vascular surgery back to basics andrew b hill md facs frcs vascular and endovascular surgery the...
TRANSCRIPT
![Page 1: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/1.jpg)
Vascular SurgeryBack to Basics
Andrew B Hill MD FACS FRCS
Vascular and Endovascular Surgery
The Ottawa Hospital
![Page 2: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/2.jpg)
OUTLINE• Acute limb ischemia
• Claudication
• Critical limb ischemia
• Aortic Aneurysm
• Aortic dissection
• Varicose veins
• Chronic venous insuffciency
• Superficial thrombophlebitis
Acute Limb Ischemia
![Page 3: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/3.jpg)
Mrs. Whitelegg
• ID:• 75 yo lady
• Active - walks her dog ~2 kms daily
• has not needed to see a doctor in the last 10 years.
Acute Limb Ischemia
![Page 4: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/4.jpg)
Mrs. Whitelegg
• PMHx/PMSx:
• remote TAH-BSO
• social smoker quit in the 1960’s
• No: DMHTN
hyperlipidemia
Acute Limb Ischemia
![Page 5: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/5.jpg)
Mrs. Whitelegg
• HPI:• watching TV
• sudden onset of numbness in her right leg - “like it went dead”
• Unable to walk
• constant, severe pain eventually involving the entire right leg.
• Called amblance
Acute Limb Ischemia
![Page 6: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/6.jpg)
Mrs. Whitelegg
• What is the diagnosis?
Acute Limb Ischemia
![Page 7: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/7.jpg)
Mrs. Whitelegg
• Acute limb Ischemia:
• abrupt cessation of arterial blood flow
• hypoperfusion of tissue
• threatened limb viability
Acute Limb Ischemia
![Page 8: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/8.jpg)
Mrs. Whitelegg
• Vital Signs
• BP:140/90 mmHg
• HR: 150 bpm
irregularly irregular
• Afebrile
Acute Limb Ischemia
![Page 9: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/9.jpg)
Mrs. Whitelegg
• Exam
Normal heart sounds
Chest clear IPPA
No pulsatile masses in her abdomen
No carotid, abdominal or femoral bruits
Acute Limb Ischemia
![Page 10: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/10.jpg)
Mrs. Whitelegg
• Exam
Pulses:
Left:
+ femoral, + politeal, + DP, + PT
Right:
- femoral, - popliteal, - DP, - PT
Acute Limb Ischemia
![Page 11: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/11.jpg)
Mrs. Whitelegg
• Exam
– Normal heart sounds
– good a/e bilat
– No pulsatile masses in her abdomen
– No carotid, abdominal or femoral bruits
– Pulses:
• L: + femoral, + politeal, + DP, + PT
• R: - femoral, - popliteal, - DP, - PT
– R foot is colder and paler than L
– Decreased sensation in R foot
– Able to move toes but difficulty with plantar and dorsi flexion
– Absence of trophic changes in her lower extremities (no hair loss, thickened nails, or thin, flaky or shiny skin)
Acute Limb Ischemia
![Page 12: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/12.jpg)
Mrs. Whitelegg
• Exam
• R foot is colder and paler than L• Decreased sensation in R foot• Able to move toes but difficulty
with plantar and dorsi flexion• Absence of trophic changes in
her lower extremities (no hair loss, thickened nails, or thin, flaky or shiny skin)
Acute Limb Ischemia
![Page 13: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/13.jpg)
Mrs. Whitelegg
• What are the 6 P’s of Acute Limb Ischemia
Acute Limb Ischemia
![Page 14: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/14.jpg)
Mrs. Whitelegg
• 6 P’s of Acute Limb Ischemia
• Pain• Palor• Polar/poikilothermia• Paraesthesia• Paralysis• Pulselessness
Acute Limb Ischemia
![Page 15: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/15.jpg)
Mrs. Whitelegg
• Classify Acute Limb Ischemia. In which category is Mrs. Witelegg?
Class Sensory deficit Motor deficit Prognosis
1 None None Not immediately threatened
2a Mild-moderate None Salvageable if treated promptly
2b Significant Mild-moderate Salvageable if immediately treated
3 Profound Profound Irreversible limb damage- likely amputation
Acute Limb Ischemia
![Page 16: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/16.jpg)
Mrs. Whitelegg
• Your working diagnosis is acute limb ischemia.
• You order CBC, electrolytes, BUN, Cr, PTT/INR (all of which comes back normal), type and cross-match blood, and a saline infusion is started.
• CXR is unremarkable
• ECG is as follows:
Acute Limb Ischemia
![Page 17: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/17.jpg)
Mrs. Whitelegg
• What is the most likely etiology of ALI in Mrs. Whitelegg?
• Cardiogenic embolism
Acute Limb Ischemia
![Page 18: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/18.jpg)
Mrs. Whitelegg
• What in her history and physical supports this diagnosis?
• lack of atherosclerotic risk factors
• no previous claudication (she walked her dog 2 km/day)
• atrial fibrillation
• normal left extremity pulses
Acute Limb Ischemia
![Page 19: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/19.jpg)
Mrs. Whitelegg
• Based on her physical examination, what is the highest point of obstruction of arterial flow?
• R ileo-femoral region
Acute Limb Ischemia
![Page 20: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/20.jpg)
Mrs. Whitelegg
• How long can a limb be without blood flow before irreversible tissue damage ensues?
• 4-6 hrs
Acute Limb Ischemia
![Page 21: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/21.jpg)
Mrs. Witelegg
• What is the surgical management of this condition?
• R femoral embolectomy
• Can we proceed to the OR without any imaging studies? If not what studies can be perfomed?
• Because of the classic history and physical findings, and because of the presence of class 2b ischemia, immediate surgery is indicated without delay for imaging.
• Angiography can be performed in certain conditions of ALI– when the suspected etiology is arterial thrombosis (i.e.
in preparation for bypass surgery)– when the patient has class 1 or 2a ischemia
Acute Limb Ischemia
![Page 22: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/22.jpg)
Mrs. Witelegg
• What medical therpay is available for ALI and when is it indicated?
• Lytic therapy (i.e. with t-PA) is used to dissolve the clot. It is a good option in the setting of acute arterial or graft thrombosis. It is not indicated in the setting of trauma or when the patient can not wait more than 24-48 hrs, as the therapy requires that period of time for clot dissolution. ( i.e. class 1 or early 2a ischemia)
• IV Heparin will not dissolve the clot but will prevent further propagation, and is only indicated if there is a delay to surgery
Acute Limb Ischemia
![Page 23: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/23.jpg)
Mrs. Witelegg
• The patient is booked for emergency embolectomy
• Under local anaesthesia, a small incision is made over the R groin. The femoral artery is exposed and controlled with vessel loops. A small arteriotomy is made and the clot is removed proximally and distally using a fogarty balloon embolectomy catheter.
• The arteriotomy is repaired and the foots “pinks up” after blood flow is returned. There is a palpable DP and PT pulse.
• The patient is returned to the recovery room.
Acute Limb Ischemia
![Page 24: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/24.jpg)
Mrs. Witelegg
• At 3 am you get paged by the recovery room nurse. Mrs. W is complaining of significant pain in her leg, it is more swollen and the DP and PT are no longer palpable.
• In addition, her urine output has diminished and she is peeing out dark urine which tested positive for “blood” on the urine dipstick.
Acute Limb Ischemia
![Page 25: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/25.jpg)
Mrs. Witelegg
• What is happening to Mrs. W?
– Reperfusion syndrome: occurs as a result of blood flow going back into previously damaged tissue, causing rhabdomyolysis and compartment syndrome..
• Rhabdomyolysis: Liberated myoglobin from dead muscle cells enters the blood stream resulting in renal tubular obstruction and direct nephrotoxicity causing renal failure. Myoglobinuria is a false positive on the urine dipstick test for blood.
• Compartment syndrome: Free oxygen radicals are created with reperfusion. These result in increased tissue edema, with in the limited facial compartments of the lower leg, this further decreases capillary blood flow and worsens the ischemia and tissue damage, causing further edema. Pain out of proportion, pain on passive stretch and high pressures in the compartments suggests compartment syndrome.
Acute Limb Ischemia
![Page 26: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/26.jpg)
Mrs. Witelegg
• How should reperfusion syndrome be managed?
– Compartment syndrome is a surgical emergency and is managed by 4-compartment fasciotomies.
– Rhabdomyolysis should be managed with aggressive IV fluids, diuresis and alkalinization of urine.
Acute Limb Ischemia
![Page 27: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/27.jpg)
![Page 28: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/28.jpg)
AORTIC DISSECTION
![Page 29: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/29.jpg)
Definition
• spontaneous tear in aortic intima allowing blood to be driven between the aortic intima and media
– acute < 2 weeks– chronic > 2 weeks
Aortic Dissection
![Page 30: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/30.jpg)
Classification
• DeBakey
• Type I - involves ascending and descending aorta
• Type II - ascending aorta only
• Type IIIA - descending thoracic aorta
• Type IIIB - Type IIIA plus abdominal aorta
• Standford
• Type A - ascending aorta and aortic arch; emergency
• Type B - aorta distal to subclavian artery; emergency surgery if complications of dissection
Aortic Dissection
![Page 31: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/31.jpg)
Etiology
• HYPERTENSION, usually uncontrolled
• TRAUMA, usually deceleration injury (falls, MVAs)
• other: cystic medial necrosis, atherosclerosis, connective tissue disease (Marfan’s syndrome, Ehlers-Danlos syndromes), congenital conditions (coarctation of aorta, bicuspid aortic valves, PDA), infection, arteritis (Takayasu’s)
Aortic Dissection
![Page 32: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/32.jpg)
Epidemiology
• incidence 5.2 in 1,000,000• male:female = 3:1• small increased incidence in African-Canadians (related to
higher incidence of hypertension)• lowest incidence in Asians
Aortic Dissection
![Page 33: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/33.jpg)
Clinical Features
• SUDDEN ONSET SEVERE CHEST PAIN RADIATION TO THE BACK (INTERSCAPULAR) +/-....
• hypertension• asymmetric BP’s and pulses between arms• ischemic syndromes due to occlusion of aortic branches:
coronary (MI), carotid (stroke, Horner’s syndrome), splanchnic (ischemic gut), renal (kidney failure)
• “unseating” of aortic valve cusps (new diastolic murmur)• rupture into pleura (dyspnea, hemoptysis) or peritoneum
(hypotension, shock) or pericardium (tamponade)• lower limb ischemia (cold legs)
Aortic Dissection
![Page 34: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/34.jpg)
Investigations
• CT scan is gold standard
• CXR
• pleural cap
• widened mediastinum
• left pleural effusion with extravasation of blood
• TEE
• ECG: LVH (90%), +/- MI, pericarditis, heart block
• aortography, MRI
Aortic Dissection
![Page 35: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/35.jpg)
Treatment
• Type A• EMERGENCY CARDIAC SURGERY
• may require putting patient on pump, hypothermic circulatory arrest, valve replacement, coronary re-implantation of aortic root
• resection of intimal tear, reconstitution of flow through true lumen, replacement of the affected aorta with graft
• Type B• MEDICAL MANAGEMENT
• very rarely urgent operation for complications (expansion, rupture, gut/leg/renal ischemia, ongoing pain
Aortic Dissection
![Page 36: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/36.jpg)
AORTIC ANEURYSM
![Page 37: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/37.jpg)
Definition
• localized dilation of an artery that is 2 x its normal diameter
• true aneurysm: involving all vessel wall layers
• false aneurysm: disruption of aortic wall with containment of blood by some layers of the aorta or a fibrous capsule made of surrounding tissue
Aortic Aneurysm
![Page 38: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/38.jpg)
Aortic Aneurysm
Aortic Aneurysm
![Page 39: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/39.jpg)
Etiology
• DEGENERATIVE (matrix metalloproteinases)
• atherosclerosis association• infection• cystic medial necrosis• trauma• vascultitis• connective tissue disease (Marfan syndrome, Ehlers-Danlos)
Aortic Aneurysm
![Page 40: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/40.jpg)
Epidemiology
• incidence 5 to 32 per 100,000 for AAA
• high risk groups:• 65 years and older• male:female = 4:1• smokers• peripheral vascular disease, CAD, CVD• family history of AAA
Aortic Aneurysm
![Page 41: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/41.jpg)
Clinical Features
• Vast majority ASYMPTOMATIC• • RUPTURE
• back pain• hypotension/syncope• pulsatile abdominal mass• ~100% mortality if untreated
Aortic Aneurysm
![Page 42: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/42.jpg)
Investigations
• abdominal US (100% sensitive)
• CT
• Aortogram (false negative normal lumen size due to thrombus formation)
Aortic Aneurysm
![Page 43: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/43.jpg)
Treatment
• Risk of rupture depends on size• <5 cm <5% / yr• 5-6 cm 10% / yr• 6-7 cm 15-20% / yr• >7 cm >20% / yr
• Risk of dying from aneurysm surgery = ~5%
Aortic Aneurysm
![Page 44: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/44.jpg)
Treatment
• Operate when
• AAA reaches 5.5 cm in an otherwise healthy individual
• >5 mm expansion in 6 months• symptomatic AAA• Rupture
• contraindications: life expectancy < 1 year, terminal disease (cancer), significant co-morbidities (recent MI, unstable angina), severe dementia, advanced age
Aortic Aneurysm
![Page 45: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/45.jpg)
Treatment: Surgical
• Surgical options:
• open surgery with graft replacement
• Endovascular aneurysm repair
Aortic Aneurysm
![Page 46: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/46.jpg)
Ruptured Aortic Aneurysm
• EMERGENCY
• clinical diagnosis class diagnostic triad (50% cases)
• sudden onset back pain
• shock (syncope/hypotension)
• pulsatile mass
• U/S in emerg or CT if stable
• IV access, start fluid resuscitation, cross and match
• EMERGENCY LAPAROTOMY and CLAMP AORTA
• Prognosis
• 100% mortality untreated, OR mortality rate 50%; 90% total mortality
Aortic Aneurysm
![Page 47: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/47.jpg)
CLAUDICATION
![Page 48: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/48.jpg)
Clinical Features - Claudication
• Pain with exertion (usually calves)
• relieved by short rest - two to five minutes
• reproducible
• P/E• hair loss, hypertrophic
nails, atrophic muscle• pulses may be absent
at some locations
![Page 49: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/49.jpg)
Etiology
• blockages in arteries to lower extremities due to atherosclerosis
• Risk factors• smoking• DM• HTN• hyperlipidemia• family history• obesity• sedentary• male gender
![Page 50: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/50.jpg)
Investigations
• Ankle Brachial Index
• Angiogram
![Page 51: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/51.jpg)
Ankle Brachial Index (ABI)
• Measure brachial pressure
• Measure ankle pressure
• Divide ankle by brachial pressure
• (example 80/160 = 0.5)
• Normal = > 0.9
Acute Limb Ischemia
![Page 52: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/52.jpg)
Treatment
• CONSERVATIVE
• risk factor modification• exercise program • cilostazol • anti platelet (ECASA, clopidrogel) for MI / stroke risk
• surgical• indications: claudication interfering with lifestyle• options: endovascular, PTA, arterial bypass grafts
![Page 53: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/53.jpg)
CRITICAL LIMB ISCHEMIA
![Page 54: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/54.jpg)
CRITICAL LIMB ISCHEMIA
night painrest pain
tissue ischemia
![Page 55: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/55.jpg)
Clinical Features - Critical limb ischemia
• Pain at rest in foot, worse at night
• relieved by short rest - two to five minutes
• reproducible
• pulses may be absent at some locations
• P/E
• hair loss, hypertrophic nails, atrophic muscle
• ruborous foot
• ulcers
• gangrene
![Page 56: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/56.jpg)
Etiology
• blockages in arteries to lower extremities due to atherosclerosis
• Risk factors• smoking• DM• HTN• hyperlipidemia• family history• obesity• sedentary• male gender
![Page 57: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/57.jpg)
Investigations
• Ankle Brachial Index
• Duplex ultrasound
• Angiogram
![Page 58: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/58.jpg)
Treatment
• Surgical
– bypass
– gortex vs vein
• Endovascular balloon angioplasty
– limited durability
– less morbid
![Page 59: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/59.jpg)
Venous disease
![Page 60: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/60.jpg)
Varicose veins
![Page 61: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/61.jpg)
Definition
• distended torturous superficial veins due to incompetent valves in the deep, superficial or perforator systems
• distribution: greater saphenous vein and tributaries
![Page 62: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/62.jpg)
Etiology
• primary• main factor: inherited structural
weakness of valves• contributing factors: age, female,
OCP use, occupations requiring long hours of standing, pregnancy, obesity
• secondary• deep vein thrombosis
• congenital anomalies • arteriovenous fistula
![Page 63: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/63.jpg)
Epidemiology
• 10 - 20% of the population
• >50% over the age of 50
![Page 64: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/64.jpg)
Clinical Features
• History
• Ankle ache
• Fatigued legs
• swelling around the ankles
• aggravated by prolongued standing (end of day)
• P/E
• dilated and tortuous superfical veins
• Brodie-Trendelendberg test
• raise leg and compress saphenous vein at thigh; have patient stand; if vein fills quickly from top down then incompetent valves; use mulitple tourniquets to localize incompetent veins
![Page 65: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/65.jpg)
Complications
• Usually benign natural history
• Most are cosmetic concerns
• recurrent superficial thrombophlebitis
• hemorrhage: external or subcutaneous
![Page 66: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/66.jpg)
Investigations
• Duplex ultrasound to assess...
• reflux of blood at sapheno-femoral junction
![Page 67: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/67.jpg)
Treatment
• Compression stocking therapy
• Saphenous vein stripping surgery • disabling symptoms
• Laser vein ablation
![Page 68: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/68.jpg)
Chronic Venous Insufficiency
![Page 69: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/69.jpg)
Definition
• chronic elevation of deep venous pressure and blood pooling in lower extremities
![Page 70: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/70.jpg)
Etiology
• valvular incompetence usually due to a previous DVT many years ago
• chronic venous obstruction
• calf muscle pump dysfunction
![Page 71: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/71.jpg)
Clinical Features
• ankle ache and edema - relieved by foot elevation
• hyperpigmentation (hemosiderin deposits)
• ulceration– shallow and irregular– above medial malleolus– painless
![Page 72: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/72.jpg)
Investigations
• duplex ultrasound to assess
• Reflux at sapheno-femoral junction
• Deep system incompetence
• chronic occlusion from an old DVT/trauma
• Venogram
![Page 73: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/73.jpg)
Treatment
• CONSERVATIVE
• compression stockings/layered compression bandages• leg elevation, avoid prolonged standing
• surgical• surgical ligation of perforators in region of ulcer, greater
saphenous vein stripping if incompetent
![Page 74: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/74.jpg)
Superficial Thrombophlebitis
![Page 75: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/75.jpg)
Definition
• inflammation secondary to acute thrombosis of a superficial vein usually the greater saphenous vein
![Page 76: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/76.jpg)
Etiology
• varicose veins
• migratory superficial thrombophlebitis• hematologic: hypercoag state, polycythemia, thrombocytosis• neoplastic: occult malignancy (especially pancreas)• idiopathic
![Page 77: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/77.jpg)
Clinical Features
• Usually involves GSV and its branches
• pain
• swelling along course of involved vein
• erythema
• warmth
![Page 78: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/78.jpg)
Investigations
• Ultrasound to exclude associated DVT (5 - 10%)
![Page 79: Vascular Surgery Back to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital](https://reader035.vdocument.in/reader035/viewer/2022062804/56649ebc5503460f94bc5785/html5/thumbnails/79.jpg)
Treatment
• CONSERVATIVE
• moist heat, compression bandages• anti-inflammatory and anti-platelet (ASA)