VASCULAR SURGERY

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VASCULAR SURGERY
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Cerebrovascular Disease
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CAROTID

• Presentation
• Asymptomatic
• Bruit (only 20 hemodynamically significant
  lesion)
• Screening prior to other surgery

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Presentation

• Symptomatic
• TIA, Stroke
• Amaurosis fugax ipsilateral to carotid lesion
• Contralateral motor or sensory deficit
• Facial droop
• Dyshasia or aphasia

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Investigations

• Duplex Scan
• CT scan - confirm or r/o infarct
• CT/Angio Confirm U/S plan OR
• MRA Similar to CT

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Management

• Asymptomatic
• - Risk factor reduction (asa,statin,ACE)
• observation with regular duplex scans
• Antiplatelet agent and surgery more controversial
• ACAS ? 60 ? OR
• Canada ? ?80 male, under 75 yrs or ? operate

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• Symptomatic
• Carotid Stenosis ? 70
• TIA, Small completed stroke with minimal residual
  neurologic deficit,
• ? antiplatelet agent carotid endarterectomy

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Arterial Aneurysms

• Definition 1.5-2x diameter adjacent normal
  artery.
• Ex. Aorta ? 3 cm
  
• True All layers of arterial wall dilated
• False Aneurysm usually consists of hematoma /-
  adventitia

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Distribution of Aneurysms

• Aorta 90-95 are infrarenal
• Peripheral Popliteal most common, 2nd femoral
• Visceral uncommon, splenic (most common)

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Aortic Aneurysms

• Risk factors male, age ? 60 yrs, smoking, COPD,
  FHx ve, CAD, PVD, peripheral aneurysms.
• Natural Hx AAA ? 5 cm grow 0.3-0.5 cm/year
• Rupture rate
• ? 5 cm - 1.5 over 5 yrs
• 5.5-5.9 cm - 25 over 1-5 yrs
• 6 cm - 35 over 1-5 yrs
• gt 7 cm - gt 75 over 1-5 yrs

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AAA Presentation

• Asymptomatic incidental finding on Px or
  Radiologic Test
• Symptomatic ABD/BACK pain (leak or rapid
  expanding)
• Rupture 35 initial presentation, Triad
  ABD/BACK pain, Hypotension, Pulsatile Mass.

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AAA Detection

• Physical Exam - not sensitive
• U/S ABD - highly sensitive and specific
• CT / MRI - sensitive, specific, but expensive
• Angio - not reliable

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AAA Management

• Indications for Surgery
• risk of rupture gt surgical risk
• size ? 5 cm FEMALE
• gt 5.5 cm MALE
• symptomatic
• ruptured
• rapid expansion
• Observation with U/S q6 months if asymptomatic
  and lt 5 cm.

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Lower Extremity Arterial Disease
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Acute Limb Ischemia

• Sudden onset of sxs/signs
• Severity presentation depends on adequacy of
  collateral circulation
• 5 or 6 Ps pain, pallor, pulselessness,
  paralysis, paresthesia, /- poikilothermia

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CAUSES

• Embolus
• Thrombosis
• Trauma

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Embolus

• Clot displaced from site of origin to occlude a
  distant artery
• Most common site to lodge bifurcation common
  femoral artery
• 90 come from the heart (atrial fibrillation,
  recent M.I.)

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Thrombosis

• Clot forms in situ in a previously diseased
  vessel or bypass graft
• Predisposing factors Dehydration, CHF or
  Hypercoagulable state

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Acute Arterial Occlusion Presentation

• Embolus
• Dramatic presentation (sudden onset)
• Opposite leg normal pulses
• Source for embolus A.fib, recent M.I.

• Thrombosis
• Bland (well dev. collaterals
• Opposite leg abn. Pulses
• Hx of chronic PVD, ex. claudication

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Investigations

• Angiogram/CTA
• Gold Std
• Embolus (not always needed prior to OR but shows
  abrupt cut off of circulation, reverse meniscus
  sign, no collaterals.
• Thrombosis - always needed, shows tapering cut
  off, lots of collaterals

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Treatment

• Embolus
• Anticoagulate with Heparin
• Medical resuscitation
• Surgical embolectomy
• Consider Fasciotomies
• Post-op life long anticoagulation Heparin ?
  Coumadin

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Treatment

• Thrombosis
• angiogram always
• thrombolysis /- later surgical intervention
• Endovascular (angioplasty/stent)
• surgical bypass
• post-op antiplatelet agents

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Compartment Syndrome

• Especially after reperfusion of the leg
• ? pressure within fascial compartments gt30mmHg.
• Symptoms/signs Pain out of proportion, pain on
  passive flexion/extension, absent pulses is a
  very late sign
• Treat fasciotomies

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Chronic Lower Limb Ischemia
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Presentation (symptoms)

• Claudication Reproducible pain in the lower
  extremities on ambulation
• Rest pain Pain at rest in forefoot, toes.
  Constant pain, worse at nite

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Presentation (signs)

• Claudicant /- pulse deficits
• Rest pain - pulse deficits, atrophic skin, hair
  loss on toes
• Tissue loss - ulcers (painful), gangrene

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Presentation (signs)

• Ankle brachial index
• Normal ? 1
• Claudication 0.5 - 0.8
• Rest pain lt 0.5
• Tissue loss lt 0.3
• ABI not always reliable in diabetic patient
• Doppler signal present does not always ensure
  adequate circulation

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Leriche Syndrome

• Absent femoral pulses
• Impotence
• Buttock Claudication

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Investigations

• Hx, Px, ABI
• Blood Flow Lab - Duplex scan, exercise testing,
  segmental pressure studies
• Angiogram/CTA - Indicated prior to intervention
  or diagnostic dilemma

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Conservative Management

• Modify risk factors - smoking cessation,
  hyperlipidemia, diabetes
• Walking exercise program (Develops collateral
  circulation)
• MEDS
• All should be on antiplatelet ECASA,
  Clopidogrel, Ticlopidine, etc
• Statin
• Consider Pentoxifylline

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INTERVENTION

• Indications
• disabling claudication
• Critical ischemiarest pain, tissue loss
• Angioplasty Stenting (best results for proximal
  lesions ex iliac lesion)
• Bypass
• Amputation

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Aortic dissection

• Definition Intimal tear leading to creation of
  a false passage way of blood within the wall of
  the aorta. Results in both a true and false
  lumen of the vessel

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AORTIC DISSECTON

• Most common catastrophic event of the aorta
• Consequences include
• weakening of aortic wall and possible rupture
• interruption of blood supply to branches of the
  aorta involved, resulting in end organ or limb
  ischemia

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Presentation

• Classically older patient with hx HTN and sudden
  onset tearing retrosternal chest back pain
• On examination HTN, pulse deficits are
  possible, murmur of aortic regurgitation

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Varicose Veins

• Dilated saccular or cylindrical superficial veins
• Different appearances/severities
• Telangiectasia (spider cluster extending out from
  feeder vessel).
• Stem veins (saphenous)
• Reticular veins (tributaries).

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Classification

• Primary - Superficial venous system only
• Secondary - Deep system and or perforators are
  also abnormal usually as result of DVT,
  Pregnancy, Trauma

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Predisposing Factors

• Family history, female, 50 yrs or older,
  multiparity, standing occupation, obesity, BCP,
  DVT

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Pathophysiology Primary Varicose Veins

• Controversial valvular incompetence, wall
  weakness, A-V fistula

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Presentation (symptoms)

• Cosmetic appearance
• Pain, leg fatigue, burning, itching
• Swelling
• Symptoms made worse by prolonged standing,
  relieved with elevation