Vascular Surgery Cases: Detours - Home - NCUSncus.org/files/fall2016/stull2.pdf · Ax-Fem Bypass...
Transcript of Vascular Surgery Cases: Detours - Home - NCUSncus.org/files/fall2016/stull2.pdf · Ax-Fem Bypass...
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Vascular Surgery Cases: Detours
Brian F. Stull, RDMS, RVT
UNC REX Healthcare
Vascular Specialists
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Objectives• Anatomy of a bypass graft
• Where does it connect, where does it course?
• How to approach and perform duplex exams on bypass grafts
• What do grafts look like by duplex?
• What can I expect to find when I perform an exam?• What does normal look like?
• What does abnormal look like?
• Examples of graft surveillance and maintenance
• What happens when grafts fail?
Diagnosis and Treatment of Chronic Arterial Insufficiency of the Lower Extremities: A Critical ReviewJeffrey I. Weitz, MD, Chair; John Byrne, MD; G. Patrick Clagett, MD; Michael E. Farkouh, MD; John M. Porter, MD; David L. Sackett, MD; D. Eugene Strandness, Jr, MD; Lloyd M. Taylor, MD
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Reasons for a Bypass?
•Critical Limb Ischemia with no other options (stenting, angioplasty)
•Non-healing wound(s)
•Poor position for stenting
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First Things First…… Know Who You Are Dealing With
Who is the more likely person to have a bypass graft?
The patient will have more than one level of disease, very likely
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Where do I start?!?!
• OPERATIVE REPORT!!! Without it you’re hunting
• Previous duplex exam. WINNER!
• Always refer to your protocol; however, these are the levels that must be evaluated
• Inflow Artery
• Proximal Anastomosis• Bypass Conduit
• Distal Anastomosis
• Outflow Artery
• If any one point is faulty there is a danger for failure
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Some Common Criteria
• Peak Systolic Velocities, “Normal” >50 to <200 cm/s
• Change in ABI at follow up 30% < or > previous
• PSV abnormal Low <45 cm/s*
• PSV abnormal High >200cm/s
• 50-75% stenosis Ratio >1.5 to 3.5
• 75+% stenosis Ratio >3.5
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First you have to know what “normal” is
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Inflow Artery: It all starts here
In lower extremity inflow is usually via common femoral artery
But not always…….
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Proximal Anastomosis: Get off to a good start
Gray scale image looking
for abnormalities, thrombosis,
Intimal hyperplasia
Color Doppler looking
for filling defects or flow
outside graft at anastomosis
PW Doppler documenting
flow velocities
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Bypass Conduit: Need a good clean path
Interrogate the entire graft, anastomosis to anastomosis in gray scale and in both color and pulsed wave Doppler
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Bypass Conduit Transverse Interrogation
Transverse views are critical to look for defects or abnormal courses.
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Distal Anastomosis: Have to end well too
Same as with the proximal anastomosis, Doppler and gray scale
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Outflow Vessel: This is the landing zone
Just like having adequate inflow is necessary, so is adequate outflow
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How do they do that? Magic?
Nope: TUNNELLING
Oh, so like this?
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No, that would end up more like this….
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Exactly like this….. Need a nice tight fit
Dr. Bobby Mendes, REX Vascular Specialists
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Bypass Graft Examples
Axillo-Bi-Fem
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PTFE and VEIN Graft Duplex Appearance
Vein Graft
PTFE Graft
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Carotid to Subclavian BypassReally? Yes, really
Occluded subclavian with inadequate collateral flow to arm
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Approaching an Incision = Scar Tissue
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Angle back into the incision from the side
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Following an Axillary to Fem-Fem Bypass Graft Patient• History of failed Aorta Bi-Fem bypass graft
• Left axillary to left femoral bypass graft with left to right fem-fem bypass graft
• June 2015 stenting of the proximal anastomosis due to stenosis
• February 2016 duplex shows subclavian stenosis with retrograde left vertebral artery flow, and stenosis in stent in the proximal bypass graft, patient had knee replacement and is minimally ambulatory, intervention is scheduled
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Duplex and Angio Findings Differ on Subclavian Steal
• Duplex shows subclavian stenosis with steal from the vertebral artery
• Angiography shows no evidence of subclavian stenosis What??
336.1cm/s
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Duplex and Angio Findings of Proximal Anastomosis/Stent Stenosis
• Velocity increase from 155.6cm/s PSV to
400.3cm/s PSV is >2.0 consistent with at
least a 50% stenosis
• Balloon angioplasty performed
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Ax-Fem Bypass Surveillance
• July ABIs: Right 0.91 Left 0.89
• Patient asymptomatic
• No intervention, follow up in 3 months
• October ABIs: Right 0.64 Left 0.62
• Patient having claudication
• Stenosis identified at proximal anastomosis
• Intervention scheduled
412.7cm/s PSV
=>200cm/s PSV & 2.33 Ratio
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SFA to Posterior Tibial Artery Bypass using Saphenous Vein
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Distal Anastomosis
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Bypass Outflow (run-off) Vessel
402cm/s PSV
117cm/s EDV
WRONG
68.2cm/s PSV
18.9cm/s EDV
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Angiography and Balloon Angioplasty
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Duplex Exam Status Post Intervention: Prox Anastomosis
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Duplex Exam Status Post Intervention: Distal Anastomosis and Outflow Vessel
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Fem-PTA: Saphenous Vein to PTFE Jump Graft
44.6cm/s PSV
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Edema in Tunneled track causing Extrinsic Compression
52.8cm/s PSV 252.1cm/s PSV
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Saphenous Vein to PTFE Jump to Posterior Tibial Artery
41.0cm/s PSV7.0cm/s PSV
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PTFE Jump to Posterior Tibial Anastomosis
77.1cm/s PSV
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To Intervene or not to Intervene?
• Surgery costs money
• People don’t like having surgery
• Patient’s wounds are healing, no other symptoms
• Let’s watch it and see how it does
• Come to the Emergency Department with onset of new symptoms (i.e. Pain, cold foot)
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Emergency Department 3 days later………dangit!
Thrombosed due to low flow state
Proximal Anastomosis PTFE at Distal aspect of bypass
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Sometimes you just can’t see much
Iliac to SMA bypass Prox Anastomosis
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Unfortunately it is usually just a matter of time
April September
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Thrombosed graft with compression
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NOTES……
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NOTES……