Download - Out of the frying pan & into the fire
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Out of the frying pan& into the fire
Dr Duncan AndersonVascular Surgeon
www.drduncananderson.co.za
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The frying pan
• Traditionally the surgeon has been based in the operating theatre
• Preoperative angiography was routinely performed by the radiologist
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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
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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
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Case 1: Critical limb ischaemia
• Who should be referred to a vascular surgeon?
• And which special investigations should be performed prior to referral?
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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
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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
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The fire
• Vascular surgeons now perform the duplex doppler ultrasound & catheter directed angiography
• Cathlab• Hybrid theatre• Offers a more goal
directed therapy
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Case 2: Complex varicose veins
• 36 year old female• Recurrent bilateral
varicose veins• Vein surgery in 2005• Pelvic congestion
syndrome– Menorrhagia– Dyspareunia– Dysmenorrhoea
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Case 2:
• Suspect pelvic /ovarian vein reflux– Recurrent varicose veins– Atypical varicose veins– Extensive groin
varicosities– Vulvae varicosities– Pelvic congestion
syndrome
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Case 2: Complex varicose veins
• CT venography• Not a routine special
investigation (timing critical)
• Catheter directed venography
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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
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VNUS ablation
• Radiofrequency ablation
• Cathlab or rooms• Ultrasound-guided• Tumescence infiltration• Immediate ambulation
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VNUS ablation
• Tumescence infiltration– Local anaesthesia– Facilitates ablation by
vein compression– Reduces risk of deep
vein thrombosis– Creates “heat sink” to
protect surrounding tissue
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VNUS ablation
• Less pain & less bruising than laser ablation
• Who should be referred to a vascular surgeon?
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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
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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)
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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
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Case 3: False aneurysm
• Proximal control digitally through pelvis
• Repaired with vein patch
• Discharged after 6 days• High risk of wound &
graft sepsis
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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
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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%
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Case 4: False aneurysm
• Long & narrow neck• Ultrasound-guided
thrombin injection
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Case 4: False aneurysm
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Case 4: False aneurysm
• Angioplasty balloon to arrest flow within aneurysm
• Thrombin (factor IIa) converts fibrinogen to fibrin
• Discharged within 48hrs
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“If all that you have is a hammer,then all that you’ll see are nails”
UROLOGIST VASCULAR SURGEON ANAESTHETIST