out of the frying pan & into the fire

Out of the frying pan& into the fire

Dr Duncan AndersonVascular Surgeon

www.drduncananderson.co.za

The frying pan

• Traditionally the surgeon has been based in the operating theatre

• Preoperative angiography was routinely performed by the radiologist

Case 1: Critical limb ischaemia

• 61 year old male• Non-healing left ankle

ulcer for 9 months• Risk factors: heavy

smoker, hypertension & hypercholestrolaemia

• Only left femoral pulse• Ankle brachial index:

0.46

Case 1: Critical limb ischaemia

• Catheter directed angiogram in the cathlab

• Left femorodistal bypass to the posterior tibial artery

• Composite graft of 6mm ring-reinforced PTFE & reversed saphenous vein

Case 1: Critical limb ischaemia

• Who should be referred to a vascular surgeon?

• And which special investigations should be performed prior to referral?

Who should be referred?

• Any patient with claudication, rest pain, ulceration >2 weeks duration or gangrene

• All patients with ankle brachial index <0.9• Any diabetic, chronic renal failure patient or

heavy smoker with absent pedal pulses

Which special investigation?

• Ankle brachial index (ABI) only– ABI 1.3-0.9 manage vascular risk factors– ABI 1.3-0.9 safely apply compression bandaging

for venous stasis ulceration• No arterial duplex doppler ultrasound• No CT angiography• No MR angiography• No cathlab angiography

The fire

• Vascular surgeons now perform the duplex doppler ultrasound & catheter directed angiography

• Cathlab• Hybrid theatre• Offers a more goal

directed therapy

Case 2: Complex varicose veins

• 36 year old female• Recurrent bilateral

varicose veins• Vein surgery in 2005• Pelvic congestion

syndrome– Menorrhagia– Dyspareunia– Dysmenorrhoea

Case 2:

• Suspect pelvic /ovarian vein reflux– Recurrent varicose veins– Atypical varicose veins– Extensive groin

varicosities– Vulvae varicosities– Pelvic congestion

syndrome

Case 2: Complex varicose veins

• CT venography• Not a routine special

investigation (timing critical)

• Catheter directed venography

Case 2: Complex varicose veins

• Traditionally vein ligation & stripping

• Endovenous laser or radiofrequency (VNUS) ablation– No groin wound– No thigh bruising– Less postoperative pain– Earlier mobilization

VNUS ablation

• Radiofrequency ablation

• Cathlab or rooms• Ultrasound-guided• Tumescence infiltration• Immediate ambulation

VNUS ablation

• Tumescence infiltration– Local anaesthesia– Facilitates ablation by

vein compression– Reduces risk of deep

vein thrombosis– Creates “heat sink” to

protect surrounding tissue

VNUS ablation

• Less pain & less bruising than laser ablation

• Who should be referred to a vascular surgeon?

Who should be referred?

• Atypical distribution of varicose veins• Recurrent varicose vein• Associated chronic venous insufficiency

(venous stasis dermatitis or venous ulcer)• Suspicion of pelvic/ovarian vein reflux• VNUS ablation for better cosmetic result, less

pain & immediate mobilization

Case 3: False aneurysm

• 49 year old female• Painful swelling right

groin 2 weeks after cathlab

• BMI 40.4• Large false aneurysm

flush with common femoral artery (no neck)

Case 3: False aneurysm

• Direct surgical approach• Burst on skin incision• Direct digital control of

2cm defect in common femoral artery

• Total of 4 unit blood transfusion

Case 3: False aneurysm

• Proximal control digitally through pelvis

• Repaired with vein patch

• Discharged after 6 days• High risk of wound &

graft sepsis

Case 3: False aneurysm

• Negative surgical aspects– Additional open surgical

procedure– Risk of anaesthesia– Prolonged hospital stay– Postoperative pain– High risk of wound &

graft sepsis– Difficult mobilization

Case 4: False aneurysm

• 74 year old female• Painful right groin

swelling 1 day after cathlab

• BMI 32.2• Dropped haemoglobin

from 13g% to 9g%

Case 4: False aneurysm

• Long & narrow neck• Ultrasound-guided

thrombin injection

Case 4: False aneurysm

Case 4: False aneurysm

• Angioplasty balloon to arrest flow within aneurysm

• Thrombin (factor IIa) converts fibrinogen to fibrin

• Discharged within 48hrs

“If all that you have is a hammer,then all that you’ll see are nails”

UROLOGIST VASCULAR SURGEON ANAESTHETIST