in the trauma patient. B. Complex vein repair should only be performed in the absence of major arterial injury. C. Complex vein repair should be used to improve venous return in unstable patients. D. Complex vein repair may prevent long-term limb dysfunction. E. Intraluminal venous shunting is an acceptable intraoperative temporising measure. In the operating theatre, under...

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,...

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...

F

Facial nerve marginal mandibular branch, 264 Factor V Leiden gene mutation, 396, 399 False aneurysm, 83 cavity of, 90 common femoral artery (CFA), 87 complications of, 91 endovascular treatments for, 92 in groin, 87-94 postcatheterization and, 88, 91 thrombin injection and, 92 Fasciotomy arterial embolism and, 109, 112 formal, 118 healing from, 119 Fasting glucose values, 133-134 impaired, 134 Fasting HDL-C level, 135 Fasting triglyceride cycle, 134 Fecal fat measurement, 215 Femoral...

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

Which of the following statements regarding postoperative outcome in patients undergoing major vascular surgery is correct A. Cardiac complications are the major cause of perioperative morbidity and mortality. B. Perioperative myocardial infarctions are related to fixed coronary artery stenosis in all patients. C. Perioperative cardiac events are related to a sudden, unpredictable progression of a nonsignificant coronary artery stenosis in all patients. D. Perioperative cardiac complications...

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...

Stage V

Elephantiasis with severe limb deformation, scleroindurative pachydermitis, and marked, extensive lymphostatic verrucosis Fig. 47a.7. Clinical instrumental diagnostic staging of lymphoedema. positive in more than 80 per cent of cases, with an even better outcome in patients operated upon precociously (at stages II and III see Fig. 47a.7). The incidence of lymphangitic attacks decreases significantly after microsurgery. The reduction in oedema volume obtained by microsurgery is seen immediately...

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...