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VASCULAR SURGERY

VASCULAR SURGERY. Cerebrovascular Disease. CAROTID:. Presentation : Asymptomatic : Bruit (only 20% hemodynamically significant lesion) Screening prior to other surgery. Presentation:. Symptomatic: TIA, Stroke Amaurosis fugax ipsilateral to carotid lesion

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VASCULAR SURGERY

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  1. VASCULAR SURGERY

  2. Cerebrovascular Disease

  3. CAROTID: Presentation: • Asymptomatic: • Bruit (only 20% hemodynamically significant lesion) • Screening prior to other surgery

  4. Presentation: • Symptomatic: • TIA, Stroke • Amaurosis fugax ipsilateral to carotid lesion • Contralateral motor or sensory deficit • Facial droop • Dyshasia or aphasia

  5. Investigations • Duplex Scan • CT scan - confirm or r/o infarct • CT/Angio – Confirm U/S plan OR • MRA – Similar to CT

  6. 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

  7. Symptomatic: Carotid Stenosis  70% TIA, Small completed stroke with minimal residual neurologic deficit,  antiplatelet agent +carotid endarterectomy

  8. Arterial Aneurysms • Definition:1.5-2x diameter adjacent normal artery. • Ex. Aorta  3 cm • True: All layers of arterial wall dilated • False: Aneurysm usually consists of hematoma +/- adventitia

  9. Distribution of Aneurysms • Aorta: 90-95% are infrarenal • Peripheral: Popliteal most common, 2nd femoral • Visceral: uncommon, splenic (most common)

  10. Aortic Aneurysms • Risk factors: male, age  60 yrs, smoking, COPD, FHx +ve, CAD, PVD, peripheral aneurysms. • Natural Hx: AAA  5 cm grow 0.3-0.5 cm/year • Rupture rate: •  5 cm - 1.5% over 5 yrs • 5.5-5.9 cm - 25% over 1-5 yrs • 6 cm - 35% over 1-5 yrs • > 7 cm - > 75% over 1-5 yrs

  11. AAA Presentation • Asymptomatic: incidental finding on Px or Radiologic Test • Symptomatic: ABD/BACK pain (leak or rapid expanding) • Rupture: 35% initial presentation, Triad ABD/BACK pain, Hypotension, Pulsatile Mass.

  12. AAA Detection • Physical Exam - not sensitive • U/S ABD - highly sensitive and specific • CT / MRI - sensitive, specific, but expensive • Angio - not reliable

  13. AAA Management Indications for Surgery: • risk of rupture > surgical risk • size  5 cm FEMALE • > 5.5 cm MALE • symptomatic • ruptured • rapid expansion Observation with U/S q6 months if asymptomatic and < 5 cm.

  14. Lower Extremity Arterial Disease

  15. Acute Limb Ischemia • Sudden onset of sxs/signs • Severity presentation depends on adequacy of collateral circulation • 5 or 6 P’s: pain, pallor, pulselessness, paralysis, paresthesia, +/- poikilothermia

  16. CAUSES • Embolus • Thrombosis • Trauma

  17. Embolus • Clot displaced from site of origin to occlude a distant artery • Most common site to lodge bifurcation common femoral artery • 90% come from the heart (atrial fibrillation, recent M.I.)

  18. Thrombosis • Clot forms in situ in a previously diseased vessel or bypass graft • Predisposing factors: Dehydration, CHF or Hypercoagulable state

  19. Embolus Dramatic presentation (sudden onset) Opposite leg normal pulses Source for embolus: A.fib, recent M.I. Thrombosis Bland (well dev. collaterals Opposite leg abn. Pulses Hx of chronic PVD, ex. claudication Acute Arterial Occlusion Presentation

  20. Investigations • Angiogram/CTA • Gold Std • Embolus (not always needed prior to OR but shows abrupt cut off of circulation, reverse meniscus sign, no collaterals. • Thrombosis - always needed, shows tapering cut off, lots of collaterals

  21. Treatment Embolus: • Anticoagulate with Heparin • Medical resuscitation • Surgical embolectomy • Consider Fasciotomies • Post-op life long anticoagulation Heparin  Coumadin

  22. Treatment • Thrombosis • angiogram always • thrombolysis +/- later surgical intervention • Endovascular (angioplasty/stent) • surgical bypass • post-op antiplatelet agents

  23. Compartment Syndrome • Especially after reperfusion of the leg •  pressure within fascial compartments >30mmHg. • Symptoms/signs: Pain out of proportion, pain on passive flexion/extension, absent pulses is a very late sign • Treat: fasciotomies

  24. Chronic Lower Limb Ischemia

  25. Presentation (symptoms): • Claudication = Reproducible pain in the lower extremities on ambulation • Rest pain = Pain at rest in forefoot, toes. Constant pain, worse at nite

  26. Presentation (signs): • Claudicant +/- pulse deficits • Rest pain - pulse deficits, atrophic skin, hair loss on toes • Tissue loss - ulcers (painful), gangrene

  27. Presentation (signs): • Ankle brachial index: • Normal  1 • Claudication 0.5 - 0.8 • Rest pain < 0.5 • Tissue loss < 0.3 • ABI not always reliable in diabetic patient • Doppler signal present does not always ensure adequate circulation

  28. Leriche Syndrome: • Absent femoral pulses • Impotence • Buttock Claudication

  29. Investigations: • Hx, Px, ABI • Blood Flow Lab - Duplex scan, exercise testing, segmental pressure studies • Angiogram/CTA - Indicated prior to intervention or diagnostic dilemma

  30. Conservative Management • Modify risk factors - smoking cessation, hyperlipidemia, diabetes • Walking exercise program (Develops collateral circulation) • MEDS: • All should be on antiplatelet: ECASA, Clopidogrel, Ticlopidine, etc • Statin • Consider Pentoxifylline

  31. INTERVENTION • Indications • disabling claudication • Critical ischemia:rest pain, tissue loss • Angioplasty + Stenting (best results for proximal lesions ex: iliac lesion) • Bypass • Amputation

  32. Aortic dissection • Definition: Intimal tear leading to creation of a false passage way of blood within the wall of the aorta. Results in both a true and false lumen of the vessel

  33. AORTIC DISSECTON • Most common catastrophic event of the aorta • Consequences include: • weakening of aortic wall and possible rupture • interruption of blood supply to branches of the aorta involved, resulting in end organ or limb ischemia

  34. Presentation • Classically older patient with hx HTN and sudden onset “tearing” retrosternal chest + back pain • On examination: HTN, pulse deficits are possible, murmur of aortic regurgitation

  35. Varicose Veins • Dilated saccular or cylindrical superficial veins • Different appearances/severities • Telangiectasia (spider cluster extending out from feeder vessel). • Stem veins (saphenous) • Reticular veins (tributaries).

  36. Classification • Primary - Superficial venous system only • Secondary - Deep system and or perforators are also abnormal usually as result of DVT, Pregnancy, Trauma

  37. Predisposing Factors • Family history, female, 50 yrs or older, multiparity, standing occupation, obesity, BCP, DVT

  38. Pathophysiology Primary Varicose Veins • Controversial: valvular incompetence, wall weakness, A-V fistula

  39. Presentation (symptoms) • Cosmetic appearance • Pain, leg fatigue, burning, itching • Swelling • Symptoms made worse by prolonged standing, relieved with elevation

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