Sihotský V., Frankovičová M. Kubikova M.

Klinika cievnej chirurgie LF UPJŠ a VÚSCH a.s.

Imagine methods in vascular

medicine

Sonography

Doppler

Triplex

CT-Angiography

MR-Angiography

MRI angiography

Angiography (AG)

Angiography - gold standard !!! DSA

Advantages

○ good resolution

○ possibility of intervetion

○ retreat from AG as a diagnostic

Disadvantages

○ invasive - possible damage - PSA and others

○ contraindications

Iodine allergy

renal insufficiency

Angiography (occlusion of common illiac arteries

Endovascular treatment

Conservative treatment

Endovascular treatment

Surgical treatment

Endovascular treatment Indication

Better for shorter, isolated stenosis

The larger the vessel, the better the throughput

TASC (Transatlantic InterSociety Consensus)

PTA and event. Stent

Pictures:

1.Angiography- stenosis of left common

illiac artery

2. Balloon angioplasty of left common

illiac artery

3. The result of intervention – restored

blood flow

Endovascular treatment Stents coated with vascular

prosthesis - stent grafts,

For treatment of aneurysms or bleeding

They do not leak blood

Endovaskular trombolysis

Arterial

Periferal arteries

Venous

phlebotrombosis

Bypass, central venous cathether, A-V

(arteriovenous) fistula

Before thrombolysis

After thrombolysis

Surgical treatment

Embolectomy: removing the embolus from the vessel using a using a balloon catheter (Fogarthy)

Surgical treatment

Endarterectomy and patch angioplasty

Surgical treatment

Resection and implantation

of interpositum (prosthetic,

venous...)

Bypass

Forms

Anatomical

Extraanatomical

Substitution (possibilities)

GSM (great saphenous vein)

Proshesis

Donor GSM

Acute limb ischemia

Akcute limb ischemia (ALI): is a

sudden drop in limb perfusion that

compromises its vitality. It requires

urgent revascularization..

Etiology

Embolia

Thrombosis

Trauma

5 P

Pain Bolesť

Pulslessness Nehmatný pulz

Paleness Bledosť

Paresthesia Parestézia

Paralysis Porucha hybnosti

Cold

Classification Rutherford I. extremity is viable

No sensitive and no motoric deficit

Conserative treatment

II. the extremity is threatened a requires revascularization

A sensitive deficit is present – may be endovascular treatment,

treatment may be delayed

B sensitive and motoric deficit is present- requires surgical

revascularization - can not be delayed

Venous flow is present (maintained)

Irreverzible ischemia

III. The limb is irreversibly damaged and cannot be saved.

Amputation required.

Irreverzible limb changes

Absence of venous flow !!!

Imagine methods

Diagnosis

Ultrasionography

CT-AG (angiography)

DSA (Digital substraction agiography)

Acute arterial occlusions

Treatment:

I. conservative.

IIa endovascular:

○ Trombolysis, aspiration..

IIb surgical:

○ Trombectomy, bypass

III. amputation

Acute arterial occlusions

Complications

Revascularization syndrome

○ Multi - organové failure

○ Exitus

Compartment sy

Finding the causes and treatment

Arterial injury Sharp injuries

Dominates bleeding !!!!!

Patient immediately at risk of hemorrhagic shock

Urgent surgical revision without imaging methods

Blunt injuries

Dominates ischemy !!!!

Necessary verification by imaging methods

It may be overlooked especially for other associated injuries !!!!!

Associated injuries

Diagnosis

Symptoms, clinic Bleeding

Disappeared pulsations (missing puls.) !!!!!!

Doppler – indicatively The normal curve is triphasic

There may be a continuous flow behind the cap

Duplex sonography

CT-Angiography (CTA)

DSA (digital subtraction angiography)

Treatment

Conservative Small intimal flaps non-closing lumen

Small pseudoaneurysms (lless than 2cm)

Neither ischemia nor extravasation is present

Endovascular treatment Bleeding, occlusion

More with blunt injuries

Advantageous for less accessible vessels ○ Subclavian, iliac, aorta

Surgical treatment

Direct suture

Avoid the

narrowing of the

blood vessel

Suture with patch

Safer

Direct end to end anastomosis In transversal laesions

sometimes reccomended

We don´t do it

Interpozitum At our workplace always in

transversal lesion

Vein – GSM

proshesis

Bypass Especially in blunt injuries

With ligation of damaged artery between anastomoses

Graft

Autologus vein GSV(grand saphenous vein)

Rezistant to low virulent infection

Convenient for reconstructing small caliber arteries

Proshesis Faster construction

No time wasting GSM collection

Upper extremity

Axilar and brachial artery Always necessary the arterial reconstruction

The nervus medianus is frequently injured

Upper extremity

Radialis and ulnaris

artery If only one of the arteries of the forearm

is injured and the Allen test shows a

passable palmar arch, the injury can be

safely ligated

If both arteries are injured, preference

is given to reconstruction of the ulnar

artery

In our workplace, we also reconstruct

the isolated injury of the forearm

artery and in case of injury of both

arteries, we reconstruct both of them

David S Kauvar, Vascular trauma: Extremity in Rutherford´s Vascular

Surgery, 8th edition, 2014

Femoral arteries AFC (arteria femoralis communis) necessary reconstruction

AFS (arteria femoralis superfitialis) the artery most commonly injured ○ necessary reconstruction

AFP (arteria femoralis profunda) it should be reconstructed ○ It is important collateral vessel

○ It may be ligated in an unstable patient

Femoral artery injury mortality is nearly 10

Popliteal artery

After AFS the second most frequently injured artery of the

lower extremity

60% blunt injuries

60-70% fracture present

20% injuty of the popliteal vein

Highest amputation rate 27%

Medial approach above and below the knee Belly position less preferred

Interpositum or bypass treatmenti

Crural arteries

50% blunt injuries

An isolated injury of a single crural artery

may be ligated

For injuries to multiple crural arteries, at

least reconstruction of one of them is

required

Poor access, reconstruction via interpositum

Venous reconstructions

The results are questionable

45%-100% of venous reconstructions are strombotized in the first days

This thrombosis may be transient

Reconstruction of the vein If the patient's condition and local conditions allow it

Certainly VFC (vena femoralis communis)

Compartment sy

Lower extremities 40% patients after revascularization require fasciotomy.

Fasciotomy concomitantly or immediately after surgery reduces the risk of amputation by 4-fold !!!

We perform fasciotomy on the lower limbs after reconstruction always !!!!!!

Upper extremities

20% of patients after brachial artery reconstruction have compartment sy

Amputations Ranging from 7-30%

The most frequent localisastion Upper extremities : forearm

Lower extremities: popliteal artery

Up to 2 times more often for blunt injuries

The presence of multiple fractures and soft tissue injury increases the risk 2-3 times

Concomitant fasciotomy reduces the risk of amputation by 4-fold

Intrathoracal and intraabdominal

arteries

Massive bleeding

Few patients survive transport

Urgent revision

Dissection – stentgraft

Stentgraft

Stenosis ACI (arteria carotis interna)

USG, CT-AG, DSA

Surgery – prevention of another stroke

Indication Above 70% in asymptomat.

Above 50% in sympt. Within 14 days of stroke

Contraindication Occlusion of ACI, stroke in

progression , intracranial pathology, pure prognosis

Acute occlusion of ACI

Revascularistion revascularization within 6 h of onset of symptoms

Brain CT to exclude intracranial haemorrhage

Due to the short time window, these were mostly patients hospitalized in neurological workplaces

AAA

Anerysma aortae abdominalis

Etiol- Atherosclerosis

Clinic Asymptomatic

Symptomatic

○ Pain

○ Embolisation

Rupture

Diagnosis: sonography, CTA, MRI Echocardiography,Transesophageal

echocardiography, thoracic aneurysm

Therapy- AAA

Indication more than 5,5 cm, all circumstances need to be considered

5-6cm 3-15%(1 year mortality)

7-8cm 20-40%

Therapy

Interpositum

Bifurcated prosthesis Einstein

Rupture-AAA

Clinic:

pain

Pulsating resistance

Shock

Dg: sonography, CT

Th: urg. surgery, stentgraft

Poor prognosis

50% does not survive transport

50% does not survive surgery

CT- rupture AAA

Predoperative procedure

Patients with systolic blood pressure of 50-70 mmHg survive

better

Infusions of more than 3.5 l before surgery resulted in a

3.54-fold increase in the risk of death Hardman DT, Ruptured abdominal aortic aneurysms, J Vasc Surg 1996

Those who get alive to the hospital are usually

stable 87% survive more than 2h, therefore most patients are

sufficiently stable to perform CT-AG !!!

Surgery without CT-AG !!! Exmination: In unstable patients with suspected AAA or usg verified AAA,

where CT-AG would lead to possession

In unstable patients, mortality increases by 1% with each

minute

Algorithm

Suspection R(ruptured)AAA

CT-AG

USG

AAA

stable

instable

Urgent

surgery

AAA

without

rupture

Elective

surgery OP

to 48h !!!

negat Another

cause

Types of aneurysms

Stentgraft

Acute occlusion a. mesenterica

superior In atrial fibrillation

Sudden abdominal pain Paralysis, vascular ileus

Finding on the abdomen non-specific Blood in stool

Dg CT-AG !!!!

Therapy

Embolectomy AMS arteria

mesenterica superior

Reversible ischemia may occur within 6-12 hours.

Intestinal resection Extensive

ileotransversoanastomosis

Second look operations Within 24h

Trombophlebitis- superfitial vein

inflammation

Ethiology Aseptic form ( paravenous application and

infusion )

Septic

Stiff painful streak, minimal edema of the surrounding tissues

Heparin ung, and local compression, ATB, ANP, mobilisation,

For severe forms- LWMH (low mollecular

heparine)

Migratory - possible malignancy

PHLEBOTROMBOSIS

Closure of deep venous system

Ethiology: Wirchov trias Hypercoagulable state

Endothelial damage

Thrombus formation Retraction of thrombi 7-12 days

Organization and recanalization of the thrombus

Phlebotrombosis

Localisation

Calf

Thigh

Pelvic veins

Upper extremities

Clinic

Asympthomatic

Pain

Calf oedema

Pretibial veins

Differentiation in the circuit of extremity

Homans, plantar sign

Dg-phlebotrombosismbózy

USG of deep venous

system

D-dimers

Phlebography

Therapy

LWMH 2x 0.1ml per 10kg - possibly outpatient treatment

Heparinisation 30000j continuously i.v to to 2-3 times aPTT + imobilisation

Intravascular trombolysis – tissue activator of plasminogen

Antikoagulant therapy for 3-12 months - angiologists

Thrombolysis

Complications

Pulmonar embolisation

Arterial blood flow failure

Postthrombotic syndroma

Further investigation

Hematologic – hyperkoaguable status

Oncology screening USG of abdomen, X-ray of the chest

Markers

Urology

Long term Bandage, drinking regime, venotonics

ANP, Clopidogrel, Vessel due, LWMH, Kumarins, NOAK

Prevention

Elastic stocks, bandage

Early RHB, breathing exercises

LWMH !!!!!

Kaval filters

In high - risk patients

OK