Heart or vascular Surgery at the Heart & Vascular Institute.
Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa...
-
Upload
madison-stanley -
Category
Documents
-
view
241 -
download
6
Transcript of Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa...
![Page 1: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/1.jpg)
Vascular SurgeryBack to Basics
Dr. George E. Hajjar
Vascular and Endovascular Surgery
The Ottawa Hospital
![Page 2: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/2.jpg)
OUTLINE
• Peripheral vascular disease• Acute limb ischemia• Mesenteric ischemia• Aortic dissection • Aortic Aneurysm• Varicose veins• Chronic venous insuffciency
![Page 3: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/3.jpg)
Peripheral Vascular Disease: PVD• Atherosclerotic disease involving the lower extremities
• Predisposing factors: smoking, male gender, hypercholesterolemia, HBP, Family history, and diabetes.
• Marker of generalized arterial involvement. Cardiac, renal, mesenteric cerebrovascular.
• Most commonly involves:Aorotiliac segment in younger patients 45-55Fem-pop segment in 55-75Tibioperoneal segments 75 + and diabetics
• Symptoms: usually claudication, can progress to rest pain and gangrene if risk factors are not controlled.
![Page 4: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/4.jpg)
Clinical Features - Claudication
• Pain (cramping, weakness in legs) with exertion.*Buttocks and thighs if AI segment is involved*Calves if SFA is involved*In step of foot if tibial segment is involved
• Relieved by short rest • Reproducible • Physical exam:
Chronic arterial skin changesRubor on dependency/Pallor on elevation ( Buerger sign)Absent pulses
![Page 5: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/5.jpg)
Clinical Features - Claudication
What is Le Riche Syndrome in PVD:
• A. Pain in both hips when walking• B. Pain and gangrene in both feet .• C. Impotence due to pudendal artery blockage• D. Bilateral thigh claudication with impotence
![Page 6: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/6.jpg)
Leriche syndrome
• Bilateral buttock or lower leg claudication
• Impotence
• Caused by poor arterial flow through aortoiliac segment
• Hypoperfusion of the internal iliacs
![Page 7: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/7.jpg)
PVD: Clinical signs• Rubor on dependency
pooling of blood in foot due to lack of pressure, and increased capillary dilatation
• Foot is cold. Often mistaken for cellulitis.
• Trophic skin changes
![Page 8: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/8.jpg)
PVD: Investigation
• Clinical exam and documentation of pulses
• Nonivasive:(diagnose and screen)Ankle/brachial pressure index: ABIDuplex scan
• More Invasive: (Plan for treatment)CTAAngiogram
![Page 9: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/9.jpg)
ABI:
• Normal ABI is 1• Helps in diagnosing PVD, quantifies the degree, monitors disease
progression, and assesses success of intervention.• Inacurate in diabetics and severely calcified distal vessels that cannot
be occluded by a pressure cuff.• Can be misleading in patients with subclavian artery stenosis
![Page 10: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/10.jpg)
Question
Which of the following statements about ABI is incorrect:
• A. Easily reproducible• B. Monitors therapy• C. Quantifies degree of disease• D. Might give a false positive result• E. Determines the location of arterial occlusion
• Answer E
![Page 11: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/11.jpg)
PVD : Approach to treatment.
• Determine degree of impairment and unmask other systems cardiac, cerebral etc…that might be involved
• A. Claudication: social, economical, Activity of daily living (ususally treated conservatively)B. Rest pain: Pain at night in foot when leg is elevated. Frequent awakening , relieved by garvity and hanging foot over the edge of the bed.C. Tissue loss or gangrene.
• Rest pain and tissue loss usually treated surgically
![Page 12: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/12.jpg)
Treatment
• CONSERVATIVE• risk factor modification. Cessation of smoking. Good hyperglycemic control,manage
hypercholesterolemia• exercise program , walking.• anti platelet (ECASA, clopidrogel) for MI / stroke risk• Follow up.
• surgical• Minimally invasive ( Angioplasty/stent..) less morbid less durable• Bypass surgery :more invasive, better durability.
![Page 13: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/13.jpg)
Question:
Which statement about patients with claudication is TRUE:
A. They will progress to severe ischemia and limb loss if not surgically treated early.
B. Despite adequate risk factor control, progression is inevitableC. Eventual limb loss is seen in 40-50% of the cases if followed long enoughD. About 50% will experience a cardiac event in five years follow up
![Page 14: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/14.jpg)
Acute Limb Ischemia
![Page 15: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/15.jpg)
Acute Limb Ischemia
Mrs. Witelegg
• ID:• 75 yo lady who lives by herself in an apartment. She is active,
walks her dog ~2 kms daily without any difficulty. She takes pride in the fact that she has not needed to see a doctor in the last 10 years.
• PMHx/PMSx:• remote TAH-BSO• social smoker quit in the 1960’s• no h/o DM, CAD, HTN, dyslipidemia, stroke, CRF
![Page 16: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/16.jpg)
Acute Limb Ischemia
Mrs. Witelegg
• HPI:• While watching TV, she had sudden onset of numbness
in her right leg. Her leg felt “like it went dead”, and she couldn’t ambulate. After a few minutes she experienced constant, severe pain starting in the toes, eventually involving the entire right leg. She called her neighbor and then brought her in to the Civic emergency department.
![Page 17: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/17.jpg)
Acute Limb Ischemia
• What is acute limb ischemia?• Sudden interruption of blood flow to the extremities threatening
its viability
• Causes:
a. Arterial embolus
b. Trauma: penetrating, blunt, iatrogenic
c. Arterial graft occlusion
![Page 18: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/18.jpg)
Acute Limb Ischemia
Differs from PVD:
• A. No collateral circulation
• B. Profound ischemia
• C. Severe pain
• D. Permanent limb damage/ loss is inevitable if not treated
• E. Acute vascular emergency.
![Page 19: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/19.jpg)
Acute Limb Ischemia
Acute leg ischemia clinical signs:
• The six Ps:
1. Paraesthesia
2. Pallor
3. Pain
4. Poikilothermia(Polar
5. Paralysis
6. Pulselessness
![Page 20: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/20.jpg)
Acute Limb Ischemia
Mrs. Witelegg
• O/E– She is in distress from pain in R leg– BP:140/90 mmHg, HR:150 bpm– pulse: irregularly irregular– Normal heart sounds, good a/e bilat– No pulsatile masses in her abdomen– No carotid, abdominal or femoral bruits– Pulses:
• L: + femoral, + politeal, + DP, + PT• R: - femoral, - popliteal, - DP, - PT
– R foot is colder and paler than L– Decreased sensation in R foot– Able to move toes but difficulty with
plantar and dorsi flexion– Absence of trophic changes in her lower
extremities (no hair loss, thickened nails, or thin, flaky or shiny skin)
![Page 21: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/21.jpg)
Acute Limb Ischemia
Acute leg ischemia clinical signs:
• Degrees of Acute Limb Ischemia.
• 6-8 hrs critical time of reversible ischemia.Class Sensory deficit Motor deficit Prognosis
1 None None Not immediately threatened
2a Mild-moderate None Salvageable if treated promptly
2b Significant Mild-moderate Salvageable if immediately treated
3 Profound Profound Irreversible limb damage- likely amputation
![Page 22: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/22.jpg)
Acute Limb Ischemia
Mrs. Witelegg
• Your working diagnosis is acute limb ischemia.
• You order CBC, electrolytes, BUN, Cr, PTT/INR (all of which comes back normal), type and cross-match blood, and a saline infusion is started.
• CXR is unremarkable
• ECG is as follows:
![Page 23: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/23.jpg)
Acute Limb Ischemia
Mrs. Witelegg
• What is the most likely etiology of ALI in Mrs. Witelegg?• Cardiogenic embolism
• What in her history and physical supports this diagnosis?• Lack of atherosclerotic risk factors• no previous claudication (she walked her dog 2 km/day)• Irregularly irregular pulse• Completely normal left extremity pulses
• Based on her physical examination, what is the highest point of obstruction of arterial flow?
• R ileo-femoral region
• How long can a limb be without blood flow before irreversible tissue damage ensues?
• 4-6 hrs
![Page 24: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/24.jpg)
Acute Limb Ischemia
Mrs. Witelegg
• What is the surgical management of this condition?
• R femoral embolectomy
• Can we proceed to the OR without any imaging studies? If not what studies can be perfomed?
• Because of the classic history and physical findings, and because of the presence of class 2b ischemia, immediate surgery is indicated without delay for imaging.
• Angiography can be performed in certain conditions of ALI– when the suspected etiology is arterial thrombosis (i.e. in
preparation for bypass surgery)– when the patient has class 1 or 2a ischemia
![Page 25: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/25.jpg)
Mrs. Witelegg
• What medical therpay is available for ALI and when is it indicated?
• Lytic therapy (i.e. with t-PA) is used to dissolve the clot. It is a good option in the setting of acute arterial or graft thrombosis. It is not indicated in the setting of trauma or when the patient can not wait more than 24-48 hrs, as the therapy requires that period of time for clot dissolution. ( i.e. class 1 or early 2a ischemia)
• IV Heparin will not dissolve the clot but will prevent further propagation, and is only indicated if there is a delay to surgery
![Page 26: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/26.jpg)
Acute Limb Ischemia
Mrs. Witelegg
• The patient is booked for emergency embolectomy
• Under local anaesthesia, a small incision is made over the R groin. The femoral artery is exposed and controlled with vessel loops. A small arteriotomy is made and the clot is removed proximally and distally using a fogarty balloon embolectomy catheter.
• The arteriotomy is repaired and the foots “pinks up” after blood flow is returned. There is a palpable DP and PT pulse.
• The patient is returned to the recovery room.
![Page 27: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/27.jpg)
Acute Limb Ischemia
Mrs. Witelegg
• At 3 am you get paged by the recovery room nurse. Mrs. W is complaining of significant pain in her leg, it is more swollen and the DP and PT are no longer palpable.
• In addition, her urine output has diminished and she is peeing out dark urine which tested positive for “blood” on the urine dipstick.
![Page 28: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/28.jpg)
Acute Limb Ischemia
Mrs. Witelegg
• What is happening to Mrs. W?
– Reperfusion syndrome: occurs as a result of blood flow going back into previously damaged tissue, causing rhabdomyolysis and compartment syndrome..
• Rhabdomyolysis: Liberated myoglobin from dead muscle cells enters the blood stream resulting in renal tubular obstruction and direct nephrotoxicity causing renal failure. Myoglobinuria is a false positive on the urine dipstick test for blood.
• Compartment syndrome: Free oxygen radicals are created with reperfusion. These result in increased tissue edema, with in the limited facial compartments of the lower leg, this further decreases capillary blood flow and worsens the ischemia and tissue damage, causing further edema. Pain out of proportion, pain on passive stretch and high pressures in the compartments suggests compartment syndrome.
![Page 29: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/29.jpg)
Acute Limb Ischemia
Mrs. Witelegg
• How should reperfusion syndrome be managed?
– Compartment syndrome is a surgical emergency and is managed by 4-compartment fasciotomies.
– Rhabdomyolysis should be managed with aggressive IV fluids, diuresis and alkalinization of urine.
![Page 30: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/30.jpg)
Question:• Ischemia reperfusion syndrome is characterised by all of the
following EXCEPT:
• A. Leg swelling• B. Pain on passive dorsiflexion of the foot• C. Oliguria• D. Hypokalemia• E. High CK levels
![Page 31: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/31.jpg)
Mesenteric ischemia
• Classification :
• Acute: embolic, thrombotic, dissecting• Chronic: atherosclerotic• Low flow: cardiogenic shock, vasopressors• Venous: Hypercoagulable , Pancreatitis, intraabdominal Ca,
cirrhosis.
![Page 32: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/32.jpg)
Mesenteric ischemia: presentation• Acute :
sudden onset of severe abdominal pain, out of proportion to physical findings.Soft abdomen early on, later might develop signs of rigidity and peritonitisSilent abdomenMedical emergency. Early recognition and treatment prevents intra-abdominal
catastrophy and reduce amount of bowel loss.• Chronic:
Chronic abdo pain,usually post prandial.Classic triad: post prandial abdo pain, weight loss, and food phobia.Treatment usually surgical interventional vs bypass
• Low flow:Usually sicker patients. ICU /CCU settingon massive ionotrops hemodynamic or septic shockTreatment is usually supportive, improving hemodynamics and treating underlying cause
![Page 33: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/33.jpg)
Mesenteric ischemia: Investigations
• Plain abdominal films:Usually not very helpful early on.Calcifications may be seen in chronic mesenteric disease
• Later stages may show:Thickening of bowel loops and thumb printing, air fluid levelsFree intraperitoneal air, air in bowel wall (pneumatosis intestinalis) air in portal vein signal advanced ischemic bowel and intestinal gangrene.
![Page 34: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/34.jpg)
Mesenteric ischemia: Investigations• CTA :
Most useful.Shows bowel perfusionmesenteric vessels.Helps in finding etiology: Thrombotic/embolic/dissectionetc…better sensitivity to other all other findings: pneumatosis, thickening , intra-abdominal fluids etc..
• Angiography:provides diagnostic and therapeutic optionvasodialator infusion to relieve spasmplanning intervention in chronic ischemia. Operative vs stenting.
![Page 35: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/35.jpg)
Mesenteric ischemia: Question• In the early stages of acute superior mesenteric artery
occlusion the most common findings are:
A. severe abdominal painB. guarding and reboundC. absent bowel sounds D. bowel edema on plain xrayE. A and D onlyF. A and C onlyG. all of the above
• Answer: F
![Page 36: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/36.jpg)
Mesenteric ischemia: Question• The classic triad in chronic mesenteric ischemia includes which of the
following:
A. Post prandial abdo pain B. Post prandial diarrheaC. ConstipationD. Weight lossE. NauseaF. Post prandial vomitingG. Fear of eating
• Answer A, D, and G
![Page 37: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/37.jpg)
![Page 38: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/38.jpg)
AORTIC DISSECTION
Vascular Surgery – Back to Basics
![Page 39: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/39.jpg)
Definition
• spontaneous tear in aortic intima allowing blood to be driven between the aortic intima and media
– acute < 2 weeks– chronic > 2 weeks
![Page 40: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/40.jpg)
Etiology
• HYPERTENSION, usually uncontrolled
• TRAUMA, usually deceleration injury (falls, MVAs, Iatrogenic catheter manipulation)
• other: cystic medial necrosis, atherosclerotic ulcer, connective tissue disease (Marfan’s syndrome, Ehlers-Danlos syndromes), congenital conditions (coarctation of aorta, bicuspid aortic valves, PDA)
![Page 41: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/41.jpg)
Epidemiology
• incidence 5.2 in 1,000,000• male:female = 3:1• small increased incidence in African-Canadians (related to
higher incidence of hypertension)• lowest incidence in Asians
![Page 42: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/42.jpg)
Classification
• DeBakey
• Type I - involves ascending and descending aorta
• Type II - ascending aorta only• Type IIIA - descending thoracic
aorta• Type IIIB - Type IIIA plus
abdominal aorta
• Standford
• Type A - ascending aorta and aortic arch; emergency
• Type B - aorta distal to subclavian artery; emergency surgery if complications of dissection
![Page 43: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/43.jpg)
Clinical Features• SUDDEN ONSET SEVERE “TEARING” CHEST PAIN
RADIATION TO THE BACK (INTERSCAPULAR)
• severe hypertension• asymmetric BP’s and pulses between arms• ischemic syndromes due to occlusion of aortic branches:
coronary (MI), carotid (stroke, Horner’s syndrome), splanchnic (ischemic gut), renal (kidney failure) ischemic legs with iliac involvement.
• “unseating” of aortic valve cusps (new diastolic murmur)• rupture into pleura (dyspnea, hemothorax) or peritoneum
(hypotension, shock) or pericardium (tamponade)
![Page 44: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/44.jpg)
Investigations
• CT scan is the gold standard
• CXR• pleural cap• widened mediastinum• left pleural effusion with extravasation of
blood
• TEE• ECG: LVH (90%), +/- MI, pericarditis, heart block• aortography, MRI Usually not needed.
![Page 45: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/45.jpg)
Treatment
• Type A• may require putting patient on pump, hypothermic circulatory arrest, valve
replacement, coronary re-implantation of aortic root
• resection of intimal tear, reconstitution of flow through true lumen, replacement of the affected aorta with graft
• EMERGENCY CARDIAC SURGERY
• Type B• MEDICAL MANAGEMENT
monitoring in intensive care settingstrict BP controllong term follow up needed, to monitor for aortic wall aneurysmal degeneration
• very rarely urgent operation for complications (expansion, rupture, gut/leg/renal ischemia, ongoing pain)
• New treatment with stenting being assessed as a preferred modality of Rx.
![Page 46: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/46.jpg)
Aortic dissection: question
• Which of the following is least likely to be associated with Thoracic aortic dissection:
• A. severe chest painB. severe abdo painC. oliguriaD. Ischemic legE. anisocoria F. left sided hemiplegia and absent right radial pulseG. E and FE. all of the above can be a feature of aortic dissection
• Answer is E
![Page 47: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/47.jpg)
![Page 48: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/48.jpg)
Definition• localized dilation of an artery that
is 2 x its normal diameter
• true aneurysm: involving all vessel wall layers
• false aneurysm: disruption of aortic wall with containment of blood by some layers of the aorta or a fibrous capsule made of surrounding tissue (penetrating trauma, infections, contained perforated aortic ulcer)
![Page 49: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/49.jpg)
AORTIC ANEURYSM
![Page 50: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/50.jpg)
Etiology
• ATHEROSCLEROTIC association most common• DEGENERATIVE (matrix metalloproteinases)
• infection• cystic medial necrosis• trauma• vascultitis• connective tissue disease (Marfan syndrome, Ehlers-Danlos)
![Page 51: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/51.jpg)
Epidemiology
• incidence 5 to 32 per 100,000 for AAA
• high risk groups:• 65 years and older• male:female = 4:1• smokers• peripheral vascular disease, CAD, CVD• family history of AAA
![Page 52: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/52.jpg)
Clinical Features
• Vast majority ASYMPTOMATIC.Incidental finding
• RUPTURE• back pain• hypotension/syncope• pulsatile abdominal mass• ~100% mortality if untreated, 50% mortality with surgery
2-4% mortality if treated electively
• Triad: back pain, hypotension, syncope = ruptured AAA until proven otherwise.
![Page 53: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/53.jpg)
AAA diagnosis.• Clinical exam unreliable in mid to large frame patients.
• Usually identified on US for other problems(Prostate, Cholecystitis, other abdominal patjologies), very sensitive
• Lumbar spine x-ray can show calcifications in the aneurysm wall in up to 50% of cases
• CTA, MR very sensitive but not readily available
• Angiography: invasive, can have a significant false negative and does not adequately estimate outer aortic wall diameter.
![Page 54: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/54.jpg)
![Page 55: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/55.jpg)
AAA: ScreeningThe best screening modality for AAA is :
A. CTA since it is highly sensitive, and specific
B. Angiography since it has the highest specificity
C. If not clinically palpated with a good physical exam no other testing is needed
D. Ultrasonography is the best screening tool
E. A lumbar plain xray is the cheapest and most effective screening modality
![Page 56: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/56.jpg)
AAA: Screening
• Answer: D• US remains the least invasive, very sensitive, readily available, easily reproducible, and
most cost effective tool for screening AAA, with high specificity and sensitivity
![Page 57: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/57.jpg)
AAA: Screening. Who?• All males over 65Years of age.• Recent studies in UK showed yield not as high as expected.
• CSVS recommendations:*all males over 65YO*Females over 65 with:first a degree relative with AAASmokers.
• “Selective” screening:any person over 65 YO with :*with first degree relative with an AAA*who ever smoked
![Page 58: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/58.jpg)
Natural history• Greatest risk is rupture• Distal embolization
• Occlusion
• Risk of rupture depends on size• <5 cm <5% / yr• 5-6 cm 10% / yr• 6-7 cm 15-20% / yr• >7 cm >20% / yr
• Risk of dying from aneurysm surgery = 3~5%Largely due to CAD
![Page 59: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/59.jpg)
Treatment
• Operate when
• AAA reaches 5.5 cm in an otherwise healthy individual
• >5 mm expansion in 6 months• symptomatic AAA• Rupture
• contraindications: life expectancy < 1 year, terminal disease (cancer), significant co-morbidities (recent MI, unstable angina), severe dementia, advanced age
![Page 60: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/60.jpg)
Treatment
![Page 61: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/61.jpg)
Treatment: Surgical
• open surgery with graft replacement*proven durability*higher rate of peri-op complications*longer hospital stay, gen anaesthesia*no need for long term follow up
• Endovascular aneurysm repair
*less morbidity, less mortality 2%vs 4% (endoleak, graft limb occlusion)*Shorter hospital stay, regional or local anaesthesia, percutaneous *higher rate of intervention*continued need for follow up and repeat CT scan or US
• Cost?
![Page 62: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/62.jpg)
Venous disease
![Page 63: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/63.jpg)
Venous anatomy of the leg
• Superficial system: Long and short saphenous
• Deep system: usually parallels the arterial supply
• Perforator system: communicates superficial to deep system.
•
![Page 64: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/64.jpg)
Venous flow
• Normal flow: Distal to proximal , superficial to deep• Controlled by:• The muscle pump• Competent valves• Gravity• Central obesity and increased intra-abdominal pressure• Pregnancy• Increased intrathoracic pressure, CHF, COPD• Venous obstruction, Clot, tumor.
![Page 65: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/65.jpg)
Varicose veins: Definition
• distended torturous superficial veins due to incompetent valves in the deep, superficial or perforator systems
• distribution: greater or lesser saphenous vein and tributaries
![Page 66: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/66.jpg)
Etiology
• primary• main factor: inherited structural
weakness of valves• contributing factors: age, female,
occupations requiring long hours of standing, pregnancy, obesity
• Secondary• deep vein thrombosis, tumors, trauma• congenital anomalies :arteriovenous fistula
![Page 67: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/67.jpg)
Epidemiology
• 10 - 20% of the population
• >50% over the age of 50• F>M
![Page 68: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/68.jpg)
Clinical Features
• History • Ankle ache• Fatigued legs• swelling around the ankles• aggravated by prolonged standing (end
of day)
• P/E• dilated and tortuous superfical veins • Trendelendberg test • raise leg and compress saphenous vein
at thigh; have patient stand; if vein fills quickly from top down then incompetent valves; use mulitple tourniquets to localize incompetent veins
![Page 69: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/69.jpg)
Symptomatology:
• Usually benign natural history
• Most are cosmetic concerns
• Ache, heaviness, fatigue and Leg swelling
• recurrent superficial thrombophlebitis, painful but benign.
• hemorrhage: external or subcutaneous
• rarely leads to venous stasis changes causing ulcerations
![Page 70: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/70.jpg)
Investigations
• Physical exam, Trendelenburg test
• Duplex ultrasound to assess...• reflux of blood at sapheno-femoral junction• Deep venous incompetence• Perforator incompetence
• Descending venography
![Page 71: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/71.jpg)
Treatment
• Compression stocking therapy
• Saphenous vein stripping surgery • disabling symptoms
• Laser vein or radio frequency ablation less invasive• Principle of treatment:
stop the refluxremove or ablate the conduitexcise or sclerose the varicosities.
![Page 72: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/72.jpg)
Superficial thrombophlebitis:Clinical Features
• Usually involves GSV and its branches
• pain and swelling along course of involved vein
• Erythema and warmth• An inflammatory process• Very rare risk of PE, no need for
anticoagulation• Rx : Anti-inflammatory meds• Recurrent migrating thrombophlebitis:
rule out hypercogulable states, malignancy, or sepsis
![Page 73: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/73.jpg)
Chronic Venous Insufficiency: Definition
• chronic elevation of deep venous pressure and blood pooling in lower extremities leading to venous hypertension
![Page 74: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/74.jpg)
Etiology
• valvular incompetence usually due to a remote DVT.
• chronic venous obstruction
• Venous hypertension
• Secondary varicose veins
• calf muscle pump dysfunction
![Page 75: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/75.jpg)
Clinical Features
• ankle ache and edema - relieved by foot elevation
• Chronic congestion: leads to • hyperpigmentation (hemosiderin
deposits)• Proteinaceous subcutaneous tissue
accumulation, inflammation,dermatosclerosis, fibrous tissue , capillary constriction in the dermis and skin ischemia
• ulceration– shallow and irregular– Medial aspect of lower leg (Gaitor
area)– Can be very painful, difficult to heal
![Page 76: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/76.jpg)
Investigations
• duplex ultrasound to assess
• Reflux at sapheno-femoral junction
• Deep system incompetence
• chronic occlusion from an old DVT/trauma
• Descending venogram
![Page 77: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/77.jpg)
Treatment
• CONSERVATIVE
• compression stockings/layered compression bandages• leg elevation, avoid prolonged standing
• surgical• surgical ligation of perforators in region of ulcer, greater
saphenous vein stripping if incompetent
![Page 78: Vascular Surgery Back to Basics Dr. George E. Hajjar Vascular and Endovascular Surgery The Ottawa Hospital.](https://reader036.fdocuments.net/reader036/viewer/2022081503/56649e4b5503460f94b3f3de/html5/thumbnails/78.jpg)
•GOOD LUCK