1.European Manual of Medicine Vascular SurgeryC. D. LiapisChief EditorK. Balzer, F. Benedetti-Valentini,J. Fernandes e FernandesEditors

2. Editors C. D. Liapis,K. Balzer,F. Benedetti-Valentini,J. Fernandes e FernandesVascular SurgeryWith 385 Figures and 58 Tables123 3. Series EditorsVolume EditorsWolfgang Arnold, MD Christos D. Liapis, MD, FACS, FRCSHNO und PoliklinikDepartment of Vascular SurgeryKlinikum rechts der IsarAthens University Medical SchoolMnchen Attikon University HospitalGermany AthensGreeceUwe Ganzer, MDHNO und PoliklinikKlaus Balzer, MDHeinrich-Heine-UniversittDivision of Vascular SurgeryDsseldorfEvangelisches KrankenhausGermany MlheimGermanyFabrizio Benedetti-Valentini, MDDepartment of Vascular SurgeryUniversity of Rome La SapienzaRomeItalyJos Fernandes e Fernandes, MD, PhDChief of ServiceDepartment of Vascular SurgeryHospital Santa Maria and Faculty of MedicineDirector Instituto Cardiovascular de LisboaLisbonPortugalISBN-10 3-540-30955-1Springer Berlin Heidelberg NewYorkISBN-13 978-3-540-30955-0Springer Berlin Heidelberg NewYorkLibrary of Congress Control Number: 2006928312The use of general descriptive names, registered names, trademarks,This work is subject to copyright. All rights are reserved, whether etc. in this publication does not imply, even in the absence of a spe-the whole or part of the material is concerned, specifically the rights cific statement, that such names are exempt from the relevant pro-of translation, reprinting, reuse of illustrations, recitation, broad-tective laws and regulations and therefore free for general use.casting, reproduction on microfilms or in any other way, and stor-Product liability: The publishers cannot guarantee the accuracy ofage in data banks. Duplication of this publication or parts thereof isany information about dosage and application contained in thispermitted only under the provisions of the German Copyright Law book. In every individual case the user must check such informationof September 9, 1965, in its current version, and permission for useby consulting the relevant literature.must always be obtained from Springer-Verlag. Violations are liablefor prosecution under the German Copyright Law. Editor: Gabriele M. Schrder, Heidelberg, GermanyDesk Editor: Waltraud Leuchtenberger, Heidelberg, GermanySpringer is a part of Springer Science + Business Media Production: LE-TeX Jelonek, Schmidt & Vckler GbR,springer.comLeipzig, Germany Springer-Verlag Berlin Heidelberg 2007Cover Design: Frido Steinen-Broo, eStudio Calamar, SpainPrinted on acid-free paper24/3100Wa 5 4 3 2 1 0 4. VAcknowledgementsWhen the invitation came from Springer-Verlag to produce this first Europeanmanual of vascular surgery, it was accepted enthusiastically by the editors, al-beit with some trepidation concerning the demands of such a venture. Thisconcern was due to the diverse nature of the vascular system, which coversevery part of the human body; therefore, diseases of the vascular system affectall organs and all parts of the human anatomy and in order to provide a thor-ough perspective on the discipline of vascular surgery, the manual would haveto cover the full spectrum of vascular diseases.However, the pressing need to produce a long-overdue European manu-al on vascular surgery was the driving force that brought together several ofthe finest minds in Europe, who so generously accepted the task of impartingtheir expert knowledge by contributing chapters in their own specific areas.The diversity of the discipline, coupled with the differences in managementof vascular diseases by authors originating from different European countries,required the work to be carefully formatted to render it an effective referencebook, based on recommended European standards for professionals and train-ees with a common goal: optimum care of the vascular patient.The editors are deeply grateful to the distinguished authors and all theirassociates involved in this compilation. Apart from these tremendous contri-butions, this project would not have been possible without the enormous as-sistance of my associate Dr. Yannis Kakisis and the invaluable cooperation ofMs. Gabriele Schroeder and Ms. Waltraud Leuchtenberger of Springer-Verlag,Patrick Waltemate of LE-TeX and my administrative assistant Ms. VivienneRose.We hope the readership will benefit from this first European Manual ofMedicine: Vascular Surgery. The editors Christos D. LiapisKlaus Balzer Fabrizio Benedetti-ValentiniJos Fernandes e Fernandes 5. VIIForewordGregory D. SkalkeasProfessor Emeritus, Academician,President of the Foundation of BiomedicalResearch of the Academy of AthensVascular surgery has acquired a well-established identity throughout the Euro-pean Union, where vascular diseases are still the leading cause (40%) of deathand disability. Proper management of vascular diseases is dependent on public awarenessand appropriate training of specialists. This stands true for every medical dis-cipline. For vascular surgery it has an additional aspect because, besides therequired above-average standard of technical dexterity, the vascular surgeonshould also be well versed in a variety of subjects such as molecular biology, inthe use of ultrasound and with the introduction of endovascular techniques a skilful operator of guidewires and laparoscopic instruments. All the accu-mulated know-how and skills required for proper management of the vascularpatient demand a rapid change in the training of vascular surgeons and an in-depth knowledge of the various manifestations of vascular diseases. The information necessary for the above is disseminated through books,journals and the internet. Most of the time, however, articles in journals reflectthe experience and enthusiasm of the authors on the subject but not the levelof knowledge of the medical community as a whole. Electronic information isfast and reliable but always gives the reader the impression of being short-lived.Books, on the other hand, allow a reflection of what has been written and a trueinteractive role for the reader. Multi-author books have the inherited handicap of not conveying a specificmessage by virtue of the diversity of thought; however, when the authors hap-pen to be experts in their field and to represent most of the countries within theEuropean Continent that is striving to prove its successful function as a union,then such a collaboration can indeed convey a message: the level of knowledgeand the modus vivendi of vascular surgery in Europe. The editor and authors of this compilation are to be congratulated for suchan endeavour, worthy of the European spirit of unity and collaboration. 6. IXPrefaceSir Peter BellProfessor of Surgery, University of LeicesterEuropean Manual of Medicine: Vascular SurgeryVascular surgery has evolved and expanded in a spectacular fashion during thelast 50 years. During this time previously untreatable conditions have becometreatable and dealt with on a regular basis by vascular surgeons. Many of thepioneers of vascular surgery were from Europe, starting with Cid Dos Santoswho invented angiography and made the whole field of vascular surgery pos-sible. Jean Kunlin in 1949 was the first surgeon to use a reversed vein by-passgraft successfully. In the field of aortic surgery, Lerich and Matas were pio-neers in this area and Felix Eastcott started the long and successful treatmentof carotid artery stenosis by surgery. Successive generations of Europeans havecontinued to be involved in the evolution of vascular surgery, taking it to a newphase of activity. European surgeons continue to be at the forefront of changesin vascular practice and have made it possible for the new era of laparoscopicand endovascular surgery to progress and flourish.One might ask why we need yet another textbook of vascular surgery. Thisis a perfectly reasonably question and the answer is because no book exists thatoffers comprehensive knowledge, both theoretical and practical, to every levelof vascular surgeon. Buying books is expensive and it is therefore importantthat such books are of use to all of those who may wish to read them. The aimof this book is to be as useful to the vascular trainee as to the established vas-cular consultant. To this end the editors have enlisted and given a clear briefto leading practitioners in the field. All of the topics that one would normallyexpect to see in such a book are included and the text is sufficiently referencedto make it authoritative. Pictures and figures are also used but not extensivelyand are not a major selling point of this volume. The theoretical and practi-cal aspects of open surgery, endovascular procedures and laparoscopic surgeryare all covered in detail and venous disease and lymphatic problems are notignored.One question that might be asked is: why are all the contributing surgeonsfrom Europe and none from other countries or continents? This is intentionaland not xenophobic, but an attempt to show that the necessary expertise tocover all aspects of the practice of vascular surgery exists in the expanded Eu-ropean community. It is also to acknowledge the fact that vascular proceduresand practice are not necessarily the same the world over. The approach to someproblems is different in Europe than it is in other continents and these differ-ences are reflected in this book. I am sure that those who buy and read thisbook will not be disappointed in its content or style. It will be extremely usefulto all readers and be a signpost to the future of vascular surgery. 7. XIIntroductionChristos D. Liapis, John D. KakisisVascular diseases are the most frequent cause of death and disability of Eu-ropeans. The aim of the present book, European Manual of Medicine: Vascu-lar Surgery, is to give an indication of European standards for the diagnosisand therapy of vascular diseases. It is designed with the same format as otherbooks in the series European Manuals of Medicine and focuses on the descrip-tion of each clinical entity (definition, epidemiology, aetiology, symptoms andcomplications) and on the recommended European standard diagnostic andtherapeutic steps. In contrast to other textbooks, most of the information ispresented in bulleted listings instead of lengthy paragraphs. This is done in thehope of enabling the reader to retrieve information easily and quickly.The first chapters of this book refer to the pathogenesis of vascular diseases,including the development of atherosclerosis and the effect of dyslipidaemia,clotting disorders and emerging biochemical risk factors. Subsequent chapterspresent the noninvasive and invasive means of diagnosis, including latest de-velopments such as computer-guided diagnosis of vascular diseases. The pre-operative evaluation and optimization as well as the peri-operative care of thevascular patient are also discussed. The book includes a review of the history ofvascular surgery in Europe and a chapter on the training of vascular surgeonsfor endovascular procedures in order to highlight the continuity and the prog-ress of vascular surgery over the past century and the future perspectives. Thechapters of the book cover the entire range of arterial, venous and lymphaticdisorders with an emphasis on all recent developments including endovascularand laparoscopic surgery. The text is comprehensive since the book is intendednot only for vascular specialists but also for students, residents in vascular sur-gery and other interested physicians.The chapters have been written mainly by national representatives on thenewly established Section of Vascular Surgery of the European Union of Medi-cal Specialists (UEMS), thus drawing upon the collective experience of vascu-lar surgeons/specialists from the various European countries. The authors areexperts in their field, providing the reader with a professional opinion reflect-ing what is generally considered to be the state-of-the-art in each area.We hope that the readers, especially the hard working trainees in vascularsurgery to whom this book is dedicated, will find it useful. 8. XIII ContentsVascular Surgery and the Vascular Patient1.2.2.2 Initiation of Atherosclerosis and Role of Endothelial1.1 The History of Vascular SurgeryDysfunction . . . . . . . . . . . . . . . . . . . . . . 23in Europe . . . . . . . . . . . . . . . . . . . . . . . . . .3 1.2.2.3 Evolution of the Atherosclerotic1.1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . 3 Plaque . . . . . . . . . . . . . . . . . . . . . . . . . . .261.1.2 The Origin and the Foundations 1.2.3 Contributive Factorsof European Vascular Surgery . . . . . . . 3 to Endothelial Dysfunction1.1.3 Europe, Cradle of the Worldsand Plaque Formation . . . . . . . . . . . . .28Vascular Surgery . . . . . . . . . . . . . . . . . . . 7 1.2.3.1 Miscellaneous Factor . . . . . . . . . . . . . .281.1.3.1 The Nursery of Vascular Surgery1.2.3.2 The Oxidized LDL Hypothesis . . . . . . 28in Europe in the 1930s was 1.2.4 Plaque Instabilitythe Ren Leriche School in and Complicated Plaques . . . . . . . . . . 30Strasburg, France . . . . . . . . . . . . . . . . . .8 1.2.5 Classification of Atherosclerotic1.1.3.2 Reference to European Surgeons Plaques . . . . . . . . . . . . . . . . . . . . . . . . . . . 30who Through their Pioneering 1.2.6 Assessment and EvaluationWork Developed Vascularof the Risk of an AtheroscleroticSurgery in their Continent withPlaque . . . . . . . . . . . . . . . . . . . . . . . . . . .31International Influence . . . . . . . . . . . . 10 1.2.7 General Therapeutic Measures . . . . .311.1.3.3 Medical and Interventional 1.2.8 Conclusion . . . . . . . . . . . . . . . . . . . . . . .32Vascular Contributions toReferences . . . . . . . . . . . . . . . . . . . . . . . .32the Development of VascularSurgery in Europe and Worldwide . . 12 1.3 Lipids and Peripheral Arterial1.1.4 European Vascular Surgical Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . 35and Angiological Societies and 1.3.1 Introduction . . . . . . . . . . . . . . . . . . . . . .35Congresses . . . . . . . . . . . . . . . . . . . . . . .14 1.3.2 Effect of Lipid Lowering on PAD . . . 351.1.5 Epilogue . . . . . . . . . . . . . . . . . . . . . . . . . .17 1.3.2.1 Prevention of PAD . . . . . . . . . . . . . . . . 35Acknowledgements . . . . . . . . . . . . . . .19 1.3.2.2 Improvement of SymptomsReferences . . . . . . . . . . . . . . . . . . . . . . . .20 Associated with PAD . . . . . . . . . . . . . 35 1.3.2.3 Reduction of the Risk of1.2 Development of Atherosclerosis Vascular Events Associated withfor the Vascular Surgeon . . . . . . . . . . .23 PAD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361.2.1 Introduction . . . . . . . . . . . . . . . . . . . . .23 1.3.3 Peripheral Vascular Surgery and1.2.2 Physiopathology of Statins . . . . . . . . . . . . . . . . . . . . . . . . . . . 36Atherosclerosis . . . . . . . . . . . . . . . . . . . 23 1.3.4 Additional Potential Actions1.2.2.1 Normal Blood Vesselof Lipid-lowering DrugsMorphology . . . . . . . . . . . . . . . . . . . . . .23 that may Benefit PAD Patients . . . . . 37 1.3.5 Are all Statins the Same? . . . . . . . . . . . 37 9. XIV Contents1.3.6Concluding Comments . . . . . . . . . . . . 37 1.6 Invasive Diagnosis of Vascular References . . . . . . . . . . . . . . . . . . . . . . . . 38Diseases . . . . . . . . . . . . . . . . . . . . . . . . . .651.6.1 Introduction . . . . . . . . . . . . . . . . . . . . . .651.4Clotting Disorders: What Should1.6.2 History . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 the Vascular Surgeon Know1.6.3 Arteriography . . . . . . . . . . . . . . . . . . . . . 68 About Hypercoagulation States1.6.3.1 Techniques . . . . . . . . . . . . . . . . . . . . . . .68 in Venous Diseases? . . . . . . . . . . . . . . . 41 1.6.3.2 Pre-procedure Evaluation1.4.1Introduction . . . . . . . . . . . . . . . . . . . . . .41 and Preparation . . . . . . . . . . . . . . . . . . . 691.4.2Venous Thrombosis . . . . . . . . . . . . . . . 41 1.6.3.3 Technique . . . . . . . . . . . . . . . . . . . . . . . . 691.4.2.1Risk Factors . . . . . . . . . . . . . . . . . . . . . .41 1.6.3.4 Post-procedure Care . . . . . . . . . . . . . . . 701.4.3What Should a Surgeon do when1.6.3.5 Complications . . . . . . . . . . . . . . . . . . . . 70 Faced with Hypercoagulation? . . . . .45 1.6.3.6 Direct Toxicity . . . . . . . . . . . . . . . . . . . 711.4.3.1Should a Search for1.6.4 Phlebography . . . . . . . . . . . . . . . . . . . . .72 Thrombophilia be Undertaken? . . . .45 1.6.4.1 Indications . . . . . . . . . . . . . . . . . . . . . . . 721.4.3.2How Should the Search1.6.4.2 Techniques . . . . . . . . . . . . . . . . . . . . . . .72 be Done? . . . . . . . . . . . . . . . . . . . . . . . . .45 References . . . . . . . . . . . . . . . . . . . . . . . .741.4.3.3Diagnosing Thrombotic Disease in Patients with Thrombophilia . . . . .46 1.7 Computer-Aided Diagnosis1.4.3.4Treating Thromboembolicof Vascular Disease . . . . . . . . . . . . . . . . 77 Disease in Patients1.7.1 Introduction . . . . . . . . . . . . . . . . . . . . .77 with Thrombophilia . . . . . . . . . . . . . .46 1.7.2 Computer-Aided Diagnosis1.4.3.5Specific Considerationsin Vascular Imaging . . . . . . . . . . . . . . . 77 in Treating Thromboembolic 1.7.2.1 Image Pre-processing . . . . . . . . . . . . . .78 Disease Related to Thrombophilia . .46 1.7.2.2 Definition of Regions of Interest1.4.4Summary . . . . . . . . . . . . . . . . . . . . . . . . . 47 Automatic Segmentation . . . . . . . . .78 References . . . . . . . . . . . . . . . . . . . . . . .47 1.7.2.3 Extraction and Selectionof Characteristic Features . . . . . . . . .781.5Noninvasive Diagnosis1.7.2.4 Classification . . . . . . . . . . . . . . . . . . . . .80 of Vascular Diseases . . . . . . . . . . . . . . .51 1.7.2.5ANALYSIS: a Modular Software1.5.1Peripheral Arterial Disease . . . . . . . . . 51 System to Support Diagnosis1.5.1.1Introduction . . . . . . . . . . . . . . . . . . . . . .51 of Vascular Disease . . . . . . . . . . . . . . . . 811.5.1.2Physical Examination . . . . . . . . . . . . . .51 1.7.3 Conclusion . . . . . . . . . . . . . . . . . . . . . . .821.5.1.3Basic Haematological References . . . . . . . . . . . . . . . . . . . . . . .82 and Biochemical Tests . . . . . . . . . . . . . 511.5.1.4Special Investigations, Other1.8 Preoperative Evaluation Than Imaging . . . . . . . . . . . . . . . . . . . . .51 of a Vascular Patient . . . . . . . . . . . . . . . 851.5.1.5Imaging Techniques . . . . . . . . . . . . . . .54 1.8.1 Introduction . . . . . . . . . . . . . . . . . . . . . .851.5.1.6Conclusion . . . . . . . . . . . . . . . . . . . . . . .55 1.8.2 Systemic Evaluation . . . . . . . . . . . . . . . 851.5.2Disease of Arteries Supplying1.8.2.1 Cardiovascular System . . . . . . . . . . . . . 85 the Brain . . . . . . . . . . . . . . . . . . . . . . . . . 56 1.8.2.2 Respiratory System . . . . . . . . . . . . . . . .861.5.2.1Introduction . . . . . . . . . . . . . . . . . . . . . .56 1.8.2.3 Renal System . . . . . . . . . . . . . . . . . . . . .881.5.2.2Imaging Techniques . . . . . . . . . . . . . . .56 1.8.3 Evaluation of Specific Vascular1.5.2.3Conclusion . . . . . . . . . . . . . . . . . . . . . . .59 Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . 891.5.3Diseases of the Venous 1.8.3.1 Aneurysmal Disease: Circulation . . . . . . . . . . . . . . . . . . . . . . . 59 Abdominal Aortic Aneurysm . . . . . . 891.5.3.1Introduction . . . . . . . . . . . . . . . . . . . . . .59 1.8.3.3 Peripheral Vascular Disease:1.5.3.2Chronic Venous Insufficiency . . . . . .59 Chronic Lower Limb Ischaemia . . . .891.5.3.3Deep Vein Thrombosis . . . . . . . . . . . .61 1.8.3.4 Peripheral Vascular Disease:1.5.3.4Conclusion . . . . . . . . . . . . . . . . . . . . . . .61 Acute Limb Ischaemia . . . . . . . . . . . . .90 References . . . . . . . . . . . . . . . . . . . . . . . .62 1.8.3.5 Carotid Disease . . . . . . . . . . . . . . . . . . . 91 10. Contents XV1.8.3.6 Venous Disease . . . . . . . . . . . . . . . . . . . 92 1.10 Training of the VascularReferences . . . . . . . . . . . . . . . . . . . . . . . . 93Surgeonfor Endovascular Procedures . . . . . . . . . . . . . . . . . . . . .1071.9 Peri-operative CareReferences . . . . . . . . . . . . . . . . . . . . . .110of the Vascular Patient . . . . . . . . . . . . .951.9.1 Introduction . . . . . . . . . . . . . . . . . . . . . . 95 1.11 Peripheral Arterial Disease and1.9.2 Preoperative Planning . . . . . . . . . . . . .95Emerging Biochemical Vascular1.9.3 Effects of Anaesthesia . . . . . . . . . . . . . . 95Risk Factors . . . . . . . . . . . . . . . . . . . .1111.9.4 Peri-operative Monitoring . . . . . . . . .96 1.11.1 Introduction . . . . . . . . . . . . . . . . . . . .1111.9.4.1 Monitoring for Cardiac1.11.2 Homocysteine (Hcy) . . . . . . . . . . . .111Ischaemia . . . . . . . . . . . . . . . . . . . . . . . .96 1.11.3 C-reactive Protein (CRP) . . . . . . . .1111.9.4.2 Peri-operative Temperature1.11.4 Lipoprotein (a) [Lp(a)] . . . . . . . . . . 112Control . . . . . . . . . . . . . . . . . . . . . . . . . .96 1.11.5 Fibrinogen . . . . . . . . . . . . . . . . . . . . . .1121.9.4.3 Level of Hypnotic Depth . . . . . . . . . . .97 1.11.6 Endothelium . . . . . . . . . . . . . . . . . . . . 1131.9.5 Prevention of Cardiac Ischaemia . . .97 1.11.7 PAD and Other Potentially1.9.5.1 Preoperative Revascularization . . . . . 97Relevant Emerging Risk Factors . .1131.9.5.2 Good Peri-operative 1.11.7.1 Creatinine . . . . . . . . . . . . . . . . . . . . . .113Haemodynamic Control . . . . . . . . . . . 97 1.11.7.2 Urate . . . . . . . . . . . . . . . . . . . . . . . . . . 1131.9.5.3 Anaemia . . . . . . . . . . . . . . . . . . . . . . . . .97 1.11.7.3 Microalbuminuria . . . . . . . . . . . . . .1141.9.5.4 Adrenergic Tone . . . . . . . . . . . . . . . . . .97 1.11.7.4 Insulin Resistance and Metabolic1.9.5.5 Postoperative IschaemiaSyndrome . . . . . . . . . . . . . . . . . . . . . .114Prevention . . . . . . . . . . . . . . . . . . . . . . . 98 1.11.7.5 Platelets, Fibrinolysis1.9.6 Aneurysm Surgery . . . . . . . . . . . . . . . . 98and D-Dimers . . . . . . . . . . . . . . . . . .1141.9.6.1 Effects of Clamping and 1.11.7.6 Other Markers of Inflammation . . 114Declamping . . . . . . . . . . . . . . . . . . . . . . 98 1.11.8 Conclusions . . . . . . . . . . . . . . . . . . . . 1141.9.6.2 Prevention of Spinal CordReferences . . . . . . . . . . . . . . . . . . . . .115Ischaemia in Thoracic AorticSurgery . . . . . . . . . . . . . . . . . . . . . . . . . . 991.12 Quality Control in Vascular1.9.6.3 Autotransfusion During Surgery . . . .99 Surgery . . . . . . . . . . . . . . . . . . . . . . . . 1171.9.7 Heparin . . . . . . . . . . . . . . . . . . . . . . . . . . 991.12.1 Introduction . . . . . . . . . . . . . . . . . . . .1171.9.7.1 Peri-operative Heparin . . . . . . . . . . . .991.12.1.1 Physical Examination . . . . . . . . . . . .1171.9.7.2 Prophylaxis of Deep Leg Vein1.12.1.2 Angiography . . . . . . . . . . . . . . . . . . . . 117Thrombosis . . . . . . . . . . . . . . . . . . . . .100 1.12.1.3 Continuous Wave (CW)1.9.8 Peri-operative MonitoringDoppler . . . . . . . . . . . . . . . . . . . . . . . . 117after Arterial Reconstructions . . . .100 1.12.1.4 Duplex and Colour Duplex Scan . . 1181.9.9 Prophylactic Antibiotic 1.12.1.5 Intravascular UltrasonographyAdministration . . . . . . . . . . . . . . . . .100(IVUS) . . . . . . . . . . . . . . . . . . . . . . . . .1181.9.10Postoperative Pain Treatment . . . .100 1.12.1.6 Angioscopy . . . . . . . . . . . . . . . . . . . . .1181.9.11Pulmonary Complications,1.12.1.7 Flowmetry . . . . . . . . . . . . . . . . . . . . . . 119Prophylaxis and Treatment . . . . . . . 100 1.12.2 Arteries of the Abdomen . . . . . . . . 1191.9.12Peri-operative Care 1.12.2.1 Abdominal Aorta . . . . . . . . . . . . . . . 119and Endovascular Surgery . . . . . . .101 1.12.2.2 Visceral Arteries . . . . . . . . . . . . . . . . 1191.9.13Intensive Care Ward is Needed 1.12.2.3 Renal Arteries . . . . . . . . . . . . . . . . . .120Only for Selected Patients . . . . . . . .101 1.12.3 Lower Extremity By-pass . . . . . . . . 1201.9.14Pre- and Postoperative Gut1.12.3.1 Angiography . . . . . . . . . . . . . . . . . . . . 121Function and Nutrition . . . . . . . . . .101 1.12.3.2 Ultrasound (CW Doppler, PW1.9.15Discharge Planning . . . . . . . . . . . . . .102Doppler, Duplex, Colour Duplex) 1221.9.16Summary . . . . . . . . . . . . . . . . . . . . . . . 103 1.12.3.3 Angioscopy . . . . . . . . . . . . . . . . . . . . .123References . . . . . . . . . . . . . . . . . . . . . .103 1.12.3.4 Flowmetry . . . . . . . . . . . . . . . . . . . . . . 1241.12.3.5 Conclusions . . . . . . . . . . . . . . . . . . . . 124 11. XVI Contents1.12.4 Carotid Arteries . . . . . . . . . . . . . . . . .124 2.2.5.3Technique of Carotid References . . . . . . . . . . . . . . . . . . . . . .127Endarterectomy . . . . . . . . . . . . . . . . . 146 2.2.6Endovascular Treatment . . . . . . . . . 149 2.2.6.1What are the EstablishedCerebrovascular ArteriesIndications for EndovascularProcedures in Extracranial2.1Haemodynamic Changes Carotid Disease? . . . . . . . . . . . . . . . . 149 and Other Risk Factors References . . . . . . . . . . . . . . . . . . . . . . 150 for Complications During Carotid Procedures . . . . . . . . . . . . . .131 2.3Eversion Carotid2.1.1Cerebral Blood Flow . . . . . . . . . . . . . 131Endarterectomy Technique . . . . . . 1552.1.2General Complications . . . . . . . . . . 131 2.3.1Introduction . . . . . . . . . . . . . . . . . . . . 1552.1.3Cerebral Monitoring 2.3.2Technique . . . . . . . . . . . . . . . . . . . . . .155 and Protection During CEA . . . . . . 132 2.3.3Advantages . . . . . . . . . . . . . . . . . . . . . 1592.1.4Cerebral Embolization during2.3.4Disadvantages . . . . . . . . . . . . . . . . . .159 CEA and CAS . . . . . . . . . . . . . . . . . . 133 2.3.5Conclusion . . . . . . . . . . . . . . . . . . . . . 1592.1.5Adjuvant Medical Therapy . . . . . . .133References . . . . . . . . . . . . . . . . . . . . . . 1592.1.6Conclusion . . . . . . . . . . . . . . . . . . . . .134 References . . . . . . . . . . . . . . . . . . . . . .134 2.4Fibromuscular Dysplasia . . . . . . . . .161 2.4.1Basics . . . . . . . . . . . . . . . . . . . . . . . . . . 1612.2Extracranial Carotid Artery 2.4.1.1Anatomy . . . . . . . . . . . . . . . . . . . . . . .161 Disease . . . . . . . . . . . . . . . . . . . . . . . . . 137 2.4.1.2Physiology, Pathophysiology . . . . .1612.2.1Introduction . . . . . . . . . . . . . . . . . . . .137 2.4.1.3Organ-related Questions . . . . . . . . .1652.2.2Pathogenesis of Brain Ischaemia . . 138 2.4.1.4Principles of Clinical2.2.3Clinical Manifestations . . . . . . . . . . 140Examination . . . . . . . . . . . . . . . . . . . .1652.2.3.1Amaurosis fugax . . . . . . . . . . . . . . . . 140 2.4.1.5Technical Diagnostic Procedures . .1652.2.3.2Transient/Reversible Cerebral 2.4.1.6Organ-specific Radiology . . . . . . . . 166 Ischaemia . . . . . . . . . . . . . . . . . . . . . . 140 2.4.2Organ-related Diseases . . . . . . . . . . 1662.2.3.3Established Stroke . . . . . . . . . . . . . . .140 2.4.2.1Synonyms . . . . . . . . . . . . . . . . . . . . . . 1662.2.3.4Stroke in Evolution (Waving2.4.2.2Definition . . . . . . . . . . . . . . . . . . . . . . 166 and Waning) . . . . . . . . . . . . . . . . . . .140 2.4.2.3Epidemiology/Aetiology . . . . . . . . . 1662.2.3.5Global Cerebral Ischaemia . . . . . . . 140 2.4.2.4Symptoms . . . . . . . . . . . . . . . . . . . . . . 1672.2.3.6Asymptomatic Carotid Disease . . .141 2.4.2.5Complications . . . . . . . . . . . . . . . . . .1682.2.4Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 141 2.4.2.6Diagnosis . . . . . . . . . . . . . . . . . . . . . . .1682.2.4.1Arteriography . . . . . . . . . . . . . . . . . . . 141 2.4.2.7Treatment . . . . . . . . . . . . . . . . . . . . . .1682.2.4.2Colour Flow Duplex Scan . . . . . . . 141 2.4.2.8Differential Diagnosis . . . . . . . . . . . 1692.2.4.3High-resolution 2.4.2.9Prognosis . . . . . . . . . . . . . . . . . . . . . . .169 Ultrasonography . . . . . . . . . . . . . . . . 143 2.4.2.10 Exemplary Surgical Procedures . . .1692.2.4.4Measuring the Degree of Stenosis .143 2.4.2.11 Special Remarks . . . . . . . . . . . . . . . . .1702.2.4.5Transcranial Doppler References . . . . . . . . . . . . . . . . . . . . . . 170 Examination . . . . . . . . . . . . . . . . . . . 1442.2.4.6Other Flow-imaging Techniques . . 144 2.5Aneurysms of the Extracranial2.2.4.7Indications for Arteriography . . . . 144Carotid Arteries . . . . . . . . . . . . . . . . 1732.2.4.8Computerized Tomography 2.5.1Definition and Historical and Magnetic Resonance Imaging144Background . . . . . . . . . . . . . . . . . . . . 1732.2.4.9Examination of the Retina . . . . . . . 144 2.5.2Epidemiology/Aetiology . . . . . . . . . 1732.2.5Selection, Treatment and Results . .145 2.5.2.1Atherosclerosis Aneurysms . . . . . .1732.2.5.1Medical Treatment . . . . . . . . . . . . . . 145 2.5.2.2Previous Surgery/POS2.2.5.2Surgical Treatment . . . . . . . . . . . . . .145Endarterectomy . . . . . . . . . . . . . . . . . 174 12. Contents XVII2.5.2.3 Trauma . . . . . . . . . . . . . . . . . . . . . . . . . 174 2.6.8.1 Technical Failure . . . . . . . . . . . . . . . . 1932.5.2.4 Infection . . . . . . . . . . . . . . . . . . . . . . .174 2.6.8.2 Contrast Encephalopathy . . . . . . . . 1932.5.2.5 Dissections . . . . . . . . . . . . . . . . . . . . .174 2.6.8.3 Access Site Complications . . . . . . . . 1932.5.2.6 Other Possible Causes . . . . . . . . . . .174 2.6.8.4 Hyperperfusion Syndrome2.5.3 Symptoms . . . . . . . . . . . . . . . . . . . . . . 175 (Fig. 2.6.16) . . . . . . . . . . . . . . . . . . . . . 1932.5.4 Complications . . . . . . . . . . . . . . . . . .175 2.6.8.5 Hypotension and Bradycardia . . . 1942.5.5 Diagnosis . . . . . . . . . . . . . . . . . . . . . . .175 2.6.8.6 Embolic Complication . . . . . . . . . . .1942.5.5.1 Recommended European 2.6.8.7 Complications Involving BrainStandard Diagnostic StepsProtection Devices . . . . . . . . . . . . . .195of Investigation . . . . . . . . . . . . . . . . . 175 2.6.9 Follow-up . . . . . . . . . . . . . . . . . . . . . . 1952.5.6 Treatment . . . . . . . . . . . . . . . . . . . . . .176 2.6.10Carotid Angioplasty and2.5.6.1 Conservative Treatment . . . . . . . . . 176 Stenting (CAS): Present and Future1962.5.6.2 Surgery . . . . . . . . . . . . . . . . . . . . . . . . .177 References . . . . . . . . . . . . . . . . . . . . . .197References . . . . . . . . . . . . . . . . . . . . . . 179 2.7 Carotid body tumour . . . . . . . . . . . . 2012.6 Endovascular Treatment 2.7.1 Synonyms . . . . . . . . . . . . . . . . . . . . . .201of Carotid Stenosis . . . . . . . . . . . . . .181 2.7.2 Definition of the Disease . . . . . . . . . 2012.6.1 Introduction . . . . . . . . . . . . . . . . . . . . 181 2.7.3 Epidemiology/Aetiology . . . . . . . . .2012.6.2 Indications for Surgery2.7.4 Symptoms . . . . . . . . . . . . . . . . . . . . . .202 Indications for Angioplasty . . . . .181 2.7.5 Complications . . . . . . . . . . . . . . . . . . 2022.6.3 Types of Stents . . . . . . . . . . . . . . . . . .183 2.7.6 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 2032.6.4 Brain Protection Devices . . . . . . . . . 184 2.7.6.1 Recommended European2.6.4.1 Distal Occlusion Balloon Standard Diagnostic Steps(Therons System, PercuSurge of Investigation . . . . . . . . . . . . . . . . .203GuardWire Medtronic)2.7.6.2 Additional Useful Diagnostic(Fig. 2.6.5) . . . . . . . . . . . . . . . . . . . . . . 184 Procedures . . . . . . . . . . . . . . . . . . . . .2052.6.4.2 Filters . . . . . . . . . . . . . . . . . . . . . . . . . .184 2.7.7 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 2062.6.4.3 Proximal Occlusion System . . . . . .186 2.7.7.1 Conservative therapy . . . . . . . . . . . .2062.6.5 Preoperative Evaluation . . . . . . . . . .187 2.7.7.2 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . 2062.6.5.1 Neurological Examination . . . . . . . 188 2.7.8 Differential Diagnosis . . . . . . . . . . .2082.6.5.2 Special Imaging Examination . . . .188 References . . . . . . . . . . . . . . . . . . . . .2082.6.5.3 Duplex Ultrasound . . . . . . . . . . . . . .1882.6.5.4 Digital Subtraction Angiography2.8 Combined Treatment of(DSA) . . . . . . . . . . . . . . . . . . . . . . . . . .188 Coronary Plus Other Arterial2.6.5.5 Magnetic Resonance Pathologies: the Magnitude ofAngiography (MRA) (Fig. 2.6.10) . .189 the Polyatherosclerotic Patient . . . 2092.6.5.6 Brain Computed Tomography2.8.1 Introduction . . . . . . . . . . . . . . . . . . . .209(CT) . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 2.8.2 The Magnitude of Multifocal2.6.6 Technique . . . . . . . . . . . . . . . . . . . . . .190 Arterial Disease . . . . . . . . . . . . . . . . .2092.6.6.1 Step 1: Approach to the2.8.2.1 Material and Methods . . . . . . . . . . .209Common Carotid Artery Access 2.8.2.2 Results . . . . . . . . . . . . . . . . . . . . . . . . . 209Site . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190 2.8.3 Multifocal Occlusive2.6.6.2 Step 2: Cannulation of the and Aneurysmal Arterial Disease . 211Common Carotid Artery2.8.4 Multifocal Carotid and(Fig. 2.6.12) . . . . . . . . . . . . . . . . . . . . .191 Coronary Occlusive Disease . . . . .2122.6.6.3 Step 3: Angioplasty and Stenting . . 192 2.8.4.1 Material and Methods . . . . . . . . . . .2132.6.6.4 Step 4: Control Angiography . . . . .193 2.8.4.2 Results . . . . . . . . . . . . . . . . . . . . . . . . . 2142.6.7 Peri-operative Monitoring . . . . . . .193 Acknowledgements . . . . . . . . . . . . .2142.6.8 Complications . . . . . . . . . . . . . . . . . .193 References . . . . . . . . . . . . . . . . . . . . . .214 13. XVIII ContentsUpper Extremity Arteries 3.2.2.2 Epidemiology/Aetiology . . . . . . . . .240 3.2.2.3 Symptoms . . . . . . . . . . . . . . . . . . . . . .2403.1Upper Extremity Occlusive 3.2.2.4 Treatment . . . . . . . . . . . . . . . . . . . . . . 241 Disease . . . . . . . . . . . . . . . . . . . . . . . . . 219 3.2.3 Acrocyanosis . . . . . . . . . . . . . . . . . . .2423.1.1Introduction . . . . . . . . . . . . . . . . . . . .219 3.2.3.1 Definition . . . . . . . . . . . . . . . . . . . . . .2423.1.2Types of Upper Extremity3.2.3.2 Epidemiology/Aetiology . . . . . . . . .242 Occlusive Disease . . . . . . . . . . . . . . . 219 3.2.3.3 Symptoms . . . . . . . . . . . . . . . . . . . . . .2423.1.2.1Acute and Chronic Ischaemia . . . . 219 3.2.3.4 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 2433.1.2.2Raynauds Phenomenon . . . . . . . . .219 3.2.4 Livedo Reticularis . . . . . . . . . . . . . . .2433.1.2.3Trophic Lesions . . . . . . . . . . . . . . . . . 220 3.2.4.1 Definition . . . . . . . . . . . . . . . . . . . . . .2433.1.2.4Differential Diagnosis of Upper 3.2.4.2 Epidemiology/Aetiology . . . . . . . . .243 Extremity Occlusive Disease . . . . . 220 3.2.4.3 Symptoms . . . . . . . . . . . . . . . . . . . . . .2433.1.3Embolism . . . . . . . . . . . . . . . . . . . . . .220 3.2.4.4 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 2433.1.3.1Definition . . . . . . . . . . . . . . . . . . . . . .220 3.2.5 Cold Hypersensitivity . . . . . . . . . . . 2433.1.3.2Epidemiology/Aetiology . . . . . . . . .220 3.2.5.1 Definition . . . . . . . . . . . . . . . . . . . . . .2433.1.3.3Symptoms . . . . . . . . . . . . . . . . . . . . . .220 3.2.5.2 Symptoms . . . . . . . . . . . . . . . . . . . . . .2443.1.3.4Diagnosis . . . . . . . . . . . . . . . . . . . . . . 221 3.2.5.3 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 2443.1.3.5Therapy . . . . . . . . . . . . . . . . . . . . . . . . 221 3.2.6 Complex Regional Pain3.1.4Occlusive Arterial Disease . . . . . . .222 Syndrome . . . . . . . . . . . . . . . . . . . . . .2453.1.4.1Definition . . . . . . . . . . . . . . . . . . . . . .222 3.2.6.1 Synonyms . . . . . . . . . . . . . . . . . . . . . .2453.1.4.2Proximal Arterial Disease . . . . . . . . 222 3.2.6.2 Definition . . . . . . . . . . . . . . . . . . . . . .2453.1.4.3Distal Arterial Disease . . . . . . . . . . . 226 3.2.6.3 Aetiology . . . . . . . . . . . . . . . . . . . . . . . 2453.1.5Aneurysms . . . . . . . . . . . . . . . . . . . . . 232 3.2.6.4 Symptoms . . . . . . . . . . . . . . . . . . . . . .2453.1.5.1Epidemiology/Aetiology . . . . . . . . .232 3.2.6.5 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 2453.1.5.2Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 232 References . . . . . . . . . . . . . . . . . . . . . .2463.1.5.3Therapy . . . . . . . . . . . . . . . . . . . . . . . . 2323.1.6Arteriovenous Fistulae . . . . . . . . . . .232 3.3 Thoracic Outlet Syndrome . . . . . . .2473.1.6.1Epidemiology/Aetiology . . . . . . . . .232 3.3.1 Definition . . . . . . . . . . . . . . . . . . . . . .2473.1.6.2Symptoms . . . . . . . . . . . . . . . . . . . . . .233 3.3.2 Neurogenic Thoracic Outlet3.1.6.3Investigations . . . . . . . . . . . . . . . . . . .233 Compression Syndrome (N-TOCS) 2473.1.6.4Therapy . . . . . . . . . . . . . . . . . . . . . . . . 233 3.3.2.1 Epidemiology/Aetiology . . . . . . . . .2473.1.7Vascular Trauma . . . . . . . . . . . . . . . . 233 3.3.2.2 Symptoms . . . . . . . . . . . . . . . . . . . . . .2473.1.7.1Epidemiology/Aetiology . . . . . . . . .233 3.3.2.3 Clinical Examination . . . . . . . . . . . .2473.1.7.2Symptoms . . . . . . . . . . . . . . . . . . . . . .233 3.3.2.4 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 2483.1.7.3Therapy . . . . . . . . . . . . . . . . . . . . . . . . 233 3.3.2.5 Treatment . . . . . . . . . . . . . . . . . . . . . . 2483.1.8Iatrogenic Aetiologies . . . . . . . . . . .233 3.3.3 Arterial Thoracic Outlet3.1.9Conclusion . . . . . . . . . . . . . . . . . . . . .234 Compression Syndrome References . . . . . . . . . . . . . . . . . . . . . .234 (A-TOCS) . . . . . . . . . . . . . . . . . . . . .251 3.3.3.1 Epidemiology/Aetiology . . . . . . . . .2513.2Vasospastic Disorders 3.3.3.2 Symptoms . . . . . . . . . . . . . . . . . . . . . .251 of the Upper Extremities . . . . . . . . .237 3.3.3.3 Investigations/Examination . . . . . .2513.2.1Raynauds Syndrome . . . . . . . . . . . .237 3.3.3.4 Treatment . . . . . . . . . . . . . . . . . . . . . . 2513.2.1.1Definition . . . . . . . . . . . . . . . . . . . . . .237 3.3.4 A Case Apart: Primary3.2.1.2Epidemiology/Aetiology . . . . . . . . .237 SubclavianAxillary Vein3.2.1.3Symptoms . . . . . . . . . . . . . . . . . . . . . .237 Thrombosis . . . . . . . . . . . . . . . . . . . . .2543.2.1.4Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 237 3.3.4.1 Epidemiology/Aetiology . . . . . . . . .2543.2.1.5Therapy . . . . . . . . . . . . . . . . . . . . . . . . 239 3.3.4.2 Primary SVT . . . . . . . . . . . . . . . . . . . 2543.2.2Hyperhidrosis . . . . . . . . . . . . . . . . . . . 240 3.3.5 Summary . . . . . . . . . . . . . . . . . . . . . . . 2563.2.2.1Definition . . . . . . . . . . . . . . . . . . . . . .240 References . . . . . . . . . . . . . . . . . . . . . .256 14. Contents XIX3.4 Traumatic Injury of Upper 4.2.3.5 Localization . . . . . . . . . . . . . . . . . . . .278Extremity Arteries . . . . . . . . . . . . . .257 4.2.3.6 Classification . . . . . . . . . . . . . . . . . . .2783.4.1 Epidemiology . . . . . . . . . . . . . . . . . . .257 4.2.3.7 Factors Determining Extension3.4.2 Aetiology . . . . . . . . . . . . . . . . . . . . . . . 257 of Dissection . . . . . . . . . . . . . . . . . . . 2793.4.2.1 Penetrating Trauma . . . . . . . . . . . . .257 4.2.4 Symptoms . . . . . . . . . . . . . . . . . . . . . .2823.4.2.2 Blunt Trauma . . . . . . . . . . . . . . . . . . .257 4.2.4.1 Stanford Type A . . . . . . . . . . . . . . . . 2823.4.3 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 257 4.2.4.2 Stanford Type B . . . . . . . . . . . . . . . . 2823.4.3.1 Recommended European4.2.5 Complications . . . . . . . . . . . . . . . . . . 283Standard Diagnostic Steps 4.2.5.1 Type A . . . . . . . . . . . . . . . . . . . . . . . . .283of Investigation . . . . . . . . . . . . . . . . .257 4.2.5.2 Type B . . . . . . . . . . . . . . . . . . . . . . . . .2833.4.4 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 258 4.2.6 Diagnosis/Investigation . . . . . . . . . . 2853.4.4.1 Conservative Therapy . . . . . . . . . . .258 4.2.6.1 Recommended European3.4.4.2 Endovascular Therapy . . . . . . . . . . .258 Standard Diagnostic Steps3.4.4.3 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . 258 of Investigation . . . . . . . . . . . . . . . . .2853.4.5 Prognosis . . . . . . . . . . . . . . . . . . . . . . . 259 4.2.6.2 Additional Useful DiagnosticReferences . . . . . . . . . . . . . . . . . . . . . .260 Procedures . . . . . . . . . . . . . . . . . . . . .2854.2.6.3 Clinical Judgement . . . . . . . . . . . . . .2854.2.7 Prognosis of Acute or SubacuteThoracic AortaAortic Dissection WithoutTreatment . . . . . . . . . . . . . . . . . . . . . . 2894.1 Thoracoabdominal Aneurysms . . .265 4.2.8 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 2894.1.1 Definition . . . . . . . . . . . . . . . . . . . . . .265 4.2.8.1 Treatment of Type A Aortic4.1.2 Epidemiology/Aetiology . . . . . . . . .265 Dissection . . . . . . . . . . . . . . . . . . . . . .2894.1.3 Investigations . . . . . . . . . . . . . . . . . . .266 4.2.8.2 Treatment of Type B Aortic4.1.3.1 Imaging . . . . . . . . . . . . . . . . . . . . . . . . 266 Dissection . . . . . . . . . . . . . . . . . . . . . .2904.1.3.2 Additional Investigations . . . . . . . . 266 References . . . . . . . . . . . . . . . . . . . . . .2964.1.4 Treatment . . . . . . . . . . . . . . . . . . . . . . 2674.1.4.1 Operative Repair . . . . . . . . . . . . . . . .267 4.3 Trauma of the Thoracic Aorta . . . .2994.1.4.2 Open Surgery: Operative 4.3.1 Introduction . . . . . . . . . . . . . . . . . . . .299Technique . . . . . . . . . . . . . . . . . . . . . . 267 4.3.2 Epidemiology . . . . . . . . . . . . . . . . . . .2994.1.4.3 Open Surgery: Adjuvant4.3.2.1 Automobile-related Incidences . . . 299Techniques . . . . . . . . . . . . . . . . . . . . .267 4.3.2.2 Blunt Thoracic Trauma . . . . . . . . . . 2994.1.5 Endovascular Intervention . . . . . . . 269 4.3.2.3 Outcome . . . . . . . . . . . . . . . . . . . . . . . 3004.1.5.1 Visceral Hybrid Procedure . . . . . . . 269 4.3.3 Aetiology . . . . . . . . . . . . . . . . . . . . . . . 3004.1.6 Outcome . . . . . . . . . . . . . . . . . . . . . . . 271 4.3.3.1 Anatomy . . . . . . . . . . . . . . . . . . . . . . . 3004.1.7 Summary and Conclusions . . . . . . . 272 4.3.3.2 Mechanism of Pathology . . . . . . . . .301References . . . . . . . . . . . . . . . . . . . . . .273 4.3.4 Symptoms . . . . . . . . . . . . . . . . . . . . . .3014.3.5 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 3024.2 Aortic Dissection . . . . . . . . . . . . . . . . 277 4.3.5.1 Recommended European4.2.1 Definition . . . . . . . . . . . . . . . . . . . . . .277 Standard Diagnostic Steps4.2.2 Epidemiology . . . . . . . . . . . . . . . . . . .277 of Investigation . . . . . . . . . . . . . . . . .3024.2.3 Aetiology . . . . . . . . . . . . . . . . . . . . . . . 277 4.3.6 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 3064.2.3.1 Association with Atherosclerotic4.3.6.1 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . 306Disease . . . . . . . . . . . . . . . . . . . . . . . . . 277 4.3.6.2 Endovascular Approach . . . . . . . . . 3094.2.3.2 Association with GeneticReferences . . . . . . . . . . . . . . . . . . . . . .312Disease/CongenitalMalformations . . . . . . . . . . . . . . . . . . 2774.2.3.3 Association with Trauma . . . . . . . . 2774.2.3.4 Other Associations . . . . . . . . . . . . . .277 15. XX Contents Abdominal Aorta and Iliac Arteries 5.3.4.2 Infection . . . . . . . . . . . . . . . . . . . . . . .3335.3.4.3 Autoimmune Disease . . . . . . . . . . . . 333 5.1Abdominal Aortic Aneurysm 5.3.5 Symptoms . . . . . . . . . . . . . . . . . . . . . . 333(AAA) . . . . . . . . . . . . . . . . . . . . . . . . . 317 5.3.5.1 Literature . . . . . . . . . . . . . . . . . . . . . . . 334 5.1.1Introduction . . . . . . . . . . . . . . . . . . . .317 5.3.5.2 Rupture . . . . . . . . . . . . . . . . . . . . . . . .334 5.1.2Definition . . . . . . . . . . . . . . . . . . . . . .317 5.3.6 Diagnosis . . . . . . . . . . . . . . . . . . . . . . .334 5.1.3Epidemiology/Aetiology . . . . . . . . .317 5.3.6.1 Recommended European 5.1.3.1Risk Factors . . . . . . . . . . . . . . . . . . . .318 Standard Diagnostic Steps 5.1.3.2Prevalence . . . . . . . . . . . . . . . . . . . . . .318 of Investigation . . . . . . . . . . . . . . . . . 335 5.1.3.3Incidence of AAA Rupture . . . . . . .319 5.3.7 Therapy . . . . . . . . . . . . . . . . . . . . . . . .336 5.1.3.4Disease Progression . . . . . . . . . . . . . 319 5.3.7.1 Surgery . . . . . . . . . . . . . . . . . . . . . . . . .336 5.1.3.5Treatment . . . . . . . . . . . . . . . . . . . . . . 320 5.3.7.2 Endovascular Treatment . . . . . . . . . 338 5.1.4Symptoms . . . . . . . . . . . . . . . . . . . . . .320 References . . . . . . . . . . . . . . . . . . . . . . 341 5.1.4.1Expanding Aneurysm . . . . . . . . . . .320 5.1.4.2Inflammatory AAA . . . . . . . . . . . . . .320 5.4 Technically Challenging Cases 5.1.4.3Rupture . . . . . . . . . . . . . . . . . . . . . . . . 320 for Endovascular Repair 5.1.5Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 321 of Aortic Aneurysms . . . . . . . . . . . .343 5.1.5.1Recommended European5.4.1 Introduction . . . . . . . . . . . . . . . . . . . . 343Standard Diagnostic Steps 5.4.2 Universally Challengingof Investigation . . . . . . . . . . . . . . . . .321 Situations . . . . . . . . . . . . . . . . . . . . . . 343 5.1.5.2Aspects on Screening . . . . . . . . . . . .321 5.4.2.1 Vascular Access Morphology . . . . . 343 5.1.6Therapy . . . . . . . . . . . . . . . . . . . . . . . . 322 5.4.2.2 Aortic Aneurysm Configuration . .343 5.1.6.1Open Surgery . . . . . . . . . . . . . . . . . . .322 5.4.3 Special Challenging Situations . . . . 347 5.1.6.2Endovascular Aortic Repair5.4.3.1 The Case of Aortic Arch(EVAR) . . . . . . . . . . . . . . . . . . . . . . . .322 Aneurysm . . . . . . . . . . . . . . . . . . . . . . 347 5.1.6.3Rupture and Reconstruction . . . . .322 5.4.3.2 The Case of Aortic Dissection . . . .347 5.1.6.4Outcome . . . . . . . . . . . . . . . . . . . . . . . 323 5.4.3.3 The Case of Aortic Bronchial 5.1.7Possible Complicationsand Enteric Fistula . . . . . . . . . . . . . .349of Surgery . . . . . . . . . . . . . . . . . . . . . .323 5.4.3.4 Other Challenging Cases 5.1.8Practical Recommendations . . . . . . 323 for EVAR . . . . . . . . . . . . . . . . . . . . . . . 350References . . . . . . . . . . . . . . . . . . . . . .323 5.4.4 Conclusion . . . . . . . . . . . . . . . . . . . . . 350References . . . . . . . . . . . . . . . . . . . . . . 351 5.2Treatment Options forAbdominal Aortic Aneurysm 5.5 Aortoiliac Occlusive Disease . . . . . 355(AAA) . . . . . . . . . . . . . . . . . . . . . . . . . 325 5.5.1 Basics . . . . . . . . . . . . . . . . . . . . . . . . . . 355 5.2.1Introduction . . . . . . . . . . . . . . . . . . . .325 5.5.2 Synonyms . . . . . . . . . . . . . . . . . . . . . . 355 5.2.2Open Repair . . . . . . . . . . . . . . . . . . . . 325 5.5.3 Definition . . . . . . . . . . . . . . . . . . . . . . 355 5.2.2.1Complications . . . . . . . . . . . . . . . . . . 327 5.5.3.1 Morphological Features 5.2.3Endovascular Repair . . . . . . . . . . . . 327 in the Chronic Forms . . . . . . . . . . . . 356 5.2.3.1Complications . . . . . . . . . . . . . . . . . . 328 5.5.4 Epidemiology . . . . . . . . . . . . . . . . . . . 357References . . . . . . . . . . . . . . . . . . . . . .329 5.5.5 Aetiology . . . . . . . . . . . . . . . . . . . . . . .3575.5.6 Symptoms . . . . . . . . . . . . . . . . . . . . . . 358 5.3Inflammatory Aneurysms5.5.6.1 Chronic AIOD . . . . . . . . . . . . . . . . . . 358of the Abdominal Aorta . . . . . . . . .331 5.5.6.2 Acute AIOD . . . . . . . . . . . . . . . . . . . . 359 5.3.1Introduction . . . . . . . . . . . . . . . . . . . .331 5.5.7 Diagnosis . . . . . . . . . . . . . . . . . . . . . . .359 5.3.2Definition . . . . . . . . . . . . . . . . . . . . . .331 5.5.7.1 Recommended European 5.3.3Epidemiology . . . . . . . . . . . . . . . . . . .332 Standard . . . . . . . . . . . . . . . . . . . . . . . 359 5.3.4Aetiology . . . . . . . . . . . . . . . . . . . . . . . 333 5.5.7.2 Additional/Useful Diagnostic 5.3.4.1Extension of Inflammation . . . . . . . 333 Procedures . . . . . . . . . . . . . . . . . . . . . 360 16. Contents XXI5.5.8 Treatment . . . . . . . . . . . . . . . . . . . . . . 360 5.6.3 Totally Laparoscopic Operative5.5.8.1 Conservative Treatment . . . . . . . . .360 Procedures . . . . . . . . . . . . . . . . . . . . .3775.5.8.2 Endovascular and Surgical 5.6.3.1 Retrocolic or PrerenalTreatment . . . . . . . . . . . . . . . . . . . . . . 361 Transperitoneal Procedure as5.5.9 Differential Diagnosis . . . . . . . . . . .363 Described by Coggia [8, 11] . . . . . . 3775.5.9.1 In the Case of Chronic AIOD . . . . 363 5.6.3.2 Combined Transperitoneal5.5.9.2 In the Case of Acute AIOD . . . . . . . 363 and Retroperitoneal Procedures . .3795.5.10Prognosis . . . . . . . . . . . . . . . . . . . . . . . 363 5.6.3.3 Retroperitoneal Operation . . . . . . . 3805.5.11Surgical and Endovascular 5.6.3.4 Direct TransperitonealPrinciple . . . . . . . . . . . . . . . . . . . . . . . 364 Procedure [7] . . . . . . . . . . . . . . . . . . . 3805.5.11.1Aortoiliac Angioplasty and5.6.4 Instrumentation . . . . . . . . . . . . . . . . . 381Stenting . . . . . . . . . . . . . . . . . . . . . . . .364 5.6.4.1 Standard Laparoscopic5.5.11.1Unilateral and BilateralInstruments . . . . . . . . . . . . . . . . . . . . 381Aortofemoral By-pass . . . . . . . . . . .365 5.6.4.2 Specific Laparoscopic5.5.11.2Unilateral or Bilateral AortoiliacInstruments for VascularBy-pass . . . . . . . . . . . . . . . . . . . . . . . . . 366 Laparoscopy . . . . . . . . . . . . . . . . . . . . 3815.5.11.3Aortic Exclusion and Bilateral5.6.5 Complications . . . . . . . . . . . . . . . . . . 382Aortoiliac or Bilateral 5.6.5.1 Intraoperative Complications . . . .382Aortofemoral Prosthetic 5.6.5.2 Early PostoperativeReconstruction . . . . . . . . . . . . . . . . .367 Complications . . . . . . . . . . . . . . . . . . 3825.5.11.4Unilateral or Bilateral 5.6.6 Current Indications and Results . . 383Thoracoiliofemoral By-pass . . . . . .367 5.6.7 Conclusions . . . . . . . . . . . . . . . . . . . . 3845.5.11.5Aortoiliac Endarterectomy . . . . . . . 368 References . . . . . . . . . . . . . . . . . . . . . .3845.5.11.6Iliofemoral By-pass . . . . . . . . . . . . . . 3685.5.11.7Femoro-femoral Cross-over 5.7 Aortouniiliac EndoprosthesisBy-pass . . . . . . . . . . . . . . . . . . . . . . . . . 368 and Femoro-femoral Crossover5.5.11.8Unilateral or Bilateral for AAA Repair . . . . . . . . . . . . . . . . .387Axillofemoral By-pass . . . . . . . . . . . 369 5.7.1 Introduction . . . . . . . . . . . . . . . . . . . .3875.5.11.9Retrograde Femoral5.7.2 Definition . . . . . . . . . . . . . . . . . . . . . .387Embolectomy . . . . . . . . . . . . . . . . . . . 369 5.7.3 Indications . . . . . . . . . . . . . . . . . . . . . 3875.5.11.10 New Surgical Trends . . . . . . . . . . . . . 370 5.7.4 Contraindications . . . . . . . . . . . . . . . 3885.5.11.11 Aortobifemoral Video-assisted 5.7.5 Preoperative Management . . . . . . . 388By-pass with Hand-Port System . . 371 5.7.6 Procedure . . . . . . . . . . . . . . . . . . . . . . 3885.5.11.12 Aortobifemoral Totally5.7.7 Results and Complications . . . . . . . 389Laparoscopic By-pass5.7.8 Patency of the Femoro-femoralwith Coggias Technique . . . . . . . . . 372 Crossover By-pass . . . . . . . . . . . . . . 390References . . . . . . . . . . . . . . . . . . . . . .373 5.7.9 Local Wound Complications,Graft Infection and Morbidity . . . 3915.6 Aortobifemoral By-pass: 5.7.10Conclusion . . . . . . . . . . . . . . . . . . . . .395Laparoscopy-Assisted andReferences . . . . . . . . . . . . . . . . . . . . . .395Totally Laparoscopic OperativeProcedures . . . . . . . . . . . . . . . . . . . . .3755.6.1 Introduction . . . . . . . . . . . . . . . . . . . .375 Visceral Arteries5.6.2 Operative Procedures . . . . . . . . . . . .3755.6.2.1 Laparoscopy-Assisted Operative6.1 Occlusive Disease of the CoeliacProcedures with Vascularand Superior Mesenteric Arteries .401Suturing by the Minimally 6.1.1 Definition . . . . . . . . . . . . . . . . . . . . . .401Invasive Route . . . . . . . . . . . . . . . . . .375 6.1.2 Epidemiology . . . . . . . . . . . . . . . . . . .4016.1.3 Aetiology . . . . . . . . . . . . . . . . . . . . . . . 401 17. XXII Contents 6.1.4Symptoms . . . . . . . . . . . . . . . . . . . . . . 402 6.3.5.1 Thrombosis . . . . . . . . . . . . . . . . . . . . . 422 6.1.5Diagnosis . . . . . . . . . . . . . . . . . . . . . . .402 6.3.5.2 Embolism . . . . . . . . . . . . . . . . . . . . . . 422 6.1.5.1Recommended European References . . . . . . . . . . . . . . . . . . . . . . 423Standard Diagnostic Stepsof Investigation . . . . . . . . . . . . . . . . . 402 6.1.5.2Additional Useful Diagnostic Lower Extremity ArteriesProcedures . . . . . . . . . . . . . . . . . . . . . 403 6.1.6Therapy . . . . . . . . . . . . . . . . . . . . . . . .403 7.1 Lower Limb Arterial 6.1.6.1Surgery . . . . . . . . . . . . . . . . . . . . . . . . .404 Recanalization . . . . . . . . . . . . . . . . . . 427 6.1.6.2Angioplasty . . . . . . . . . . . . . . . . . . . . .406 7.1.1 Introduction . . . . . . . . . . . . . . . . . . . . 427 6.1.7Conclusion . . . . . . . . . . . . . . . . . . . . . 408 7.1.2 Problems and Questions . . . . . . . . . 427References . . . . . . . . . . . . . . . . . . . . . . 408 7.1.2.1 Solved Problems . . . . . . . . . . . . . . . .428 7.1.2.2 Unsolved Problems . . . . . . . . . . . . . .428 6.2Visceral Artery Aneurysms . . . . . .411 7.1.2.3 Permanent Problems . . . . . . . . . . . . 430 6.2.1Introduction . . . . . . . . . . . . . . . . . . . . 411 7.1.2.4 Arising Questions . . . . . . . . . . . . . . .430 6.2.2Epidemiology . . . . . . . . . . . . . . . . . . . 411 7.1.3 Conclusions . . . . . . . . . . . . . . . . . . . .432 6.2.3Aetiology . . . . . . . . . . . . . . . . . . . . . . .411 References . . . . . . . . . . . . . . . . . . . . . 433 6.2.4Symptoms . . . . . . . . . . . . . . . . . . . . . . 412 6.2.5Complications . . . . . . . . . . . . . . . . . .412 7.2 Femorodistal By-pass Surgery . . . . 437 6.2.6Diagnosis . . . . . . . . . . . . . . . . . . . . . . .413 7.2.1 Introduction . . . . . . . . . . . . . . . . . . . . 437 6.2.7Therapy . . . . . . . . . . . . . . . . . . . . . . . .413 7.2.2 General Considerations . . . . . . . . . . 437 6.2.7.1Surgery . . . . . . . . . . . . . . . . . . . . . . . . .413 7.2.3 Operative Indications . . . . . . . . . . . .438 6.2.7.2Endovascular Therapy . . . . . . . . . . . 414 7.2.4 Technical Considerations . . . . . . . . 438 6.2.8Prognosis . . . . . . . . . . . . . . . . . . . . . . .414 7.2.4.1 Proximal Anastomotic Site . . . . . . .438References . . . . . . . . . . . . . . . . . . . . . . 415 7.2.4.2 Graft Material . . . . . . . . . . . . . . . . . . . 439 7.2.4.3 Distal Anastomotic Site 6.3Acute Ischaemia of the Visceral(Fig. 7.2.3) . . . . . . . . . . . . . . . . . . . . . . 441Arteries . . . . . . . . . . . . . . . . . . . . . . . . 417 7.2.5 Special Considerations . . . . . . . . . . . 442 6.3.1Acute Intestinal Ischaemia . . . . . . . 417 7.2.6 Graft Surveillance . . . . . . . . . . . . . . . 443 6.3.1.1Basics . . . . . . . . . . . . . . . . . . . . . . . . . . 417 7.2.7 Results . . . . . . . . . . . . . . . . . . . . . . . . .443 6.3.2Acute Thrombotic or Embolic7.2.7.1 Survival . . . . . . . . . . . . . . . . . . . . . . . . 443Arterial Occlusion . . . . . . . . . . . . . . 417 7.2.7.2 Graft Patency and Limb Salvage . . 443 6.3.2.1Epidemiology/Aetiology . . . . . . . . . 417 7.2.7.3 Quality of Life . . . . . . . . . . . . . . . . . .445 6.3.2.2Symptoms . . . . . . . . . . . . . . . . . . . . . . 417 References . . . . . . . . . . . . . . . . . . . . . . 445 6.3.2.3Complications . . . . . . . . . . . . . . . . . .418 6.3.2.4Diagnosis . . . . . . . . . . . . . . . . . . . . . .418 7.3 Acute Ischaemia of the Lower 6.3.2.5Treatment . . . . . . . . . . . . . . . . . . . . . .419 Extremities . . . . . . . . . . . . . . . . . . . . .449 6.3.3Mesenteric Venous Thrombosis . . 419 7.3.1 Synonyms . . . . . . . . . . . . . . . . . . . . . . 449 6.3.3.1Epidemiology/Aetiology . . . . . . . . . 419 7.3.2 Definition . . . . . . . . . . . . . . . . . . . . . . 449 6.3.3.2Symptoms . . . . . . . . . . . . . . . . . . . . . . 420 7.3.3 Epidemiology . . . . . . . . . . . . . . . . . . . 449 6.3.3.3Diagnosis . . . . . . . . . . . . . . . . . . . . . . .420 7.3.4 Aetiology . . . . . . . . . . . . . . . . . . . . . . .449 6.3.3.4Therapy . . . . . . . . . . . . . . . . . . . . . . . .420 7.3.4.1 Embolism . . . . . . . . . . . . . . . . . . . . . . 449 6.3.4Intestinal Ischaemia 7.3.4.2 Thrombosis . . . . . . . . . . . . . . . . . . . . . 450after Aortoiliac Surgery . . . . . . . . . . 420 7.3.4.3 Trauma . . . . . . . . . . . . . . . . . . . . . . . . . 451 6.3.4.1Epidemiology/Aetiology . . . . . . . . . 420 7.3.5 Symptoms . . . . . . . . . . . . . . . . . . . . . . 451 6.3.4.2Symptoms . . . . . . . . . . . . . . . . . . . . . . 421 7.3.5.1 Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . 451 6.3.4.3Diagnosis . . . . . . . . . . . . . . . . . . . . . . .421 7.3.5.2 Paraesthesia . . . . . . . . . . . . . . . . . . . . 451 6.3.4.4Treatment . . . . . . . . . . . . . . . . . . . . . .421 7.3.5.3 Paralysis . . . . . . . . . . . . . . . . . . . . . . . .451 6.3.5Acute Renal Ischaemia . . . . . . . . . . .422 7.3.5.4 Pallor . . . . . . . . . . . . . . . . . . . . . . . . . . 452 18. Contents XXIII7.3.5.5 Pulselessness . . . . . . . . . . . . . . . . . . . . 452 7.5 Buergers Disease of the Lower7.3.6 Complications . . . . . . . . . . . . . . . . . . 452 Extremities . . . . . . . . . . . . . . . . . . . . .4717.3.7 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 452 7.5.1 Synonym . . . . . . . . . . . . . . . . . . . . . . .4717.3.7.1 Recommended European7.5.2 Definition . . . . . . . . . . . . . . . . . . . . . . 471Standard Diagnostic Steps 7.5.3 Epidemiology . . . . . . . . . . . . . . . . . . . 471of Investigation . . . . . . . . . . . . . . . . .452 7.5.4 Aetiology . . . . . . . . . . . . . . . . . . . . . . .4717.3.7.2 Additional Useful Diagnostic7.5.5 Symptoms . . . . . . . . . . . . . . . . . . . . . . 472Procedures . . . . . . . . . . . . . . . . . . . . .453 7.5.6 Diagnosis . . . . . . . . . . . . . . . . . . . . . . .4737.3.8 Treatment . . . . . . . . . . . . . . . . . . . . . . 453 7.5.6.1 Recommended European7.3.8.1 Conservative Treatment . . . . . . . . .453 Standard Diagnostic Steps7.3.8.2 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . 453 of Investigation . . . . . . . . . . . . . . . . . 4737.3.8.3 Thrombolytic Therapy . . . . . . . . . . .455 7.5.7 Treatment . . . . . . . . . . . . . . . . . . . . . .4767.3.9 Differential Diagnosis . . . . . . . . . . .457 7.5.7.1 Conservative Treatment . . . . . . . . . 4767.3.10Prognosis . . . . . . . . . . . . . . . . . . . . . . . 457 7.5.7.2 Surgery . . . . . . . . . . . . . . . . . . . . . . . . .476References . . . . . . . . . . . . . . . . . . . . . .457 7.5.7.3 Differential Diagnosis . . . . . . . . . . . 4777.5.7.4 Prognosis . . . . . . . . . . . . . . . . . . . . . . .4777.4 Lower Extremity Aneurysms . . . . . 459 References . . . . . . . . . . . . . . . . . . . . . . 4777.4.1 Basic Concepts . . . . . . . . . . . . . . . . . .4597.4.2 Popliteal Aneurysms (PA) . . . . . . . .459 7.6 Popliteal Artery Entrapment7.4.2.1 Definition . . . . . . . . . . . . . . . . . . . . . .460 and Popliteal Adventitial Cystic7.4.2.2 Epidemiology/Aetiology . . . . . . . . .460 Disease . . . . . . . . . . . . . . . . . . . . . . . . .4797.4.2.3 Symptoms . . . . . . . . . . . . . . . . . . . . . .460 7.6.1 Definition . . . . . . . . . . . . . . . . . . . . . . 4797.4.2.4 Complications . . . . . . . . . . . . . . . . . . 460 7.6.2 Epidemiology/Aetiology . . . . . . . . . 4797.4.2.5 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 460 7.6.3 Symptoms . . . . . . . . . . . . . . . . . . . . . . 4797.4.2.6 Treatment . . . . . . . . . . . . . . . . . . . . . . 461 7.6.4 Diagnosis . . . . . . . . . . . . . . . . . . . . . . .4807.4.2.7 Prognosis . . . . . . . . . . . . . . . . . . . . . . 462 7.6.4.1 Recommended European7.4.3 Aneurysms of the Common Standard Diagnostic StepsFemoral Artery . . . . . . . . . . . . . . . . .462 of Investigation . . . . . . . . . . . . . . . . . 4807.4.3.1 Definition . . . . . . . . . . . . . . . . . . . . . .462 7.6.5 Treatment . . . . . . . . . . . . . . . . . . . . . .4817.4.3.2 Epidemiology/Aetiology . . . . . . . . .462 7.6.5.1 Recommended European7.4.3.3 Symptoms . . . . . . . . . . . . . . . . . . . . . .463 Standard Surgical Procedures . . . . 4817.4.3.4 Diagnosis . . . . . . . . . . . . . . . . . . . . . . 464 7.6.6 Special Remarks . . . . . . . . . . . . . . . . .4837.4.3.5 Treatment . . . . . . . . . . . . . . . . . . . . . . 464 References . . . . . . . . . . . . . . . . . . . . . . 4847.4.3.6 Prognosis . . . . . . . . . . . . . . . . . . . . . . 4667.4.4 Aneurysms of the Superficial7.7 Vascular Trauma of the LowerFemoral Artery . . . . . . . . . . . . . . . . .466 Limb . . . . . . . . . . . . . . . . . . . . . . . . . . . 4857.4.4.1 Definition . . . . . . . . . . . . . . . . . . . . . .466 7.7.1 The Problem . . . . . . . . . . . . . . . . . . . .4857.4.4.2 Epidemiology/Aetiology . . . . . . . . .467 7.7.1.1 Encountering Vascular Injury . . . . 4867.4.4.3 Symptoms . . . . . . . . . . . . . . . . . . . . . .467 7.7.1.2 How Can Ischaemia of the7.4.4.4 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 467 Lower Limb be Detected7.4.4.5 Treatment . . . . . . . . . . . . . . . . . . . . . . 467 or Ruled Out Reliably? . . . . . . . . . . . 4867.4.4.6 Prognosis . . . . . . . . . . . . . . . . . . . . . . 467 7.7.2 Mechanisms of Injury . . . . . . . . . . . 4887.4.5 Aneurysms of the Distal 7.7.2.1 Sharp Injury . . . . . . . . . . . . . . . . . . . . 488Branches . . . . . . . . . . . . . . . . . . . . . . .468 7.7.2.2 Blunt injury . . . . . . . . . . . . . . . . . . . . . 4887.4.5.1 Epidemiology/Aetiology . . . . . . . . .468 7.7.2.3 Iatrogenic . . . . . . . . . . . . . . . . . . . . . . 4907.4.5.2 Clinical Symptoms . . . . . . . . . . . . . . 468 7.7.3 Consequences of Arterial Injury7.4.5.3 Diagnosis . . . . . . . . . . . . . . . . . . . . . . 468 of the Lower Limb . . . . . . . . . . . . . .4937.4.5.4 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 468 7.7.3.1 Compartment Syndrome . . . . . . . . 493References . . . . . . . . . . . . . . . . . . . . .468 19. XXIV Contents 7.7.3.2False Aneurysms and Arterio-9.1.1Introduction . . . . . . . . . . . . . . . . . . . .525Venous Fistulas . . . . . . . . . . . . . . . . . 494 9.1.1.1Scope of the Problem . . . . . . . . . . . .525 7.7.4The Management of Vascular9.1.2Incidence and MorbidityTrauma (With Special Reference of Amputation . . . . . . . . . . . . . . . . . . 525to the Knee Joint) . . . . . . . . . . . . . . .494 9.1.3Classification and Indications . . . .526 7.7.5Bulleted Summary . . . . . . . . . . . . . .497 9.1.3.1Emergency Amputation . . . . . . . . .526References . . . . . . . . . . . . . . . . . . . . . .497 9.1.3.2Elective Amputations . . . . . . . . . . . .5269.1.4Determination of Amputation Level . . . . . . . . . . . . . . . . . . . . . . . . . . . 527 Diabetic Foot9.1.4.1Transcutaneous Oxygen Tension (PtCO2) Measurement . . . . . . . . . . . 528 8.1Diabetic Foot . . . . . . . . . . . . . . . . . . . 501 9.1.4.2Clearance of [133Xe] . . . . . . . . . . . . .528 8.1.1Definition . . . . . . . . . . . . . . . . . . . . . .501 9.1.5Preoperative Management . . . . . . . 528 8.1.2Epidemiology . . . . . . . . . . . . . . . . . . .501 9.1.6Surgical Techniques of 8.1.2.1Foot Ulcers . . . . . . . . . . . . . . . . . . . . . 501Amputation . . . . . . . . . . . . . . . . . . . .528 8.1.2.2Amputation . . . . . . . . . . . . . . . . . . . . .501 9.1.6.1Toe Amputation . . . . . . . . . . . . . . . . .528 8.1.2.3Social and Economic Costs . . . . . . . 502 9.1.6.2Ray Amputation . . . . . . . . . . . . . . . .529 8.1.3Aetiology . . . . . . . . . . . . . . . . . . . . . . . 503 9.1.6.3Transmetatarsal Amputation . . . . .530 8.1.3.1Pathogenesis of the Neuropathic 9.1.6.4Symes AmputationUlcer . . . . . . . . . . . . . . . . . . . . . . . . . . . 503(Ankle Disarticulation) . . . . . . . . . . 531 8.1.3.2Pathogenesis of the Ischaemic 9.1.6.5Below-knee Amputation . . . . . . . . . 532Ulcer . . . . . . . . . . . . . . . . . . . . . . . . . . . 505 9.1.6.6Above-knee Amputation . . . . . . . . . 533 8.1.4Complications: Neuro- 9.1.6.7Amputation of the UpperOsteoarthropathy . . . . . . . . . . . . . . .506Extremity . . . . . . . . . . . . . . . . . . . . . . 534 8.1.4.1Definition . . . . . . . . . . . . . . . . . . . . . .506 9.1.7Postoperative Considerations 8.1.4.2Epidemiology . . . . . . . . . . . . . . . . . . .506and Rehabilitation . . . . . . . . . . . . . . .534 8.1.4.3Aetiology . . . . . . . . . . . . . . . . . . . . . . . 507 9.1.8Complications . . . . . . . . . . . . . . . . . . 535 8.1.4.4Symptoms/Investigations/ References . . . . . . . . . . . . . . . . . . . . . .535Diagnosis/Treatment . . . . . . . . . . . . 507 8.1.5Diagnosis/Investigations . . . . . . . . .507 8.1.5.1Clinical Examination . . . . . . . . . . . .507 Venous Diseases 8.1.5.2Circulation . . . . . . . . . . . . . . . . . . . . . 508 8.1.5.3Paraclinical Evaluation . . . . . . . . . . 509 10.1 Chronic Venous Insufficiency . . . .539 8.1.5.4Classification Systems . . . . . . . . . . .509 10.1.1 Introduction . . . . . . . . . . . . . . . . . . . .539 8.1.6Differential Diagnosis . . . . . . . . . . .509 10.1.2 Functional Anatomy and 8.1.7Infections . . . . . . . . . . . . . . . . . . . . . . .510Physiology of the Venous System . . 539 8.1.7.1Introduction . . . . . . . . . . . . . . . . . . . .510 10.1.2.1 Superficial Veins . . . . . . . . . . . . . . . . 539 8.1.7.2Pathophysiology . . . . . . . . . . . . . . . . 511 10.1.2.2 Deep Veins . . . . . . . . . . . . . . . . . . . . .539 8.1.7.3Microbiology . . . . . . . . . . . . . . . . . . .512 10.1.2.3 Perforating Veins . . . . . . . . . . . . . . . . 539 8.1.7.4Clinical Presentation . . . . . . . . . . . . 512 10.1.3 Chronic Venous Insufficiency . . . .539 8.1.7.5Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 513 10.1.3.1 Definition . . . . . . . . . . . . . . . . . . . . . .539 8.1.7.6Severity Classification . . . . . . . . . . . 514 10.1.3.2 Epidemiology/Aetiology . . . . . . . . .540 8.1.7.7Treatment . . . . . . . . . . . . . . . . . . . . . . 515 10.1.3.3 Symptoms . . . . . . . . . . . . . . . . . . . . . .541 8.1.8Treatment of the Diabetic Ulcer . . 517 10.1.3.4 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 543References . . . . . . . . . . . . . . . . . . . . . .518 10.1.3.5 Treatment . . . . . . . . . . . . . . . . . . . . . . 54510.1.3.6 Conclusion . . . . . . . . . . . . . . . . . . . . .549 References . . . . . . . . . . . . . . . . . . . . . .549 Amputations10.2 Deep Venous Thrombosis . . . . . . . .551 9.1Amputation of Extremities . . . . . . . 525 10.2.1 Epidemiology/Aetiology . . . . . . . . .551 20. Contents XXV10.2.2 Symptoms . . . . . . . . . . . . . . . . . . . . . .551 12.1.6 Diagnosis . . . . . . . . . . . . . . . . . . . . . . .58010.2.3 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 551 12.1.6.1 Examination . . . . . . . . . . . . . . . . . . .58010.2.3.1 Clinical Signs . . . . . . . . . . . . . . . . . . .551 12.1.6.2 Laboratory Investigations10.2.3.2 Laboratory Tests and Imaging . . . .552and Imaging . . . . . . . . . . . . . . . . . . . .58010.2.3.3 Recommended European12.1.7 Treatment . . . . . . . . . . . . . . . . . . . . . .581 Standard . . . . . . . . . . . . . . . . . . . . . . .552 12.1.7.1 Treatment According to the Type10.2.4 Treatment . . . . . . . . . . . . . . . . . . . . . . 552of the Malformation . . . . . . . . . . . . .58110.2.4.1 Conservative Treatment of DVT . . 552 12.1.7.2 Conservative Treatment . . . . . . . . . 58210.2.4.2 Invasive Treatment of DVT . . . . . . 553 12.1.7.3 Surgery . . . . . . . . . . . . . . . . . . . . . . . . .58310.2.4.3 Prevention of DVT . . . . . . . . . . . . . . 556 12.1.8 Prognosis . . . . . . . . . . . . . . . . . . . . . . .58310.2.5 Differential Diagnosis . . . . . . . . . . .556References . . . . . . . . . . . . . . . . . . . . . . 58310.2.6 Prognosis . . . . . . . . . . . . . . . . . . . . . . . 557 References . . . . . . . . . . . . . . . . . . . . . .557 Angioaccess SurgeryLymphatics 13.1 Vascular Access to Patients inHaemodialysis . . . . . . . . . . . . . . . . . .58711.1 Lymphoedema . . . . . . . . . . . . . . . . . . 561 13.1.1 Introduction . . . . . . . . . . . . . . . . . . . . 58711.1.1 Introduction . . . . . . . . . . . . . . . . . . . .561 13.1.2 Urgent (Acute) Haemodialysis . . . . 58711.1.1.1 Capillary Microcirculation . . . . . . .561 13.1.2.1 External AV Shunt . . . . . . . . . . . . . 58711.1.1.2 Capillary Circulation and Limb13.1.2.2 Subclavian Catheters . . . . . . . . . . . . 588 Oedema . . . . . . . . . . . . . . . . . . . . . . . .562 13.1.2.3 Jugular Catheters . . . . . . . . . . . . . . . .58811.1.2 Definition of Lymphoedema . . . . . 563 13.1.2.4 Femoral Catheters . . . . . . . . . . . . . . .58911.1.3 Aetiology/Epidemiology . . . . . . . . .563 13.1.3 Chronic Haemodialysis . . . . . . . . . .58911.1.3.1 Primary Lymphoedema . . . . . . . . . . 563 13.1.3.1 Internal AV Shunt (AV11.1.3.2 Secondary Lymphoedema . . . . . . . . 565Fistula) . . . . . . . . . . . . . . . . . . . . . . . . . 58911.1.4 Symptoms . . . . . . . . . . . . . . . . . . . . . .566 13.1.3.2 Arteriovenous Grafts . . . . . . . . . . . . 59111.1.5 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 566References . . . . . . . . . . . . . . . . . . . . . . 59411.1.5.1 History and Examination . . . . . . . . 56611.1.5.2 Laboratory Tests . . . . . . . . . . . . . . . .56711.1.5.3 Imaging . . . . . . . . . . . . . . . . . . . . . . . . 567 Multidisciplinary Vascular Issues11.1.6 Treatment . . . . . . . . . . . . . . . . . . . . . . 56811.1.6.1 Conservative Treatment . . . . . . . . .568 14.1 Infections in Vascular Surgery . . . . 59711.1.6.2 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . 568 14.1.1 Introduction . . . . . . . . . . . . . . . . . . . . 597 References . . . . . . . . . . . . . . . . . . . . . .570 14.1.2 Pathogenesis of Infection . . . . . . . .597 14.1.2.1 Pathogen Virulence . . . . . . . . . . . . . 597 14.1.2.2 Host Response . . . . . . . . . . . . . . . . . .598Arteriovenous Malformations14.1.2.3 Device Factors . . . . . . . . . . . . . . . . . . 598 14.1.3 Microbiology and Diagnosis . . . . . 59812.1 Arteriovenous Malformations . . . . 573 14.1.4 Imaging . . . . . . . . . . . . . . . . . . . . . . . .59912.1.1 Synonyms . . . . . . . . . . . . . . . . . . . . . .573 14.1.5 Antimicrobial Therapy . . . . . . . . . . .59912.1.2 Definition . . . . . . . . . . . . . . . . . . . . . .573 14.1.6 Prevention . . . . . . . . . . . . . . . . . . . . . . 60012.1.2.1 Terminology . . . . . . . . . . . . . . . . . . . . 573 14.1.6.1 Primary Prophylaxis . . . . . . . . . . . . .60012.1.3 Epidemiology . . . . . . . . . . . . . . . . . . .573 14.1.6.2 Local Antibiotic Prophylaxis . . . . . 60212.1.3.1 Classification . . . . . . . . . . . . . . . . . . .573 14.1.6.3 Secondary Prophylaxis . . . . . . . . . . .60212.1.4 Aetiology . . . . . . . . . . . . . . . . . . . . . . . 575 14.1.6.4 Other Measures of Prevention . . . . 60212.1.4.1 Embryology and Anatomy . . . . . . .575 14.1.7 Infections in Specific Vascular12.1.5 Symptoms . . . . . . . . . . . . . . . . . . . . . .576Implants . . . . . . . . . . . . . . . . . . . . . . . 60212.1.5.1 Vascular Bone Syndrome . . . . . . . .576 14.1.7.1 Prosthetic Graft Infections (PGI) . .60212.1.5.2 Specific Vascular Malformations . . 577 21. XXVIContents 14.1.7.2 Peripheral Vascular Stent14.4.1 Aortic Arch AneurysmsInfections (PVSIs) . . . . . . . . . . . . . . . 604in Coarctation of the Aorta . . . . . . 639 14.1.7.3 Prosthetic Carotid Patches 14.4.1.1 Epidemiology/Aetiology . . . . . . . . .639Infections (PCPIs) . . . . . . . . . . . . . . 607 14.4.1.2 Treatment . . . . . . . . . . . . . . . . . . . . . . 640 14.1.7.4 Arterial Closure Devices 14.4.2 Intramural Haematoma . . . . . . . . . .640Infections . . . . . . . . . . . . . . . . . . . . . . 608 14.4.2.1 Synonyms . . . . . . . . . . . . . . . . . . . . . .640 14.1.7.5 Venal Caval Filter Infections . . . . .609 14.4.2.2 Definition . . . . . . . . . . . . . . . . . . . . . .640 14.1.7.6 Infections of Haemodialysis14.4.2.3 Epidemiology/Aetiology . . . . . . . . .640Prosthetic Grafts and14.4.2.4 Symptoms . . . . . . . . . . . . . . . . . . . . . .640Autologous Arteriovenous 14.4.2.5 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 640Fistulas (HPGFIs) . . . . . . . . . . . . . . .609 14.4.2.6 Treatment . . . . . . . . . . . . . . . . . . . . . . 640References . . . . . . . . . . . . . . . . . . . . . . 611 14.4.2.7 Differential Diagnosis . . . . . . . . . . .641 14.4.2.8 Prognosis . . . . . . . . . . . . . . . . . . . . . . . 641 14.2 Vascular Problems in Urological14.4.3 Obstructed Aortic Arch . . . . . . . . . .641Surgery . . . . . . . . . . . . . . . . . . . . . . . .615 14.4.3.1 Synonyms . . . . . . . . . . . . . . . . . . . . . .641 14.2.1 Introduction . . . . . . . . . . . . . . . . . . . . 615 14.4.3.2 Epidemiology/Aetiology . . . . . . . . .641 14.2.2 Vascular Lesions 14.4.3.3 Symptoms . . . . . . . . . . . . . . . . . . . . . .641on Preoperative Evaluation . . . . . . 615 14.4.3.4 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 641 14.2.2.1 Abdominal Aortic Aneurysm14.4.3.5 Treatment . . . . . . . . . . . . . . . . . . . . . . 642(AAA) . . . . . . . . . . . . . . . . . . . . . . . . .615 14.4.4 Recurrent Obstruction of the 14.2.2.2 Renal Tumours Involving Aortic Arch . . . . . . . . . . . . . . . . . . . . 642the Vena Cava . . . . . . . . . . . . . . . . . .616 14.4.5 Takayasus Arteritis . . . . . . . . . . . . . .643 14.2.3 Unexpected Iatrogenic14.4.5.1 Synonyms . . . . . . . . . . . . . . . . . . . . . .643Vascular Injuries . . . . . . . . . . . . . . . .618 14.4.5.2 Definition . . . . . . . . . . . . . . . . . . . . . .643 14.2.3.1 Venous Injuries . . . . . . . . . . . . . . . . .618 14.4.5.3 Epidemiology/Aetiology . . . . . . . . .643 14.2.3.2 Arterial Injuries . . . . . . . . . . . . . . . . .619 14.4.5.4 Symptoms . . . . . . . . . . . . . . . . . . . . . .644 14.2.4 Bulleted Summary . . . . . . . . . . . . . . 620 14.4.5.5 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 644References . . . . . . . . . . . . . . . . . . . . . . 620 14.5.5.6 Treatment . . . . . . . . . . . . . . . . . . . . . . 644 14.5.5.7 Prognosis . . . . . . . . . . . . . . . . . . . . . . . 645 14.3 Vascular Trauma in Orthopaedic 14.4.6 Aortic Arch AtheroscleroticSurgery . . . . . . . . . . . . . . . . . . . . . . . .623Aneurysm . . . . . . . . . . . . . . . . . . . . . .645 14.3.1 Introduction . . . . . . . . . . . . . . . . . . . . 623 14.4.6.1 Epidemiology/Aetiology . . . . . . . . .645 14.3.2 Basic Principles 14.4.6.2 Symptoms . . . . . . . . . . . . . . . . . . . . . .645in Microvascular Surgery . . . . . . . . 623 14.4.6.3 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 646 14.3.2.1 Basic Microvascular Techniques . . 624 14.4.6.4 Treatment . . . . . . . . . . . . . . . . . . . . . . 646 14.3.3 Application of Microvascular 14.4.6.5 Prognosis . . . . . . . . . . . . . . . . . . . . . . . 647Surgery to Trauma Orthopaedics . . 626 14.4.7 Atheromas and Penetrating 14.3.3.1 Replantation . . . . . . . . . . . . . . . . . . . . 626Atherosclerotic Ulcerations of 14.3.3.2 Major Limb Revascularizationthe Aortic Arch . . . . . . . . . . . . . . . . . 648and Replantation . . . . . . . . . . . . . . . . 630 14.4.7.1 Definition . . . . . . . . . . . . . . . . . . . . . .648 14.3.3.3 Open Fractures Type IIIb 14.4.7.2 Symptoms . . . . . . . . . . . . . . . . . . . . . .648and IIIc . . . . . . . . . . . . . . . . . . . . . . . . 634 14.4.7.3 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 648 14.3.4 Vascular Complication14.4.7.4 Treatment . . . . . . . . . . . . . . . . . . . . . . 648in Orthopaedic Patients . . . . . . . . .635 14.4.8 Aortic Arch Thrombosis . . . . . . . . .649References . . . . . . . . . . . . . . . . . . . . . . 635 14.4.8.1 Epidemiology/Aetiology . . . . . . . . .649 14.4.8.2 Symptoms . . . . . . . . . . . . . . . . . . . . . .649 14.4 Treatment of Aortic Arch 14.4.8.3 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 649Diseases . . . . . . . . . . . . . . . . . . . . . . . . 639 14.4.8.4 Treatment . . . . . . . . . . . . . . . . . . . . . . 649 14.4.9 Aortic Arch Trauma . . . . . . . . . . . . .650 22. Contents XXVII14.4.9.1Synonyms . . . . . . . . . . . . . . . . . . . . . .650 14.4.11.7 Treatment . . . . . . . . . . . . . . . . . . . . . . 65514.4.9.2Definition . . . . . . . . . . . . . . . . . . . . . .650 14.4.11.8 Differential Diagnosis . . . . . . . . . . .65514.4.9.3Epidemiology/Aetiology . . . . . . . . .650 14.4.11.9 Prognosis . . . . . . . . . . . . . . . . . . . . . . . 65514.4.9.4Symptoms . . . . . . . . . . . . . . . . . . . . . .650 14.4.12 EhlersDanlos Syndrome . . . . . . . .65514.4.9.5Complications . . . . . . . . . . . . . . . . . . 651 14.4.12.1 Synonyms . . . . . . . . . . . . . . . . . . . . . .65514.4.9.6Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 651 14.4.12.2 Definition . . . . . . . . . . . . . . . . . . . . . .65614.4.9.7Treatment . . . . . . . . . . . . . . . . . . . . . . 651 14.4.12.3 Epidemiology/Aetiology . . . . . . . . .65614.4.9.8Differential Diagnosis . . . . . . . . . . .651 14.4.12.4 Symptoms . . . . . . . . . . . . . . . . . . . . . .65614.4.9.9Prognosis . . . . . . . . . . . . . . . . . . . . . . . 652 14.4.12.5 Complications . . . . . . . . . . . . . . . . . . 65614.4.10 Ascending Aortic Dissection . . . . . 652 14.4.12.6 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 65614.4.10.1 Synonyms . . . . . . . . . . . . . . . . . . . . . .652 14.4.12.7 Treatment . . . . . . . . . . . . . . . . . . . . . . 65614.4.10.2 Definition . . . . . . . . . . . . . . . . . . . . . .652 14.4.12.8 Differential Diagnosis . . . . . . . . . . .65614.4.10.3 Epidemiology/Aetiology . . . . . . . . .652 14.4.12.9 Prognosis . . . . . . . . . . . . . . . . . . . . . . . 65614.4.10.4 Symptoms . . . . . . . . . . . . . . . . . . . . . .653 14.4.13 Noonan Syndrome . . . . . . . . . . . . . . 65614.4.10.5 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 653 14.4.13.1 Synonyms . . . . . . . . . . . . . . . . . . . . . .65614.4.10.6 Differential Diagnosis . . . . . . . . . . .654 14.4.13.2 Definition . . . . . . . . . . . . . . . . . . . . . .65614.4.11 Marfans Syndrome . . . . . . . . . . . . . . 654 14.4.13.3 Epidemiology/Aetiology . . . . . . . . .65614.4.11.1 Synonyms . . . . . . . . . . . . . . . . . . . . . .654 14.4.13.4 Symptoms . . . . . . . . . . . . . . . . . . . . . .65614.4.11.2 Definition . . . . . . . . . . . . . . . . . . . . . .654 14.4.13.5 Complications . . . . . . . . . . . . . . . . . . 65714.4.11.3 Epidemiology/Aetiology . . . . . . . . .654 14.4.13.6 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 65714.4.11.4 Symptoms . . . . . . . . . . . . . . . . . . . . . .654 14.4.13.7 Treatment . . . . . . . . . . . . . . . . . . . . . . 65714.4.11.5 Complications . . . . . . . . . . . . . . . . . . 654 14.4.13.8 Differential Diagnosis . . . . . . . . . . .65714.4.11.6 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 655 References . . . . . . . . . . . . . . . . . . . . . .657 23. XXIXList of ContributorsAcosta, Stefan, MD, PhDBarbas, Maria Jos, MDDepartment of Vascular Surgery Hospital Garcia de OrtaMalm General Hospital Servico de Angiologia e Cirurgia VascularMalm, SwedenAlmada, Portugal(E-mail: stefan.acosta@telia.com)(E-mail: jose.barbas@clix.pt)Angelides, Nicos S., MDBastounis, Elias A., MD, PhDCardiovascular and Thoracic Unit First Department of SurgeryNicosia General Hospital Athens University Medical SchoolNicosia, CyprusAthens, Greece(E-mail: n_angelides@hotmail.com (E-mail: ebastoun@med.uoa.gr)Anagnostopoulos, Constantine E., MD, ScD Bell, Sir Peter, MDDepartment of Cardiothoracic Surgery University of LeicesterAthens University Medical School Department of SurgeryAthens, Greece Robert Kilpatrick BuildingandLeicester Royal InfirmaryColumbia UniversityLeicester, UKSt. Lukes/Roosevelt Hospital New York (E-mail: peterrfbell@ntlworld.com)New York, USA(E-mail: cea8@columbia.edu)Benedetti-Valentini, Fabrizio, MD Department of Vascular SurgeryAnagouras, Dimitrios C., MD, FETCS University of Rome La SapienzaDepartment of Cardiothoracic Surgery Rome, ItalyUniversity of Athens School of Medicine(E-mail: chvs.rm@flashnet.it)Attikon Hospital CenterAthens, Greece Berg, Patrick, MD(E-mail: dangouras@yahoo.com)Department of Vascular Surgery Centre Hospitalier LuxembourgBalas, Panagiotis E., MD (E-mail: berg.patrick@chl.lu)P. Psihico, Greece(E-mail: pbalas@otenet.gr) Bergqvist, David, MD, PhD, FRCS Department of Surgical SciencesBalzer, Klaus, MDUppsala University, HospitalDepartment of Vascular Surgery Uppsala, SwedenEvanglisches Krankenhaus Mlheim (E-mail: david.bergqvist@surgsci.uu.se)Mlheim/Ruhr, Germany(E-mail: klaus.balzer@evkmh.de) 24. XXXContributorsBiasi, Giorgio M., MCHiR, FACS, FRCS Carmo, Michele, MDDepartment of Surgical Sciences and Intensive Care Division of Vascular SurgerySchool of Medicine, University of Milan-BicoccaOspedale S. Carlo BorromeoSan Gerardo Hospital University of MilanMonza, Italy Milan, Italy(E-mail: giorgio.biasi@unimib.it)(E-mail: michele.carmo@unimi.it)Bjrck, Martin, MD, PhDCau, Jrme, MDDepartment of Vascular Surgery Vascular Surgery ServiceAcademic Hospital UppsalaUniversity Hospital Jean BernardUppsala, SwedenPoitiers, France(E-mail: martin@bjorck.pp.se)(E-mail: j.cau@chu-poitiers.fr)Black, Stephen A., MDChamogeorgakis, Themistocles, MDRegional Vascular Unit Department of Cardiothoracic SurgerySt. Marys HospitalUniversity of Athens School of MedicineLondon, UK Attikon Hospital Center(E-mail: drsablack@hotmail.com)Athens, Greece (E-mail: thchamogeorgakis@yahoo.com)van Bockel, J. Hajo, MD, PhDDepartment of Vascular Surgery Cormier, Jean-Michel, MDLeiden University Medical Centre Division Vascular SurgeryLeiden, The NetherlandsSt. Joseph-Hospital(E-mail: bockel@lumc.nl) Paris, France (E-mail: jm.cormier-vasc@wanadoo.fr)Brooks, Marcus J., MDRegional Vascular Unit Daenens, Kim, MDSt. Marys HospitalDepartment of Vascular SurgeryLondon, UK University Hospital Gasthuisberg(E-mail: marcus.brooks@btinternet.com) Leuven, Belgium (E-mail: kim.daenens@uz.kuleuven.ac.be)Cairols, Marc, MDServei dAngiologia I Cirurgia VascularDallatana, Raffaello, MDHospital Universitari de Bellvitge Division of Vascular SurgeryUniversity of BarcelonaOspedale S. Carlo BorromeoBarcelona, Spain Milan, Italy(E-mail: mcairols@csub.scs.es) (E-mail: rdallatana@libero.it)Camesasca, Valter, MDDaskalopoulos, Marios E., MSC, DIC, MDSchool of Medicine Department of Vascular SurgeryUniversity of Milan-BicoccaUniversity of Athens Medical SchoolSan Gerardo Hospital Athens, GreeceMonza, Italy (E-mail: daskalopoulos@mail.com)(E-mail: valter.camesasca@inwind.it) 25. Contributors XXXIDaskalopoulou, Stella S., MsC, DIC, MD, FASAFebrer, Guillaume, MDDepartment of Vascular SurgeryDepartment of Vascular SurgeryUniversity of Athens Medical School University HospitalAthens, GreecePoitiers, Franceand Department of Clinical Biochemistry and Surgery (E-mail: guillaume.febrer@gmail.com)Royal Free HospitalLondon, UKFernandes e Fernandes, Jos, MD(E-mail: stelladaskalopoulou@mail.com)Professor of Surgery and Chief of ServiceDepartment of Vascular SurgeryDe Angelis, Gianni A. T., MDHospital Santa Maria and Faculty of MedicineDivision of Vascular SurgeryDirector Instituto Cardiovascular de LisboaOspedale S. Carlo BorromeoLisbon, PortugalUniversity of Milan (E-mail: jmfernandes@fm.ul.pt; ffernandes@icvl.pt)Milan, Italy(E-mail: deangelis.gianni@libero.it)Fourneau, Inge, MDDepartment of Vascular SurgeryDefraigne, Jean-Olivier, MD University Hospital GasthuisbergDepartment of General and Human BiochemistryLeuven, Belgiumand Physiology, Centre Hospitalier Universitaire(E-mail: inge.fourneau@uz.kuleuven.ac.be)du Sart TilmanUniversity of Lige, BelgiumFraedrich, Gustav, MD(E-mail JO.Defraigne@ulg.ac.be) Department of Vascular SurgeryMedical University of InnsbruckDeleo; Gaetano, MDInnsbruck, AustriaSchool of Medicine(E-mail: gustav.fraedrich@uibk.ac.at)University of Milan-BicoccaSan Gerardo HospitalFroio, Alberto, MDMonza, ItalyVascular Surgery Unit(E-mail: gaetano.deleo@unimib.it) University of Milano-BicoccaSan Gerardo HospitalDimakakos, Panos B., MD Monza, ItalyVascular Department-B (E-mail: alberto.froio@unimib.it)Surgical ClinicAretaeion HospitalGeelkerken, Robert H., MDUniversity of Athens, Medisch Spectrum TwenteAthens, GreeceEnschede, The Netherlands(E-mail: bxei@aretaieio.uoa.gr) (E-mail: r.geelkerken@ziekenhuis-mst.nl)Dzsinich, Csaba, MD, PhDGeorgopoulos, Sotiris E.Department of Cardiovascular SurgeryFirst Department of SurgerySemmelweis University Athens University Medical SchoolBudapest, Hungary Athens, Greece(E-mail: csdzsinich@erseb.sote.hu)(E-mail: sgeorg@med.uoa.gr)Farghadani, Hirad, MDDepartment of Vascular SurgeryCentre Hospitalier Luxembourg(E-mail: hiradfarghadani@hotmail.com) 26. XXXIIContributorsGerasimidis, Thomas, MDHeikkinen, Maarit A., MDProfessor of Vascular SurgeryDivision of Vascular SurgeryHead of the Fifth Surgical ClinicTampere University Hospital and Tampere UniversityAristotle University of Thessaloniki Tampere, FinlandHippokrateio Hospital(E-mail: mheik@netti.fi)Thessaloniki, Greece(E-mail: gerasimi@med.auth.gr) Horrocks, Michael, MD Academic Department of SurgeryGiamarellou, Helen, MD, PhDRoyal United Hospital4th Department of Internal Medicine and Infectious Bath, UKDiseases (E-mail: profhorrocks@btclick.com)Athens University Medical SchoolUniversity General Hospital ATTIKONHorsch, Svante, MDAthens, Greece Department of Vascular and Endovascular Surgery(E-mail: hgiama@ath.forthnet.gr) Krankenhaus Porz am Rhein Porz, GermanyGiannopoulos, Aris M., MD(E-mail: prof.horsch@khporz.de)First Urology DepartmentUniversity of Athens Kakisis, John D., MDMedical School, Laiko Hospital 3rd Department of SurgeryAthens, Greece Attikon Hospital(E-mail: agiannop@med.uoa.gr)Athens, Greece (E-mail: kakisis@yahoo.gr)Golematti, Spyretta, MD, PhDBiomedical Simulations and Imaging LaboratoryKaramanos, DimitriosFaculty of Electrical and Computer Engineering Vascular SurgeonNational Technical University of AthensFifth Surgical ClinicAthens, Greece Aristotle University of Thessaloniki(E-mail: sgolemati@biosim.ntua.gr) Hippokrateio Hospital Thessaloniki, GreeceGossetti, Bruno, MD(E-mail: dkaramanos@in.gr)Department of Vascular SurgeryPoliclinico Umberto 1 Katsilambros, Nicholas, MDUniversity of Rome La Sapienza First Department of Propaedeutic MedicineRome, ItalyAthens University Medical School Laiko University HospitalGoulao, J., MD Athens, GreeceHospital Garcia de Orta(E-mail: laennec@techlink.gr)Servico de Angiologia e Cirurgia VascularAlmada, Portugal Kiskinis, Dimitrios A., MD, PhD(E-mail: joaogoulao@hotmail.com) Papageorgiou General Hospital Department of Vascular SurgeryGuillou, Matthieu, MDAristotle University of ThessalonikiDepartment of Vascular Surgery Thessaloniki, GreeceHospital Jean Bernard(E-mail: kiskinis@med.auth.gr)Poitiers, France(E-mail: matt.guillou@gmail.com) 27. Contributors XXXIIIKlocker, Josef, MDLaurito, Antonella, MDDepartment of Vascular SurgeryDepartment of Vascular Surgery and Service ofMedical University of Innsbruck Nuclear MedicineInnsbruck, AustriaPoliclinico Umberto I, La Sapienza University(E-mail: josef.klocker@uib.ac.at) Rome, ItalyKonstantinidis, KonstantinosLecis, Alexandre, MDVascular SurgeonDepartment of Vascular SurgeryFifth Surgical Clinic University Hospital Jean BernardAristotle University of ThessalonikiPoitiers, FranceHippokrateio Hospital (E-mail: a.lecis@aliceadsl.gr)Thessaloniki, GreeceLens, Vincent, MDKostakis, Alkiviadis, MDDepartment of Radiology and NeuroradiologyDepartment of Surgery Centre Hospitalier LuxembourgAthens University Medical School(E-mail: lens.vincent@chl.lu)Laiko Peripheral General HospitalAthens, GreeceLiapis, Christos D., MD, FACS, FRCS(E-mail: akostak@med.uoa.gr)Department of Vascular SurgeryUniversity of Athens Medical SchoolKotsis, Thomas E., MD Athens, GreeceVascular Department-B (E-mail: liapis@med.uoa.gr)Surgical Clinic Aretaeion HospitalSchool of Medicine, University of AthensLiloia, Angela, MDAthens, GreeceDepartment of Surgical Sciences and Intensive(E-mail: kotsisth@otenet.gr)Care, School of MedicineUniversity of Milan-BicoccaKtenidis, Kiriakos, MD, PhD, EBSQ-VASC. San Gerardo HospitalPapageorgiou General Hospital Monza, ItalyAss.Prof. Dr. K. Ktenidis (E-mail: angela.liloia@tiscali.it)Aristotle University of Thessaloniki1st Department of Surgery-Vascular SurgeryLimet, Raymond R., MDThessaloniki, GreeceDepartment of Cardiovascular Surgery(E-mail: kiriakos@dr-ktenidis.gr) University Hospital of LigeCHU Sart-TilmanLamont, Peter, MD, FRCS-EBSQ-VASC Lige, BelgiumConsultant Vascular Surgeon (E-mail: rlimet@ulg.ac.be)Bristol Royal InfirmaryBristol, UK Lindahl, Anne-Karin, MD(E-mail: Peter.Lamont@ubht.swest.nhs.u