Vascular Surgery Back to Basics

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Vascular SurgeryBack to Basics

• Dr. Sudhir Nagpal
• Division of Vascular Surgery
• The Ottawa Hospital

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OUTLINE

• Acute limb ischemia
• Claudication
• Critical limb ischemia
• Carotid Artery Disease
• Aortic Aneurysm
• Aortic dissection
• Varicose veins, Chronic venous insuffciency,
  Superficial thrombophlebitis

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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 1960s
• no h/o DM, CAD, HTN, dyslipidemia, stroke, CRF

Acute Limb Ischemia
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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 couldnt 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.

Acute Limb Ischemia
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Mrs. Witelegg

• What is Acute limb Ischemia?
• An abrupt cessation of arterial blood flow to an
  extremity resulting in hypoperfusion of tissue,
  threatening limb viability

Acute Limb Ischemia
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Mrs. Witelegg

• O/E
• She is in distress from pain in R leg
• BP140/90 mmHg, HR150 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)

Acute Limb Ischemia
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Mrs. Witelegg

• What are the 6 Ps of Acute Limb Ischemia
• Pain
• Palor
• Polar/poikilothermia
• Paraesthesia
• Paralysis
• Pulselessness

Acute Limb Ischemia
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Mrs. Witelegg

• Classify Acute Limb Ischemia. In which category
  is Mrs. Witelegg?

Acute Limb Ischemia
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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

Acute Limb Ischemia
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Mrs. Witelegg

• Before you call the vascular surgeon on-call,
  what test can you do at the bed side that can
  objectively assess acute limb ischemia?
• Ankle Brachial index
• Measure brachial pressure (example 160 mmHg)
• Measure ankle pressure (example 80 mmHg)
• Divide ankle by brachial pressure (exmple 80/160
  0.5 anything lt0.9 is abnormal)

Acute Limb Ischemia
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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

Acute Limb Ischemia
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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

Acute Limb Ischemia
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Mrs. Witelegg

• What medical therapy 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

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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 foot pinks
  up after blood flow is returned. There is a
  palpable DP and PT pulse.
• The patient is returned to the recovery room.

Acute Limb Ischemia
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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.

Acute Limb Ischemia
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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.

Acute Limb Ischemia
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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.

Acute Limb Ischemia
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Peripheral Vascular Disease
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Peripheral Vascular Disease

• Claudication
• Critical Limb Ischemic
• Rest pain
• Ulcers
• Gangrene

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Etiology

• blockages in arteries to lower extremities due to
  atherosclerosis
• Risk factors
• smoking
• DM
• HTN
• hyperlipidemia
• family history
• obesity
• sedentary
• male gender

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Clinical Features - Claudication

• Pain with exertion (usually calves)
• relieved by short rest - two to five minutes
• reproducible
• P/E
• hair loss, hypertrophic nails, atrophic muscle
• pulses may be absent at some locations

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Investigations

• Ankle Brachial Index
• Duplex
• Ct angio/ Angiogram

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Treatment

• CONSERVATIVE
• risk factor modification ( smoking cessation)
• exercise program
• cilostazol , Trental (Pentoxifylline)
• anti platelet (ECASA, clopidrogel) for MI /
  stroke risk
• Statin
• ACE inhibitor
• surgical
• indications claudication interfering with
  lifestyle
• options endovascular, PTA, arterial bypass
  grafts

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CRITICAL LIMB ISCHEMIA
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Clinical Features - Critical limb ischemia

• Pain at rest in foot, worse at night
• Improved with dependant postion
• Ischemic ulcers
• gangrene
• P/E
• Pulse deficits
• hair loss, hypertrophic nails, atrophic muscle
• ruborous foot

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Investigations

• Ankle Brachial Index
• Duplex ultrasound
• Ct angio/Angiogram

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Treatment

• Surgical
• bypass
• gortex vs vein
• Endovascular balloon angioplasty
• limited durability
• less morbid

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Cerebrovascular Disease
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CAROTID STENOSIS

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

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Presentation

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

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Investigations

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

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Management

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

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

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AORTIC DISSECTION
Vascular Surgery Back to Basics
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Definition

• spontaneous tear in aortic intima allowing blood
  to be driven between the aortic intima and media
• acute lt 2 weeks
• chronic gt 2 weeks

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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

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Etiology

• HYPERTENSION, usually uncontrolled
• TRAUMA, usually deceleration injury (falls, MVAs)
• other cystic medial necrosis, atherosclerosis,
  connective tissue disease (Marfans syndrome,
  Ehlers-Danlos syndromes), congenital conditions
  (coarctation of aorta, bicuspid aortic valves,
  PDA), infection, arteritis (Takayasus)

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Epidemiology

• incidence 5.2 in 1,000,000
• malefemale 31
• small increased incidence in African-Canadians
  (related to higher incidence of hypertension)
• lowest incidence in Asians

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Clinical Features

• SUDDEN ONSET SEVERE CHEST PAIN RADIATION TO THE
  BACK (INTERSCAPULAR) /-....
• hypertension
• asymmetric BPs and pulses between arms
• ischemic syndromes due to occlusion of aortic
  branches coronary (MI), carotid (stroke,
  Horners syndrome), splanchnic (ischemic gut),
  renal (kidney failure)
• unseating of aortic valve cusps (new diastolic
  murmur)
• rupture into pleura (dyspnea, hemoptysis) or
  peritoneum (hypotension, shock) or pericardium
  (tamponade)
• lower limb ischemia (cold legs)

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Investigations

• CT scan is gold standard
• CXR
• pleural cap
• widened mediastinum
• left pleural effusion with extravasation of blood
• TEE
• ECG LVH (90), /- MI, pericarditis, heart
  block
• aortography, MRI

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Treatment

• Type A
• EMERGENCY CARDIAC SURGERY
• 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
• Type B
• MEDICAL MANAGEMENT
• very rarely urgent operation for complications
  (expansion, rupture, gut/leg/renal ischemia,
  ongoing pain

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AORTIC ANEURYSM
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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

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Etiology

• DEGENERATIVE (matrix metalloproteinases)
• atherosclerosis association
• infection
• cystic medial necrosis
• trauma
• vascultitis
• connective tissue disease (Marfan syndrome,
  Ehlers-Danlos)

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Epidemiology

• incidence 5 to 32 per 100,000 for AAA
• high risk groups
• 65 years and older
• malefemale 41
• smokers
• peripheral vascular disease, CAD, CVD
• family history of AAA

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Clinical Features

• Vast majority ASYMPTOMATIC
• RUPTURE
• back pain
• hypotension/syncope
• pulsatile abdominal mass
• 100 mortality if untreated

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Investigations

• abdominal US (100 sensitive)
• CT
• Aortogram (false negative normal lumen size due
  to thrombus formation)

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Treatment

• Risk of rupture depends on size
• lt5 cm lt5 / yr
• 5-6 cm 10 / yr
• 6-7 cm 15-20 / yr
• gt7 cm gt20 / yr
• Risk of dying from aneurysm surgery 5

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Treatment

• Operate when
• AAA reaches 5.5 cm in an otherwise healthy
  individual
• gt5 mm expansion in 6 months
• symptomatic AAA
• Rupture
• contraindications life expectancy lt 1 year,
  terminal disease (cancer), significant
  co-morbidities (recent MI, unstable angina),
  severe dementia, advanced age

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Treatment Surgical

• Surgical options
• open surgery with graft replacement
• Endovascular aneurysm repair

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Ruptured Aortic Aneurysm

• EMERGENCY
• clinical diagnosis class diagnostic triad (50
  cases)
• sudden onset back pain
• shock (syncope/hypotension)
• pulsatile mass
• U/S in emerg or CT if stable
• IV access, start fluid resuscitation, cross and
  match
• EMERGENCY LAPAROTOMY and CLAMP AORTA
• Prognosis
• 100 mortality untreated, OR mortality rate 50
  90 total mortality

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Venous disease
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Venous Reflux
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Varicose veins
Ulceration
Hyperpigmentation
Lipodermatosclerosis
Ankle Flare
Stasis Dermatitis
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Varicose veins
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Definition

• distended torturous superficial veins due to
  incompetent valves in the deep, superficial or
  perforator systems
• distribution greater saphenous vein and
  tributaries

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Etiology

• primary
• main factor inherited structural weakness of
  valves
• contributing factors age, female, OCP use,
  occupations requiring long hours of standing,
  pregnancy, obesity
• secondary
• deep vein thrombosis
• congenital anomalies
• arteriovenous fistula

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Epidemiology

• 10 - 20 of the population
• gt50 over the age of 50

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Clinical Features

• History
• Ankle ache
• Fatigued legs
• swelling around the ankles
• aggravated by prolongued standing (end of day)
• P/E
• dilated and tortuous superfical veins
• Brodie-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

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Trendelenberg test
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Complications

• Usually benign natural history
• Most are cosmetic concerns
• recurrent superficial thrombophlebitis
• Up to 15 of venous ulcers can be from
  superficial vein incompetence

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Investigations

• Duplex ultrasound to assess...
• reflux of blood at sapheno-femoral junction

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Reflux (with Valsalva)
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Treatment

• Compression stocking therapy
• Saphenous vein stripping surgery
• disabling symptoms
• Laser vein ablation
• Foam sclerotherapy

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Chronic Venous Insufficiency
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Definition

• chronic elevation of deep venous pressure and
  blood pooling in lower extremities

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Etiology

• valvular incompetence may be due to a previous
  DVT many years ago
• chronic venous obstruction
• calf muscle pump dysfunction

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Clinical Features

• ankle ache and edema - relieved by foot elevation
• hyperpigmentation (hemosiderin deposits)
• ulceration
• shallow and irregular
• above medial malleolus

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Investigations

• duplex ultrasound to assess
• Reflux at sapheno-femoral junction
• Deep system incompetence
• chronic occlusion from an old DVT/trauma
• Venogram

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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

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Superficial Thrombophlebitis
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Definition

• inflammation secondary to acute thrombosis of a
  superficial vein usually the greater saphenous
  vein

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Etiology

• varicose veins
• migratory superficial thrombophlebitis
• hematologic hypercoag state, polycythemia,
  thrombocytosis
• neoplastic occult malignancy (especially
  pancreas)
• idiopathic

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Clinical Features

• Usually involves GSV and its branches
• pain
• swelling along course of involved vein
• erythema
• warmth

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Investigations

• Ultrasound to exclude associated DVT (5 - 10)

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Treatment

• CONSERVATIVE
• moist heat, compression bandages
• anti-inflammatory and anti-platelet (ASA)